Keeping Frail Elderly out of the Hospital

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When I was a medical resident at Boston City Hospital, a large, public, inner city hospital, I began wondering whether hospitals sometimes caused as many problems as they cured. Over and over, I saw older patients admitted with one disease such as pneumonia or a heart attack, who ended up falling and breaking a bone or getting a blood clot from being confined to bed. So I did a study in which I measured how often older people became confused, stopped eating, developed incontinence, or fell while they were in the hospital. I tried to separate out those cases in which the new symptom could be plausibly related to the admitting diagnosis: for example, someone who was hospitalized with a stomach ulcer would normally stop eating during the initial treatment, and someone with a stroke might well be confused. Then I compared the rates at which people over 70 developed these unexpected complications with the rates at which younger people developed them. Finally, I speculated that each of these problems might trigger a cascade of adverse events: a patient who became incontinent might have a catheter placed in his bladder, which in turn might cause a urinary tract infection; a patient who got confused might be physically restrained and his immobility might lead to a blood clot. 

What I found was that among the 502 patients I examined, a startling 41% of those over 70 developed 1 or more of the 4 problems I was interested in compared to only 9% of the younger group—and these were all problems that could not clearly be related to the acute illness for which the patient was being treated. It made me question whether hospitals were a safe place for older patients. 

Of course the older patients might have developed the same difficulties if they had been cared for at home, but I was skeptical. I thought that the unfamiliar environment of the hospital might be causing the confusion so common in hospitalized older individuals. I believed that being in a strange place might lead people to have trouble finding the bathroom at night and to fall as they groped trying to find their way.  And certainly the response of doctors and nurses to these new symptoms—putting in a catheter or using physical restraints or sedating medications—was far less likely to occur in the home setting.

Stimulated by my study and others like it, some physicians tried to design safer hospitals. That’s a noble endeavor and the result, the ACE unit (acute care for elders) has made it somewhat less likely that patients develop the kinds of complications I enumerated and far less likely that doctors and nurses responded to those complications, when they did occur, in the unfortunate ways I wrote about. But despite these improvements, older hospitalized patients have an unacceptably high risk of becoming acutely confused, receiving sedating medications, and falling, among other problems. 

At the same time that older patients continue to do poorly in the hospital—particularly the oldest and the frailest of the old—they have very high rates of repeat admissions to the hospital, sometimes within 30 days of discharge. As a consequence, many frail elderly patients have not just one opportunity to develop complications in a short period of time, but several chances. As it turns out, Medicare is very concerned about the high rate of readmissions, not so much because the Medicare program recognizes that hospitals can be hazardous for your health, but because repeated hospitalizations are very expensive. Not only that, but Medicare officials suspect that the reason older patients are being readmitted is that they weren’t properly taken care of the first time round. So the solution, Medicare reasons, is to penalize hospitals for high readmission rates, thus strongly incentivizing them to assure they get things right during the initial hospitalization.

It is a nice idea, and there is quite a bit hospitals can do to prevent readmissions. They can make sure patients are taking the medications they are supposed to take once they get home. They can check that they have a follow up appointment with their primary care physician within a few days of discharge. They can guarantee that the primary care physician receives a good summary of what happened in the hospital. But the assumption underlying the push to decrease readmission rates is that if only doctors do a good job with their frail, old patients, those patients won’t get sick again. The truth is that frail, old patients will inevitably get sick, even if physicians and nurses and hospitals do the best possible job taking care of those patients. The reason for this sad reality is that the essence of frailty is a heightened vulnerability to illness. So frail people will, by definition, repeatedly become sick.

Which brings me full circle to the study I did in the 1980s about the adverse consequences of hospitalization in the elderly.  The question, as I posed back when I wrote up my findings many years ago and again in an article I recently published in the Annals of Internal Medicine, is how we should respond when frail elders get sick. And my answer, then as now, is that we should try very hard to keep them out of the hospital. That means developing viable alternatives to hospital treatment. Frail, old people will sometimes want to be hospitalized for their acute medical problems. The hospital may prove to be the best site for achieving certain goals of care. But if they are interested in maximizing their quality of life, as many frail elders are, and if they have the option of home rather than hospital care, many of them would choose that route. 

The secret that policymakers do not seem to have recognized is that doing all these good things could save Medicare billions of dollars. Hospital care makes up 25% of Medicare spending and frail elders account for a disproportionate share of hospital days. So if we want to avoid hospital-induced iatrogenesis and assure that treatment conforms to patients’ goals and save money, we need to design new ways to treat patients outside the acute care hospital. 

