An unsuitable old age: the paradoxes of elder care

There is a spectre haunting Canadians. Will we be able to get the health care we need when we need it? Many Canadian baby-boomers first encounter a system gone wrong when a parent becomes ill: they become caught in the emergency department crisis, the waits on hallway stretchers, the palpable frustration of all. The problem is often portrayed as government inefficiency, but this incomplete diagnosis leads to wrong prescriptions. To sharpen the diagnosis, consider the following paradoxes about ageing and health care.

Figure. Photo by: Canadian Press CP

1. Unless they double up and triple up on their illnesses, there won't be enough old people to go around. This may seem ludicrous, but let's do the math. The heart society advocates for more heart doctors and heart nurses, and for the latest heart diagnostic devices to allow for the latest heart treatments. It's a neat syllogism: heart disease is highly age-related; the population is ageing; therefore, there will be more heart disease, and we must act now. The lung society tells us the same about lung disease, the kidney society about kidney disease ... But when many of these old people show up in facilities ostensibly built in their name, they are sent away as “unsuitable.” Why? Because they arrive for their procedure not just with one problem but with a host of other ailments, too. In a word, their multiple, interacting medical and social problems make them frail. Geared to the sophisticated treatment of single problems, our system doesn't accommodate the complexity of caring for frail elderly patients, even though that is where much of our demand comes from.

2. The ideal patient is otherwise healthy. The unsuitability of frail older people for the patient role is well known: many cannot give a proper history; their temperatures go down in the face of infection; they are hyponatremic for no good reason; and their medication list is endless. Not to mention the “unsuitable” demands made by their families, who naturally focus on outcomes: “I need Dad to walk again if I am to take him home,” versus “We have treated his pneumonia and now it's time for him to go.” In such a case, families can be forgiven for thinking that it is the care that is unsuitable, not the patient. Not recognizing the cognitive impairment that makes for the “poor historian,” or sending home a patient who newly cannot walk are common examples of how “the system” fails because we don't know better. The reasons that we don't are complex, but they are an educational, not a moral, failing: simply blaming doctors won't do. Not admitting our ignorance won't, either.

3. It's more rewarding to do things to people than for them. When people have just a few things wrong with them, it's perfectly reasonable to focus on those few things, especially when “to do to” (say, replace a painful hip) equates with “to do for” (relieve suffering, increase mobility). In such cases, we can ignore a few days of discomfort and focus on (and pay for) the skilled procedure. But this might not take into account the vulnerability of the patient who is frail. To replace a hip in someone who never recovers from an unrecognized and untreated postoperative delirium means that the link between the procedure and the preferred patient outcome has been lost. Yet our present accounting of what goes on and what goes wrong is often silent on patient function. We pay more to perform a complex procedure with a bad outcome than to achieve a better outcome with less technology.

4. We're willing to pay less, not more, for comprehensive care. The experiment of the last 20 years shows that underpaying family doctors for nursing-home care does not enhance care there, and paying geriatricians badly means that few people want to become geriatricians. Just as the hardest-working doctors are not always the highest-earning ones, the skills essential to good care of the frail are little prized in our remuneration systems. This is a tricky area for doctors: in a single-payer system, physicians' salaries are a zero-sum game. Hence, there is a strong temptation to view private care as a “win–win” solution that injects more cash into the system and allows us all to be better paid.

5. We let perverse incentives persist. Fee-schedule oddities are not the only perverse incentives that undermine the care of frail elderly patients. In Halifax, for example, we now annually admit to acute care about 125 people for every 100 nursing-home beds. A local group has reckoned that these costs are at least twice as high as they need to be and that we could improve care at less cost if even just the money now put into unnecessary ambulance transfers were used to provide better on-site care. So, why don't we? History and silos aside, health care organizations are both the recipients of funds and the auditors of quality: we rely on ourselves to say whether we are doing a good job, and it is often easier to say that we are than to undertake fundamental reform. If we are to save medicare, we must discuss, not deny, perverse incentives. (We could start by recognizing that length of hospital stay is a system input, not a health outcome.) Without such a discussion, private providers, doing what they know best, will skim. They will efficiently treat single-problem patients and attribute their success not to careful patient selection but to the inherent virtues of privatization. The other, “unsuitable” patients will be left to the public system, which is why medicare has no choice but to face up to frailty.

6. Physicians are their own worst enemies. We have to find a way to engage debate about “the system” that recognizes how we contribute to its ills as well as how we might make things better. For example, how much of the “wait-list crisis” persists not just because of the obvious inefficiencies in the ways that lists are assembled and maintained, but because we have done little to prioritize by likelihood of benefit? How many people await high-tech, physician-driven solutions for which they have little hope of benefit while being denied low-tech services that might mitigate their suffering? In 2002 I worked with the Canadian Cardiovascular Society to discuss the management of heart disease in elderly people.1 One of the most impassioned presentations we heard advocated for implantable cardiac defibrillators, from an evidence base that included virtually no patient that I would recognize from my geriatric medicine practice. But the momentum was unstoppable, and within a short time a cardiologist colleague asked my opinion about a patient who had been referred for an implantable cardiac defibrillator but whose multiple medical problems and cognitive impairment had led to the patient being designated as “no code.” If we lack the wherewithal to rationally discuss outcomes, how can we rationally advocate inputs? Our most passionate advocacy might go down well with the public, but it will be viewed sceptically by colleagues unless we can share a better sense of ends and their achievement.

Canada's dilemma of providing care for an ageing population is of course a privilege denied to many countries. Those of us who are baby-boomers face the challenge of growing old as a group. Think of it as a bequest from our parents, who faced challenges of depression and war that must have sometimes seemed overwhelming to them, too.