Monday, June 19, 2017

--I see lots of frail, older patients with four, eight, even 10 diagnoses. Some have trouble breathing, others have dehydration or pneumonia. Some need surgery. Our instinct is to start aggressive treatment. We send some of these patients to the intensive care unit. At first, patients and families might like the feeling something is being done. Eventually, many don't like or want it. -------Things could be different for older patients. The alternative is to make the ER a place where patients who don't benefit from lifesaving care get less of that and more comfort. ------ Each of us should figure out what kind of care we want near the end of life.----Julie Ali Flag Julie Ali Seniors certainly are not well served in emergency and nor are handicapped citizens. I believe they are not well served because some doctors consider them more disposable as patients. Why else would emergency doctors put "Do Not Resuscitate" (DNR) orders on my handicapped sister's file when she was a good candidate for resuscitation as per the ethics report that was later issued. In my family's experience it is not that doctors are busy in the ER, it is that they are overly conscious of the costs of keeping chronic patients alive and beyond a certain number of ER visits and beyond a certain age, there is reluctance to do the resuscitation. In my opinion, this is ageism and euthanasia. I would suggest to families that they accompany elderly family members to hospital as well as those who are handicapped to contest DNR orders. These folks aren't dead yet are they? Why should they be given no chance to live when their personal directive specifies full resuscitation? Palliative care is fine for those who are truly dying but to wrongly define the frail elderly, those with dementia and those with mental illness as palliative is plain wrong.« less


#NotDeadYet--If you are not dead yet why should you be told you are a
"palliative case" just because the system thinks this is a better designation for you to save the system money?
You're not dead yet are you? Why would you accept the decisions of doctors unilaterally? Do the research. Think about what they are saying and then you decide for yourself.
If you can't get them to change the DNR order then go through the kangaroo court of the internal to AHS appeals process.
If that doesn't work, go public and go to the court system.
You are not dead yet. You have a right to life. And you should fight for that life if you want to live.
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How do ERs and more specifically emergency doctors fail the frail elderly, seniors with dementia and the mentally ill? They can unilaterally decide to withhold treatment putting these still living folks into a terminal situation.
Why do doctors have the power to do this? Because they have been given this power by the government and by the health authority that is mandated to provide care to citizens.
Why should we accept such unilateral decisions by the medical professionals? They are stigmatizing the elderly who cannot fight for their lives or the handicapped citizen who is not able to advocate for herself.
This junk needs to be made public so families know and can contest these unilateral DNR orders in Alberta with the internal to AHS appeal process which in my opinion is pretty rigged to ensure that the authority wins out and then in the court system.
No one should have the power of life and death based on the economics of the system.
No one.



ERs are built to take on all patients of all ages, but seniors may wonder if they’ve come to the wrong address. @NightshiftMD has the details.
CBC.CA

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http://www.cbc.ca/radio/whitecoat/blog/how-ers-fail-older-patients-1.4156246


White Coat, Black Art
with Dr. Brian Goldman

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How ERs fail older patients







By Dr. Brian Goldman
palliative care
Moncton's Dr. Pamela Mansfield said without a palliative care strategy in place, New Brunswick patients and their families will continue to suffer needlessly. (Canadian Press)
Emergency departments are the usual destination for older patients in need of treatment. For the sick and injured, the ER is supposed to be a beacon of hope. For seniors, it's becoming a place of futility. That trend has started in Canada, but is well established in the U.S.  

If you don't believe our population is aging, visit an ER.  South of the border, Americans age 65 and older make over 21 million visits a year make a visit to the ER. One out of every six patients who come to the ER is of retirement age and older.

In Canada, after infants, seniors make up the largest group of patients, many of them near the end of life.  One study found that half of all older people go to emergency at least once in the last month of life.  And when they get there, they find a growing clash between the treatment that ERs offer and what patients want.  

The cliché is that families demand lifesaving treatment. But lately, we're starting to see a new trend:  doctors pulling out all the stops, and patients and families wishing they would just stop.

I see lots of frail, older patients with four, eight, even 10 diagnoses.  Some have trouble breathing, others have dehydration or pneumonia.  Some need surgery.  Our instinct is to start aggressive treatment.  We send some of these patients to the intensive care unit. At first, patients and families might like the feeling something is being done. Eventually, many don't like or want it.  