Dr. Muriel Gillick, who will qualify for Medicare in three years, is a geriatrician and palliative care physician, and a professor in the Department of Population Medicine at Harvard Medical School. She has written four books for a general audience discussing ethical, medical, and other issues arising in old age, most recently “The Denial of Aging: Perpetual Youth, Eternal Life, and Other Dangerous Fantasies” (Cambridge, MA: Harvard University Press, 2006). She blogs at Life in the End Zone, where this post was initially published.

11 Responses to “Keeping Frail Elderly out of the Hospital”

  1. Carol Eblen

    I agree that hospitals are dangerous places for the frail elderly —-and the not- so- frail elderly, as well —and very dangerous for all elderly/disabled Medicare/Medicaid patients who might exceed the Diagnosis Related Group Caps because they have suffered hospital complications —and especially when these complications are NOT reimbursed by Medicare/Me4dicaid/private insurance because they are “adverse” events that are NOT reimbursed under CMS Reimbursement protocols.

    The frail elderly and all elderly/disabled on Medicare/Medicaid are doubly endangered because THEN they might be denied any further life-extending treatment by the hospital by means of covert unilateral or overt(default) DNR Code Status that is then misapplied to limit or withhold further life-extending hospital treatment. The elderly patient then either dies prematurely or is referred to Hospice by the hospital if they survive.

    (You must know that HOSPICE is now an ELECTIVE. Patients cannot be forced onto Hospice under current Medicare Law, but it appears that CMS intends to change the law, if the 2014 Trial is successful, so that Hospice will no longer be an elective and will be the end result of curative care.)

    But, of course, if the elderly/disabled on Medicare/Medicaid and in residential Nursing Homes or in their own residences do break bones and are in pain and are running high temperatures from infections and become dehydrated, etc.. and don’t respond to antibiotics, they have to be hospitalized if they want to live, don’t they?

    The reimbursement protocols of Medicare/Medicaid and the somewhat obvious targeting of the elderly/disabled on Medicare/Medicaid to achieve end-of-life savings for CMS and private insurance do render hospitals to be very unsafe places for Medicare/Medicaid patients.

    What do you suggest? Do we need Geriatric Hospital Wards wherein frail old patients who want to live will be given the indicated curative care until they can return safely to their custodial care?

    Or what? Surely! you are not in agreement with the hastening of death of elderly frail Medicare patients who will die if they are not hospitalized but who don’t yet want to die, and want to live as long as possible.

    I agree, of course that the elderly frail patient should be told about the Hospice entitlement and palliative care and shouldn’t be subjected to non beneficial aggressive treatments —that may or may not be reimbursed under CMS Reimbursement protocols.

    No easy solutions. But! as you appear to say in your other Article “Pulling the Plug on DNR” and in this article, it is time to make some changes to protect the elderly/disabled on Medicare/Medicaid who have paid into Medicare/Social Security all of their working lives and who deserve to be put first, for a change.

    The Hastings Center has the power to ask The Congress or the Executive to stop the passive euthanasia of the elderly/disabled on Medicare/Medicaid that is now a reality by clarifying the goals of the 1991 Patient Self Determination Act.

    Isn’t this a problem that can be solved right now?

    • daphne lawton

      Hospitals DO have death panels that push vulnerable seniors to “palliative care”, which is actually a euphemism for murder. My husband had cardiac arrest in a hospital and was revived, but within MINUTES the hospital harassed me to kill him off. I also recall that there were “clerical” types roaming the ICU trying to “counsel” me to kill off my husband. He eventually died of a second CA, but that could have been prevented if the hospital had implanted a defibrillator, but they never mentioned that possibility to me.

    • Lori Smith

      The Hospitals have formed “High Risk” Committees to target frequent flyers in efforts to reduce readmit rates. My Mother was a victim. I’ve worked in healthcare for 20+ years & I can’t believe this happened. 66 years old, Mild CHF, obstructive sleep apnea, fibromyalgia, depression & IDDM. The Hospital recommended hospice, she didn’t qualify as her risk for mortality was very low according to her records from days earlier. She did sign on for palliative care because they told her they help manage her breathing & fibromyalgia pain. They began Roxinol (Morphine) every 2 hours, Ativan TID & OxyContin BID. Less than a month later my Mother was readmitted to the same hospital where they increased the Morphine to every hour via IV. My Mother passed 14 hours later from what I’m sure was Morphine toxicity. Of course the hospital denied us our autopsy request. This was their answer to readmit reductions. I want to do all I can to make sure this doesn’t happen to anyone else.

