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Special Perspectives on Acute Hospital Care Carol I. Gray Of critical consequence in quality of care are the attitudes, perceptions, knowledge, and skill of practitioners. For purposes of this paper, I sought the opinion of individuals in clinical practice though the means of an interview guide~he format of which included questions about def~ru- tions: health care, elderly, the proportion of individuals "in-house" who were elderly, and questions regarding philosophy of care and age-related alterations of that philosophy in tens of (a) access to technology, (b) aggressiveness of diagnostic and therapeutic uses of technology, and (c) termination of technology, such as life support systems. ~ also included questions regarding the vulnerability of sick elderly to underuse, misuse, or overuse of technology. Finally, ~ asked questions about need for availability of support services and identification of policy issues and research needs all. Discussion that follows is an amalgamation of observations and perceptions carrying no pretense of a research effort. Clearly, the limited data base from which ~ speak can serve only to generate questions rather than define solutions. THE INTERVIEW SAMPLE AND PROCESS The participants in the interview sample represented Tree institu- tions: a large I,200-bed teaching hospital, a 500-bed intermediate hospi- tal, and a 250-bed community hospital. The interviewees included clini- cians and administrators in general medical-surgical department, inten- sive care units, coronary care units, and "step~own" units. 94

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SPECIAL PERSPECTIVES ON ACUTE HOSPITAL CARE 95 DEFINITION OF TERMS To establish a common frame of reference for the interviewees, I defined health technology as the fun range of technolog~es~iagnostic and therapeutic—including but not limited to (a) a set of techniques, thugs, equipment, and procedures used by health care providers in deliv- ering care to individuals; and (by "mini" technology, which includes standard hospital routines, repeated blood tests, diagnostic tests requiring fluid restriction, extensive bedrest, extensive therapeutic regimes, issues of technological restraint, and biotechnology for use in diagnostic probes (2,3~. Rather than establish a common frame of reference for We term elderly, ~ was curious to know how that population was characterized by the nurse clinicians. Several respondents said that they thought being elderly starts at about age 70. Another, more specific in her definition, identified "young" elderly to be 55 to 60 years, and "old" elderly to be over 60. Yet another respondent took a broader viewpoint by defining elderly as starting at about age 80, but at the same time, some persons are clinically and physiologically very old at 60. Another said that to be elderly is not, in and of itself, a state of being inept, sick, or pathological as some might characterize it; rather, it is a phase of life that carnes certain attributes. THE DISTRIBUTION OF ELDERLY IN ACUTE CARE HOSPITALS According to the respondents in a large hospital, the general medi- cal and surgical units as well as intensive care units average an increased proportion of elderly. In the smaller community hospital, the proportion of elderly is even greater, attributed in large part to the highly ethnic mix of the population served in the inner city. These perceptions expressed by clinicians paralBe] the observation of the American Hospital Association past-president, Carol McCarthy. The types of patients being treated in an acute inpatient care setting tend to be older. Admissions for people under 65 are the lowest in over 14 years and the length of stay is shorter than it has been for AX years (4~.

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96 CAROL J. GRAY THE ELDERLY'S ACCESS TO TECHNOLOGY Asked if age influenced the elderly's access to advanced technol- ogy, respondents expressed a common philosophy which was to provide He best possible care for aU patients without age distinction. The respon- dents9 without exception, had the impression that technology was applied equally to all and that age-related discrimination was not apparent. One respondent made the point that multiple systems failure occurs at all ages and requires timely evaluation and monitoring. Professional judgment about a patient's potential for recovery tempered most decisions about the use of advanced technology. One respondent noted that today's approach differs from that 15 years ago when age did play a greater role. Ultimately, the patients themselves or their families often determine the use of technology. The Aggressive Use of Diagnostic and Therapeutic Technology Among the Elderly Respondents identified a tendency for caution win the elderly, for example, in the use of chemotherapy. At one time protocols prohibited intense chemotherapy for individuals over 56. Today, quite aggressive therapy is administered to the elderly. By way of another example, heart transplants were Medicare driven in the past, with a cap at age 55. That restriction has recently been lifted. Cardiopulmonary patients now go to surgery in their seventies. The decision to use aggressive diagnostic and therapeutic techniques is often a function of social variables, individual choice, and the availability of support networks and their ability to sup- port and sustain. Other vanables, such as He will to live, enter into the choice of therapy. Bypass surgery is performed on elderly who are not good candidates for other procedures, such as angioplasty, or as a last resort to relieve symptoms. The impressions of the respondents regarding aggressive use of technology were validated, in my opinion, when I made an on-site visit to some clinical units. Two situations caught my attention. First, in one surgical intensive care unit, a patient was surrounded by four intravenous pumps, one chest tube, one respirator, one EKG monitor, venous pressure equipment, arterial pressure, and a cut-down procedure to infuse hyperal- imentation fluids for maintaining nutrition, including lipid replacement fluids and electrolytes. This patient had been admitted for bowel surgery at age 73.

