When you visit a doctor's office, hospital or nursing home, what determines the type of care you receive? That's the question Muriel Gillick, M.D., professor of population medicine at Harvard Medical School, explores in "Old and Sick in America: The Journey Through the Health Care System" (University of North Carolina Press, $30).
All too often, Gillick argues, treatment decisions reflect the priorities of doctors, hospitals, pharmaceutical companies and Medicare -- not patients' best interests. In this edited conversation, Gillick talks about how patients and their families can get better care.
Q: What are the biggest ways that medical care for older patients is falling short?
A: I see the biggest problems for the sickest people -- people we call frail, who have multiple chronic illnesses and have difficulty being independent. Our system is not well designed to handle those people.
Q: Why is that?
A: Often what people who are frail need is coordination of care -- what's called high touch rather than high tech care. But our system is designed to provide technologically intensive, hospital-based care, and that's often not what's in the best interest of this group of people.
Q: How can older patients find higher-quality care?
A: For someone who is frail and has multiple chronic conditions, a good place to start is to have a geriatrically oriented primary-care physician. [He or she] doesn't have to be a board-certified geriatrician but someone who has expertise and interest in older people with complex diseases. One way you can figure out if they have that interest is if they have a nurse practitioner and social workers working with them to coordinate care and deal with all these aspects of illness. And ask for a geriatric assessment if you feel that the doctor isn't addressing a lot of the problems you or a family member is experiencing.
Q: What is a comprehensive geriatric assessment, and what should patients expect from it?
A: In addition to thinking about specific diseases in a conventional medical way, it looks at people's functioning. Can you get out of a chair by yourself, bathe yourself, navigate the hall, take a bus or call for a cab? And what interventions might make it feasible for you to do those things? Would a cane, a walker or a device to make your telephone louder help? Another part of a geriatric assessment is looking at cognitive ability. It's important to look at mobility, function and cognition, and put them all together.
Q: Let's talk about the hospital. You write about certain experiences, such as being on a ventilator, that may be burdensome for patients and best avoided if they're not likely to provide a benefit. What's your advice to patients on avoiding unwanted treatments or procedures in the hospital?
A: I'm not talking about depriving people of things that are likely to be helpful or that they may genuinely desire, but for a lot of people, particularly with advanced conditions, the degree of benefit for some of these more-invasive procedures is likely to be small and the degree of suffering may be great. Ask, "What good will this do me? Why are you proposing this test? What is the alternative? What are the risks of this procedure?"
At a more general level, advance care planning is a useful approach. Ideally before you get to the hospital, talk about the big picture of your illness and what your overall goals are.
Q: What's your advice for patients and their families on evaluating skilled-nursing facilities?
A: There are ratings; Nursing Home Compare is one that Medicare provides. Word of mouth is still a very potent source of information. And accessibility for family members is very important. If you're looking at two places that have comparable care, it's really important for it to be someplace family and friends can visit.
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