Sunday, 30 December 2012

Christmas #2 - the depressing side of the season

Although I wasn’t working on actual Christmas day, I was working on Christmas Eve, and as mentioned previously, a 12 day stretch in the run-up to Christmas. Christmas around the hospital can be a pretty depressing affair, not because people have to stay in over Christmas and "isn’t that sad?" – it is, but family visiting can make up for it, and when patients are properly ill they seem content to be in the right place and receiving intensive medical intervention, even if the timing is a bit rubbish. It’s depressing because of the patients who want to be there, because hospital at Christmas is the best they’ve got.

I’ve come across a number of patients recently (it’s more of an issue in general surgery than it was in gynae) who are in hospital more because they want to be than because they need to be. I can imagine the outcries of “how is this possible, the NHS is stretched enough as it is!” but the difficulty is that it is very difficult to boot patients out, kick them out and onto the street. Discharge is a collaborative process, and requires the patient’s input, or if the patient has no capacity for this input, then the family or nursing home etc are involved.

There are the patients who were content at home, but came into hospital for surgery, and rather enjoy the multi-bed ward and socialising with other patients, the being cooked for, the lovely nurses and the nursing care, and suddenly realise that home is desperately lonely and they don’t like it anymore. This manifests itself as them realising, or proclaiming, that they need care at home, and it then falls to the hospital to try to organise this, which is a very lengthy process. 

The time taken for this is why many patients, particularly in an elderly care ward, will have days of “MFFD” recorded in the notes – medically fit for discharge, i.e. awaiting the social situation to be sorted out. Obviously sometimes this is absolutely essential, such as for elderly people with a very high care requirement and complex medical needs, which cannot be catered for in many care homes so it takes time to find the right one. But there are others for whom the care given is less essential, they coped without it previously and they are hardly less able to cope now, but it’s become understood that it is required.

A specialist nurse I work with believes the cuts to day centres have led to an increase in the number of patients who decide to stay in hospital because home is lonely. If they could go to a regular day centre, home wouldn’t be as lonely, and therefore hospital wouldn’t be as appealing. Yet another example of how cuts can lead to increased costs elsewhere…

There are the patients who can’t possibly go home because the problem they came into hospital with has not been fixed; they are still suffering with pain or sickness or whatever brought them in. As much as I love the idea that we can fix everyone who comes in the door, solve every problem, and make everyone feel better, that is sadly not how it works in reality, but sometimes is how it works in a patient’s head. It’s a sad thing, an unpleasant situation, to send a patient home still suffering, and with an end to that suffering not necessarily in sight – but sadly we are not magic. 

Explaining to the patient that our thorough and extensive investigations have shown no cause for their pain, there is no acute or life-threatening problem, there is no cancer, there is no obvious disease, there is essentially, nothing that can be fixed by a hospital stay, and nothing that can’t be improved by some pain relief, regular review with the GP, and community-based input such as physiotherapy, is not always a fruitful exercise, and some patients end up staying longer in hospital because they think they should be there. 

Those patients are slightly less likely to stay in hospital over Christmas, because they may eventually have somewhere better to be, once they have realised that there really is nothing more that the hospital can do to “fix” them, and being in hospital over Christmas is not the best thing that life has to offer them, and the benefits of going home start to outweigh the (perceived) benefits of staying in hospital.

The most depressing thing is the patients for whom staying in hospital, or even worse, being readmitted to hospital following discharge, is the best thing life has to offer them at Christmas. Their family either don’t want them, or don’t make it clear to the patient that they are wanted, so the patient has the sense of being a burden on the family, even if they aren’t (this seems to be a depressingly common occurrence amongst the elderly). So having a hospital bed over Christmas is the nearest they can get to seasonal happiness.

That doesn’t reflect well on us as a society. Look after your old people – if only for the sake of keeping the hospital beds free for the people who really need them.

(I realise this may come across as hypocritical following my complaints about my grandmother in my previous post, but she has never spent Christmas alone. The responsibility is shared between my relatives, not because she is a burden, but because we have a sense of duty to ensure she feels welcomed and as happy as possible each Christmas, and regularly throughout the year.)

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