“She’s 95.”
I know her age. I’ve seen her several times over the last few weeks – each time for something minor. Exacerbation of asthma. Mild cellulitis. Just last week I visited her to make sure a small leg wound was healing. I spent almost an hour with her, laughing and chatting. She told me she was going out to the club for lunch on Friday. She was really looking forward to her weekly outing. The only thing that troubled her was ‘that damn fluid pill’ – she refused to take it on Friday mornings because it interfered with her enjoyment of the visit to club. She just didn’t trust herself to get to the bathroom on time in a public place.
We joked about putting a catheter in just for Fridays, so she could still take her medicine and not interupt the lunch. She said it would be too obvious if she wore a skirt, so it probably wasn’t a good idea. We agreed that she could take the tablet when she returned, rather than with breakfast. There was definitely nothing wrong with her sense of humour.
“She’s 95.”
Today is different. This is not a minor problem.
Mild hip pain developed at the end of last week. Over the weekend it escalated, causing severe pain. One day she could walk independently with her wheelie walker and take herself to the bathroom. The next day she could not stand. Ambulance. Emergency Department. Attempt to scan. Too much pain, mission aborted, scan cancelled. Discharged.
“She’s 95.”
Yes, she has some chronic health problems, but if I hadn’t seen the evidence in writing on her medication chart, I would have guessed she was only in her mid 80s at best. Her mind is sharp. Her body is a little slower than she’d like, she gets breathless sometimes, but it doesn’t stop her from enjoying life. She participates in the activities. Goes out. Maintains some independence.
She describes the pain. Sharp, shooting, grabbing. It travels from her lower back through the buttock to the hip, then down the thigh to the leg. The slightest movement is excruciating. A quick neurological exam – she cannot move her toes. No reflexes in both legs or feet. Cannot feel painful stimuli. A very full bladder, and an inability to void.
She is frustrated, angry. Wants to know how this could suddenly occur, and whether it can be fixed. She doesn’t want to be bed-bound and dependent on others. Friday is only 4 days away, and she can’t miss going to the club.
Her GP and I agree that we really need a scan so that we know what we are dealing with, and how best to manage her pain. Putting a catheter in to empty her bladder and sending her back to the emergency department for investigations seems to be the best option to get the answers we need. The longer we delay, the higher the risk that she could have irreversible damage, which would hugely impact her quality of life. We agree that I will speak with the ED admitting doctor, and facilitate the transfer.
“She’s 95“.
The words seem to echo. They have been repeated over and over during the course of the conversation. I’ve done my best to present her case – starting with the history of the presenting condition, her background, usual level of functioning, my assessment findings, and the request for ED assessment and diagnostic imaging.
“She’s 95“, the ED physician keeps repeating.
“Nothing is reversible at her age. She’ll get a delirium. Sending her to hospital is cruel. She should just be kept comfortable. She’s not suitable for investigations. Not suitable for surgery. Not suitable for radiotherapy.”
Not suitable for….anything.
I’m struggling to stay calm and professional. She’s a good 95! Until four days ago, her quality of life was good. I am a strong advocate for avoiding hospital transfers if the risks outweigh the benefit, and as a palliative care nurse practitioner I have many years of experience ‘keeping people comfortable’. I politely and firmly continue to advocate for her. If it turns out to be a pathological fracture with cord compression, then perhaps radiotherapy would be the best form of pain relief. Age should not be a barrier to investigating this sudden acute problem.
“She’s 95.”
I have been firmly put in my place. Told not to call an ambulance and that the ED would not be accepting her. Told to liaise with her GP and keep her comfortable. Basically, I’ve been told that if you are 95, you don’t deserve to access health care in hospital. You don’t deserve answers. You don’t deserve treatment.
I am shocked to my core. I can barely speak. I am angry.
But why am I surprised?
Ageism in healthcare is not new. Elderly patients and carers say age discrimination in NSW hospitals is real and heartbreaking. Older people are made to feel that their healthcare is a waste of resources. In the recent world-wide pandemic, there has been abandonment and resultant deaths of older people in long term or aged care facilities, and ongoing debates about the ethicality of refusing care and life‐saving support to older individuals diagnosed with COVID‐19. Some hospital clinicians argued for a blanket policy that people from residential aged care facilities be denied access to emergency department transfers and hospital admissions to conserve resources for those younger and fitter and more likely to survive.
There is concern that the ageing population will put unsustainable pressure on public spending, with a focus on rising health costs and whether the health system will be able to serve the increasing numbers of older people needing care. A 2020 systematic review found that practitioners were apt to make clinical decisions that limited patients’ access to care based on patients’ age rather than their health needs, and demonstrates the pernicious reach of ageism. Ageism affects older people’s access to preventative and curative interventions – so much so that one Australian university now offers a short course which addresses pervasive ageism in the health and aged care sectors.
“She’s 95.”
My service is a”hospital avoidance” outreach service, and I do my best to prevent hospital admissions when it is appropriate and in the person’s best interest to do so – but this case is different. She isn’t dying – not even close. I ask myself the surprise question. While I wouldn’t be suprised if she died in the next 12 months, I would be suprised if she died in the next 6 months.
Whatever time she has left, it will be totally miserable if she is bed-bound due to paralysis and pain. She should still be entitled to access the health care and services she needs that are appropriate to her physical, mental, emotional and social needs and which contribute to her quality of life and general wellbeing (COTA).
After all, she’s only 95.