- A Bitter Pill: How the Medical System is Failing the Elderly
- Greystone Books (2009)
A few hundred aging British Columbians currently have access to a remarkable new approach in home medical care pioneered by a local physician, a method that enhances comfort and dignity for the ill elderly and saves the system money at the same time.
But only five or six B.C. doctors are currently implementing this approach, so far as The Tyee can determine, and the need for it is escalating every year.
Hollywood icon Bette Davis said it best -- "Old age is not for sissies." And if you are old enough to remember her movies, you probably have some painful personal data to support her position.
The bad news is that there are going to be more and more Canadians living with the multiple diseases and failing capacities of old age. Canadians over 65, who numbered 3.92 million in 2001, will amount to more than 9 million in 2041. Close to a quarter of the population will be on Social Insurance then, and many of us will be very ill.
Some of us will meet the definition of the frail or fragile elderly, older patients who suffer from multiple pathologies and are dependent on others for activities of daily living. According to Dr. Martha Donnelly, director of the community geriatrics division at UBC Medical School's department of family practice, approximately 10 per cent of those over 65 are among the frail elderly. By the time Canadians reach 90, as many as 30 per cent fall into that category.
Many commentators have painted grim pictures of what this ever-swelling crowd of the unwell will do to public health care finances. And while most of us know a few exceptions -- fierce white-haired creatures who run marathons and till the garden -- for many Canadians the last years of life can be haunted by discomfort and disability.
The good news is that at least a few Canadian physicians have developed a way to practice medicine that is tailored to the unique needs of this group, an approach that increases comfort and dignity, allows the frail elderly to stay at home in comfort longer and choose the terms of their final days.
John Sloan is the Vancouver-based general practitioner and UBC Medical School professor who has pioneered this new approach, which is long on common sense and kindness and notably short on high tech interventions and expensive multiple medications. He makes the case for it in his 2009 book A Bitter Pill: How the Medical System is Failing the Elderly.
Sloan met with The Tyee at a Vancouver coffee shop recently to discuss his book and the transformative model for serving the elderly it describes.
Prescribing a drugectomy
Standard modern medical practice, he said, is built around disease prevention (think, for example, of statins for cholesterol and various blood pressure medications) and "rescue"-oriented crisis response to injury or acute illness.
Both approaches, which Sloan said work well for the bulk of the population, fail spectacularly when they collide with the special needs and circumstances of the fragile elderly. Preventing heart disease with medication doesn't make as much sense when you're 90 as it does at 45, and "rescue" interventions can often cause more trouble than they cure.
When taken together with the often desperate emotional, physical and economic stresses that face those who care for the elderly at home, the "rescue and prevention" paradigm can lead to sudden unnecessary hospitalization, unneeded and very expensive testing procedures and catastrophic over-medication, Sloan said.
"Typically," he said, "the crisis comes in the middle of the night, and if the care giver doesn't have someone to call outside of office hours, someone who can respond immediately, the absolutely understandable impulse of a caregiver who is already pushed to the limit, is to dial 911. Then you get a cascade of response, with ambulances, a fire truck, a police car and sometimes more. This sort of scenario doesn't fit for a 90 year old lady with a bit of dementia and arthritis."
After the middle of the night trip to the emergency ward, Sloan said, too often the real trouble begins.
"The wonderful people who work in hospitals are stuck in a box of risk avoidance pathways," Sloan said. Practice guidelines and hospital protocols typically require a range of expensive test procedures, which often reveal ongoing pathologies and problems. The drugs that are often prescribed in response to the test results can have serious and unintended side effects, often, for example, making it more likely the patient will be unsteady on her feet and thus liable to a dangerous fall, or increasing already present confusion or cognitive difficulties.
"One of the procedures I often have to perform when I start working with a new patient is what I call a 'drugectomy,' a careful staged process of getting him or her off some of the medications that have been piled on," Sloan said.