Just recently, I saw a patient with dementia who was sent in by a doctor for some tests.  Obligingly, I ordered a CT scan.  Next thing I know, the patient's substitute decision maker called from out of town to say she wanted to cancel the tests.  I had tried to reach her and had left a message.  The thing is, I had assumed incorrectly that the doctor who sent the patient to the ER knew the family's wishes.  I cancelled the tests, and the family took the patient home.  That story opened my eyes.

Why is there such a clash of opinions? Patients and families need to understand that most people like us went into the health professions to do things like cracking open chests, setting broken bones, shocking hearts and dissolving blood clots that cause strokes.  That's what's known as acute medicine.  At least privately, many health professionals admit they didn't go into medicine to treat chronic diseases like dementia, heart failure and cancer. And yet, that is what older patients have.

Expectations are another factor. Health professionals who shock hearts and take patients to the operating room are considered heroic; those who don't are considered weak and even incompetent.  

Another factor in the ER is the need for speed. A wise colleague once told me it takes 10 minutes to put an older patient with dementia on a ventilator, but it can take hours to talk with a family about death and try to figure out what the patient really wants.

Things could be different for older patients. The alternative is to make the ER a place where patients who don't benefit from lifesaving care get less of that and more comfort.  There's a movement to make palliative care an essential part of the mission of the ER. The aim of palliative care is to improve the quality of life by managing pain and other symptoms. Hospitals in several states across the U.S. have brought palliative care services directly into the ER. The triage nurse screens patients to identify those who might benefit from comfort measures. Some have built rooms in the ER that are separated from the rest of the department and are better for quiet discussions.  Around 150 board-certified ER physicians in the U.S. have become certified in palliative care.

I hope we see similar changes in Canada. There are family doctors in Canada who do both palliative care and emergency medicine, but they're an anomaly.  I'd love to see more ER physicians take this on.  With tight provincial budgets, I doubt we'll see ERs retrofitted to do more palliative care.

I'm keeping my eye on Eastern Health in Newfoundland.  Last year, the health region began implementing a policy to ask every patient admitted to hospital – regardless of age – their end of life wishes. I like that idea, but we should not wait until people are admitted to the hospital.  Each of us should figure out what kind of care we want near the end of life.  That would take some of the guesswork and the stress out of visits to the ER – for everyone.

Palliative care services remain woefully inadequate in Canada.  Without improvements, it will be impossible to deliver a more compassionate option, and the conflict between patients, families and people like me will continue to widen.


Julie Ali
  • Julie Ali
Seniors certainly are not well served in emergency and nor are handicapped citizens. I believe they are not well served because some doctors consider them more disposable as patients. Why else would emergency doctors put "Do Not Resuscitate" (DNR) orders on my handicapped sister's file when she was a good candidate for resuscitation as per the ethics report that was later issued.

In my family's experience it is not that doctors are busy in the ER, it is that they are overly conscious of the costs of keeping chronic patients alive and beyond a certain number of ER visits and beyond a certain age, there is reluctance to do the resuscitation.

In my opinion, this is ageism and euthanasia. I would suggest to families that they accompany elderly family members to hospital as well as those who are handicapped to contest DNR orders. These folks aren't dead yet are they? Why should they be given no chance to live when their personal directive specifies full resuscitation?
Palliative care is fine for those who are truly dying but to wrongly define the frail elderly, those with dementia and those with mental illness as palliative is plain wrong.« less
  • 23 minutes ago
Ian Scott
  • Ian Scott
Kinda of a weird article, nothing new here, its been going on for years. Usually they are brought to the ER for a specific reason, an acute on chronic issue. Space resource and staff continue to be issues. Few clinics or offices can deal with blood work or x-rays and mobility to get those as outpatients is limited with the elderly. Therefore they land in the ER. Heroics don't need to be done but getting a renal function and potassium level on those with complex meds is not unusual care. Since family docs don't seem to cover after hours or weekends in most cities and are lousy at same day assessments it falls to ER.« less
  • 3 days ago
Julie Ali
  • Julie Ali
@Ian Scott The point being made here is to encourage all of us to think about whether we should keep the frail elderly, those with dementia and mental illness alive or simply allow them to die with "palliative care".
Withholding of care once normalized will save the system big bucks but you have to get the citizens to agree to this sort of euthanasia based on consent of families.

