Transcript Keeping frail Out of the Hospital

Keeping
Frail Patients
Out of the
HOSPITAL
Isn’t HOSPITAL
the right place for
SICK
PEOPLE?
THE MARRIAGE MADE IN HELL
MY THESIS:
• The problems of frailty are
compounded, not solved, by acute care
• The problems of acute care are
compounded by frailty
Why do the Frail Elderly
end up in
Acute Care?
GOOD Reasons
• Hip fracture
BAD Reasons
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•
•
•
Can’t resolve “medical” issue
No MD available
Family feels responsible and unable
Facility staff likewise
• THE RESCUE EXPECTATION
FRAILTY DYNAMICS
REAL Natural History
function
time
INESCAPABLY
THEREFORE:
Frail elderly people will experience
CRISES OF FUNCTION
with minor changes in health status
…the challenge is to deal with these
rationally and compassionately
How does our system
RESPOND
to that kind of crisis?
ATTEMPT RESCUE!
911
(…the only light on at 3 am)
Typical Hospital Course
(a true story)
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Admitted to medicine
Treated with antibiotics
Confused and noisy day 3
Diarrhea day 4
Climbs over side rail, fracture humerus
day 5
Hospital Course (cont’d)
• SPECIALISTS (cardiology, infectious disease, wound
nurse, swallowing-evaluation OT, geriatric psychiatry,
rheumatology, alternate-care-level manager)
• 11 medications day 15
• Hypotensive and not speaking day 18
• Family declines ICU
• dies day 21
PREVENTION = DRUGS
RESCUE = HOSPITAL
AND…
DRUGS
DRUGS
HOSPITAL
HOSPITAL
When we ask,
What does a
“sunshiner”
want?
WHAT SHE FEARS
INTOLERABLE SYMPTOMS
BEING A BURDEN
TERRIFYING FUTILE HOSPITAL
EXPERIENCE
WHAT SHE WANTS
1.
2.
3.
4.
Keep me comfortable
Keep me functioning
Don’t abandon me
Let me make the DECISIONS
What we “know”:
• Frailty does poorly in the hospital
• Frail older people don’t want to be in the
hospital
Hospital is the
venue of default
because we
don’t provide an alternative
How do we Keep
Frailty OUT of
Acute Care?
ADVANCE DIRECTIVES:
“Degrees of Intervention”: failed
experiment?
“Let Me Decide”: even worse?
WHAT NOW?
Ask The Critical Question:
HOW
Do you
want to spend
the rest of
YOUR LIFE?
To Make ADs WORK:
Competent geriatric assessment
INFORMATION about prognosis
Comfort versus prolonging life
preference
A physician who will visit
A substituted decision-maker
(Leave the specifics to the patient)
BUILD TRUST
You can’t expect caregivers to cope alone
PROMISE to take RESPONSIBILITY
KEEP THE PROMISE
CHANGE THE MINDSET
THROUGH TRUST
About hospital default in crisis
About preventive meds
About primary care at home
About shared responsibility
SOME EXAMPLES
Where the patient wants comfort
and prefers
NO HOSPITAL
PRINCIPLES OF
COMMUNITY
CRITICAL CARE
1. You CAN assure comfort
2. Your chance of curing major event is
SMALL but about equal to hospital’s
3. Share these expectations
4. History and Physical for diagnosis
5. Trial of therapy replaces investigation
CHEST PAIN
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•
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Priorities do NOT include MI rescue
Treat the OTHER causes
Manage the hemodynamics
Hypotension plus pulmonary edema
equals MORPHINE
BREATHLESSNESS
• Trials of therapy; NOT investigation
• BELIEVE your history and physical
• When in doubt, use both (all four)
barrels
DELIRIUM
• Round up the usual suspects
• “Drugs and Bugs” first
• Then volume, the abdomen, alcohol,
stroke
• Blood work in the morning
SEPSIS
• Try for a focus
• IV push broad-spectrum antibiotic
• Hypodermoclysis if hypotensive
ACUTE ABDOMEN
Treat expectantly as sepsis including
anaerobes
In The Facility
• Insist on availability of MD
• Know your residents’ wishes
• Be prepared to support crisis
intervention
• Critical drug box
The Doctor’s Role:
• INFORM about prognosis
• Encourage delegation of a substituted
decision-maker
• Encourage advance-directive
conversation
• Family on board
• Permission to say no
BE AVAILABLE
and
when they call you
SHOW UP!!
(you’ll be amazed what a
difference you can make)