Sometimes the losses elders sustain occur in rapid-fire sequence, with little or no recovery time in between.1,6
It is no wonder that older adults, in one way or another, exhibit what we consider resistance to their changing lives. In terms of a hospitalization, this may mean saying “no” to medications, individual providers, tests, surgery, home-health visits, or something as small as being talked to or touched in what they perceive as a disturbing, overly familiar, or mechanized manner.
“Many patients are resistant to having people come into their homes and help them, and at the same time they are resistant to going to a skilled nursing care facility,” says Dr. Green, “and it has to do with their [feelings of the] loss of independence and control over their lives.”
“It’s very easy if you’re in medicine to normalize your context of the hospital,” says Solie. “In other words, the hospital seems familiar to you and you’re very comfortable moving around there, and mainly because you’re in control. You’re the doctor … and you move in the hospital in order to make things happen and you never feel all that threatened. But when you bring an older person who already has a heightened sensitivity toward losing control into the hospital—this complex, technological world of medicine—and they have the cumulative disadvantage of being sick,” says Solie, “it’s really important to remember that there will probably be no other state that they’ll be in, except maybe nursing home care, where they will feel so out of control.”
A good first step in communicating with older patients is to quickly develop a rapport with them and show them you recognize what they’re up against.7 “They really want to know whether or not I get it,” says Solie.
The way you communicate that you get it, he says, is fairly straightforward: When I’m first interacting with the patient, I say, “if you are like my [other] elderly patients … I’m sure you’re feeling a lot of anxiety over [not having much] control and, first of all, I want to assure you that I’m going to make sure you understand the choices and help you make all the decisions. And … I’m definitely going to … put everything in a language that you understand. But if I’m not successful, I’m going to employ someone from your family. We’re going to work together. Even though you’re hospitalized and even though you’re fighting this illness (or whatever the condition might be), you still [have] the right to make choices, and my goal is to partner with you. My expertise is medicine, but you have an expertise in your life.”
In other words, you are signaling that you recognize that control is the issue. Acknowledge the loss, ask about the value of the event or decision to the patient, ask what you can do to help them deal with their feelings or make up their minds. It also allows you to remind an older patient’s children that control is a big and normal concern for their mother or father.
Many people who are hospitalists—who are even in their late 20s, 30s, 40s—have been totally healthy their whole life, so it is hard to relate to what it’s like to be older and to be losing function, losing friends who are also dying, losing their house … it can be helpful for the hospitalist to take time and explore those issues [of loss and legacy].
—Eva Chittenden, MD
Hospitalists at a Different Time and Place
The elderly desperately need people who can serve them as natural healers, who are not constantly in a hurry, and who care what they are thinking and feeling. How can hospitalists relate to those who are in the midst of life review and who are hanging on to an escaping control? How can they serve their patients in a way that meets all needs?