Medical Matters: Go gently into the good night . . .

Is it getting harder to die at home? A strange question you might think, but one that is increasingly relevant in modern medicine.

With such a vast range of life-
saving interventions now available in hospital, the pressure to move older people with chronic debilitating illness such as a severe stroke or profound dementia from their home or nursing home when acute illness strikes is significant.

But sitting for hours or even days on a trolley in an emergency department can be frightening and uncomfortable for frail patients.

I am not for one minute advocating that they do not receive treatment. Much can be done for patients without moving them from the security of their “own place”.

Pneumonia, urinary tract infections and heart attacks can be treated at home.

Long list of illnesses
I recently looked after a 90-year-old woman who developed pneumonia. She has a long list of chronic illnesses which have reduced her mobility but she is still sharp mentally. About two and a half years ago she was hospitalised. The experience wasn't a good one.

Afterwards she told her daughter, whom she lives with, that she didn’t want to be an inpatient ever again. She gave me the same message. But last week the issue became a live one.

After five days of antibiotic treatment, her left-sided pneumonia was increasing in size. She was bed-bound and was having some difficulty breathing. She then became intermittently confused, her blood pressure dropped and her pulse became weak and thready.

Despite what had been said previously, I felt obliged to tell her that she probably needed hospital admission in order to receive intravenous antibiotics. Her answer was faint but clear: “I want to stay here at home no matter what happens.”

A final goodbye
So I changed her treatment to a different antibiotic and said what I reckoned was likely a final goodbye. As I drove home I reflected on Sir William Osler's view, uttered more than 100 years ago that pneumonia was a frequent, non-painful, lethal event in older patients.

He wrote: “Pneumonia may well be called the friend of the aged. Taken off by it in an acute, short, not often painful illness, the old man escapes those ‘cold gradations of decay’ so distressing to himself and to his friends .”

Ever since known as “the old man’s friend”, the person with pneumonia often lapses into a state of reduced consciousness, slipping peacefully away in their sleep, giving a dignified end to life. Or not. Some 24 hours later, my patient had unexpectedly turned a corner.

She was still quite ill, but her vital signs had improved. Within days the pneumonia was receding and she eventually got to sitting up and walking with assistance. As I write, she continues a slow but definite recovery.

No need for hospital
So you don't have to go to hospital to be treated for pneumonia. It remains the older man's (and woman's) friend. If the treatment doesn't work, it's not a bad way to slip away.

I wonder do we – doctors and relatives – sometimes abandon relatives to further treatment that may not extend their lives without asking them how they feel about it?

Treatment costs aren’t just economic, they can be emotional and spiritual as well.

And if you are looking after a relative who is unable to communicate with you and a potential life-

ending illness occurs, before asking for them to be admitted to hospital, thinking about the following may help:

What would I want to have done?

What outcome would I like to see in my family member?

What am I willing to put that person through?

What would they realistically want if they could tell me?

* Last week’s column on the community availability of CBT may have given the impression that one-to-one therapy is available only from clinical psychologists. In fact, there are many qualified CBT therapists who are not psychologists.

mhouston@irishtimes.com

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