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SPECIE PERSPIRES ON ACRE HOSPICE CAPE 97 The second example occurred in an intensive care unit. The pa- tient's diagnosis was extensive right occipital hemorrhage, In other words, a cerebral-vascular accident. He was supported by a respirator, heart monitor, central venous lines, arsenal line, heparin flush, nasogastr~c tube, and intravenous tube for peripheral medications. A Foley catheter, hyper- alimentation setup, and infection protocols were also in place. His age was 74. Only one of these cases was in the larger research hospital, the over was in a small community hospital. Termination of Life Support Technology in the Elderly Several respondents spoke to He ethical and philosophical dilem- mas associated with termination of life support '`Technology keeps people alive longer, but their quality of life and He family's resources are at risk." Family wishes are generally honored, and age is a major consid- oration, but decisions are not age-l~mited. Legislation and living wins have probably assisted in making decisions for terminating the life sup- port systems. Vulnerability of the Sick Elderly to Underuse, Misuse, or Overuse of Modern Technology This question caused a mixed reaction. One respondent compared the aggressiveness of diagnostic and therapeutic approaches in an aca- demic health center with that in a community hospital in which family practice prevails. She responded "yes" on aB Wee coun~nderuse, misuse, overuse. Especially vulnerable are biologically older individuals affected in mind, body, and spirit who need help and who acquiesce to anything. Older persons not able to articulate subtle changes that occur and who have no family to advocate or interpret for them might be the most vulnerable. The difficulty in predicting the value of technology was expressed by several respondents. "It is situationally dependent"; said one respon- dent, ". . . elderly are especially vulnerable." What is known after the fact cannot be predicted with degrees of assurance. The outcome is most often unknown until it is tried. The frail elderly are more prone to discomfort, but He question of their vulnerability to misuse of technology was unclear in the respon- dents' minds. Time constraints driven by prospective payment and diag- nosis-related group (DRG) insurance put the elderly at higher risk than

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98 CAROL J. GRAY inappropriate use of technology (5). Same~ay surgery on an outpatient basis and procedures for diagnosis and therapy often devastate both the family and the individual elderly patient. IMPROVING SUPPORT SERVICES FOR THE ELDERLY How might we make better use of support services, and what additional services are needed? While respondents acknowledged the availability of a gamut of services, they also expressed the need for improvement of services, especially for the elderly. The need for a communication system is great. For example, when an elderly person is scheduled for surgery, the records include a written communication be- tween the admixing and attending physician or surgeon, and perhaps one preoperative visit with He surgeon; a surgical checkup might occur weeks after discharge. Communication in the interim consists of a letter be- tween the physicians. Little is noted about rehabilitation and future care. Informed admissions and discharges could be improved Rough, for example, a primary nurse serving as a liaison before, during, and af er hospitalization. Telephone calls or visits to the patient are helpful when careful explanations are given about the hospital environment, expecta- tions of care, self-help versus help by others, and so form. Better information systems are needed Hat contain more Han computerized laboratory reports (61. Frequendy, He pre-admission inter- view is extremely stressful, pressing patients or family for a detailed medical history when they have been taxed significantly just making Heir way through the maze of long comdors, multiple signs, and queries with strangers. Another unmet service need is financial counseling. Social work- ers have provided extraordinary support, but there seems to be an urgent need for earlier, more timely advisement. For example, He postsurgical patient who has had an organ transplant and is placed on daily cy- closponne can expect the bill for drugs alone to be $50,000 per year. Finally, same-day surgery and diagnostic procedures place signifi- cant physical and emotional stress on He elderly. More choices for services, such as one-day diagnostic procedures and those driven by He DRG system, are needed for patients and their spouses. Older people have great difficulty win an operative schedule in which the patient comes in the morning and goes home that day—for example, cataract surgery on an 82-year-old; right inguinal hem~orrhaphy, 70-year-old;

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SPECIAL PERSPECTIVES ON ACUTE HOSPITAL CARE 99 hemor~hoidectomy, 76-year-old . . . each admitted and discharged the same day. Examples of same-day diagnostic procedures included cystoscopy on persons age 60 and older, endoscopy for 67- and 70-year-olds; and in one situation, colonoscopy, esophagoscopy, gastroscopy, and duo- denoscopy, all for a patient of 81 years. Might it be possible to restrain diagnostic and therapeutic technology routines in the acute care hospital to account more humanely for me physiological resources and limitations of the elderly? Responses varied widely: aff~rmadve, neutral, and nega- tive views were expressed, one expressing an emphatic "yes, we are pushing me limits of technology and need universal standards of care for the elderly." Examples of procedures for which we need restraint include (~) rigid protocols for bloodletting; (2) routinely waking patient to take vital signs through the night this results in fatigue and confusion the next day; and (3) iatrogenically induced starvation for 3 days from a 3-day diagnostic workup that required nothing by mouth for 3 days followed by discharge to home on the fourth day. The patient was very much weak- ened and more debilitated than when he entered Me hospital. Other respondents would like to see diagnostic and therapeutic aggressiveness modified especially for life-threaten~ng procedures in which Me infonnation is not vital to know. For reasons real or imagined, the respondent in the research institution and academic health center ex- pressed greater concern for diagnostic, rather than therapeutic, restraint. Respondents suggested that better mowtoring was needed for elderly patients on medical teals, hypertensive drugs, and so form. Shorter stays reduce effective assessment in the hospital, while effects on general systems often occur after hospital discharge. The frail elderly, who sometimes have no spouse or other support at home, might have to deal with untoward and unexpected reactions following discharge and become quite frightened. For example, in the elderly, blood pressure can be very labile and subject to or~ostatic changes, especially in response to drug therapy days after return to home. POLICY ISSUES The policy issues rest in the area of reimbursement- funding or lack of it for prevention and the cost benefits of health over illness. Quality of life and family and societal resources must receive greater

