Care of the very old in hospital

The problem

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, 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.

Towards solutions

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 discard it.
• 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 patient.
• 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. Even the demented have a person suffering within.
• 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 business.

• Personal reminders of 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?

• Mementoes 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.