In Times like these....

These past 2 weeks have been busy. "Busy crazy" as I call it. I returned from a week away and scrambled to catch up. Surprisingly, despite the busy-ness of it all, I have been very focused. More so than in the longest time. My first week back, I was on call. That means from 6 or 8 p.m. I carry a pager and respond when it goes off. The first day I had it, it went off at 2:30 a.m. I called in to find out that the staff were in the middle of a code (complete with CPR) and that the family member was on their way up to the ward. I made it there is 30 minutes instead of the usual hour. I guess it is partly due to the lack of traffic on the usually crowded highways...

Then when I was there supporting the family member, I was paged by another unit saying that a patient had died and that the family would like an Anglican minister to come and pray. At 4 in the morning, it was unlikely that I would find anyone as I think we mostly have office numbers as contact. So I went and prayed with them even though I am not Anglican, then I went back upstairs to continue with family #1. I got home when I would normally be getting up and "slept in" going back to work for 10 a.m.

This week has been busy as well. Referals about patients who are depressed and want to die. They "want to go to sleep and not wake up" or they are just "tired of being sick". I have been watching some of my long-term patients (people I have known for many months, and in some cases, many years) decline. Loosing their physical function, or cognitive status -- not knowing where they are, when did they last talk to their family member (yesterday or 2 hours ago), or going into cardiac arrest.

Yesterday, I attended a code blue before I left that day. The patient's family was there and I knew them all pretty well. I actually cried when I left them. It is hard to see patients crash. It is hard to leave them while the story is still playing out...

This morning I was thinking about the patient who crashed before I left. They "aren't really religious". The family has church afilliations but they have not been active for a number of years due to working schedules and health status. And for some reason, the verse of a hymn that I learned as a child came to my head. This is what I have to offer them...



In times like these, we need a Savior.
In times like these, we need an anchor.
Be very sure, Be very sure,
Your anchor holds and grips the solid Rock.



My head messes up and says "be very sure your anchor hold through the storms of life" which alludes to another hymn, "Will your anchor hold in the storms of life?"






That is what a lot of people need in their lives, is to know that when life's storms come, that they are strong enough to weather it, and won't crash into the sea of turmoil. But also to know that should they crash into the sea, that there is someone to help pull them out. A friend, a brother, a mom, a nurse, a doctor, ... a caring soul... who won't let them go down alone.

Lessons from the "Other side of the Bed"

Over the past few weeks, I have learned what it is like to be IN the hospital bed, versus being caregiver to people in the hospital bed. I wasn't admitted, but I did spend a lot of time in ER, as an outpatient. The waiting is hard.

My husband is not good with the hospital experience -- people in the beds next to you , moaning and groaning, calling out for attention... being forced to wait for ... whatever. He coined it "hurry up and wait". The doctors did not like some of the test results I have had, and then call me up after I have just been there for 8 hours at work and then ask if it's too much of an inconvenience to come in so that they could see me. So I fed my husband supper and we went to the hospital yet again. Then we waited ... for an hour. Then a grumpy nurse took my vitals. Then another hour. A doctor finally showed up. Told me stuff that I didn't like. Told me to wait some more. Then sent me home at 1 in the morning telling me to go for more tests.

Then I was woken up first thing in the morning by a doctor on the phone telling me to come today. "Aren't you working anyhow? " (After getting home at 1 in the morning, I was sleeping. So no, I was not going to work. How was I expected to function and provide comfort and pastoral care to others when I needed some pastoral care myself?) So I went back in, they told me what the treatment plan is. And I agreed to do it. Even if it is just to get ALL of this over with.

Waiting for "whatever it is"... is hard. Being told things about your health that you don't want to hear is hard. Worrying about the worst case scenario is hard. What is worse? Knowing.. or not knowing. This is one of the lessons that I have learned about being a patient, versus caring for patients.

