Care of the very old in hospital
Training in thoughtfulness for all staff is more important for the
old and the dying in hospital than medical research into the rarer
diseases. And it costs less.
- If they live longer more happily, they are easier to nurse
- If they are spared unnecessary (and expensive) testing and
'heroic' treatments, they may die a week or so sooner but will be
much more comfortable and happy.
Thoughtfulness is putting first the most important things for the
patient ahead of the rituals and the tests and even the meetings -
important as the meetings are to alleviate constant stress on the
staff. For example:
- Take seriously the records that the patient brings, and what
the relatives say. Do not just rely with a tinge-of-pride attitude
on 'starting diagnosis from scratch' and ignoring the past.
Put both old record and new findings
together. This is particularly important when specific
treatment for the patient has been working - do not immediately
- Portrait of youth. Place at each
bed a photograph of the old person when they were in their youth
or their prime, so that young staff can always see in that old
person, that shell, what they really were. Then young staff
respond to that image, of another human being like themselves,
inside the shell they see in the bed.
- Let them have peace if they want
it, even if it does 'shorten their days' when their days
give them no pleasure (See Ecclesiastes on that). Let the very old
rest in bed if they want to. There's nothing I like myself more
sometimes than a 'good lie down' and I am petrified that in my old
age I could be kept sitting up bored, weary, uncomfortable and
chilly all day.
- More attention to bowels than to
clever tests that only help to train medical students. To put a
high priority on the dignity of the old person means putting a
high priority on helping them to remain continent and clean, and
never leaving them helpless so that they are in physical and
emotional distress about elimination.
- Let the patient set the
name-calling. First-name calling between people of the same
age can establish friendliness, but when young staff first-name
the elderly before the senior gives permission, it can be like
declaring second childhood and the lower status of the
- Always assume the patient retains
awareness somewhere. Underestimating patients is easy and
will easily push them into the state they are supposed to be.
Behave as if a person even in a coma can hear. Give physical
contact to the dying even if they seem unconscious. I have learnt
this from experience and observation. Weariness, despair and drug
effects are not the same as dementia. Few old people know or care
what day it is anyway. With their friends and relatives old people
can often still show a spark of life that staff may not see when
they have put a patient at a physical disadvantage. The demented, too, have a person suffering
- Put any necessary organizing paperwork for the patient as
a priority before staff and other
meetings. Social workers, however nice, can easily be
incommunicado in too many meetings, leaving undone paperwork and
phone calls that would have taken five minutes and really helped
patients and families. A good deal of busy time (and family's
time) can therefore be wasted in the social worker answering calls
that were just repeating the same unfulfilled requests and
- Personal reminders of old people themselves, and
their lives. I have been surprised by how often nursing
staff in nursing homes as well as in hospitals object to old
people having personal reminders of their lives with them, because
'they're a nuisance to the cleaners'. And if they do have
photographs and cards, they are often put on the wall behind the
bed where the patient cannot see them !!
The happiest people I have seen in nursing
homes have mementos of their lives around them, to remind them
who they still are. When Everyman dies, he can take nothing with him,
he is stripped of all (except, some say, Good Deeds) - but why should
he be stripped while he is still alive?
- Mementos of the dead. Ensure
that grieving relatives receive all the personal belongings of the
patient, and that they are not the perks of some cleaner.
- Psychologist in hospitals have a
job to ensure that all these are carried out, as well as attending
t the welfare of the nurses, cleaners, social workers, medical
staff, students, visitors, administrators, and others, so they too
feel cared for and can enjoy their work and their responsibility,
and use their own commonsense and imagination. This, too, means
attending to the small 'horse-shoe-nails' that lose battles and
cause deaths, and which can be more useful than arranging small
groups talking or running paper tests.
- Pictures on walls, flowers and
where affordable, washable carpets, make the place more pleasant
for staff, visitors - and patients. Any nursing home that looks
like a bare Institution should lose its registration, for
home-touches are not expensive.
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