Sloan's practice is entirely carried out in the homes of his patients. He closed his conventional family practice office 15 years ago and has since operated out of his car and home. Now semi-retired, Sloan continues to see some patients in their homes and is devoting more time to educating the public and other doctors about the benefits of the kind of practice he advocates. (He published a text book for medical students, Protocols for Primary Care Geriatrics, in 1992 and Bitter Pill, for lay readers in 2009, and he maintains a website devoted to his work, and a second one, Sunshiners which he describes with a rueful laugh as "my attempt to start a social movement and rebrand the fragile elderly, all courtesy of my daughter who's in marketing in Toronto."
UBC's Donnelly says that Sloan, who lectures at the local medical school, has "an expert, excellent approach." She cautions that only a minority of seniors fall into the frail elderly category, and thus are likely to be housebound and ideal candidates for the kind of practice Sloan advocates. That said, Sloan's approach is "the only one that works well for the housebound elderly," Donnelly said.
Sloan said that he "fell sideways" into working with the fragile elderly in the 1970s, when, as a young GP, he was asked to provide care for residents at a couple of local rest homes. He quickly realized that his medical school training had not given him the background he needed to be useful to the patients he met there. The fragile elderly, he discovered, differ sharply from the rest of the population in many ways, including how they respond to medication and in what they want from medical professionals. To make it even more difficult, they vary widely within their own group, and are much more heterogeneous than younger patients.
He took a six-week break from practice and studied with Dr. Bill Dalziel, one of Canada's pioneers in the field of geriatrics, and continued to listen hard to what his patients themselves told him they needed.
Medical response without the panic
The key to Sloan's approach is skepticism about standard practice medicine's usual prevention and rescue model and a tight focus on maintaining as much function and comfort as possible for the patient, while always making the practice patient directed.
"If you listen to my patients, you find out what they want and need is fairly simple. They want to be comfortable, they want to stay at home and they do not want to be abandoned. Once we get them off unnecessary medications and figure out how to support their ongoing functioning at home, consultation and help available 24/7 and the prior discussions done with patients and caregivers about what options we'll have when there is a crisis mean that we're better prepared to respond without panic," he said.
To illustrate the dangers of hospitalization for the fragile elderly, Sloan tells the story in his book of an 86-year old patient he calls Mary McCarthy. An episode of shortness of breath had seen her admitted to a local hospital, where she was diagnosed with heart failure, vascular dementia, osteoporosis, diabetes, high blood pressure and arthritis. By the time Sloan saw her again the previously bright-spirited, attractive woman was slumped in near coma in front of a TV set in a darkened room. Her hospital stay had left her with 30 pills a day to consume, and with a dramatically diminished quality of life.
Over several weeks of careful work, Sloan was able to get McCarthy off some of the new medications she'd acquired in hospital and she was walking around again, talking normally and eating and drinking without help. Sloan followed up on the "selective drug-ectomy" by carefully discussing with his patient and her caregiver, an adult daughter, the question of when, if ever, it would make sense for this patient to return to hospital. In the meantime, Sloan reports, his approach has helped McCarthy regain much of the function and autonomy she lost during her time in hospital.
'A very practical advocate'
UBC's Donnelly sounded a cautionary note about Sloan's approaches to hospitalization and preventative medication.
"Sometimes," she said, "John is tempted to throw out the baby with the bathwater. Yes, it is a good idea to avoid unnecessary hospitalization and overmedication, but even with the frail elderly, there are times that you want to get someone into the hospital or onto appropriate medication. I am not totally against meds, but I do hate to see people on 14 or 15 different prescriptions, many of them interacting with each other. And hospitalization can be appropriate.
"The real problem, often, is getting hospitalized older patients back out into the community. We don't have enough non-acute rehabilitation beds in this province to address that need."
Sloan's style of practice has not yet become popular among Canadian doctors. He is aware of only four other doctors applying his approach in B.C., and one in Toronto. Donnelly cited one additional doctor on the North Shore, Kathy Bell-Irving, who she said was doing a lot of home-visit based work with frail elderly patients.
