The frail and elderly, it has been said, consume too many health services, languish in hospital beds, then die in them. But maybe the problem is that few explain the risks of medical interventions or offer them a better death.
Instead of herding the frail elderly through hospital, one Nova Scotia program informs them of their risks, after an assessment: among them, cognitive decline and loss of mobility.
Since the 200 or so patients fitting the definition of "frail and elderly" have gone through this program since 2009 – some have been slated for tests, procedures and operations including open-heart surgery, dialysis and chemotherapy – there has been a 76-per-cent reduction in interventions.
"We help them understand the pros and cons of even simple treatments," said Dr. Paige Moorhouse, who co-founded the palliative and therapeutic harmonization program at Dalhousie University and the QEII Health Sciences Centre.
Open-heart surgery is different for a fit 50-year-old and a cognitively impaired 85-year-old. It's about tradeoffs: Is it worth losing memory for an improved heart?
Some forgo operations and choose medication instead. Others have modest goals of staying at home, not wanting to return to hospital. Some charge on with the intervention.
All eventually face a health crisis that prompts them to decide how much treatment is too much.
Some 70 per cent of people die in hospital, though most say they want to die at home. Residential hospices, where palliative-care doctors offer symptom management, cost far less than hospital beds, and are seen as being part of the solution.
"What we've seen increasingly," said Dr. Daren Heyland, an intensive-care physician with a special interest in end-of-life issues, "is escalation of care, leading to an elderly patient with chronic, advanced disease, put on life supports, coming to an intensive care unit, where we just end up two, three or four days later, withdrawing life sustaining treatment and the patient dies. One has to ask the question: Why did death have to be that way?"
Far too often, the elderly are passive bystanders in a medical system that does things to them rather than for them. It's time to offer better options. Sometimes less truly is more.