Bringing the Hospital Home: Ethical and Social Implications of High-Tech Home CareBMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7030.587a (Published 02 March 1996) Cite this as: BMJ 1996;312:587
- Bryan Jennett
Ed John D Arras Johns Hopkins University Press, pounds sterling33, pp 259 ISBN 08018 4990 X
Accounts of trends in medical care in the United States that focus on the inequities and commercialism of medical provision in that country are often dismissed as irrelevant to Britain. However, recent organisational changes in the NHS mean that the problems of US medicine are likely to spread across the Atlantic sooner rather than later. In Bringing the Hospital Home American doctors, ethicists, and economists highlight the debatable balance between the benefits and burdens of high technology home care. As hospitals seek to discharge patients “quicker and sicker” the market in the United States has responded aggressively by developing care packages that facilitate this trend. Such home based technologies include ventilators and dialysis machines, and infusion pumps for antibiotics, analgesics, cancer chemotherapy, and total parenteral nutrition. These care packages include equipment, personnel, and consumables—the last made up in easy-to-use format for domestic use, but often at prices that greatly exceed their cost in hospital. Moreover, marketing strategies may result in the over use and inappropriate application of some technologies in the home. As a result the alleged cost savings can be illusory, and in any event the main effect on cost is to shift it from hospitals to other providers. Most savings depend on the uncompensated support given by family, who become major care givers.
Apart from cost, the question arises as to whether home is still a homely place providing high-touch care when it has been converted to accommodate high technology, and also whether some patients might not have more autonomy, privacy, and confidence in a sympathetically run hospital or nursing home, shielded from the tensions of families. Family carers are put under stress from coping not only with the burdens of unremitting care but also with the challenge of dealign with unfamiliar technology—without the continuing support of doctors and nurses to deal with complications and progressive decline.
There should therefore be careful consideration as to whether home care for a given patient is appropriate and feasible and is the wish of the patient and family. Too often it may be presented as the obvious next stage in care without discussion of the alternatives of continued institutional care or discontinuing technological support. A distinction should be made between the long term care of patients with static conditions and of those with progressive diseases such as AIDS, cancer, and dementia.—BRYAN JENNETT, professor emeritus of neurosurgery, Glasgow
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