I don't agree with it but I note the number of articles that are promoting "palliative care" and death by doctor far exceed the number of articles encouraging better continuing care services and supports or even a dementia strategy in Alberta. The latter solutions to the problems of the upsurge in the elderly population would require intelligence, leadership and money which is in short supply and so the emphasis is on withholding of services.« less
  • 9 minutes ago
Ian Scott
  • Ian Scott
Many hospitals have DNR committees . It still means the patient needs to go somewhere in the complex out of the ER setting for acute care. Its space and resource. If they are on deaths door then power or attorney or other family talks need sorting out right then. If its an acute on chronic issue then it needs sorting out. A patient with a fractured hip may still be easier to care for in a home if it is repaired.
  • 3 days ago
Ian Scott
  • Ian Scott
Kinda of a wierd article. They are coming to the ER usually for a specific event .It may have occurred on top of chronic issues. Those need sorting out up to a point.The corollary are those who are well past their due date before the family or neighbour or some other concerned person lands them in the ER saying they cannot take care of themselves.They need alternate care and that is where we are failing badly due to lack of space and resource.
  • 3 days ago
SarahRose Werner
  • SarahRose Werner
"Last year, the health region began implementing a policy to ask every patient admitted to hospital – regardless of age – their end of life wishes." My mother had a hip replacement in Maine when she was 75. The pre-operative paperwork included forms for expressing her end-of-life wishes. This allowed my siblings and myself to start a conversation with Mom on this issue and to take care of the legalities - will, POAs, etc. Otherwise that conversation wouldn't have happened. It all came in very useful four years later when Mom had a fall in her kitchen, was taken to the ER - and in the course of being treated was diagnosed with dementia and Parkinson's.« less
  • 3 days ago
Don Melady
  • Don Melady
As an ED physician focussed on care of older people I agree that EDs can significantly improve their approach to end of life care for all patients. However excellent ED care of older people is about more than the choice of palliative care vs acute care. EDs were established-- and most Emerg docs were trained -- to identify and treat single emergent problems in young people who have ONE medical problem. The reality is that most older people presenting to an ED have a complex web of problems. Many of them are not even medical, but rather psycho social and have a strong impact on the person's wellbeing and the outcome of their ED visit. For the most part EDs around the world are not good at assessing older people in a holistic manner using an interdisciplinary team and linking with community based care. The senior-friendly ED of the future will be staffed with people knowledgeable about the special needs of older people -- including end of life needs, yes, but also their complex interwoven medical pharmacological and social needs -- and with access to resources to address them including a link to community-based care so that the ED isn't just the front door to the hospital but also a front porch for the community.« less
  • 3 days ago
Julie Ali
  • Julie Ali
@Don Melady Thank you for this sensitive response to this article which as you point out has limited options for the elderly.

A framework for treating the elderly is required in Alberta as well as those with mental health issues who may not be elderly but may have the same lack of insight and inability to advocate for themselves as those with dementia for example.

The lack of gerontologist support is acute. The Glenrose Rehabilitation Hospital in Edmonton, Alberta has a few doctors specializing in the care of the elderly and these doctors could work with ER doctors as well as the personal physicians to assist in quality of life as well as end of life decisions of patients.

It's troubling that there appears to be no integrated care in Alberta whether in the regular population or those in institutions such as in the continuing care system. Lack of integrated care planning is very detrimental for all but most especially for those with multiple chronic illnesses and mental health issues.

