By: Ana Cheung
I never considered specializing in geriatric nursing before my academic career at New York University mainly because I have had limited interactions with the elderly. My maternal grandparents died while trying to escape the Vietnam War and my paternal grandparents lived out in the Midwest so I rarely saw them. It wasn’t until last summer that I was able to connect to geriatrics on a more personal level.
At the tail end of summer 2013, I volunteered with the medical relief organization, Floating Doctors, which provides healthcare and medical treatment to isolated coastal communities in Panama. They also worked locally with a live-in geriatric facility, the asilo, by providing regular visits to conduct check-ups and physical assessments, administer medications as well as offer companionship to the residents. For the most part, the residents were in good health and mentally present. However, open sores, scabies, dementia, and debilitation were common afflictions.
Half of my time was spent at the asilo and it was a memorable experience. Most of the residents only spoke Spanish, and even though I didn’t know any, I was able to communicate with them through smiles, laughs, touch and basic greetings. I knew all their names and they affectionately called me “China,” which would become my nickname during my stay. A handful of residents did speak English and I often spent my afternoons chatting with them. As a group, we took walks to the park, danced (especially those in wheelchairs), played cards and when it wasn’t raining, I would sit with one or two of my new friends in the backyard, watching the sun set across the ocean, as we listened to the rhythmic lapping of the waves.
This idyllic picture of beauty did not discount the daily reality that some of the residents faced— of being in pain, confused, unable to walk, tired, depressed and/or agitated. The true beauty of this picture lay in their ability to grin, joke, and relish the bright moments of their days. Rolando* would follow our senior volunteer supervisor around and playfully tell everyone they were brothers. His eyes always twinkled mischievously and he seemed like the kind of grandfather who would help his grandkids play pranks on each other. Sylvia*was constantly confused but she was saccharine sweet and had a smile that would light up the room.
The human spirit is amazing, especially when it is resilient. What I learned most from my volunteer experiences with the elderly and NYU clinical rotations is humility. Humility from being humbled by my patients’ life stories, humility from being inspired by their strength, humility from their kindness to let me see them at their weakest and to assist them. Humility as in we are all human and vulnerable—and it is our humanity which binds us together. By helping others, we respond to our innate humanity to nurture, be compassionate, to listen and to learn. I have a lot to learn and a long way to go but I am so thankful to have patients from all walks of life and backgrounds to guide and teach me the skills and traits I will need on my journey to becoming a successful geriatric nurse.
About the Author: Ana Cheung is a nursing student in the last semester of her accelerated baccalaureate program at New York University College of Nursing. Specialties in which she is interested in pursing are geriatric, hospice/palliative care, and community/public health nursing. As a former Peace Corps Volunteer, she is also drawn to working as a nurse internationally. Within the NYU community, she is a board member of the Geriatric Student Interest Group and Nursing Students for Global Health.
When Mrs. P’s husband was dying he asked a good friend of the family, and long-term business partner of his spouse, Mr. C, to watch after her. What did that entail, he thought? What did Mr. C agree to?
As we care for older adults, those who have assumed that role across the lifespan and others who are suddenly thrust in the role, the range of emotions that one experiences after such an announcement can vary. At first blush, one is honored to be asked. After all one doesn’t typically delegate important decisions to people they can’t trust and who they believe is incapable of making sound decisions, right? Albeit, Mr. C did not volunteer to take care of Mrs. P, he did accept the responsibility and was honored in knowing that Mr. and Mrs. P trusted him to do the right thing, and to act in her “best interest.” The honor of being asked and the reality of what that meant were not clear until years later. Mrs. P, an African American female, age 89, lived alone, was functionally independent, and didn’t suffer from any chronic conditions. She was able to engage in activities of daily living and enjoyed reminiscing about the early years of being in business. Three months prior to suffering a fall, which resulted in a hip fracture, Mrs. P had a sudden weight loss. Mr. C took Mrs. P to see her primary care provider who was concerned about the weight loss but upon completing labs did not subject Mrs. P to further diagnostics. As the weeks progressed, Mrs. P was taken back to see her primary care provider and even made one trip to the Emergency Room complaining of not feeling well yet unable to articulate a chief complaint. Approximately 6 weeks later Mr. C found Mrs. P on the kitchen floor, a bit clouded, and an ambulance was called.
