Monday, 11 July 2016

What CGA means to me

It worries me when someone talks about 'doing a CGA.' I shy away from CGA evangelism, but comprehensive geriatric assessment is the cornerstone of geriatric practice. Put as simply as I can manage, CGA is the holistic assessment of a patient, to capture all the issues that may be affecting a patient. Done well, it should cover medical, psychological, social and functional domains, creating a detailed picture which helps to explain the presentation of the patient at that moment.

Simple to understand, difficult to implement.

One of the tricks of geriatric medicine is to make sensible treatment decisions for the patient you are dealing. Achieving 'sensible' relies on having a clear picture of what that person is like when they are not ill, and not in hospital.

Admission to hospital is a cognitive stress-test, which usually takes place in the context of the physiological stress-test of acute illness. Often, the patient in front of you is far from the person they usually are. Imagining your way to that person in their routine is like foraging through a thick forest, looking for clues. The risk is significant: underestimate their usual level of function and deny them treatment that might be effective because we think they are too frail; overestimate them, and subject them to futile, disorientating care that offers them little utility.

I wrestle with the challenge of knowing my patients. I also wrestle with the concept of a CGA done in an acute crisis. It yields important information, but it yields it too late, and often incompletely. Too often it tells me too little about the recent narrative of that patient's life, the trajectory they have been on, and if offers them too little opportunity to take part in planning their care.

Serving a frail, elderly patient well asks that you involve them in their care, that your practice is influenced by their preferences, their style and their goals. These all vary hugely, and practicing geriatrics only one way means expecting your patients to all fit in with your judgments, preferences and biases. This is a certain way of ensuring that you partially serve most of your patients.

In the world of community geriatrics that I circulate in, we have been building services that aim to manage patients holistically, gently and responsively over time. The cornerstone of our adapted services has been the recognition that almost all of our frail, elderly patients are known well to at least one community service. Over time, these services, and key people within them understand in some detail what that patient deals with, what they are looking to achieve, and what they want to achieve from future care as they become more frail.

We base our conversations about how we help patients through periods of crisis or deterioration on the information provided by the person who knows them best. We develop our input around what we have learned about them from their previous care. It is an approach that requires carefully nurtured team cultures that encourage participation from staff of all roles, and it is an approach that demands significant investment of time, to allow for conversations that often swirl and circulate before you are able to focus in on the key issues that have been identified.

What we have yet to achieve is a system in which every routine assessment contributes to a centrally collated CGA, built up over time, and from every healthcare interaction, to which any relevant health professional can refer when they meet a patient. Some people call these care plans - I like to think of it in the narrative sense.

I am working towards a world in which CGAs are not done, but continuously honed. I look forward to a world in which every interaction with an elderly patient is treated as an opportunity to contribute to care when they get sicker or frailer; in which a crisis is just another chapter in the process of caring for frail, elderly patients. We should be able to leverage the opportunity offered by electronic records to collate this information automatically.

The goal is this: whenever a patient presents with an acute illness or crisis, their admission should be underpinned by an holistic care plan, built up over time, honed at every opportunity and able to support critical decision-making at any time.

My great frustration with acute geriatrics before I moved to the community was that I would spend time helping patients recover from their illnesses, understand how their diseases responded to treatment, and then have nothing to do with them until they became sick again.

After three years working in the community, I am much closer to understanding how holistic geriatric care could work effectively in the modern health system. And it's not as far away as you might think it is. 

Tuesday, 5 July 2016

Modern rituals.

Life has a lot of rituals. From the way we organise child-birth, to the day we die, our lives are marked in the stage-posts of periodic rituals. My little girl is due to start school in September, and even that has the hallmarks of a ritual. From the care-free playful days of her first four years, she will embark on a routine that starts to embed in her an understanding of the way that our world works. She will make friends (hopefully), she will learn to read and write. She will take exams - one of my favourite rituals of all.

Perhaps I am being too liberal with the word 'ritual'. Our lives are not governed in the way they once were by religion. That is not true everywhere, but here in the UK, religious practice is a matter of personal choice, rather than compulsory observation. Ritual has become secularised, which is not without its pitfalls.

I see evidence of secular ritualism all over the place, from humanist naming ceremonies, to football matches, summer festivals, graduation, even Christmas. Who can still argue that Christmas remains a primarily religious celebration?

I like rituals. They give us context, grounding and perspective. But primarily, they must have purpose. A good ritual allows us to appreciate where we stand in the world, where we have come from, and where we are going. It is a piece of community history, that encapsulates the learning of the past for the benefit of future generations.

Baptisms introduce a new child into their families and communities. Weddings celebrate the bonding of a couple. Funerals organise the grief over a lost friend or relative. It is always good to forge one's own path, but it is also important to understand from whence you came.

Yet, the ebbing away of religious practice from wider communities has left a big gap in how we deal with death. Today, over half of people die in hospital, yet only 8% want to. The majority would prefer to die at home.

At first glance this appears to be a fundamental failure of the health service to adapt appropriately to the needs of the people it serves; but hold your counsel for just a moment. How many of those people who were asked were actively dying at the time they were asked? I suspect not many.

I have supported a great many people in their final days, and done well, it can be a serene and valuable experience. Many of my patients were ready to die, and tired of life. Yet many were understandably scared and lonely. I try to advise families not to keep vigil, but to keep loving in those final days and hours. To talk, to hold hands, to give space and quiet. I have encouraged them to enjoy final lucid moments, to look out for signs of distress that we can help with, but more importantly to talk openly, honestly and candidly about what is happening, and to take a final chance to say the things they won't ever have a chance to say again.

And sometimes, to me, it feels a little absurd that it is I, a physician in his 30s, who is giving advice to families about how to deal with the process of seeing a loved one die. I never really thought I would become an expert in dying, even as a geriatrician, but then again, who else has the chance to become expert?

Patients often come into one of my community hospitals for palliative care, and we are glad to have them. We are pleased to be able to help. The nurses I work with offer the kind of care I wish everyone could have. With a calm, compassionate simplicity, they tend these patients compassionately, and allow the patients and their families to focus on the things that are important to them.

Many of these patients arrive having had a fraught time at home. Often they are desperate to be at home, and their relatives are desperate to support them. But the challenge of meeting the care needs of some very frail relative, often in pain, or with other symptoms can be overwhelming and incredibly stressful. It is also entirely unfamiliar. What is normal when someone is dying? How do you know what to expect?

Many of us, I suspect have never seen someone die, or even seen a dead person. I remember clearly the first time I was present at the very moment of death. You can tell instantly, and you start to understand why we used to believe in a spirit leaving a body, because that is exactly what it looks like.

It used to be the case that many people died young, or the elderly died at home. It used to happen all the time. Within communities, it was something that most people had experienced.
Vestiges of the past still live on through our hospital chaplains, who minister our patients with grace, calm and compassion. It is through our local vicars that some of this community expertise lives on. The double-edge of the success of modern medicine is that these routine occurrences have passed out of the collective experience. End of life care has been outsourced to hospitals, which means that when it does happen at home, it can be a scary experience for all involved, because there is too little access to people who know how it all works.

Much of the comfort that patients and relatives get from dying in one of my community hospitals is from being surrounded by staff who can help them know what to expect; people who will tend to routine care that is important, so that they can enjoy some tender last moments, without the pressure of attending to basic needs.

Perhaps this was a ritual that we used to have the community expertise to do at home. Perhaps it's something that we still have the expertise to do at home. What I know is that for some patients, being cared for in a calm, expert environment that isn't their home, is often the right thing to do.