After the passing of my father-in-law a few weeks ago the family slowly emerged from the finality of the death but what stayed with me was how we could have done better for him. He was a dignified man, as we know our fathers to be, how did we let him down so that his quality of life until the end was not perhaps as dignified as he or we would have preferred.
This left me to reflect on my past experiences in the first world National Health System (NHS) in England and the private health care industry in South Africa where he spent his last days. The NHS has long understood that it is caring for an increasingly ageing population and as such focuses its limited resources on enabling where possible to help elderly patients return to normal activities of daily living rather than spending time in secondary care that is not only costly on an occupied bed basis, but also in terms of increasing risk of infection and further complications.
The NHS has adapted to looking after its elderly patients with more specialised care in the form of rehabilitation or occupational therapy and specialised pharmaceutical, nursing and medical care. As a clinical pharmacist on one of the elderly care wards there I remember the frequent discussions amongst the clinical team as to what we could do to help Mrs Jones get home and continue with her life as normally as possible. One can appreciate that the solution is complex and requires this multidisciplinary approach.
For me from a pharmaceutical care point of view, we needed to help Mrs Jones by: Rationalising her medications, helping her to understand what they were for and how to take them correctly. With all the will as there was it was still difficult to achieve all these ideals.
Rationalising her medications was the first hurdle. Time and time again in both private care in South Africa and the NHS it is very difficult to find a medic willing to stop or at least reduce the list of medications. The main reason for this is that wherever you are in the world your care is shared amongst colleagues and specialists and I have yet to meet a doctor who is willing to stop a long-term medication prescribed by another, potentially unknown, prescriber. In the NHS I did come across geriatricians who understood the complexities of ageing and drug metabolism well enough to reduce some or stop all medication and this not just in patients in their final days. How can we do better? One option is to not prescribe in the first place or to set review time limits. How many patients are left on proton pump inhibitors for years? Generic medications are reducing financial costs but are the long-term side effects actually costing Mrs Jones and the health system a lot more than the cheaper generic proton-pump inhibitor is saving?
It is difficult to contrast private healthcare as seen in South Africa and the NHS. The former does not benefit from close health worker teams and this surely compounds the lack of systemic care for the elderly. Lack of team work means duplicating care and costs. Too many people trying to help but no-one making a decision. Are we getting rehabilitation therapists in rather than another neurologist’s opinion? Why not get the geriatrician involved from admission? Does anyone think about getting the pharmacist up to ward prior to discharge to review and make sense of what is new and what is changed to make sure the patient and carer go home fully informed about how to take the medications safely?
On the teamwork front, the NHS does do better. It has networks between GPs and secondary care and throughout the admission to hospital there are healthcare professionals who are trained to help the patient return home to a normal a life as soon as possible. The NHS is not perfect by any means, there are: communication gaps, funding gaps and complex care and decision pathways; but it does provide us with an idea of what can be done in a different setting.
Countries like South Africa with a large mixed healthcare system have a tough challenge ahead. The public sector does not have the funds or perhaps expertise to help drive integrated care for the elderly. The private sector is a mix of providers with their own interests at stake. One may ask whether a private hospital has any interest in rehabilitating a patient as soon as possible to go home or to a step-down facility.
I see the way forward for people like my father-in-law, in a health system like South Africa, who spent longer in hospital than they should have, taking far more medication than was needed or helpful and spending his last few days in a state I do not wish for myself, as difficult to change. Unless the private sector can come together to create mutually recognisable, inter-sector and interfacility best practice pathways for care of the elderly and raise the awareness of the importance of geriatric medicine while also automatically including other healthcare professionals in the care of the elderly this will not happen. It is not to say it can’t but it will take an enormous amount of will and determination. And when it does maybe we can apply it to other areas of care.
And so, I am still left with the feeling that I could have done more to make his last days more peaceful if I had been around in the final weeks to be directly involved. But even if I had who would still have wanted to make decisions about stopping all or some of his basketful of medications? Who would have listened to put him in a more peaceful and less institutionalised environment? How could a dedicated elderly care team have made his last days more comfortable? This raises bigger questions of structure and governance than we can discuss here but perhaps we can start doing better by just listening and then imagining ourselves in the same situation in the future.
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