Failing the frail
Dr Hannah Ireland
Saturday, June 4th, 2016
What would society be, so that in his last years a man might still be a man? The answer is simple: he would always have to have been treated as a man. By the fate it allots to its members who can no longer work, society gives itself away.
-Simone de Beauvoir, The Coming of Age (1972)
Currently our elderly are enduring the harsh rationing of medical care. Their age rather than their capacities and needs is directing the treatment, or the lack thereof, that they receive in hospital. As a student walking the wards, I’ve heard clinicians exiting the room of a grey-haired, frail grandmother saying, “What kind of life is that?”, “What’s the point in transfusing her?”, “Treatment is futile, she should be palliated.” All of these phrases and the derivations of them grate on me. I am not a proponent of over-treating, over-testing, and needless infliction of pain against a patient’s wishes. However, when I hear these utterings I wonder whether the elderly patient’s interests are at heart. I wonder if the fact that they are an octogenarian influences the doctor’s view of futility. Futile for whom? Is the treatment futile because it is evident that it won’t cure the patient? Is a cure even what we are looking for in multi-morbid geriatric patients? What if it buys more time for the patient and their family? What if that patient and their family think a few extra days or weeks are exactly what they need to say goodbyes? Surely that is not futile.
Futility can be subjective. We attempt to deny this fact. Doctors are not obliged to give treatment that they consider to be futile. However, prognostication is inexact. It is extremely difficult to determine when treatment is futile for an elderly patient with another infective exacerbation of their chronic obstructive pulmonary disease. No one can tell if this will be the infection that literally knocks the wind right out of them or if they will respond to antibiotics, nebulisers and fluids as they have before and return home. Nothing we have in our vast medical arsenal can precisely determine when a person will die. Therefore, the concept of withholding futile treatment is benevolent in intention but may be treacherous in practicality.
Knowing this, it is important that doctors present the options and possibilities to the patient and their family. This is not something that can be done with speed in the chaos of a morning ward round. It takes time, careful consideration, and discussion of uncertainty. It requires looking at the patient as a whole, identifying their wishes, fears and goals  and their family’s desires for them. It is a process that acknowledges that medical treatment extends to an understanding of both the social and psychological needs, not just the medical history and vital signs. It is a deviation from the traditional medical approach, which makes us uncomfortable. But it is undoubtedly the approach that patients need and deserve, especially as they enter the final years, months and days of their life.
In relatively recent times a new medical discourse has emerged. It is peppered with words like “advance care directive”, “not for resuscitation”, and “end-of-life planning”. These concepts are admirable.  They are a step towards ensuring that appropriate treatment is given to elderly patients. They are a systematised way of elucidating the patient’s desires for the end of their life in the event that they are not able to communicate these intentions independently. They can give another degree of certainty that doctors are doing the right thing by the patient when caring for those who are very ill and elderly. They attempt to ensure that patient autonomy is upheld even in their final days. It has been shown by randomised trials that this end-of-life planning, when done thoroughly and correctly, results in increased patient and medical team satisfaction. [3 ] However, when done poorly they have the capacity to collapse into a paper storm of inadequately completed forms, unchecked tick-boxes and a flurry of confusion.
The danger with this contemporary discourse and ever-evolving multitude of forms is that they become a veil for sanctioned ageism in our hospitals.  They pretend to address the patient as a whole but have the potential to bolster the fiscal constraints placed on hospitals that indirectly promote limitation of treatment according to age. They may even deny the elderly the empathy that other younger patients with better chances of full recovery receive without question. They are supposed to empower the patient but can instead circumvent the need for physicians and surgeons to learn how to have iterative meaningful conversations with the elderly and their families about their medical care.  There is a danger that these forms emerge as yet another mechanism for denial of deserved medical attention. They support the tired cry to create a “sustainable” medical system by discretely refusing the most vulnerable people in hospitals adequate medical consideration and thus further cement the lowly position of our elderly in our health care system.  Most worryingly, they delay the important recognition that we are failing our elderly and that our approach needs to change.
Part of the reason I believe that we avoid real discussions with elderly patients with complex health requirements is because it requires us to see ourselves in these osteoporotic, hard-of-hearing folk. [2,4] Too often we separate ourselves from them. We label them as “acopics” on “social visits”. We fail to see the aged as depicting our own destination in life. Perhaps we do this because recognising the elderly as related to us requires us to confront our mortality and contemplate our own ageing and death which is understandably uncomfortable. We don’t want to become them so we run from them as if avoiding the elderly will make us immune to ageing.
