Tuesday, 14 April 2015

Community Geriatrics: The Way In. Biography-Based Medicine

In the last blog I talked about the real nature of the challenge that faces community geriatrics: that of meeting the expressed and felt needs of the elderly, rather than their supposed or assumed needs. I talked about this in terms of biography, and I hope that I conveyed the sense that what is valuable to an elderly patient moves away from the objective to the phenomenological. The experience of being frail and elderly is something I can only appreciate vicariously. I have seen it hundreds or thousands of times, but I have never lived it; and while there are themes and commonalities, it is the differences between my patients that distinguishes them.

I recently told an elderly man that he had metastatic bowel cancer, involving his spine and liver. He painted me a context of that news, which took him back to reflections of his experiences of the 2nd World War in Burma. He recalled the men he’d left behind, who with him had endured very difficult conditions, but unlike him, hadn’t survived. Being told he had an incurable illness was of little moment to him, when every moment he had lived since 1945 felt like both a bonus and an undeserved privilege.

These are the narratives that frame the context in which we deliver care to the elderly. Where are they now, where have they been? The biography of the elderly sits at centre stage of our efforts to serve them well. It is our guide, and our obligation to them. Let’s call it biography-based medicine – medicine that fits poorly on protocols, medicine that urges you to understand deeply with whom you are dealing, and what it is that you can do to most faithfully serve them.

I still feel that I know my patients only superficially. There are moments when they let you in, and give you a real glimpse of what you can do for them. The challenge for creating conditions for their trust and confidence are the trickiest part of community geriatrics. It is the creation of these conditions that is one of the key challenges for a community team.

For a while I scratched my head about how to do this – but then a realisation crept in. The more I spoke to district nurses, community therapists and GPs, the more I realised that there already exist whole teams of people that know these patients well, and understand where they are in their lives. I heard vivid narratives of patients struggling on at home, and these teams struggling on to support them. These nurses and therapists are not just committed to their jobs, they are trusted by the patients they help, in relationships that have been forged and nurtured over time.

The more I listened, the more I realised that these teams were the way in. They have almost everything: skill, knowledge, commitment and the trust of patients. What they were lacking was the medical support to manage complexity, to deal with uncertainty, and to seek support rapidly and easily. My role started to become clear.

I have a running debate with a local practice manager. Her question to me is whether we know who all the frail and vulnerable patients are locally. I can’t yet give a definitive answer yet– we are still looking into that – but it is my sense that in a town like Bridport, it is rare for a frail, elderly patient in need of support and care not to be known to at least one of the health or social care services. I might be wrong, but I intend to find out. But if I am right, then it means that we have broad coverage of our local elderly patients, and the challenge is to ensure that if one of the teams notices a deterioration, or requires additional help in the management of a patient, then that help is easy to come by.

This is what we have been ramping up – the cross-support and co-ordination of community teams. We met every week to discuss our patients, and we coordinate our actions for the patients. It starts with the person who knows the patient best describing their situation, and continues with the team members clarifying, suggesting and offering actions to help the situation. Anyone can bring a patient up for discussion, and we keep the patient under review until we are happy that things are back on track. We discuss what to do in an emergency, we agree appropriate actions, and we follow it up.

It feels right, because it is based on a narrative of the patient from the team member who knows them best. It feels right because everyone who needs to be there is there, and we have a breadth of experience and expertise to call upon, from social services, safeguarding, GPs, nurses, therapists, and mental health services; there is an old-age psychiatrist, and of course, me.

Someone who came to the meeting told me that they thought it should be more structured. I could see their point, but I argued that too much structure can stifle. Not everyone in that room speaks the same form of descriptive narrative, and nor should they. What emerges from the description of the situation is an ever-more detailed picture, and it needs space to emerge.

What really matters is that these dedicated members of the team have the opportunity to enlist support with patients they know well, and that the team gives them the airtime to outline their concerns, in the context of the knowledge they have of the person. That’s the starting point from which everything else can follow.

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