Four decades ago, I finished my training in internal medicine. My first real life “job” was working at On Lok in San Francisco Chinatown. On Lok focuses on providing healthcare to frail older patients. There is an emphasis on home and community-based services. Daycare services and medical transport are included. On Lok was the original site of the Program of All-Inclusive Care for the Elderly (PACE).
The above picture was taken at On Lok. I’m sitting with a 100-year-old patient. She would always walk up to me, show me her watch, and ask me what time it was. It was an expensive watch, and she was very proud of it.
An important goal at On Lok was to avoid unnecessary trips to the emergency room and hospital. This meant I was regularly “on-call” at night to manage urgent problems. One night I was called because an elderly male had acute urinary retention. He couldn’t urinate and his bladder was too full. This is a major problem. We’ve all had the uncomfortable sensation of needing to find the bathroom right away. But acute urinary retention is much worse. The bladder is ready to explode but the urine doesn’t come out. It is extremely uncomfortable. Blood pressure is usually sky high due to the distress.
When I heard about the situation, I got on my motorcycle, went to the office, and picked up supplies. Then I went to his home. He lived in low-income senior housing for single men. I quickly “betadyne prepped” him and inserted a Foley catheter. (A Foley catheter is commonly used in the hospital. It is a tube inserted into the bladder to drain urine.) There was immediate relief as the urine gushed out. The senior was so “relieved”. He offered me $20, a lot of money back then. I refused. But there was a bigger gift for me. Inserting the catheter was not difficult. I enjoy the science of medicine, making a diagnosis and treating a problem. The patient did fine in the following days. But the science of medicine wasn’t the reason I went to medical school. It was the opportunity to do good.
This story stayed with me and guided me. What is good care when a person is old and frail? What is the value of timely help for a person who lives alone and uses a walker? In the decades since then I have tried to replicate that kind of care in healthcare systems. In most places across the United States, it still hasn’t happened.
In recent posts, I have discussed the importance of frailty. It is a major turning point in a person’s life. Certain factors predispose to frailty. Lifestyle choices can help delay its onset. But frailty is a part of life as we live longer. Most people who live past the age of 80 will have a period of frailty before death. (I will discuss this in a future post with Dr. Joanne Lynn.)
Even Marie-Louise became frail
Marie-Louise Ansak was the co-founder of On Lok. We were friends for over 40 years. She was no ordinary person. She retired at the age of 65 and decided to learn how to sail. She sailed around the world, at times alone. Marie-Louise passed away this year. She had an amazing and long life. If anyone could escape frailty, Marie-Louise would have been the one. But she did have a brief period of frailty in her last year.
What does “doing good” mean for a frail older person?
I write these posts because they give voice to my thoughts and feelings. Frailty can be a short or long chapter late in life. For instance, one friend of mine cared for his mother for almost ten years. Short or long, it is important that this chapter in life is good, like a good ending to a long book. Below are my broad guideposts for “doing good”. The guideposts are easy to understand but often harder to implement. For instance, what does “doing good” mean when a person refuses help? What are the give and takes? The patient, the family and caregivers, the community, and the healthcare system all play important parts. I’ll discuss this in future posts.
PS: I say it over and over again: There's no one more important than the caregiver in the daily life of a frail person.