December

"My mother got worse during her admission to hospital, despite treatments doctors gave her. Why??

Mary is 94. She was out shopping with her daughter Rose when she fell. Rose took her to a GP who said that Mary might have an infection and should go to hospital. After waiting several hours in the A&E, doctors admitted Mary supposedly for a urinary infection. During a period of nine days in hospital, Mary was moved between three separate wards, was seen by different doctors every day and was becoming increasingly confused. By the end of her hospital stay she could no longer walk on her own, did not know where she was and had to go into a care home for respite care. Rose cannot understand why her reasonably fit mother deteriorated despite treatments and whether she will ever be back to her normal self.

Unfortunately, this is an all too familiar story as I hear complaints related to terrible hospital stays almost daily. As a geriatrician and a hospital doctor I also witness them first hand and frequently question whether certain admissions are necessary or whether the benefits of hospitalisation are actually countered by potential adverse complications, such as hospital acquired infections, confusion (also called delirium), poor sleep, and many other ailments.

To minimize the trauma of hospitalisation there has to be some understanding of the nature of these complications, and I hope my explanations below will help families to ease a loved one's hospital stay or at the very least gain more of an insight into the processes at play.

Let's start with the process of hospitalisation. Frequently patients are sent to hospital in panic because of inadequate support at home. Even simple ailments such as infections can cause an older person to become weaker, less able to self-care and potentially fall. However, not every fall requires a visit to the A&E department. An initial evaluation by a GP might, firstly rule out fracture, and secondly lead to conclusive diagnosis and treatment. Families should organise help for their loved one and ideally become a part of the overall care program itself. In specific cases, extra support could be requested from social services but at times like this I recommend an increased input from family rather than social workers. The reason for this is that older people have reduced energy reserves (as a result of age-related decline and lesser functioning of body parts as well as diseases they have accumulated during their lives) and even minor medical problems makes them confused, weak and vulnerable. They become suspicious, tearful, scared and are more likely to accept help from a familiar trusted person. For this same reason I advise family members to help as much as possible with feeding and care within the hospital setting as well. On my ward, visiting hours are unrestricted and there are many families that form part of the team looking after their loved ones.

Once a patient is taken to hospital here are some ideas how the family can make the admission as safe and comfortable as possible.

It is important to have an updated list of medications and medical problems. Make several copies of these as what you gave to the ambulance crew might not make it to the hands of a doctor. Bring everything relevant you have at home: latest letter from the hospital, GP summary from surgery, boxes of medicines, any written wishes, living wills, lasting power of attorney, etc. Stay as long as possible with your loved one in the emergency room, and when he/she is transferred onto the ward, make sure glasses/dental prosthesis/walking stick/hearing aids are not left behind.

Very early in the admission decide who will be the spokesperson for your family as doctors will not be able to talk to every family member (they have 20-plus other patients to look after, all needing attention and having families who also want to speak to a doctor).

As early as possible find out who the doctor in charge will be. You will come across junior doctors of various levels of training, and different medical specialists who might be advising on the care of your loved one, but you need to know who the final decision maker will be. Frequently, Geriatricians take over older patients with complex needs, as these patients need a holistic whole-person approach to their care. Having one person from the family talk with this one person from the medical team makes things smoother.

Next, you need to be aware of hospital complications. I will write about these in more details next year but here are some ideas:

As I said previously, older people, especially in the face of even a minor illness, become very vulnerable. Their body does not have any extra energy left to deal with the additional stress. Change of a familiar environment (from home to hospital), many hours in a noisy A&E, transfers from one ward to another, different doctors and nurses every day, new medications, invasive and sometimes painful procedures, might prove too much for that patient and precipitate a confused state (also called delirium). Even after the infection has been treated, delirium can go on for weeks or months, leading to poor eating and drinking, poor mobility and further demoralisation and weakening of the patient. The best chance that a patient has to recover from confusion is to get out of hospital as soon as "practically" possible. Once the infection has been treated, (and this usually takes 5-7 days), patients should be returned to the familiarity of their own home and under the care of their family. I often see discharges delayed because families mistakenly think that if confusion is present than the infection is still not treated. Delayed discharges make the confusion worse, and put the patient at risk of hospital-acquired infections.

The discharge itself is a major process, but I will be short here. Firstly I would avoid discharges when it is already dark-discharges should happen in the first part of the day. Darkness makes confusion worse. Secondly, it will take weeks before your loved one is back to normal: make sure home help is organised either via social services or family members or both. Some patients might never get back to their normal state, and after a trial of living at home may consider moving into a residential care.

Finally talk with your loved ones before they get sick, to understand what they would and would not want to happen to them if they get unwell. I frequently see families assuming things and be in conflict with each other. Making an advance care plan is the way to go. This could be done verbally or be documented with the help of a GP or hospital doctor. None of us wants to suffer. In old age some of us might prefer minimal medical interventions and opt for comfort measures, others may be willing to withstand aggressive medical treatments in the hope for recovery. It is important to make our wishes known.

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