The Dignity of the Social Admission

An old idea we'll need to embrace once more

This was originally published last year in EM News at the following link.

https://journals.lww.com/em-news/fulltext/2023/07000/the_dignity_of_the_social_admission.6.aspx

Sick, old, and frail patients are often in need of much more than prescriptions and procedures

This was made easier, of course, when physicians knew their patients and were invested in their lives. “Oh, poor Mrs. Asbury! You know she's never been the same since her son died. She has nobody at home. Let's put her in the hospital for a couple of days to see if we can make her feel better.”

This was undoubtedly abused, but I suspect it sometimes saved lives, avoided worsening injury, prevented litigation, and offered enormous comfort.

I've come to realize from watching people in the ED and in my family, that sick, old, and frail patients are often in need of much more than prescriptions and procedures. Often what they need is mobility, hygiene, and the dignity afforded by both. These things are all too often harder in an increasingly isolated and lonely time than we imagine in our youth, vigor, and relative affluence.

More and more, I see patients who are brought from homes that they navigate alone and in which there are decades of accumulated possessions and decades of magazines, correspondence, unpaid bills, and old food containers as well as soiled briefs and empty dog food cans.

Age and immobility make it too hard for them to clean these things out, and at a certain point, some combination of pride and resignation coupled with the comfort offered by familiar things means that their houses become disasters.

Homes in rural areas are sometimes the actual habitation of chickens, pigs, or untold numbers of adopted cats and shaggy stray dogs. Tragically, we have all seen diabetic toes chewed by rats.

No small number of these individuals are unable to make it to the restroom on time, far more so when afflicted with urinary tract pathology or severe diarrhea. Many times, even normal bowel and bladder function is problematic due to mobility issues made worse by arthritis, neurologic disease, and cluttered houses. Sometimes the problem is loss of electricity or water for financial reasons. I recently had an oncology patient struggling with a lack of electricity in his rural home.

These people in time seem to lose the ability to notice the smell or feel of their soiled clothes and bodies. They also become nose blind to the waste left by their pets, who are often their only companions.

Paramedics, physicians, nurses, and techs shake their heads when the smell of ammonia and stool fills the air of the ED. Those smells are sometimes connected with oppressive and unmistakable odor of decaying limbs, open wounds, and untreated or unrecognized decubitus ulcers.

My point is that we take so many simple things for granted. What a thing it is to have the ability to manage and dispose of bodily waste, to move from room to room unassisted, to have the means to wash ourselves and change into clean clothes, the strength to obtain and prepare our own meals. Poor hygiene and filth were the common condition of many of our ancestors, but it is tragic when it is the case in such times as these.

We are so reductionist. We, sometimes necessarily, see our patients in terms of the fixes we can provide through pills or procedures. Many of those fall short, however, when their homes or weaknesses trump whatever pill or referral we provide and when disease proceeds from a simple lack of cleanliness.

I recently injured my knee in a fall, not paying attention while walking down a city street. I was shocked at how hard it was to put on socks and shoes or simply to ease myself into a chair. And that at a spry, fit 58 years. (Don't judge; I really am spry.)

Our health care system is awash in the pitiful, weak, and old. Our emergency departments, as some have said, are largely geriatric centers. The house of medicine will have to come to terms with these issues as our population ages, our social services become more overwhelmed, and young people elect to have fewer children who might serve as helpers in the future. (A childless youth can be liberating, but a childless old age can be daunting.)

In the meantime, we may need to learn to embrace the good old social admission once again or accept the squalor that sends our patients back to us over and over.