1. Keeping
Frail Patients

2. Out of the
HOSPITAL

3. Isn’t HOSPITAL the right place for SICK PEOPLE?

4. THE MARRIAGE MADE IN HELL
MY THESIS:
The problems of frailty are compounded, not solved, by acute care
The problems of acute care are compounded by frailty

5. Why do the Frail Elderly end up in Acute Care?

6. GOOD Reasons
Hip fracture

7. BAD Reasons THE RESCUE EXPECTATION Can’t resolve “medical” issue
No MD available
Family feels responsible and unable
Facility staff likewise
THE RESCUE EXPECTATION

8. FRAILTY DYNAMICS
REAL Natural History
function
time

9. INESCAPABLY THEREFORE:
Frail elderly people will experience
CRISES OF FUNCTION
with minor changes in health status
…the challenge is to deal with these rationally and compassionately

10. How does our system RESPOND to that kind of crisis?

11. ATTEMPT RESCUE!
911

16. (…the only light on at 3 am)

19. Typical Hospital Course (a true story)
Admitted to medicine
Treated with antibiotics
Confused and noisy day 3
Diarrhea day 4
Climbs over side rail, fracture humerus day 5

20. Hospital Course (cont’d)
SPECIALISTS (cardiology, infectious disease, wound nurse, swallowing-evaluation OT, geriatric psychiatry, rheumatology, alternate-care-level manager)
11 medications day 15
Hypotensive and not speaking day 18
Family declines ICU
dies day 21

21. PREVENTION = DRUGS RESCUE = HOSPITAL

22. AND…
HOSPITAL
DRUGS
HOSPITAL
DRUGS

23. What does a “sunshiner” want?
When we ask,
What does a “sunshiner” want?

24. WHAT SHE FEARS INTOLERABLE SYMPTOMS BEING A BURDEN
TERRIFYING FUTILE HOSPITAL EXPERIENCE

25. WHAT SHE WANTS Keep me comfortable Keep me functioning
Don’t abandon me
Let me make the DECISIONS

26. What we “know”: Frailty does poorly in the hospital
Frail older people don’t want to be in the hospital

27. don’t provide an alternative
Hospital is the
venue of default
because we
don’t provide an alternative

28. How do we Keep Frailty OUT of Acute Care?

29. ADVANCE DIRECTIVES: WHAT NOW?
“Degrees of Intervention”: failed experiment?
“Let Me Decide”: even worse?
WHAT NOW?

30. Ask The Critical Question:
HOW
Do you
want to spend
the rest of
YOUR LIFE?

31. To Make ADs WORK: Competent geriatric assessment
INFORMATION about prognosis
Comfort versus prolonging life preference
A physician who will visit
A substituted decision-maker
(Leave the specifics to the patient)

32. BUILD TRUST You can’t expect caregivers to cope alone
PROMISE to take RESPONSIBILITY
KEEP THE PROMISE

33. CHANGE THE MINDSET THROUGH TRUST
About hospital default in crisis
About preventive meds
About primary care at home
About shared responsibility

34. Where the patient wants comfort and prefers NO HOSPITAL
SOME EXAMPLES
Where the patient wants comfort and prefers
NO HOSPITAL

35. PRINCIPLES OF COMMUNITY CRITICAL CARE
You CAN assure comfort
Your chance of curing major event is SMALL but about equal to hospital’s
Share these expectations
History and Physical for diagnosis
Trial of therapy replaces investigation

36. CHEST PAIN Priorities do NOT include MI rescue Treat the OTHER causes
Manage the hemodynamics
Hypotension plus pulmonary edema equals MORPHINE

37. BREATHLESSNESS Trials of therapy; NOT investigation
BELIEVE your history and physical
When in doubt, use both (all four) barrels

38. DELIRIUM Round up the usual suspects “Drugs and Bugs” first
Then volume, the abdomen, alcohol, stroke
Blood work in the morning

39. SEPSIS Try for a focus IV push broad-spectrum antibiotic
Hypodermoclysis if hypotensive

40. Treat expectantly as sepsis including anaerobes
ACUTE ABDOMEN
Treat expectantly as sepsis including anaerobes

41. In The Facility Insist on availability of MD
Know your residents’ wishes
Be prepared to support crisis intervention
Critical drug box

42. The Doctor’s Role: INFORM about prognosis
Encourage delegation of a substituted decision-maker
Encourage advance-directive conversation
Family on board
Permission to say no

43. (you’ll be amazed what a difference you can make)
BE AVAILABLE
and
when they call you
SHOW UP!!
(you’ll be amazed what a difference you can make)