Second Opinion: ‘Bed-blockers’ begone: vulnerable patients need diagnosis, not dismissive terms

Society must become less gerontologically illiterate if old people are to get proper care, says Des O’Neill

One of the lasting legacies of the scabrous yet deeply entertaining Viz magazine is Roger's Profanisaurus, a predictably naughty take on Roget's Thesaurus. Following my last column on the unsuitability of "step-down" care for the complex needs of older people, I was disturbed in the interim to find not only the Irish Nurses and Midwives' Organisation but also the Alzheimer's Society of Ireland calling for more step-down.

So, following the lead of the current president of the British Geriatrics Society, the highly literate and entertaining David Oliver – see iti.ms/166DxIC – it is clearly time that we in Ireland developed a profanisaurus of ageing, highlighting the negativity of certain words and phrases, rooted in ageism and indifference to the needs of older people, and avoiding their use.

After “step-down”, there are a host of candidates jostling for a place in the Profanisaurus, starting with the terrible twins of “bed-blockers” and “delayed discharges”. Spawned from the same bedrock of the adversarial patient management system as “step-down”, these phrases imply action or inaction on the part of vulnerable patients and their families that prevent access to healthcare services for others.

In fact, the fault usually arises out of a series of system failures rather than failures by patients, including non-detection of complex illnesses, loss of function at entry to emergency departments, non-prioritisation of admissions and failure to provide due rehabilitation and support both during a hospital stay and afterwards, whether at home or in a nursing home.

READ MORE

Classifying patients

All too often, doctors and nurses collude with this unhappy state of affairs by classifying patients (in further Profanisaurus terms) as “fit for discharge” or, worse still, “medically discharged”. While what they usually mean is that a specific input or treatment course may no longer be needed, this is unfortunate at two levels.

First, it is a complete misreading of the challenging nature of the hospital experience. Virtually anyone who can leave to get back to their own home, no matter how humble, will do so as soon as possible.

Second, it is a derogation of the broader duty of medical care above and beyond specific medical and surgical procedures. For example, if Mrs Murphy was continent, mobile and clear in her mind before admission, and is now impaired in all three areas, there are clearly medical and care issues that remain to be addressed through diagnosis, treatment, rehabilitation and support.

Equally, the lack of appropriate post-discharge support and rehabilitation or long-term care facilities (an unreleased Prospectus report for the Health Service Executive in 2006 showed glaring deficits in the provision of nursing-home places in urban areas) is the fault of the system, not of vulnerable older people. A more appropriate phrase might be “discharge support failure”.

Profanisaurus phrases

Further Profanisaurus phrases include those still occasionally encountered on admission to hospital, when, for example, a patient is labelled a “social admission” or diagnosed with “acopia” (not coping). These again display a debilitating lack of understanding of how disease in later life manifests itself through loss of function – immobility, incontinence, falls, and so on – which requires both social and medical intervention and support.

An exacerbation of such illness(es) may compromise the ability to manage at home, and requires skilful diagnosis and treatment, not dismissive terminology. The great geriatrician Bernard Isaacs wrote that behind every social admission is an undiagnosed illness. Indeed, in common with other geriatricians, I have found undiagnosed cancer, fractures, drug intoxication and neurological conditions, such as Parkinson’s disease, in these cases.

“Acopia” in this context also suggests failure on the part of a patient and family rather than empathy with the challenges of managing, and caring for, a life of complex illnesses and frailty. From the perspective of geriatricians, the use of the term acopia indicates a doctor who does not know how to recognise and manage frailty, a key clinical concept in modern healthcare of older people.

At the heart of such profane terms is gerontological illiteracy, which seems to extend disturbingly far into areas of professional practice and, occasionally, advocacy. The recent outcry and subsequent apology by Benedict Cumberbatch over inappropriate terminology for ethnicity indicates that we have developed a sensitivity to the power of words in such areas.

Given that most of us, too, will be fortunate enough to live into old age, we all have an interest in developing a similar sensitivity about describing our needs in later life – and eventually render our Profanisaurus of ageing redundant.

Des O’Neill is a consultant physician in geriatric and stroke medicine, and professor in medical gerontology at Tallaght hospital and the Trinity Centre for Health Sciences in Dublin.

He blogs at iti.ms/166DZXu

Twitter: @Age_Matters