When Mrs. P arrived at the hospital, accompanied by Mr. C, she was evaluated and a hip fracture was confirmed. Mr. C, in his role as health care agent, began to question the plan of care for Mrs. P. He understood that hip fractures increase exponentially with age and that people 85 and older are 10 to 15 times more likely to sustain hip fractures than are those age 60 to 65; and that one out of five hip fracture patients dies within a year of their injury. With this in mind, it was reassuring to Mr. C when the ER physician said that a meeting would take place to discuss next steps. Imagine then Mr. C’s surprise when he returned hours later to learn that Mrs. P was taken to the Operating Room (“OR”). She is in the OR the nurse explained when he asked for her whereabouts. Why wasn’t I called? Who consented her for surgery, he asked? He nurse replied, “I don’t have the chart it is with the patient.” Mr. C became angry that he wasn’t notified given that he is health care agent and sole family member. In the midst of this, he began to anticipate the outcome of the surgery and the overall impact of the fall, as well as what it meant to be asked to watch.
After a three (3) day admission, Mrs. P was discharged to a nursing home for rehabilitation. She was alert and orientated and upon admission signed a DNR order and Medical Orders for Life-Sustaining Treatment (MOLST) form. One week post admission she developed pneumonia as confirmed by chest x-ray and it also found a “dark area” in the lung. The chest x-ray was repeated 7 days later and because Mrs. P wasn’t eating, Mr. C was being asked to consent to a PEG-tube. When Mr. C questioned the PEG-tube, and whether it was life-sustaining treatment, coupled with the fact that the status of the ‘dark area’ was unknown, he requested a team meeting.
At the team meeting Mr. C expressed concerns about the plan to insert a PEG without knowledge of the suspicious area while the team argued in support of the tube. “We must feed her; we have tried everything and she won’t eat.” Mr. C was aware of the eating issue because he too brought in favorite foods and tried to encourage her to eat. Mrs. P was discharged to hospital to further evaluate the suspicious area and to have PEG inserted if indicated. A cat-scan revealed lung and esophageal cancer and metastasis to kidney. Hospice was called immediately for consultation and Mrs. P returned to nursing home for comfort care where she died 3 days later.
As Mr. C worked to honor Mrs. P’s wishes, he continued to ask himself, did I do the right thing? Should I have taken her to the hospital? Should I have left her bedside to allow someone to ask for her consent for surgery? What was the conversation like when the doctor obtained consent for surgery? Was it, “do you want to walk again? If you do, then you must have surgery?” Did she understand that ‘walking again’ and returning to her home was unlikely? How did the hospital miss the ‘dark area’ if in fact a chest x-ray was done before surgery? Why was her health care agent, her next of kin, not notified before the hip repair was done? Did the doctors see Mrs. P as an old lady without family and they could just take her to the OR, knowing the likely outcome, without any consequence? Would they have taken someone of a different ethnic and/or racial background to the OR without family and/or health care agent’s knowledge? These questions became more central as the bills came in. The hip repair, hospital bill alone, was $50,000. Providers, transportation, nursing home rehabilitation center etcetera were all additional costs. Thirty-eight (38) days later, with her new hip, and the trauma of surgery, she passed away. Was the hospital motivated to perform the surgery? Did they stop to think was this the best thing for her or was that only Mr. C’s concern?
Advance care planning today. When we think about health care in America, and the need for advance care planning, studies show that only 20-30% of American’s complete directives and that number is far less for racial and ethnic minorities. Some studies found that African Americans don’t complete advance directives. Here Mrs. P had completed the Durable Power of Attorney for Health Care, a Do Not Resuscitate Order, and the newly adopted Medical Orders for Life-Sustaining Treatment (MOLST). Mrs. P was not interested in having extraordinary measures taken given her age and her view of a good life. The very thing she thought she provided for, and what her late husband sought to establish, was at risk. She did as health care professionals advocate, she made her wishes and preferences known, and shared them with her health care agent. Mr. C struggled as to whether the right decision was being made and knew if he didn’t take a position a PEG-tube would be inserted and it would be far harder to withdraw treatment than never starting it. Mr. C drew comfort in knowing the status of the ‘dark area,’ the cancer, and that it caused the patient to lose weight, have a loss of appetite, and to be unable to eat. The decision to not insert the PEG-tube was clear and comfort measures would be the final treatment.
Having a health care agent who is willing to assume the role is important. Like Mr. C one doesn’t always know just what their role will entail. However, being willing to speak up; to separate ones values as agent from those of the patient; knows the patient well and know what is important to them; and you are someone that they trust are all necessary if you are asked. Honoring the request when the time comes, albeit years later, is a gift and may you, if asked, pass this gift along. I/we did!
