When I spoke recently with a group of senior citizens, the most common refrain as they recounted terrible tragedies — typically, the needless death of a spouse at the hands of the health care system — was, “That’s health care. There’s nothing anybody can do about it.” This fatalistic assumption that nothing can be done to change the outcome can become a self-fulfilling prophecy.
June 30, 2010
June 29, 2010
Realize that you can break out of the Greek tragedy mold — you can often get better results from health care by taking an active role. A feature of Greek tragedies is a chorus that chants, in effect, “A terrible tragedy is about to befall us,” and then it does. It doesn’t have to be that way. My new book Killer Cure: Why health care is the second leading cause of death in America and how to ensure that it’s not yours offers a toolkit to help you.
June 28, 2010
Myth or fact: health care causes so many problems, it’s best just to avoid it at all costs.
Fact: Avoiding all health care isn’t an effective approach to dealing with its problems. For one reason, sometimes injuries or illnesses occur even in people who take excellent care of themselves — if you are in an automobile accident, you still need a cast put on your broken arm even if you always eat your vegetables. If your approach is to avoid health care, you may be spectacularly unprepared to deal with it when you or someone you care about ends up in the emergency room.
A typical Greek tragedy features “a heroic individual who is often overcome by the very obstacles he is struggling to remove.” (from The Free Dictionary online) Health care often looks like one big Greek tragedy.
June 25, 2010
One study showed that people who develop delirium during a hospital stay are 13x as likely to die in the hospital as equally sick people who don’t develop delirium. (Wes Ely, see 20 Jun Overview for attribution.)
So what’s going on here? What’s the root cause? In my opinion, the largely unrecognized epidemic of hospital-acquired delirium has a simple psychological error on the part of health care professionals at its root: patients are viewed as mechanical and chemical objects to whom mechanical and chemical treatments can be applied with little thought to the effects of those treatments on their minds.
When a mechanic changes the oil in a car, he doesn’t worry about the impact of that oil change on the car’s mind. The health care system tends to treat patients the same way. I suspect that when people are physically and chemically restrained — via ventilators, IV lines, in some cases wrist and ankle restraints, drugs like fentanyl (which, besides being used in ICUs, doubles as a drug “to incapacitate people in hostage situations” according to Princeton University’s WordNet) and midazolam — their minds make a break for it in an attempt to escape the confinement.
In the process, they often suffer terrible, violent hallucinations in which captivity, torture, and profoundly brutal, bloodthirsty opponents loom large. My take on it is that those hallucinations represent their minds’ interpretation of the hostage-like situation in which they find themselves, a situation in which they are physically and mentally almost paralyzed.
People in intensive care may be “receiving doses of sedatives, narcotics and anesthetics high enough to make even healthy people stop breathing on their own.” (Gina Kolata, see 22 Jun for attribution.) One doctor wondered whether the sedatives keeping patients comfortable might actually be making them worse. He “tried an experiment, waking patients briefly every day by turning off their infusion of sedatives. Not everyone approved. ‘People were concerned about waking patients every day, that that might put patients in a state of fear and dread and anxiety,’ he said. But, he added, ‘we found, to the contrary, that patients actually did better’ and even had a significantly lower rate of post-traumatic stress disorder.” (Kolata, as above.)
Note the assumption on the part of most care providers that people can simply be drugged into oblivion. It doesn’t work. Their minds don’t turn off. They struggle valiantly to escape the captivity — and they break.
June 24, 2010
June 23, 2010
“We would have to build 100 more floors” to treat all the people who develop delirium in the hospital. (Dr. Julie Moran, quoted in Belluck — see attribution in 20 Jun Overview.)
June 22, 2010
If someone you care about is hospitalized, ask that they be formally assessed for delirium several times a day (most delirium is overlooked, and assessment takes only about 30 seconds (see Wes Ely, attribution in 21 Jun Overview) and be assertive about trying to prevent delirium from arising.
Steps to prevent delirium include:
- Ask that doctors think twice before prescribing midazolam (tranquilizer) and/or fentanyl (narcotic analgesic). Midazolam use is “the strongest modificable predictor” that delirium will develop in a patient, and fentanyl is also a contributing factor, per Wes Ely.
- Ask that restraints be avoided if at all possible, and that mechanical devices that limit the patient’s free movement be avoided or removed at the earliest opportunity. About 50-80% of patients on ventilators develop delirium (Wes Ely); catheters, IV lines, etc. “can make patients feel trapped, leading to deliriuim.” (Belluck, see 21 Jun Overview for attribution.)
- Ask that the patient have ready access to their eyeglasses and hearing aids.
- Ask that lights be dimmed at night and that noise be minimized so that their sleep is not disrupted.
- Ask that they be assisted to get out of bed and move around as soon as possible. “Getting patients up and walking even though they are gravely ill, complete with feeding tubes, intravenous lines and tethers to ventilators . . . [leads them to] seem to recover faster, spending less time in intensive care and the hospital.” (Gina Kolata, “A Tactic to Cut I.C.U. Trauma: Get Patients Up,” New York Times, 12 Jan 2009.)
June 21, 2010
Myth or fact: It’s no big deal if the elderly get “confused” during a hospital stay. It’s temporary and doesn’t really matter.
Fact: After even short bouts of delirium, older patients are “placed in nursing homes 75 percent of the time, five times as often as those without delirium. Nearly one-tenth die within a month.” (Belluck, see Monday’s earlier entry below.)
Hospitalized patients, particularly the elderly, often lose touch with reality. Said another way, about one-third to two-thirds of older hospitalized patients become insane while in the hospital. They start hallucinating, and the hallucinations tend to be terrifying. Those who experience delirium end up much worse off than equally sick patients who don’t. That is, delirium often causes severe and permanent damage, even if people return to sanity later.
In this week’s blog, I discuss this issue. Primary sources include Pam Belluck, “Hallucinations in Hospital Pose Risk to the Elderly,” New York Times, 20 June 2010 and E. Wesley Ely, “ICU Delirium Epidemiology, Monitoring & Management,” Vanderbilt University, 2006