The Chaos, Distress of Caring for the Old

An 88-year-old man with dementia is sent to the emergency room with vague symptoms. He's poorly cared for, not because the doctors and nurses are bad, but because he is a low priority.

A frail grandmother suffers a heart attack at home, and an ambulance is called. The doctors shock her several times. They shove a tube down her throat. After several days on a respirator in the cardiac-care unit, the decision is made to turn off the ventilators. She passes away.

For what purpose were these many thousands of Medicare dollars spent? They helped neither patient and subjected them to pointless trauma.

Old people require a new model for care. They are not just adults with more things going wrong. They require a specialized approach, which geriatrics can best deliver.

"Geriatrics is essentially a mirror image of pediatrics," explains Juergen Bludau, acting chief of Clinical Geriatric Services at Boston's Brigham and Women's Hospital, part of Harvard Medical School. For example, children have caregivers, but so do old people no longer able to remember or explain what's wrong.

"You don't ask a child, 'Are you toilet trained?'" Bludau says. "You ask the parents. In geriatrics, we do the same with caregivers. 'Call me if he doesn't seem right.'"

Both groups have diseases not common among the general population. They require different doses of medications. Their development must be observed — such matters as language, social interaction, and the ability to stand and do certain things.

Doctors can't serve old people with a quick 10-minute exam. The patients may need time getting onto the table. Their medications must be checked. Treating them involves a lot of talking, an activity for which Medicare offers little reimbursement.

And one of the things discussed should be advance directives for end-of-life care.

Consider the frail woman who died days after a heart attack. Bludau says that he could have sat down with the patient and her daughter and asked: "Mrs. Smith, what would you want done if your heart stopped? Would you want to be resuscitated?" She might respond, "Oh no, I've seen this and don't want that to happen to me."

Such instructions could have gone into her living will, and when she had a heart attack, no one would have called 911. She would have passed away peacefully at home.

In the case of the man with dementia, the nursing home called his doctor to report that he wasn't doing well. The doctor had few good options. He could have run over to check him and billed Medicare for no more than $30. But if the man had pneumonia and wasn't treated promptly, the doctor could have been sued. By sending the man to the ER, the doctor avoided that risk and collected a bigger fee. The hospital also made money, as did the nursing home when the patient returned for acute care.

And what about his well being? Suppose the man had been repeatedly thrown into ambulances for previous pneumonias. Wouldn't it have been better for him and Medicare's finances if there were a directive saying, "No more," the next time this happens?

Geriatricians guide the elderly and their families through the complex medical options of old age. They can help assess whether aggressive treatments might do good or just pile misery onto the patient's last days. And by preventing even one hospitalization, they could save Medicare a lot of money.

The current system imposes chaos and distress on the very old — and does so at great cost. Americans need to think through what sort of care they want for loved ones — and themselves — when they near their end.

To find out more about Froma Harrop, and read features by other Creators Syndicate writers and cartoonists, visit the Creators Syndicate web page at www.creators.com.

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