Gloria Ramsey, JD, RN, FAAN
Graduate School of Nursing
Director, Community Research Engagement
Center for Health Disparities
Uniformed Services University of the Health Sciences
One of the most talked about subjects these days is healthy aging. Just yesterday the Wall Street Journal dedicated an entire section to “retirement” and today the NY Times dedicated a section to “retirement”. Each of these had extensive articles on active aging and keeping the mind and body at their highest potential. Last week we saw a 64 year old female swim from Cuba to Florida and tell the world, “You are never too old to chase a dream”. Yesterday I spoke with a 73 year old film director and told him how great he looked. He told me he had a triple bypass six months ago and has never felt better in his life. He said he had just finished one film, had another in production and was looking at a script for yet another film. Jimmy Connors, the tennis great, was recently heard saying that overall he is a better tennis player today than he was in the height of his career. Although not as fast or as strong, he feels his endurance is better and his vision and strategy for the game is much better because his perspective has developed over years of experience. These good stories are testimonies to encourage people to be active as they age and remember that anything is possible.
The Hartford Institute new APP and executive director Tara Cortes were featured in the Health AGEnda blog of the John A. Hartford Foundation - Tools You Can Use: A New APProach to Treating Older Patients.
The ConsultGeriRN app is designed to help healthcare professionals with their decision making in providing the best quality care for older adults without needing to leave their side. This mobile reference provides information and tools to treat common problems encountered in the health care of older adults. Current topics include Delirium, Agitation, Confusion, Fall Prevention and Post Fall.
ConsultGeri App costs 1.99 and can be purchased here.
As my father turned 95 years old on May 15th I reflected on what a wonderful portrait of aging he has become. His journey through life has been an interesting one. Born of immigrant parents and poor, he was always taught how important it was to be educated. He excelled in high school as a football player and was accepted on full scholarship to Columbia University. He was All American at Columbia and was drafted by the Chicago Bears. While playing for the Bears and helping them to 3 national championships he completed his studies at Northwestern University to become a dentist. He served as a Lieutenant in the US Navy where he was a dental officer and then went on to practice dentistry for nearly 45 years. Today he is the oldest living Chicago Bear and on his birthday received a phone call from them letting him know that a video about him was posted on their home page, http://www.chicagobears.com.
I have learned so much from watching my father over the years. His values of integrity, humility and passion for always doing your very best have ruled my life. I also consider him my personal laboratory on aging. The Spring of his 90th year he tilled and planted his vegetable garden. A few months later he fell on the steps and never told anyone that he knew he had a broken rib – one of those painful events he learned to live with during his days of low protection football. Three nights later when he collapsed in his bedroom he was rushed to the hospital and diagnosed with a punctured lung. After being in bed at the hospital for several days he was sent to a “rehab” unit where he had what was called “geriatric” rehab. For one hour per day he had rehabilitation and spent the rest of the day in his room where he remained immobile. He was discharged home one week later with delirium and on a walker. He lost his mobility while in the hospital and has never gotten it back. This was an avoidable loss of function. He has some dementia and lives at home with 24 hour assistance. His gait and balance are impaired and he continues to use a walker. The delirium was managed by a loving family and wonderful paid caretakers who provided structure and meaning to his days. Although his dementia sometimes takes over, medication and loving caregivers keep his cognition at the highest level of his potential. His sense of humor continues and his stories and recall are often amazing.
Another thing I have learned watching him through these past years is how difficult it has been to have medical care for him without having to go out to the providers’ office which requires at least two people to assist in getting him down the stairs and out the door. Rather than have a nurse check on a symptom that might be handled in the home with communication to the provider, my father must have a face-to-face with the provider. In this day and age when we have far fewer primary care providers than we need and more people aging every day, this problem will only become more difficult. We must find ways to use the right provider, at the right time with the right care if we are to keep people at home with the best quality of life they can have. My father has a good quality of life because he has a significant support system. Most older people are not this fortunate and have poor access to appropriate care. Our older population is growing and more people will be living to 95 and beyond like my father. Their lives have been journeys of good times and bad times. When they are in the twilight of their lives, we must assure that they can stay safe with the right care at the right time wherever they are. I have no doubt I will learn more from my father during whatever time we have left together.
