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Home InSite Review The Needs of the Frail

The Needs of the Frail

Published on August 23, 2010 by in InSite Review

A BITTER PILL by John Sloan, M.D.
Greystone Books, Toronto, 2009. Reviewed by William Sheridan.

The North American population, along with the rest of humanity, is aging at a predictable rate. Longevity is increasing, and the median age is on the rise. The United Nations predicts that the challenge of aging will be one of the most important social issues of the 21st century. Most countries are NOT adequately preparing for this challenge.

Amongst the elderly, some are healthy and robust, but many are not. Dr. Sloan visits and attends to those seniors who are both frail and ill. Their numbers will only grow as longevity continues to increase and medical intervention continues to innovate. Regrettably however, conventional medical practices do NOT serve the needs of the frail.

As Dr. Sloan sees it, there is a radical disconnect between the methods of conventional medicine and the needs of the frail elderly. In most cases these people are suffering from multiple pathologies, their systems can no longer benefit from standardized medication, and their primary concerns are to maintain simple functions and gain some degree of comfort. More tests, more procedures, more drugs – none of these will any longer help.

What WILL help is to listen effectively to their articulated needs, and administer the kind of assistance that will restore functioning (walking, eating, etc.) and produce comfort (easing pain and constant worrying). None of this is really very hard to do – BUT it will only likely happen in the context of an understanding of both the benefits AND the limits of conventional medicine.

This is the case that Dr. Sloan makes. The available evidence clearly indicates that his is correct. The demographic trends now underway suggest that the current situation will only worsen. Both medical care givers AND the elderly themselves need to read this book, and then pass it onto someone in a policy-making role. Only through the coordinated actions of the elderly, medical practitioners, and health policymakers can the true needs of the frail elderly be administered to, and the costly misapplication of resources be corrected.

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2 Responses

  1. During her final months, my 93 year old mother endured many of the same ordeals that Dr. Sloan describes in his book callous, guideline-based standards of care taking precedence over empathy-based standards of caring and common sense: how about starting a cholesterol lowering drug, at age 93 if you please? Or, initiating blood pressure medication that produced side effects mistaken for the signs of heart failure, which in turn led to even more pills; or a diet of thickened food prescribed to prevent choking which inevitably led to dehydration – a diet ordered despite the fact that I had no trouble getting Mom to drink fluids; then there was the anti-psychotic medication ordered for ‘delusional’ traits in Mom’s behaviour though, if anyone cared to know, this behaviour had not changed in the previous five decades that I could remember, so why anti-psychotics now ? My call to the psycho-geriatrician went unanswered.Professional clinical judgement seemed clouded too often by a compulsion to act, whether or not the ‘best’ evidence made a scintilla of difference under the circumstances. Too often in medical practice if guidelines don’t fit the patient we choose to err in favour of making the patient fit the guidelines. Problems, after all, must be matched to solutions, or else, what is it we pay professionals to do? If, perchance, it means that square pegs need be gently forced into round holes, so be it. But who are these older people? What was the story of life and meaning that came together in a woman of ninety-three years? I had to repeat myself far too many times on that account and on the account of my mother’s wishes to believe that providers had either the time or interest to learn or make better judgements based on what they knew of my mother, the person. For all the bleakness and hand-wringing I went through with my mother, one incident stands out above all others that shows, just how close, and, by the same token, just how far, we are from providing the type of comfort and care the elderly deserve. It was on a particular evening that I came upon my mother in her room where she stayed at an assisted-living facility. Two caregivers were in attendance, one a member of the nursing staff, the other a young personal care worker. Mom moaned with every breath. During the last few months she had taken to moaning regularly, though for what reasons nobody was entirely certain. It was never as simple as asking for an explanation from Mom. Was it pain? Was it psychological? Mom fought as a member of the Dutch resistance during WWII and I knew only too well of the terrifying flashbacks she suffered.Among the nursing staff, a few found it especially difficult coming to terms with my mother’s behaviour. Their foremost concern was to relieve Mom of physical pain, on the chance this was the cause of her distress, which invariably meant more narcotic analgesia. This night, I demurred vigorously. Narcotics meant constipation, cramps and difficulty breathing. No, I did not want Mom to have more pain pills. This was not my first run-in.The nurse left the room. With none to overhear, the personal care worker, kneeling by mother, turned to me and in a quiet voice said, “When your mother moans, I gently stroke her head and comb her hair, or I’ll take some lotion and massage her legs, then she calms down.” We are that close to getting it right – yet, also still that far removed.

  2. This can be all extremely new to me and this article actually opened my eyes.Thanks for sharing with us your wisdom.

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