more_vert
THE term “aged care” currently encompasses too many different aspects of care — from a clinical perspective it makes more sense to talk about long-term care for those patients requiring residential aged care.
Nearly all elderly residents of high-level long-term care facilities have some disability and have more than one advanced chronic illness. The majority have severe dementia, and many are in the palliative phase.
These residents need expert health care, not just accommodation and personal care.
An Australian Institute of Health and Welfare report shows that in 2008‒2009 almost 10% of 1.1 million hospitalisations for older people were for people already living in long-term care.
However, old people with dementia and residents of aged care facilities are not very welcome in our acute hospitals. They become increasingly unwelcome the longer they stay as “bed blockers”. In fact, I have come to the conclusion that the main business of hospitals is clearing beds.
Aged care assessment teams and social work departments are put under great pressure to get people out of hospitals. When I set up one of the first regional assessment teams in South Australia, when the system was first introduced in 1997, I would preach that the role of our team was to find the best care and accommodation option for the people we assessed. I don’t believe that this is true any longer.
As I have previously argued in MJA InSight, aged care services are outside the state-run health systems, and changing this at a structural and political level would be a monumental task.
However, this does not mean that we have to wait for a miracle to happen.
We run hospital in the home (HITH) services. A nursing home is a home, irrespective of which bit of government funds it.
If high-level long-term care facilities were supported to provide hospital services using the same model as HITH services, many of the issues that result in hospital admission could be avoided, to the benefit of the patient.
Rather than admitting a nursing home resident to hospital, a system could be devised whereby investigations could be done urgently and the resident returned to the facility, to be attended by a service similar to HITH for their actual care. This would make earlier discharge possible, especially if specialist-led services could be continued in the aged care facility with input from additional nursing and allied health staff.
If we add regional geriatric services to offer a continuum of services, rather than geriatric units or departments in hospitals, geriatricians could provide specialist support to GPs, who are currently given very little help with managing very complex and difficult long-term care of aged patients.
A number of years ago I had an excellent arrangement with a non-government organisation (NGO) that had established a new residential facility in our region, where respite admissions were treated as rehabilitation admissions. The facility had the rehabilitation space and allied health staff, and I contributed my time and clinical skills to provide an active service to our mutual client population. This offered much more than an often-resented temporary change in accommodation.
Alas, the experiment failed because the funding authority felt that it was outside the NGO’s province and did not meet the requirements of the funding model.
Yet, it shows that it is possible to make miracles happen.
Dr Ludomyr Mykyta is a consultant geriatrician based in South Australia.
Loading ...
I seem to have difficulty making my messages understood. What I am advocating is not admission of residents to tertiary facilities but means of avoiding this when it is against that patient’s best interest. I am pleading that they are entitled to benefit from the expertise that is currently almost exclusively available only in hospitals. This should be available to all who need it wherever they may be in support of their GP, who is rightly their principal medical care provider.
I would argue that the last thing residents of high care facilities who have “severe dementia” or are in the “palliative phase” need is any sort of aggressive medical interventions in the way of “urgent investigations ” or acute hospital admissions. In fact I believe the best option is high quality personal care managed by their GP in their resident facility. There seems to be a fixation on longevity rather than quality of life, and I am constantly both amazed and distressed by the investigative lengths and poly pharmacy to which some of our very elderly patients are subjected. Just because we ‘can’, should not mean that we automatically ‘do’. Once patients are admitted to a specialist unit in a tertiary hospital, the focus is immediately on a single area, frequently to the detriment of the patient as a whole. A far better option is to manage these patients with care and dignity in their own facility wherever possible.
I am not sugesting or implying that acute care for old and disabled people will achieve any sort of miracle. The point that I am trying to make is that specialist medical care should be available to the whole population, irrespective of where they find temselves. Alas, is only available through the hospital system, because by and large specialists seem unable to break the umbilical cord that keeps them to their comfort zone. What can be done in the community or residential facilities, should be done in those settings.
I frequently see people with advanced dementia in residential facilities and I am the first one that tells the family and carers that this is the palliative phase of their relative’s illness, and that we must switch to a palliative care approach that is simply put as freedom from distress of all kinds (physical , emotional, psychiatric), the provision of needed care that does not endanger the carers, safety, and whatever quality of life is achievable in the circumstances.
Many of these people continue to have needs that in any other setting would be met by specialists in geriatric medicine, psychiatry, or palliative care. None of these should be location-dependent.
Unfortunately, acute care for the very disabled very old doesn’t often result in a ”miracle”, and all too often prolongs needless suffering. In advanced dementia, the inability to protect one’s own airway from aspiration is an irreversible and life-threatening decline in function – it is not ”community acquired pneumonia”. Also, refusal to eat and drink at the end of life should be recognised for what it is – not bypassed by IV or NG feeding. Families need to be ready for the death of a very old loved one with advanced dementia, and understand what processes are happening. SOme organ system must fail at the end – otherwise we would all be immortal. I don’t want to detract from Dr Mykyta’s important work, but there are times to seek acute care for nursing home residents, and times to let nature take its course.