Written by: Derek Bisset
Things were different where I was a boy.....
I can see the family shaking their heads. Here goes Grandpa again. The grandchildren look slightly interested but texting is more important; their mother returns to her book; if you say that one more time Chris says. But it is isn't me this time. It's him, the man in the book Alison is reading. Besides, I said “where” not “when”. Well, we'll listen just this once.
Atul Gawande is an American surgeon who is also an excellent writer about the health system. He wrote Being Mortal about end of life care in North America and in it he is critical of what he sees and even of what he has done himself as he has become aware of the impact of the system on elderly people going through the various stages leading up to eventual dying. Yes, it is a difficult subject, but he makes it very readable because of his skill and compassion for those he deals with. In part criticises his own business. The drive in medicine to find a cure when there is none, to cause unnecessary suffering when dying is inevitable; the failure to have compassionate discussion about final decisions. He uses the death of his own father, also a surgeon, to present personal experience.
He contrasts how he remembers elders being treated as honoured and respected members of extended families when he was growing up in India with their treatment by modern families here. Elders there knew that families would be ashamed not to keep them in the family home to the end of their lives, functioning as they were able. Elders here expect to make their own arrangements for care when it is needed. That might not be a bad thing in itself, but Gawande sees some unpleasant consequences, and he in not talking about uncaring families or caregivers, or warehousing of seniors in institutions. Sometimes it is the very care that can be the problem.
As an example he targets what might be called overcaring. This occurs when everyone, families and caregivers together, does their utmost to prevent harms, falls and kitchen stoves left on for example. Too much of this can lead to someone being unable to do things like dressing and cooking that they could somewhat do for themselves and have done all their lives. In care homes it sometimes means that people are given meals at 7.00 am and dressed by a caregiver in the name of efficiency and safety. This can be compounded by the home being criticised and perhaps threatened with being sued for any lapse in vigilance. In the meantime, costs require that minimum staff carry this out as quickly as possible.
We were passing through Antwerp on a tour this year and went for a walk with our guide in the evening. He had been a social worker and he stopped outside a gate to look into a courtyard with what might have been a monastery around it. He explained that he was interested in this experiment in senior living in which individuals had their own rooms and the intention was to help them stay independent as long as possible. I would have liked to hear more but he went on to say that an important part of the plan was that there was an elementary school across the lane who would use the courtyard as a playground because the school had none and the seniors could have the children around.
Gawande talks about a Pennsylvania surgeon with similar ideas. He was a part time farmer who had left surgery because he couldn't take night shifts any more and taken a job as manager of a care home. He was concerned about the deadness about the place. Inmates seemed listless and, many wheelchair bound, many drugged heavily and some never leaving their rooms. So he approached the governing board to discuss animals. Would they allow a dog? Yes the rules would permit a dog. More than one? What about cats? Well.... What about a cat for each floor. The state rules would not permit that. In the end he got his way by presenting it as an experiment in reduction in drug use. He got his animals and included a bird for each room. When the birds arrived they were unprepared and the truck driver opened his doors and had the birds fly into a public room, leaving the manager and his helper assemble a cage for each and catch free flying birds. At one point they looked up and saw the first sign of fun they had seen in the place. Their people had come to the windows and were looking in convulsed with laughter. The need for drugs dropped dramatically over time and patients started to live again.
This a much needed discussion for an aging population.