ERs are not adept in Alberta for the care of the elderly/or the mentally ill-- and changes need to be made in the training of ER doctors who also need to be able to ensure that community supports are available after the typical catch and release work of the ER is done. Reaching for a DNR order instead of doing investigation and follow up to ensure that repeated hospitalizations do not occur should be part of the mandate of work of ER doctors.« less
  • 2 minutes ago
Jessica Simon
  • Jessica Simon
All adult Canadians, younger and older adults, can plan ahead for the possibility of emergent or serious illness by talking to those close to them. www.advancecareplanning.ca Talk about what your priorities and wishes you would want taken into account if you were so sick you couldn't talk for yourself. Preparing our loved ones for those in-the-moment decision making brings peace of mind to them, to our doctors and nurses when we need then and to ourselves.
  • 3 days ago
Ruth Storms
  • Ruth Storms
What should be really looked at are the doctors who call the shots. They will take care of a younger person first then maybe they will get around to a senior. They figure seniors have lived their life and are just a burden on society therefore they will help the problem along by taking care of seniors last.
  • 4 days ago
Julie Ali
  • Julie Ali
@Ruth Storms Seniors deserve the same care as young folks. If they don't get it complain to the health minister. Probably nothing will get done but don't give up. Keep complaining and go public if you can't get the help you need.
We are paying for the whole system. Seniors have a right to care. They also are vulnerable and without a voice in our society. Families need to provide them with the voice they do not have.
  • Just now
Chris Carpenter
  • Chris Carpenter
I'm glad that CBC and Dr. Goldman are drawing attention to the unique challenges of older adult emergency care. However, the discussion is incomplete because the CAEP, ACEP, SAEM, and AGS (among many others like the John A. Hartford Foundation and Gary & Mary West Health) have been working diligently to find effective solutions to these challenges for over a decade. Like what? First, we identified high-yield research priorities towards which to focus scant federal funding (http://pmid.us/2149... » more
  • 5 days ago
Susan Macaulay
  • Susan Macaulay
As the daughter of a mother who lived and died with dementia, I fully agree with everything you've said. I highly recommend Being Mortal by Dr. Atul Gawande, and offer this poem about being with my mom when she died on August 17, 2016:http://myalzheimersstory.com/2016/08/20/dying-with-my-mom/

That said, I also believe we should help people to LIVE while they are still alive and not to die before they're dear:http://myalzheimersstory.com/2017/04/20/i-want-to-live/

Thank your for your... » more
  • 5 days ago
Clarence Guenter
  • Clarence Guenter
Health interventions have become a staple in Western countries, but many interventions are not effective or even harmful - especially in the elderly. Read Ultimate Health, Finding It, and short book which examines how patients can engage their physicians in appropriate discussions, rather than simply adding more intervention.
www.clarenceguenter.com
  • 6 days ago
Susan Macaulay
  • Susan Macaulay
@Clarence Guenter Thanks for the suggestion and I highly recommend Being Mortal by Dr. Atul Gawande.
  • 5 days ago
Sue McPherson
  • Sue McPherson
Watch what you say, Dr Goldman. You're making assumptions again. Some older patients may have legitimate reasons for going to Emerg, and your article downplays that scenario. We live in a society where old people may not always get the best treatment, or treatment that would be beneficial for them, in Emerg. It is easier for some doctors to disregard what the patient came to the hospital for and to minimize their complaint, through inattention or just making assumptions, or by leaving out or distorting relevant aspects of their complaint. That happened to me very recently.« less
  • 6 days ago
Susan Macaulay
  • Susan Macaulay
@Sue McPherson good points. I believe people who need and WANT treatment should get it, and those who don't should have the prerogative to choose not to receive treatment. I agree with Dr. Goldman that too many extraordinary measures are used to extend the lives of people who might rather transition to another dimension. I highly recommend Being Mortal by Dr. Atul Gawande.
  • 5 days ago
Catherine Sarginson
  • Catherine Sarginson
@Sue McPherson If you live in Victoria BC you are practically forced into going to Emergency because there are literally thousands of people in this city with no family doctors. The doctor shortage is the most acute in Canada in this city. Yes there are walk in clinics. Which are only open for less than 12 hours a day. Some are only open part time. Some if they get too many patients waiting simply shut their doors for the rest of the day. In BC as a whole 42 walk in clinics have closed because there are no doctors to staff them. Any new doctors coming into the city join the local hospitals and act as hospitalists. No 24 hour days, no staff/office overhead. A life/work balance. The last time I went to a walk in clinic for necessary blood work I waited 4 hours only to discover after I left that I had been given the wrong test request. If I had gone back I would have taken another place waiting for hours. I finally have had to settle for a doctor from Ottawa via video counselling. God help me if I have to have any actual physical exams because it will be back to the 4 hour wait at the clinic again.« less




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