The Hospital Dependent Patient--some people will be in and out of the hospital despite our best efforts to make them well

This week the New England Journal of Medicine published an article by David Reuben MD and Mary Tinetti MD, both academic gerontologists, about patients who are unable to stay out of the hospital. The two physicians study the problems of old people, and are of the opinion that most of these "hospital dependent" patients are elderly. Certainly some of them are, but in my experience a surprising number are just chronically ill, usually also poor and with home situations unequal to their vast medical needs. Drs. Tinetti and Reuben are apparently studying these patients, thinking about solutions and now focusing us on this special population.

Hospitals potentially risk not being paid for patients who return to the hospital with new or persistent diseases within a short time of discharge. (I wrote an article on the history of this several months ago which points out some of the same issues that Dr. Reuben and Dr. Tinetti mention as well as how this fits in with the history of Medicare. Not as dry as it sounds. You should check it out.) Physicians who readmit patients after less than a 30 day hiatus are made to feel that they have participated in some sort of failure of management. Sometimes they have, but sometimes that isn't the case at all. If a patient is readmitted with an illness that is still troublesome, but clearly improving out of the hospital, for which the patient has visited the emergency department only for reassurance, this is a failure of management, due to unfamiliarity with the patient's history, often because the doctors in charge haven't really read the chart, reviewed the history or talked to the patient. If a patient is readmitted because treatment has lead to a preventable complication, that is a failure of management. If the readmission could have been prevented by a timely visit to an outpatient physician, this is a system failure of some kind and potentially avoidable. If the patient returns, however, because he or she is just too sick and fragile to remain well outside of a hospital, there is no failure, other than that expectation of success was overly optimistic.

The reason that we have hospital dependent patients is that our hospitals are really quite good at keeping people alive, even when they are balanced on a knife edge of medical stability. Twenty-four hour attentive nursing and frequent visits by physicians, respiratory and physical therapists, dietitians, patient educators and social workers along with spare-no-cost life saving technology is wondrously effective at shoring up the nearly dead. For many people, though, life without all of this is hard or impossible, so after a few days at home or in a nursing home, they will return to the hospital to be saved again.

Solutions involve difficult decisions. Is it worth the staggering amount of cash it takes to keep people in marginal health marginally healthy? How can one enter into the discussion of allowing natural death with a patient who feels mostly pretty good with ordinary hospital care? Herein lies the fallacy: once we get to this point, hospital dependency, it is hard to back off. The trick is to not get there in the first place.

Most people who are independent and in full possession of their faculties do not want to be a burden on others. There are many moments between this point and full dependency when decisions could be made to withhold life prolonging medical care, and it is important that we present patients with these options without making them feel that they need to at least try what we have to offer. Although we as physicians are becoming more accepting of withdrawing life support or at least not intensifying it as people become desperately ill, most of us feel justified in allowing natural death only in people who have become truly miserable. Our patients, however, would usually prefer not to be truly miserable ever.

Many of our hospital dependent patients have survived some last ditch attempt at keeping them alive. Given the opportunity to do it all again, from the standpoint of their well selves, many would say no.  It is interesting, though, that from the standpoint of being rescued and now dependent, many patients will continue to undergo painful and progressively disabling medical treatments until at last nothing will work.

I'm wondering if it is possible to end our love affair with medicine that defies death in our waning years. Might it be acceptable, at least sometimes, to allow our patients to die without a diagnosis? No cause of death. Death certificates could say "old age" or "natural causes" without further clarification. When death comes knocking, sometimes, if the time is ripe, we might let him in the front door, bid our loved ones goodbye and depart. Or have we as a society really decided that lengthening life is pretty much always a good thing? If we have, hospital dependent patients will be increasingly part of our jobs. Shaming ourselves when they are readmitted is misguided and very unlikely to change anything.