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100 CAROL ]. GRAY priority. Sophisticated high technology raises inordinate expectations of cure and recovery, but its use cannot ensure good outcomes. Patients and families need a fun accounting of possibilities and expectations, if at aD possible, before hospitalization. The fear of acquired immune deficiency syndrome (AIDS) is of growing concern with technology, and many patients Worry about contracting the disease while in He hospital. Addi- tionaBy, legislative issues, resource avocations, and information systems Al loomed high in the respondents' identification of policy issues. There is concern for the nontherapeutic effect on frail elderly placed in ex- tremely stressed situations for purposes of both diagnosis and treatment because of compliance win Medicare. DRG directives are also having an impact on the elderly's access to care in He hospital or forcing an early discharge often times in marginal states of recovery from illness and without reasonable support systems (spouse, friends, family) capable of caring for them at home. RESEARCH NEEDS AND OPPORTUNITIES There is a need for research into the process of socialization and acculturalization of elderly in the hospital setting. That would include expectations and accommodation of their role~y the padents, their families, and health care providers. Research is needed to evaluate pre- hospital education, its effect on compliance, role congruency, and so on. By way of example offered by one respondent, the generation of elderly now in acute care have expectations for care unlike those of the care providers who recognize the therapeutic effect of self-help. Most urgent is the need for collaborative research among profes- sional care providers to capitalize on experiences of physicians and nurses, clinicians and researchers; to analyze the whole gamut of biotechnology, its systems and design, its application, its effectiveness, and its costs. Is it available both for diagnostic and therapeutic purposes for He population of frail elderly who have the misfortune of ill-treat? Is it used judi- ciously to the best advantage of the population served- Hat is, are He potential benefits balanced against the potential for hann? SUMMARY Through means of an interview guide, an attempt was made to sample perceptions held by nurse clinicians about diagnostic and thera-

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SPECIAL PERSPECTIVES ON ACUTE HOSPrTAL CARE 101 peutic use of technology in tertiary care hospices where care was pro- vided to Me populations of frail elderly. While respondents unanimously agreed that access to technology was not age-dependent, there was among me respondent group a shared concern and some misgiving about me overuse =4 misuse of diagnostic and therapeutic technologies applied to We frail elderly. The costs borne by those individual~physically, emotionally, and financially—seemed to some respondents disproportionate to the benefits accrued. Specifi- cally, in the realm of diagnostic technology, it is believed that greater consideration might be given to the often-compromised state of the foil elderly. However, of greater concern than the occasionally questionable use of technology, is the compression of time allowed for hospitalization of the elderly under the hospital policies driven by the DRG legislation REFERENCES I. Interview Guide. See appendix to this paper. 2. Feeny, D. Neglected issues in me diffusion of heals care technolo- gies. Intemational Joumal of Technology Assessment in Health Care 1(3):681, 1985. 3. Intensive care for the elderly. Intemadonal Joumal of Technology Assessment in Health Care 1~11:2, 1986. 4. McCarthy, Carol. Insider review. Heals Week 7:3~31, 1987. 5. Smith, C.T. Commentary: High expectations versus limited re- sources. Health Affairs 86(FaB), 1986. 6. Lenhard, R. Personal interview. The Johns Hopkins Hospital. Balti- more, Maryland, September 1987.

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102 CAROL J. GRA] APPENDIX Interview Guide A. OVERVIEW OF TOM FORUM: purpose, audience, participants B. Request to identify individuals as interviewee C. CHARGE: to speak to the issues related to providing appropn ate inpatient care for the sick elderly D. QUESTIONS: I. Definition of "elderly" (e.g., age versus physiological, psycho- log~cal classifications 2. - Proportion (%) of patients, on average, who are "elderly" 3. Philosophy of care: any differential because of age re: A. Access to technology B. Aggressiveness of diagnostic therapeutic uses of technology C. Termination of technology Gife support systems, etc.) 4. Do you perceive the sick elderly patient to be "especially vuiner- able to underuse, misuse, or overuse of modern technologies? 5. How might we make better use of support services for He eld- erly home, community, and hospital? 6. What support and services are needed in acute care hospitals that do not exist now? Might it be possible to adapt or restrain diagnostic and therapeutic technology or "routines" in He acute hospital to better account for physiologicaVpsychological resources* and limitations of the eld- erly? 8. Policy issues 9. Research needs 7. *Cardiac output, tissue perfusion, absorption—alterations in urinary elimination, in perceptions, physical mobility, cognition, vision, support systems, self-conceptual alterations through nonnative development that impact on structure and fimction to the human being's physiological processes.