Dr. Larry Dian, a colleague of Sloan's at the UBC Medical School, says that Sloan is "a unique and very practical advocate for patients. John has espoused a clinical, bed-side approach that links good clinical judgment and philosophy to patient feed back. He is very compassionate."
In Vancouver, three doctors, Jay Slater, Conrad Rusnak and Rod Ma, each devoting half of his work time to the project, are the staff physicians for a home care geriatrics program called Home Vive, which opened in 2008 and took over some of Sloan's patients as he moved into semi-retirement. The program, which Slater told The Tyee is "docked" within Vancouver Coastal Health Region, uses home visits on the Sloan model to try to keep patients functional and at home.
A plea for new funding models
Ted Rosenberg is a Victoria general practitioner who calls John Sloan "a pioneer." Rosenberg conducts a home visit based practice for the elderly long in part under public funding and in part through the payment of private fees. Working from a home office, Rosenberg has approximately 300 patients on his practice. He offers them both publicly insured medical services and supplementary nursing, physiotherapy and dietician services for which patients pay privately.
"One thing that prevents more doctors from doing this kind of practice," Rosenberg told The Tyee, "is that it is financially difficult." Recent changes in MSP billing for home visits, he said, now make it marginally more possible to sustain the kind of home visit practice for the elderly Sloan pioneered. But without charging extra for private services, Rosenberg said, he would not be able to afford the extra staff he has on his practice.
In 2007, according to an email to The Tyee from B.C.'s ministry of health services, the fee doctors can charge for home visits to fragile elderly increased by nearly two-thirds, from $64.56 to $105.91 per visit, yet in the following two years the number of home visits dropped.
The ministry spokesman said the increased fee was prompted by his government's recognition that "chronic disease and other illnesses can be caught early and needless visits to emergency departments avoided with an emphasis on primary care."
Last year the Medical Services plan paid more than 2,400 doctors to make home visits in B.C., according to the ministry email. The ministry did not respond to Tyee questions about whether it had any further plans to encourage more doctors to take up the home visit model of working with the fragile elderly.
"Clearly," Rosenberg said, "new models are needed. The model I use is partly private, but I could imagine this service being entirely publicly funded if the government was willing to pay monthly capitation fees for each patient on the practice."
Adrian Dix, the NDP's health critic in Victoria, told The Tyee that John Sloan "is actually doing what everyone in the system says they are doing, and often don't. He is helping patients stay at home and maintain their functioning. I can't imagine anyone reading about this work and not wanting more of it in the province. It has enormous emotional appeal. We should encourage this kind of practice."
Ways to pay
When it was pointed out to Dix that despite the newly increased funding incentives, the number of home visits performed in B.C.'s public system had fallen between 2007 and 2009, Dix said that fact might represent an argument for the kind of capitation funding Rosenberg suggested.
Under a capitation funding system, doctors who had fragile elderly patients would be paid a flat per capita amount each month, rather than the fee for service model that is in place in B.C.'s Medical Services Plan currently. Such per capita funding, Rosenberg said, might make it possible for B.C. physicians to fund the sort of multi-disciplinary teams of doctors, nurses, physiotherapists and dieticians he currently conducts partly in and partly out of the public system.
New Zealand is one off-shore jurisdiction where some health care is delivered under a capitation funding model while in California the Knox-Keene Act of 1975 created the possibility of capitation funding for health management organizations in that state.
Whether the home care-based model of medical delivery for the fragile elderly depends upon the idiosyncratic virtues of unusual doctors like John Sloan or whether it can become, with funding reforms, a more widespread treatment approach employing health care professionals who may not share Sloan's unusual level of willingness to work outside the office remains to be seen. This much, however, is already clear. As the Canadian population ages and includes more and more of the fragile elderly, we are going to need to change our medical system to meet the needs of that group.
If we fail to extend the kind of practice John Sloan and a few other pioneers are currently demonstrating in their practices, the costs, both to patients and to the health care budget, could be immense.
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