Jerald Winakur practiced internal and geriatric medicine for 36 years and is an associate faculty member at the Center for Medical Humanities and Ethics at the University of Texas Health Science Center in San Antonio.
The 91-year-old woman fell in her garage.
There was no reason for her to be in the garage. The car had been sold after her husband died of Alzheimer’s nine years before, and she couldn’t drive anyway. Her macular degeneration was bad enough that she could barely make out anything on the TV unless she sat two feet away and tilted her head just so.
But the washer and dryer were in the garage, just a few steps off the kitchen in the little house she loved, her home of 40 years. It was so easy to go through the door into the garage and start something in the washer — her “delicates” especially. She didn’t like anyone else washing these. Even though she had caring help almost every day, she ignored the warnings of everyone and would — from time to time — go into the garage.
Thank God she always remembered to wear her emergency alert necklace around her neck. She hit the concrete floor, then caught her breath after the sickening sensations of cracking bone and searing pain passed through her. And then she triggered the alarm. Five minutes later emergency medical techs were through the front door calling out, “Where are you?”
Fifteen minutes after that she was in the emergency room, where she would spend the next eight hours waiting to be seen, getting X-rays and lab results, and waiting for a hospital bed. No one paid much attention to her pain.
The primary-care doctor she had been seeing for years — and who knew about her hypertension, her diabetes, her stroke five years prior (from which she had mostly recovered) and who had prescribed all her medications — no longer saw his patients every day in the hospital.
An orthopedist surgically stabilized her hip the next morning, and because her respiration and blood oxygen saturation were problematic — and at the urging of one of her worried sons (the one who happened to be a geriatrician) — she was moved into the intensive-care unit. “Hopefully, all will go well,” the surgeon said as he acquiesced.
Now, in addition to the surgeon, there was a hospitalist (a general hospital physician) and an intensive-care specialist involved. The patient did not know them and had no role in choosing them. It was not apparent who ordered the chest X-ray for the next morning, but despite fever, coughing and low blood oxygen levels, no one viewed the film until the son — worried that his mother was dying — asked 12 hours later what it showed. A left lower lobe pneumonia had blossomed, and antibiotics were finally — sheepishly — begun.
The sons, one or the other, remained by her side in the ICU cubicle. Aides and nurses, respiratory techs and phlebotomists, case managers and quality monitors came and went. From day one, a discharge planner came by. A transitional-care nurse stuck her head in, looked around and said she’d be back.
Meanwhile, the old woman hovered between this world and the next. Through her oxygen mask, she spoke to loved ones long departed. The television that hung from the ceiling across the room flickered continuously, but she could not see it. One day the president spoke on the news about “personalized medicine” and “precision medicine.” He did not make a distinction between them. But whatever they were — DNA, computers and other technology seemed to be involved — they were going to revolutionize health care for everyone in the country.
The old woman in the bed, her organ systems toppling one by one, now had more doctors attending her. More tests were ordered. She wasn’t eating much. Her food trays, containing an unappetizing conglomeration of puréed mush, were delivered to her room and left out of her reach. Since no one made an effort to offer her any sustenance, her sons took up the challenge. With assistance and patience, their mother ate food brought in from the outside. Not a lot. Not enough. But a start.
No one asked about her advance directive — which specified that she did not want intubation, cardiopulmonary resuscitation or artificial nutrition if she were incapacitated, unable to communicate with doctors and dying. These documents were supplied by her sons anyway and duly scanned into cyberspace with the rest of her record. The intensive-care specialist wanted a gastroenterologist to place a feeding tube into her stomach. “I think she’s aspirating,” he said. “And it’s quicker for the nurses to get calories in her that way.” The geriatrician said: “She doesn’t want a feeding tube. And for your information, tube feedings do not keep people from aspirating.” The subject was dropped.
Every two hours a blood pressure cuff, left continuously in place, inflated. Numbers were recorded, the electrocardiograph was continuously monitored. Alarms regularly pierced the solitude — tortuously to the patient and her family members nearby — but no one came to silence them unless the call button on the bed was triggered. The patient, blind and sick, could never find the correct spot to push on the multifunctional device that lay somewhere tangled in the sheets.
No one came to give the old woman a bed bath for more than a week. No one repositioned her. No one came in the middle of the night to put a hand on her forehead or to ask: “Are you able to sleep? Are you in pain? Can I get you anything?” When asked about this, more than one nurse said, “We used to do all those things, but there is no longer any time.”
Sometimes it seemed as if the only “personalized medicine” my mother received over the two months before she came home, frail and battle-worn, was when my brother or I brought a spoon with ice chips to her lips after she requested it.
Such is the state of medical care for many of our elderly in our best hospitals. Aside from spending untold dollars mapping the genomes of Americans, we must — once again — learn to provide true “personalized care” to every one of the soon-to-be 72 million geriatric patients in our midst. While not scientifically “precise,” nurturing in caregivers the skillful application of compassion and empathy it takes to do this work will — in the end — benefit us all.