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Care of the Elclerly Patient: Summation of the Forum David E. Rogers This forum has helped me think more intensely about how we, as health professionals, can do a better job of taking care of our elderly people. During the first session (Home and Community Care of the Elderly) we looked at out-of-hospital care, home care, and community care. This made good sense, for most of our elderly who get medical care sleep in their own beds at night. In the second session (The Acute Care Hospital and the Elderly) we examined the very real problems associated with their care in the acute hospital setting. Four major areas of concurrence emerged from our discussions on Home and Community Care of He Elderly. First, it was noted that, for aD kinds of historical and financial reasons, we had developed a system of medical care Hat fitted rather poorly with the medical needs of the elderly. Worrisome was the overuse of high technology in the diagnosis and treatment of the elderly, the overuse of the hospital as a setting for Heir care, and the virtual absence of any decent financing for long-tenn care. Second, we agreed that we tended to ignore and/or underutilize all kinds of human support services that could be useful in improving He welfare and the comfort of the elderly. One of the participants said that "the territory of care of the elderly does not belong to the health profes- sions alone." We should remember that and Dr. Avedis Donabedian's comment "that the aged are everyman." Fundamen~y, the elderly need the same kinds of care services that the rest of us do, except that they are often more delicate, more easily thrown into physiologic or emotional imbalance; more often for them, ~36

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CARE OF THE El nERLY PATIENT: SUMMATION OF THE FORUM social support services need greater emphasis, while high-technology medical services do not. Third, we aU agreed with the statement that "form follows fund- ing." The design of our public programs (Medicaid and Medicare) almost 25 years ago, as well as most forms of private health insurance, have tended to perpetuate a system of health care as we perceived it should be in the mid-1960s. It probably did not make great sense even in me 1960s. It is clearly id suited to the needs of today, and considerable evidence was presented to show that it is not working wed for us in me late 19SOs. The present financing of our medical care system tends to overreward for hospitalization. It tends to overreward for use of high technology. It underrewards health professionals for using their heads and their hearts. Fours, it was agreed that new technologies permitted much more complicated care of patients outside the hospital than in days past, and physicians and other heady professionals are trying rather desperately to gear up for, or adapt to, this change. In He second session, we fumed to He problems of the elderly in acute care hospitals and, again, certain new and powers themes emerged. Dr. Jeremiah Barondess set the tone when he asked us to consider care- fully when and how we should use the acute care hospital and its tech- nologies for the care of the frail and sick elderly. He pointed out that answers to these two questions were of considerable importance because the elderly are hospitalized about six times more frequently then the rest of us. Further, he noted that in most of our hospitals the elderly consti- tuted the majority of patients on ad services except pediatrics or obstet- rics. He gave us a yardstick by which to judge care for our elderly. He said, "Maximal appropriateness, maximal benefit, minimal risk, accept- able cost," but freely admitted Hat we lacked good methods by which to measure those parameters. Both Dr. Barondess and Dr. Mitchell Rabkin graphically portrayed He special problems of the elderly Hat we often handle poorly In me hospital. They outlined the very special nsks, both biologic and psychol- ogic, that beset the hospitalized elderly: He hazards of organ failure, of adverse drug reactions, and of mentative changes that were too often induced or aggravated by hospital care. Dr. Rabkin called these in- hospital events "~e agony of He elderly," whom he labeRed"fragile." They had fragile respiratory tracts, skins, minds; they had fans that broke bones; they had episodes of confusion; Hey had episodes of depression. 137

