Ten things everyone should know about geriatric medicine.
High level care does not mean bed bound and demented beyond humanity. Often it can mean doubly incontinent but completely with it and social and happy. If you receive a patient “from HLCNH” this is not license to immediately turf them back because you’ve made the above assumption. You must ask why they are in this level of care before you decide.
If you can’t quite tell if someone is delirious, before you do that B12/folate/TSH arrangement, try download and print out a CAM or a 4AT. Both are four short questions which will help you.
Nursing homes aren’t called nursing homes anymore. They’re called “Aged Care Facilities”. Why? because it’s misleading to call a facility a nursing home when there’s no nurses. There’s ‘carers’. And maybe one RN to give out the medications. Nursing homes are not like mini hospitals. There is no inprest. There is no bladder scanner. Sending people back there with drains and medications that need dual signatures will score them a trip back to hospital.
You don’t have to get the not-for-CPR form signed on the first phone call but it’s good to ask anyway because advanced care planning is a process and family members need time to think it through and have lots of discussions. Initiate the discussion.
Elderly patients can have acute abdomens too. They might not be able to tell you where the pain is but it is up to you to think of it and if you suspect it and can’t rule it out with the history, rule it out with the CT scanner. Non-con will still show a mass.
Pneumonia and antibiotics WILL send the INR sky high.
Listen to the family. Listen to the family. Listen to the family.
If a nursing home can’t give the palliative medications overnight, and you don’t want to get the on-call pharmacist in to dispense them, don’t discharge them. Not only is it obviously cruel, but it’s also illegal to deny a patient palliative care and it could be career-ending for you.
An inappropriate investigation in this cohort is one that will cause harm. Most of them don’t. And while it may not change your management, the family sure do like to know what has caused their dearly loved mother to start to die. It’s called closure. Obviously don’t do a PET scan but it’s okay to investigate even when it seems futile. Never use the word futile out loud.
Listen to the family. Even if they seem unreasonable and ‘demanding’. There is no greater power than love. It drives people to madness. Listen to them, try to accommodate them, take a deep breath and be patient. And when they say “something is wrong”, find that something because 99% of the time they’re right.