An article and video interview with Dr. Siegal was featured on May 15th and is available on the Chicago Bears website. http://www.chicagobears.com/news/article-1/Oldest-living-Bears-player-turns-95-years-young/b2201539-1e40-42ed-b963-f4e9d37eb241
May is Older Americans Month!
As the number of people over the age of 65 continues to grow with the aging of baby boomers and increased longevity, the need for accessible, coordinated and collaborative primary care for this population also grows. The older population (65+) numbered 40 million in 2010, and the number of Americans aged 45-64 who will reach 65 over the next two decades increased by 31% over the past ten years. Over one in every eight, or 13.1%, of the population is an older American, and persons reaching age 65 have an average life expectancy of an additional 18.8 years (20.0 years for females and 17.3 years for males). Older people have a higher prevalence of chronic disease that needs to be managed, are more prone to experience falls and related injuries, and more rapidly lose function resulting in the need for long term care. Most older persons have at least one chronic condition and many have multiple conditions. 1
The complexity of caring for this diverse older population means that we need a healthcare workforce prepared to address these challenging healthcare needs. The primary care setting is the hub for not only the management of chronic disease, but also the prevention of avoidable function loss and the coordination of care as people move in and out of different healthcare settings as their healthcare needs change. There is a need for primary care providers to have the access to resources that enhance their ability to deliver this kind of care. Effective primary care depends on high functioning, interprofessional teams which utilize evidence-based practice to achieve quality outcomes. There is, however, a crisis in primary care. By 2020 there will be a shortage of as many as 45,000 primary care physicians.
The 2008 Institute of Medicine (IOM) report, Retooling for an Aging America: Building the Healthcare Workforce 2, underscores that our current healthcare system is ill-equipped to deal with this pending crisis. The report lays out
the demographics, health status, and long-term needs of this population, and the challenges in caring for the aging population. It recommends that all healthcare professionals be trained to care for older adults and that there needs to be increased recruitment and retention of geriatric specialists in all fields of practice.
Geriatricians can address the healthcare concerns of older adults, but there simply are not enough physicians prepared as geriatricians to meet this need. Recent workforce projections estimate that 150,000 physicians will be needed in the next 10-15 years to meet the goal of providing primary care access to all U.S. citizens.3 This workforce projection will be particularly acute for primary care physicians since only 2% of all new physicians chose primary care for their career path in 2008.4 NPs provide high quality and cost effective care, produce outcomes comparable to physicians, and provide care that covers 80-90 percent of the services physicians provide.5,6
In 2010 President Obama addressed the House of Delegates at the American Nurses Association to announce a number of investments to expand the primary care workforce. It included increasing funding for nurse/NP-run clinics to “work well for nurses and doctors, and to improve the quality of care for patients”.7 Nurses have been providing care to vulnerable and medically underserved populations through Nurse Managed Health Clinics since the 1960’s. Many of these sites are Federally Qualified Health Centers (FQHCs), which have traditionally served families with children, and they have recently been certified as medical homes.
It is time for sweeping regulation to allow NPs to practice independently and provide these essential services to the growing number of people needing primary care. In order to maintain older adults at their highest level of function, manage chronic disease and keep them safe in the community, there needs to be adequate access to quality primary care. Nurse Practitioners can provide this care and must be allowed to be full partners practicing independently in team based primary care.
1. Administration on Aging. A Profile of Older Americans: 2011. U.S. Department of Health and Human Services. 2011. (Online accessed March 18, 2012)
2. Institute of Medicine. Retooling for an Aging America, Rebuilding the Healthcare Workforce. Washington, DC: National Academy Press. 2008.
3. Association of American Medical Colleges. The Complexities of Physician Supply and Demand: Projections Through 2025. 2008.
4. Hauer, K. et al. Factors Associated With Medical Students’ Career Choices Regarding Internal Medicine. Journal of the American Medical Association. 2008. 300(10):1154-1164
5. Mezey,M. et al. Experts recommend strategies for strengthening the use of advanced practice nurses in nursing homes. Journal of the American Geriatrics Society. 2005. 53(10):1790-1797.
6. Lenz,E. et al. Primary care outcomes in patients treated by nurse practitioners or physicians: Two-year follow-up. Medical Care research and review. 2004. 61(3):332-351.
7. White House. Remarks by the President to the American Nurses Association. 2010. http:/whitehouse.gov/the -press-office/remarks-president-a-joint-session-congress-health-care.