The Medical Reality of an Ageing Population

WSelfieith the UK’s ageing population increasing and greatly impacting the field of medicine, Anahita Sharma, 2nd year, shares her personal experiences of working with the elderly.

Whilst all individuals in this article are anonymous in order to respect their confidentiality, these are real people and were real incidents. Thank you to Ha Phuong Do Le and fellow care staff for sharing their invaluable thoughts and advice.

The Beginning

There is nothing quite like a wintry, Scottish morning. It was a few minutes past 8 a.m. as I trudged through a field laden with grimy snow. The sunshine was pale, the world was quiet, and buildings were dark silhouettes against a blue sky. My mood oscillated between empty, drained and low. I drifted into my room… and hid under the duvet, seeking solitude, silence, and sleep, in the darkness.

Screenshot 2014-07-31 21.15.25

The above is (an abridged version of) a text I sent a friend after that memorable first night shift, one year ago at a geriatric home, as a ‘care assistant’. I came onto the shift at 8 p.m. the previous night, rather bushy-tailed, wearing a freshly ironed shirt. Twelve hours later, I was sleep-deprived, but more importantly, in turmoil over whether I had made a foolish commitment – in fear that I would do a terrible job.

My previous volunteering experiences felt deceptive. There was an obvious gap between the acts of visiting, chatting, playing Bingo… and the fundamental, 24-7, reality of life in a geriatric home, which I had naively missed.

The intimacy of the care process – of washing, dressing, changing, moving, toileting – of all these little things we intermittently do for ourselves in our private domains – felt like a consistent intrusion. I repeatedly found myself in apology and embarrassment, my fingers fumbling with towels, pads, and pants.

What is Care? As it currently stands…

On retrospection with my colleagues, all of us beginning in care were deer in headlights. The job description is vague. By definition, ‘healthcare assistants’ handle the non-clinical aspects of a patient’s care, and are sometimes referred to as ‘auxiliary nurses’. It is a division of labour niched by the modernization of the NHS. A typical shift at a care-home is 12-hours long, in which you are allocated to the care of 8-10 residents.

But where, precisely, does one start looking after someone who has lived a long, full, life, and is unable to understand his or her present degree of physical and mental incapacity? A browse through a resident’s ‘care plan’ presents the following as important elements of a person’s health:

• communication

• eating and drinking

• elimination

• lifestyle and activities

• mental health and cognition

• mobility

• personal hygiene

• sleep

• skin integrity changes

• positional changes and bedsores

The Problem With It: do we know our patients?

This list reduces the act of ‘living’ into a series of micro-manageable chunks. Every aspect of a resident’s life: their health, their location in the care-home, any incident, and any decision related to their care, is fully documented in this care plan. Whether this is of genuine use is debatable. It is a common view among staff that paperwork represents a loss of energy and time that could be better spent, and is more of an insurance measure.

Screenshot 2014-07-31 21.25.02Never in my life have I seen so much information aboutan individual and their activities, yet so very little about the person. A typical, daily entry may be “Resident X manages their care independently, and is in good spirits. They spent the morning in the lounge chatting to the other residents. Food and fluid intake is normal. Mobilising well with a zimmer. Skin integrity not witnessed.” Thisentry could very easily reflect a resident who was in tears forhours during the night, acutely misses her daughter and is unable to understand why she lives here.

This approach is recognised as reductionist and generic – hence the recent emphasis on person-centered care. You look at the person, not his oScreenshot 2014-07-31 21.26.39r her disease.

As one of my colleagues pertinently observes, however, “You cannot be perfect. It is difficult to keep your energy up and look after every detail. You will be strong in some areas and not in others. “

The hands-on nature of the work requires a high degree of contact (termed direct care time) with patients. Good, because you develop a real affection for residents, even when this relationship does not resemble a normal, mutual interaction. Even if the residents are only fractions of their former selves, you come to adore that fraction.

It’s A Team Effort

The work is physically and emotionally taxing. The job is underpaid. The will to return and continue is, therefore, extremely admirable. I would be utterly lost without the warm and reassuring “Ay, nay bother”, “Don’t worry, doll”, or “Don’t take it personally” from fellow staff, who go well out of their way to teach me the ropes – down to the minutiae of putting on a shirt in a resident’s preferred manner, applying analgesic gels to their knees, or whipping on trousers in one slick motion. After my third shift, another care assistant told me : “When you spend all day caring for other people… you got to make sure you go home and look after yourself.”

Once residents and routines became familiar, and my hands moved with smooth certainty, a love for ‘care’ grew – as well as a love for the dry, slightly grumpy, Scottish sense of humour, which makes light of really tough work. Once I realised that I was more uncomfortable than the resident in front of me, and that this was very unhelpful, the work became lovely.

Death

One of my colleagues, now a close friend, articulates this beautifully : “You can’t get too attached,” he cautions, “You have to distance yourself emotionally. Especially when it comes to end-of-life care, when you will naturally deal with death “.

“You have to leave it behind when you walk out of the door, and accept that this is where people come to die. People who have usually lived very long lives. It must be more difficult watching young people walk into A&E”.

“With care work, you have to invest in someone emotionally, without putting your emotional baggage into it – to be able to cope without becoming vulnerable “.

The Residents

The four “geriatric giants”: “immobility, instability, incontinence and intellectual impairment” are the most common presentations of the morbidities the residents live with. You become so accustomed to the grey, the wrinkles, and the arthritic shuffle, that you are struck by your own youth in the bathroom mirrors. The following diagram is a simple, but useful, summary of this cycle of decline :

Screenshot 2014-07-31 21.34.36

Some residents may be prone to giving up what they love, which accelerates their collapse. Others retain a semblance of their selves, striving to remain healthy and alert. In my opinion, the residents who live in their own little bubbles probably draw the best end of the deal.

Coming from Asia, I noticed significant differences in the treatment of the elderly. Not only is our population structure flipped, but attitudes surrounding the elderly are also different. The potential to become lonely and isolated here is enormous.

Screenshot 2014-07-31 21.36.42

Screenshot 2014-07-31 21.37.26

Nothing had shown me what life could really be like for many older people. Is this is a reflection of where society’s attention lies? Whilst understandable, ‘health burden’ as a descriptor for this age bracket, seems pretty disrespectful. It does not encapsulate the rich narratives and the sacrifices made over a lifetime adequately enough.

As ‘future doctors’, it is important that we realise not only the importance of care work as part of our arsenal, but of looking after and listening to the healthcare assistants on our wards – they are vital team members.

Care work is not essential to a medical curriculum, but it has been an excellent education. To me, this job is a strong reminder of the ‘care relation’ at the core of medicine, which has the potential to be lost under the mechanised, clinical façade of hospital administration. It comes back to human touch and fragility.

Screenshot 2014-07-31 21.39.23

REFERENCES

1. Clover, Ben. “Healthcare Assistants Take over Bulk of Bedside Care.” Nursing Practice and Peer-reviewed Clinical Research for All Nurses. Nursing Times.net, 22 June 2010. Web. 15 Nov. 2013.

2. Woodford, Henry. Essential Geriatrics. 2nd ed. Oxford: Radcliffe Pub., 2010. Print.

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