      • Daphne Lawton

        Please google Novus Hospice, Frisco TX if you don’t think this form of MURDER is common. In the Novus case,the hospice director actually texted nurses instructing them to kill patients.

    • Ricardo

      I’ve had enough of life- I’m ready to go. I’ve had a good life, I know my chridlen worry about me and I want to be done now, it’s only my body being maintained. I felt awful as I encouraged her to have another bite of her mush called lunch. I’ve written to St Michael (the patron St of death) she said, and the bugger he hasn’t answered me yet. I responded by saying, is this something you talk to your sons about? Oh yes, she replied , I’ve asked them if they know any gangsters! .Obviously Mary had a wonderful sense of humor but her point was made, longer is not necessarily better and frankly, quite often it’s worse. Wouldn’t you rather live 3 months in peace (hopefully in your own home) then 3 years in a facility, existing?? I’m only suggesting that we start talking about having a choice. For all of our sakes, something needs to change. So lets start talking. Thank you for giving us a platform Dr Sloan, for getting this important ball rolling.

  2. Steve Moffic

    Dr. Gillick, reading between the lines, it seems like there may be a fair amount of anxiety in the elderly (and likely families, and even physicians) concerning physical worsening and approaching death that is connected to the desire for hospitalizations. If so, how much are psychiatric social workers, psychiatric nurse practitioners, psychologists, or psychiatrists involved in the situations you describe, both in and out of the hospital? I would have the same question about the involvement of pastoral care.

    -Steve Moffic

  3. Carol Eblen

    There is certainly terrible anxiety for elderly Medicare patients and their loved ones when they discover that the physician and hospital that they trust with their lives are willing to hasten their deaths without their informed consent for fiscal and personal expediency —-and not because of medical futility.

    It was my experience that the hospital USED the Chaplain and the Nurse to attempt to get my husband to state to her and those present in his hospital room that he would NOT want to be resuscitated if he had a heart attack during surgery, i.e. a tracheotomy. To her chagrin, my husband answered the question as to resuscitation with a whisper “of course, I would.” ( When the covert DNR Code Status was discovered and overcome and my husband survived the tracheotomy, this Chaplain never again in the weeks following visited my husband and me in this hospital room.)

    But, of course, this lack of consent hadn’t stopped the nurse from following the orders of the treating physician to place a Do Not Resuscitate Order in my husband’s chart.

    So much for “pastoral help” —Chaplains are Agents of the Hospital and not Agents of God when they attempt to elicit statements from elderly patients that will permit the hospital to place DNR Code Status in the Hospital Chart—aren’t they?

  4. Carol Eblen

    I find it shocking, appalling, and sickening that the Bioethicists have not warned the elderly/disabled on Medicare and Medicaid about the dangers that they face in their local public hospitals when they become the victims of “adverse” events that are not reimbursed to the hospitals under Medicare reimbursement protocols.

    The Hastings Center must realize that the epidemic of unilateral covert and overt(default) DNR code status is a direct response by the hospitals to the reimbursement protocols of Medicare since 2006 when “pay for performance” was first introduced into the Medicare system.

    Why was there no law passed in the Congress at the same time that would require notification to Medicare/Medicaid patients that their government insurance was not paying for their hospital care because of an “adverse” event? How can this lack of notice to patients by either the physician, the hospital, or the Medicare Administrators be justified? .

    Who is watching the store for the elderly/disabled on Medicare who pay Social Security Taxes and Medicare Taxes all of their working lives and who are forced onto Medicare at 65?

    No wonder that neither political party will “tell” on the other and this injustice has remained under the radar of public scrutiny.

    Really unforgiveable!

    • daphne lawton

      Completely agree with Carol. The death panel yuppies expressed disapproval of my being “emotional” about my husband’s life.

  5. Frances L Garcia,MD

    I can certainly identify with Carol Eblen and her experience concerning her husband. When my mother, morbidly obese with pulmonary fibrosis and diabetes developed pneumonia at age 87, she was admitted to the MICU and placed on a ventilator. The chaplain attempted to convince me and my siblings to sign a DNR for my mother.If we had signed, she would have been transferred to the general floor for further care. Not only that, they were pressing to discontinue the mechanical ventilator and so allow her to die. Mom actually survived this episode. She died a few years latter at 89. For our family this was actually young!
    It is inconceivable to me that Medicare has taken these steps, with the full knowledge that the patients will bear the brunt of the consequences. We are people who have paid taxes for Medicare all our working lives and continue to pay taxes on social security “benefits”. We deserve better!