{"id":31390,"date":"2014-04-16T15:56:36","date_gmt":"2014-04-16T14:56:36","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=31390"},"modified":"2014-11-11T17:36:50","modified_gmt":"2014-11-11T16:36:50","slug":"david-oliver-how-real-life-stories-can-help-us-understand-the-challenges-of-care-for-older-people","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2014\/04\/16\/david-oliver-how-real-life-stories-can-help-us-understand-the-challenges-of-care-for-older-people\/","title":{"rendered":"David Oliver: How real life stories can help us understand the challenges of care for older people"},"content":{"rendered":"

\"david_oliver\"<\/a>On television we can often tell more from peoples\u2019 words or reactions than from any scripted voiceover. In \u201cProtecting our Parents\u201d\u2014a three part BBC 2 documentary, due to be screened on 17 April, this holds very true.<\/p>\n

Our society is often afraid to face up to the realities of old age, and a youth fixated broadcast media compounds this. Yet here, we have a moving, thought provoking, and beautifully constructed series, courageous enough to highlight the dilemmas faced by those at the extremes of age and frailty, and when confronted with life changing decisions at the interfaces between remaining at home, being in hospital, or requiring long term care and support. The light touch used by the programme\u2019s makers allows us to draw our own conclusions rather than be steered, and to appreciate that these dilemmas come in many shades of grey and have no perfect solution or neat resolution. The cases are entirely typical of the work many of us do day in day out in frontline services.<\/p>\n

The films give equal weight to the voices of the older people, their spouses and relations, and the professional staff trying heroically to support them at such difficult transitions. The decisions are fraught with risks, benefits, and regrets, whichever road is taken. In many cases, the outcome which would make people happy is undeliverable in our current systems\u2014from the older person\u2019s health not deteriorating in the first place, to a couple being able to stay together or remain safely at home with seamless 24 hour responsive services to support this.<\/p>\n

In episode one, we follow three older people, all admitted to Heartlands Hospital following falls at home. Betty, a widow \u201cbut not ready to join my husband just yet\u201d is on-the-ball, clear about her wish to get back to the home she has lived in for years, but equally clear that she doesn\u2019t want professionals de-cluttering it of much-loved possessions to make it \u201csafer.\u201d Jim\u2014already suffering from severe dementia lost his wife just before his admission. She was compensating for his illness and helping him stay put, but on discharge, he would be living alone for the first time in his life. Finally, there is Henry\u2014a proud and dignified man whose wife died three years ago. He becomes unwell with pneumonia just as his (admittedly precarious) discharge home is being planned. Episode two concerns an utterly devoted couple\u2014Kathleen and Leonard, married for 60 years, and whose whole reason for living, in the face of increasing ill health, is one another. She sleeps in her hospital bed, reliant on a care package, and Len sleeps on the living room sofa to be with her. She phones 999 several times each month\u2014not usually for high tech paramedic responses, but for reassurance and low grade support of a type and frequency which statutory social care just can\u2019t deliver. This costs money and diverts ambulance crews from more urgent duties\u2014making the case precisely for more integrated health and social services. But how to differentiate one 999 call from another? We see Kathleen on two occasions acutely admitted with severe respiratory infections. Len doesn\u2019t last long without her and twice ends up in the same hospital soon afterwards. They have a son who visits when he can, Betty has a caring and involved niece, and both Jim and Henry have children. All are committed to helping their loved ones exercise choice and remain independent, while also equally worried about risks to their welfare. Their concern is etched on their faces. No narration is required.<\/p>\n

So back to what the participants say on camera. These quotes give a flavour.<\/p>\n

Peter Wallis, a wise and caring geriatrician points out that Betty is, \u201clucid and capable of taking risks\u201d though her equally caring niece, Rhonda, referring to Betty\u2019s existence in a cluttered house, unable to manage the stairs, sleeping in a kitchen which she often risks setting on fire says, \u201cyou wouldn\u2019t let a dog live like that.\u201d Whereas Betty herself, expressing her desire to get back home points out that \u201cthe house isn\u2019t what it was twenty years ago I admit, but it\u2019s still home, they are my things and I don\u2019t want anyone else touching them.\u201d Dr Wallis goes on \u201cif they (patients) are here in hospital long enough, hospital complications will set in and they will lose ability to be at home so we have to strike a balance.\u201d Later, regarding Henry \u201cstaying in hospital leads to all kind of risks, but if he had gone home there would have been a range of others.\u201d<\/p>\n

Ultimately, Betty accepts some help and moves temporarily to a nursing home while her house is cleaned and adapted. Surprisingly, she settles there, likes her room, and jokes with staff that \u201cI might be here for longer than you thought.\u201d Jim does leave hospital, but returns to a home he has never lived in without his wife and a one-room triangle of bed, chair, and commode, with the \u201ccouncil maximum\u201d of four short care visits a day, punctuating hours of loneliness. He deteriorates rapidly and is soon re-admitted. Henry, a proud man, who says that \u201cthey treat you like kids, trying to do everything for you\u201d is on the point of getting back home with the full support of his children and the staff (despite their concerns that it could go wrong) when he develops pneumonia and dies in hospital, his family around him.<\/p>\n

Kathleen and Leonard? Well they are eventually supported in their wish to remain together and in their own home, despite staff trying hard to persuade them to move to a care home together. Kathleen makes a further 38 calls to 999 in the following six weeks.<\/p>\n

These shows are a credit to the makers and to all who feature. They provide a moving human insight into the realities of modern health and social care\u2014whose core business is increasingly the care of our oldest old\u2014and the need radically to transform our service models to make them fit for our ageing population. It\u2019s an insight that no amount of worthy academic papers or policy documents could match. And it\u2019s the first time I have seen a programme which showed those outside of geriatric medicine what it is that we do all day. Most geriatricians are dually certified in acute general internal medicine for non-frail and younger patients. And we know which branch is more complex, more nuanced, and requires a more holistic approach.<\/p>\n

Competing interests: None declared.<\/em><\/p>\n

David Oliver<\/strong>, consultant geriatrician, visiting fellow at The King\u2019s Fund, and president elect of the British Geriatrics Society.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

On television we can often tell more from peoples\u2019 words or reactions than from any scripted voiceover. In \u201cProtecting our Parents\u201d\u2014a three part BBC 2 documentary, due to be screened […]<\/p>\n

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