I hear doctors and students joke, in tutorials and at the end of a ward round, “I never want to get that way, I hope I die suddenly at 75”. They click their fingers to emphasis the swiftness with which they wish to depart the earth. They all want to spare their inner light from the ravages of time. They playfully ask their colleagues to just titrate morphine up to toxic doses if they have a stroke or become demented. They talk about growing old as if it is a fate worse than death. In doing so, they devalue the elderly that populate the busy wards.  Our grandparents become the least worthy of treatment because the implication is that they, as a collective, have nothing to contribute anymore.  They have lost their social worth. These phrases perpetuate ageism and they erect barriers which shut out the elderly from an impartial medical system. These jovial remarks are said without any consideration of the fact that they too will grow old. Most probably, they will grow older than the grey-haired people they walk past on the wards because that is the way our demography is headed, largely thanks to modern medicine. By “othering” the elderly, by failing to see the individual behind the date of birth, the connection is never made between doctor and patient, and austerity of care creeps in.
The other reason I believe we relegate the elderly to the medical scrap heap is because they challenge our medical capacities. They sit uncomfortably outside the modus operandi we learn at medical school. In the current hospital system, doctors approach patients with a view to compartmentalise them and break them down into discrete systems and then further into isolated organs within those systems. This method is neat and tidy. It is an efficient method that seeks to unravel dense biological complexities into manageable medical and surgical problems. It is goal-oriented and treatment-focused and on many occasions it makes patients better. However, the flaws in the system present themselves when the geriatric patient arrives in the emergency department. These patients can’t be dissected and deconstructed so easily and consequently they challenge our method. They test our Sherlockian reasoning and routinely disprove our beloved Occam’s razor theory that each and every patient can be summarised with a unifying diagnosis. They stand in the lesser known Hickam’s dictum camp that states that, “Patients can have as many diseases as they damn well please”.  This is daunting for us in the medical world. It signals longer assessment times, more complex diagnostics, less reliability in old-faithful heuristics and the possibility that the patient’s problems won’t be neatly tied up at the conclusion of the consult. The elderly are often perceived as a potential threat to our diagnostic and management skills simply because it feels strange to settle with a management plan where a medical cure and resolution is not the endpoint. We perceive this as some sort of failure on our part or a compromise of our identity,  but really it is an indication that we, as a group, are not equipped to deal adequately with the elderly patients that are populating our hospitals. It is an indication that we are failing them and that a cultural shift needs to occur within the medical fraternity.
Atul Gawande, the famous American surgeon responsible for the now commonly used “surgical checklist”, describes the inevitable population change occurring in developed nations in his latest book Being Mortal.  Traditionally, our demography has been pyramidal in configuration. The broad base of the population is occupied by those under the age of five and the small pointed apex accommodates a much smaller number of those over 80 years of age. However, with the passing of time and the impressive acceleration of modern medicine the shadow this traditional pyramid casts has begun to change shape. Gawande describes it as a “rectangularisation”  of the population, whereby the over-80-year-olds are increasing to be greater in proportion with the under-five-year-olds.  In essence, people are living longer and the elderly now represent a greater proportion of our society. I believe this new longevity of humanity is exciting as it presents an abundance of new possibilities; however, not all people see it that way. The growth of the elderly is often viewed with the gaze of a miserly economist, where the elderly are seen as a huge financial burden and are simply mopping up valuable health dollars. Whatever your view, it doesn’t really matter as the growth of the elderly is not reversible. It is happening and we as a medical community must shift to accommodate it and work with it, not against it. As such, the medical treatment of the elderly can no longer be the job of the specialised geriatricians alone. In fact, the number of training geriatricians is amongst the lowest of all the specialties in this time of their greatest demand.  This means that we all have a role to play in the care of the elderly in our hospitals. We must use the knowledge that we have to the benefit of our elderly and ensure that the medical treatment they receive supports their individuality and healthy ageing.
Unquestionably this will require a seismic cultural shift amongst doctors. It will require doctors to have that prickly confrontation with their own mortality and to acknowledge the limitations of their skills in this area. It will require openness to learning new skills and a reordering of priorities of treatment in some cases. It will involve an abandonment of the inertia that medical traditions and systems have created in favour of necessary innovation for the future. This seems a daunting task to embark on, but without change we will undoubtedly find ourselves living in a society that displeases us, a society that is fraught with injustice and inequity. The changes we make now must ensure that in the future our society is one that Simone de Beauvoir  describes, where a man in his last years might still be a man.  Where the vulnerable, those unable to work and those who are grey and tired are protected and their humanity is respected and upheld.
Conflicts of Interest
 Gawande A. Being Mortal: Medicine and what matters in the end. New York: Metropolitan Books, Henry Holt and Company; 2014.
 Hitchcock K. Dear Life: On caring for the elderly. Quarterly Essay. Issue 57, Australia: Penguin Books; 2015.
 Detering K, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010;340:c1345. DOI: 10.1136
 Montgomery K. How Doctors Think: Clinical Judgment and the Practice of Medicine. Oxford: Oxford University Press; 2006.
De Beauvoir S. The Coming of Age. New York: G.P. Putnam & Sons; 1972.
 Hitchcock K. Little White Slips, Australia: Pan Macmillan Australia; 2009.