Entering the minds of the elderlyBMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7212.737 (Published 18 September 1999) Cite this as: BMJ 1999;319:737
I was sorting things out pretty well. They had been attending for only a few weeks, but I had managed to reduce their multiple drug regimens and to diagnose and control his atrial fibrillation. Bill and Netty were a delightful couple, always attending together and obviously devoted to one another. Their delight in their new sheltered house and enjoyment of their new town was a pleasure to see.
Now I raised the question of Bill's microscopic haematuria, discovered at the registration medical and present on further samples. “Probably due to your prostatectomy five years ago,” I said, “but I'd advise a check at the hospital just to be sure.” He seemed hesitant. “It's a small operation—you'll be in and out in a day,” I reassured and went on to outline the procedure. Netty beamed her approval. “Well, if you're quite sure, Doctor,” Bill said uncertainly. I felt clever and kind
At cystoscopy no cause of haematuria was found, but a large bladder diverticulum (with suspicious ultrasound echo) could not be visualised. Problems developed a few days later. He developed a urinary infection, acute retention, and renal failure and required urgent admission to hospital. A niece took Netty to her home at which point the extent of her dementia became apparent. The niece was unable to cope with the agitation and the wandering. A few days later, Netty too required admission to hospital, and the unhappy scenario was complete—Bill and Netty separated and both in hospital. As the instigator of this disaster I felt foolish and cruel.
What had gone wrong? I had failed to recognise Netty's dementia and her complete dependence on Bill. Their attendance always together was the clue I had missed. But missing this would not have been disastrous had I sought to involve Bill in the decision to refer him for cystoscopy. Had I done this, he would surely have indicated his concerns and communicated his priorities. I had not stopped to consider that there might be a priority of maintaining their joint independence which far outweighed the need to diagnose urological cancer in an asymptomatic 85 year old.
Fortunately, all was not lost. The holistic and non-elaborate care of the community hospital came to the rescue and allowed their eventual joint discharge home. Bill now shared his view that he would not contemplate further investigation while his overwhelming priority was to keep Netty at home with him for as long as possible. He would take the risk of undiagnosed advancing cancer.
For a further six months he continued to achieve his aim of caring for Netty Then he ran into further trouble with renal failure caused by obstructive uropathy. He died a few days after readmission. A large fungating bladder tumour was found at necropsy.
Communicating with the elderly is a difficult skill. All sorts of factors get in the way, not least a paternalistic approach, often misguided, sometimes disastrous. Perhaps even more than with younger patients, we need to find time to seek the ideas and concerns of elderly people if we are to meet their needs adequately and sensitively. The priorities of the elderly can be surprisingly different from those of younger patients. The need to preserve and not to put at risk personal or coupled autonomy is sometimes of paramount concern.
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