JULY 8, 1996 VOLUME 4, NUMBER 2
Two different stories about medical care for the elderly in recent weeks caught our attention atElder Law Issues. Although they appear to be unrelated, they both address the growing problems of securing adequate care for older Americans.
Falls in the Home
An all-too-common story among the elderly begins with a fall at home and ends with placement in a nursing home. Logic would suggest that this scenario plays out more often among those who live alone; a recent study confirms that this is true.
According to research conducted at the University of California at San Francisco and reported in a recent issue of The New England Journal of Medicine, each year approximately 300,000 elderly live-alones will be found by neighbors, family or professionals after having fallen in their home. What happens after they have been found is not usually positive.
About one-quarter of those elderly will be found dead in their homes. Another ten percent or so will die shortly after in the hospital.
Of those who survive the fall, slightly more than half will end up in long-term custodial care or skilled nursing care. In other words, only about a third of all elderly live-alones who fall and are unable to get up on their own remain in their homes after the incident.
This is true even though the subjects of the study were not necessarily poor. In fact, most were middle-class and lived in residential neighborhoods. Seventy percent even had supplemental medical insurance (Medigap) policies.
What can be done to reduce the danger for these at-risk elderly? In an editorial accompanying theJournal article, Deputy Editor Edward W. Campion observed that “the best solution to the dangers of isolation is the most obvious one: being part of a community that will respond … well-designed communities that work and that people want to join and can afford.”
In a separate report, the Alliance for Aging Research warned that the shortage of doctors qualified in geriatric medicine is bound to worsen in the next few years. Currently, according to the Alliance, there are only about one-third as many geriatrics specialists as are needed, and the outlook is not good for improvement of the shortage.
Currently 6,784 doctors nationwide are certified in geriatrics. That figure represents less than one percent of all doctors.
Only 14 of the nation’s 126 medical schools make geriatric training mandatory. The number of geriatrics programs is small and has failed to grow with the population of potential elderly patients.
Q&A: From Our Readers
Question: What should a hospital or nursing facility do after a patient has signed a “Do Not Resuscitate” form but before the physician has entered a formal DNR order?
Answer: You are probably thinking of the Prehospital Medical Care Directive, often described as “the Orange form” for its required bright orange color. The Directive instructs emergency room doctors and emergency medical technicians not to resuscitate the patient, and is effective immediately after it has been properly completed.
In most institutions a “DNR” order requires the attending physician’s signature. Should the patient’s wishes be honored before the doctor has signed? Absolutely. Patients have the right to refuse treatment even without the doctor’s permission. In nursing home cases the more important question is usually whether to transport to the hospital in the even of a cardio-pulmonary attack. If transported, the Orange form should accompany the patient, and CPR should be withheld.