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138 DAVID E. ROGER' In sum, they were delicate creatures with a brittle homeostasis that was easily disturbed. The hospital emerged as often a rather dangerous place for them. Let me paraphrase another powered statement made by Dr. Rabkin. He said: "As the hospital stay gets shorter and shorter, it is less and less satisfying for the patient, less and less satisfying for the physician, and neither of them reach a point of closure with which they are comfortable before the patient goes home." This too short period of contact with its absence of real bonding between physician and patient has escalated the problems and frustrations of both pardes and has added to the litigious nature of patient and physician interactions. There were two suggestions for change to improve our manage- ment of the elderly in hospital settings. Dr. Rabkin suggested that hospi- tals should be regarded as nursing institutions, not doctor institutions. He felt that we should introduce the concept of the primary nurse as the principal responsible, in-hospital professional who had continuity and 24- hour responsibility for patients even though the primary nurse often delegated duties to others. Other participants suggested that we should also think about a similar delegation of responsibilities to the nurse in He home care of the elderly. Clearly elevating the importance of the nurse's role in this man- ner might also improve the recruitment and the retention of nurses in both in-hospital and out-of-hospital roles. Indeed, it might come to resemble more the British system than our own. There is no question about who is in charge of a ward in Britain. It is the head nurse. You do not even enter her ward without her permission, and her stature is significant. Dr. William Hazzard made yet another suggestion for how we might improve our hospital care of the elderly~hat we develop in-house geriatric teams. Here he described his own use of teams consisting of a physician, a nurse, and a social worker. This group crosscut departmental fines within He hospital and could assess and evaluate the care of elderly patients and make appropriate plans for Hem about medication, surgery, or over services. This deserves wider exploration. Using her survey data, Dr. Carol Gray made a rather powerful argument for us to pay more attention to He issue of the quality of life. She outlined some of the ethical dilemmas of hospitalization of the elderly and also recommended that the nurse play a more central role In their care. Mr. Jack Christy expressed major concerns about the quality of care in its totality as it pertained to the elderly and made a plea for

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CARE OF THE OVERLY PATIENT: SUMMATION OF THE FORUM 139 developing better yardsticks by which to judge that care, using the whole episode of illness, and not just a fragment of the acute- hospitalization or home care to make quality assessments. Mr. Joseph Westbrook captured the intensity of the concerns of many of us with his statement that "many elderly people are more afraid of living than dying." He also outlined some of the reasons for that fear: the absence of "tender loving care" in the acute care setting; the ex- pense in which one hospitalization could bring a patient to indigence; the dreadful absence of any good financing for long-term care; and the humiliation that we put some people through before we pay for their long- term care. These were dreadful commentaries on what we now do or do not do for some of our elderly. So we generally agreed that we do not do as wed as we should with elderly patients in the acute-hospit~ care setting, despite the fact that they represent the majority of our hospitalized patients, and despite the fact that we have plenty of resources available for their acute care if we deploy them appropriately. Dr. Stephen McConnell outlined a series of policy issues that surround problems of the care of the elderly, particularly for those in Congress or in other policy-making positions. He suggested that payment mechanisms affect the quality of care of the elderly. Although all of us agreed that this was probably significant, we need to have this docu- mented more clearly. We also need more information on what might be done to slow the escalation of costs and fees now so worrisome to those who pay the bids. Although there has been general agreement that much of the care of the elderly should be moved out of the hospital, there have been worries about how we can determine the quality of that care. One of the positive features-of in-hospital care is that in this setting aU of us who practice Here live in a glass house. It is very easy to see who is practicing good medicine and who is not. How we are going to do that kind of monitoring of quality when much of the care is shifted into He privacy of the doctor's office remains a worrisome problem. Furler, ~ have the uneasy feeling that any system of monitoring that we set up in this setting may be more expensive to carry out than the care itself. To close, let me give you five major areas of agreement that ~ Wink emerged from the conference. First, that we need a thoughtful, sensible, readily understandable integrated system of care that win permit the elderly to be cared for as much as possible out of hospital, but with close linkages among hospital, home, nursing home, and hospice settings.

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140 DAVID E. ROGERS Second, Mat we develop a system that recognizes and integrates within that care the informal care given by families and significant others, and me critical importance of over support systems in their welfare. Third, that we look more carefully at the quality of life mat we can offer the elderly; our medical care should be focused on functional out- comes; we should strive to add "life to years, not years to life." Fours, mat Were is a crying need for more and better research in a number of areas. Dr. Barondess outlined several: Use of technologies, particularly big ticket technologies, and their place in the care of the elderly. Whether it does or does not make sense to develop intensive care units for the care of the elderly. Problems of acute confusional states so common in the elderly in our hospitals. Better predictors of how elderly patients would fare with par- ticular disease problems in particular settings. The value of hospital-based consultation teams rather like Lose descnbed by Dr. Hazzard in improving the prognosis of older folks. Fifth and last, we Al agreed that absolutely fundamental, and particularly urgent, was the need to recast the financing of hemp care of me elderly, both public and pnvate, to encourage imaginative and re- smined and discriminating use of technologies, He fuller use of other kinds of support systems outside the hospital for the elderly, and for more and better long-term care. Clearly it is our collective hope that doBars will follow the services that we fee} important, rather than dollars dictat- ing where and what care is to be given. Our elderly deserve more from our U.S. system of health care than they now receive.