Looking After Our Elderly - Ten Rules For Showing Respect by Sue Ieraci, MBBS, FACEM

Sue Ieraci, MBBS, FACEM We all know it – the population is ageing, expectations for intervention are rising, risk-aversion is growing, dying old people aren’t allowed their dignity any more. The more sceptical I get about the diminishing returns of high technology, the more I realise that a little kindness, consideration and respect are what our elderly patients actually need. Here’s my attempt to summarise what I have learned into ten easy principles:

RULE ONE: PHYSICAL COMFORT MATTERS

EDs are noisy, cold and lonely, trolleys are hard and narrow, everyone forgets to feed you and talk to you. Think about sitting in a cold, confined space for hours and hours, with no food or drink, shivering in a cotton gown. Here are a few easy ideas that are always appreciated – a cup of tea, a sandwich, a warm blanket, adjusting the bed head, a little privacy, a kind word.

RULE TWO: DON’T LOOK FOR TROUBLE

People over ninety are allowed to have dizzy turns – it comes with the territory. They are also allowed to have high blood pressure (safer than low at that age). The very well, independent very elderly with minor symptoms should be left alone – given physical comfort, something to eat and drink, minimal testing, and, wherever possible, returned to their own home.

RULE THREE: OLDIES LIKE TO TALK

There is always time to share a few conversational words while we do our quick physical exam: how many grandchildren do you have? Did you fight in the war? What job did you do? When did you come to this country? Showing an interest and opening up a conversation can make their day – and ours.

RULE FOUR: OLDIES SHOULD NOT BE POISONED

At some point in great age, the risk of anticoagulation becomes greater than the benefit. I have a principle of suggesting stopping Warfarin (Coumadin) in everyone over ninety, or over eighty-five with significant falls risks. Apart from the big risk of intracranial or gut bleeds, there are all the bruises and blood tests. They generally agree. The same goes for lipid-lowering agents, many antihypertensives, in fact – most drugs.

RULE FIVE: OLDIES SHOULD ENJOY THEIR FOOD

I love to sneak them a chocolate from the store in my desk – always appreciated. Have you seen that mush they get served?

RULE SIX: LIFE EVENTUALLY ENDS

 A person with advanced dementia who is incontinent and totally dependent is at the end of their life. If they aspirate (because they are unable to protect their airway), then their body is in terminal failure. Treating the aspiration in an acute hospital bed can only prolong this abject position until the next episode. I try to take the time to talk to the family and nursing home staff, and convince them to let nature take its course. I believe that prolonging a life with this type of discomfort is cruel.

RULE SEVEN: THERE IS LIFE OUTSIDE HOSPITAL

Our residents and interns tend to forget that any abnormal finding doesn’t necessarily mandate hospital admission. The very elderly, and those already in nursing homes, can benefit from time in their own homes, without exposure to the discomfort and risk of the acute hospital.

RULE EIGHT: THE ELDERLY ABDOMEN IS A MINEFIELD

In contrast to healthy young males, abdominal pain in the elderly can be a complex and mystifying problem. Personally, I am very cautious about ordering abdominal CT scanning in patients below age 50, but I am starting to concede that nearly every elderly abdomen needs radiotherapy – and the distant complications of radiation don’t matter so much.

RULE NINE: IT COULD BE YOU

It’s always instructive to think about that patient in front of you as yourself, or someone you love. Is this the type of treatment you would hope for in your own advanced old age?

RULE TEN:  I’VE FORGOTTEN RULE TEN

Add your own favourite.

Comments

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