From his experience in intensive care in one of Australia’s busiest intensive care units at Liverpool Hospital in Southwest Sydney, Professor Ken Hillman describes the failure of specialised, super-specialised, medicine to deal appropriately and humanely with seriously ill aged persons and those whose life has run its course. (Ageing and end-of-life issues, posted 9/7/2016 in Pearls and Irritations)
Ockham’s Razor (1) is wielded inappropriately when there is not a single biological breakdown but many breakdowns. Ageing causes progressive erosion of the reserve capacity in all body systems; and chronic disease impairs the function of many organs. The aims in preventive medicine and successful ageing are to protect and preserve the function of body systems with advancing age and to prevent the onset and progression of chronic disease.
As Professor Hillman observes, a fall, pneumonia or a urinary tract infection in older people is enough to upset the precarious balance and cause multiple systems to go awry. For an increasing number of patients, this is how life ends – alone in intensive care. In the UK, 65 % of people aged 65 – 84 years and 82% if those 85 and over, have multiple chronic diseases; and 60% of hospital admissions and 65% of emergency department re-admissions are people over 65. (2) These patients need compassionate care amongst relatives and friends and not end up hooked to machines in a “stainless steel” ICU.
Imaginative clinicians who work in these environments have learnt that Ockham’s Razor fails in the management of the predicaments of the seriously ill, especially the very old. The reductive approach we learnt in medical school, a good servant of medical science, has to give way to higher systems-level thinking and ethical appraisal in these situations.
The same issues occur outside the hospital. The common chronic diseases of today cannot be cured as we once thought. They are essentially intractable conditions to be managed to achieve quality-of-life outcomes for that person rather than a cure. Diabetes affects the cardiovascular and nervous systems, kidneys and eyes; alcohol and drug problems sit alongside serious disorders of mental health, physical health and social problems. People with a chronic disease don’t have one problem but many problems.
Homeless people, with their high prevalence of mental illness, physical disease and alcohol and drug dependence, exemplify the extremes of medical complexity. There is not one problem, or one handful, but two handfuls. When a homeless person, or any seriously disadvantaged person, needs specialised treatment they are too often excluded because they can’t meet the clinic’s eligibility criteria for service. How can a homeless man with an inguinal hernia or a woman with a gynaecological problem get on to a public hospital waiting list, or, indeed, stay on a list?
Just as the modern hospital has to reinvent the way it manages critically ill and ageing patients, in the community, where people live and work, strategies are needed to better manage the complex intersections of chronic disease and ageing.
The nascent primary health care networks and general practice have the orientation and approach which can do this for us. For it is in this environment where undifferentiated health problems are managed without having to be screened and tested for eligibility and the presence of specific diagnoses that are required to see a specialist. Indeed, many patients in primary health care have conditions for which a formal diagnosis cannot be made and for that matter for whom it may well be inappropriate.
This means governments should focus health policies and more resources on community-based primary health care.
- William of Ockham, 14th century Franciscan monk, ‘Do not put forward more than suggestion for something with without necessity’. Also known as the principle of parsimony – choosing the simplest theory.
- Banerjee S. Multimorbidity – older adults need health care that can count past one. 2015; 385: 587-589.
Ian Webster is Emeritus professor of Public Health and Community Medicine, University of New South Wales.