While waiting in various waiting areas of the hospital, it is interesting to see the types of cases that came in. People brought out in by ambulance drivers, head injuries, bleeding, people wanting pain control, homeless people, elderly, teenagers... all types of people with different cases trying to get help for whatever it is that ails them. Some get help in a timely manner, while others seem to sit and wait a long time. Based on what I saw, my issue was minor and while I hate being a patient and feared being admitted to my own hospital, I sure didn't want to be in the shoes of those I saw in the waiting room either.

More Headlines..

Academic freedom and assisted suicide

This instructor wants to witness assisted suicide for his research. A fight is brewing over his right to do that.

Douglas Todd, Vancouver Sun, Thursday, July 3, 2008

Canada's university professors are preparing to defend the right of a Metro Vancouver researcher to witness illegal assisted suicides in the name of increasing understanding of the right-to-die movement.

The Canadian Association of University Teachers (CAUT) has formed a high-level committee to investigate claims that Kwantlen Polytechnic University sociologist Russel Ogden was unjustly denied the chance to research new techniques for assisted suicide.

"In the face of it, it looks as if there has been a violation of academic freedom," James Turk, executive director of the CAUT, said Wednesday in an interview from Ottawa.

The CAUT has formed what Turk call a "blue-ribbon committee" to look into why the Kwantlen administration is effectively blocking Ogden from researching assisted suicides, even after the university-college's ethics committee approved his research three years ago.

For more than 14 years, Ogden has engaged in controversial and ground-breaking research into scores of underground assisted suicides (often known as "Nu Tech deathing") by people dealing with AIDS, cancer and other terminal illnesses.

Ogden has frequently run into opposition from university administrators who fear their institutions could wind up in trouble for allowing him to possibly skirt the edges of the law.

In 2003, Ogden was awarded $143,000 in damages after it was determined that Britain's Exeter University had illicitly backed out of an agreement to protect the identities of scores of people Ogden found had taken part in illegal assisted suicides.

More recently, Ogden has discovered that more than 19 British Columbians have committed suicide through an increasingly widespread technique known as "helium in a bag."

Helium is seen as a swift, highly lethal and painless way to die without involving physicians or drugs. Helium is also nearly undetectable in toxicological probes.

The latest confrontation over Ogden's pioneering research techniques has arisen at the same time that assisted suicide has become big news in Washington state. Former Democratic governor Booth Gardner, who struggles with Parkinson's disease, is campaigning for a November ballot initiative on doctor-assisted euthanasia, which will go ahead if state supporters gather 225,000 signatures by today.

However, the CAUT worries that Ogden is being blocked from continuing legitimate research into the right-to-die movement by Kwantlen officials.

Despite receiving earlier ethics board approval, Ogden has since been told by Kwantlen's administration he cannot "engage in any illegal activity, including attending at an assisted death," says a CAUT letter written by Turk, which was addressed to eight academics and administrators. A copy was obtained by The Vancouver Sun.

Neither Ogden nor Kwantlen officials were available for comment Wednesday.

The CAUT's Turk maintains that, although assisted suicide is illegal in Canada (unlike in the state of Oregon, as well as the countries of Switzerland, Belgium and the Netherlands), it is neither illegal to commit suicide nor against the law to witness an assisted death in this country.

"Witnessing an illegal act, such as a husband murdering his wife, is not illegal behaviour on your part," Turk said.

Therefore, Turk said, it would not be illegal for Ogden to witness an assisted suicide, since he would be neither discouraging nor encouraging it.

It's important, Turk said, for academic researchers to be given the freedom to try to "understand politically unpopular behaviour." Even while a Canwest poll last year showed three-quarters of Canadians approve of assisted suicide, compared to 48 per cent of Americans, Turk said researchers like Ogden are being held back by university administrators "who might think the [federal] government is going to get mad at them."

The high-level CAUT committee that will review Ogden's case and issue its findings in a few months includes Kevin Haggerty, a sociologist at the University of Alberta; John McLaren, professor emeritus of law at the University of Victoria; and Lorraine Weir, an English professor at the University of B.C.

dtodd@png.canwest.com

© The Vancouver Sun 2008

The subject of euthanasia or assisted suicide is rift with controversy. The two sides would basically be Side one: All life is sacred. No one has the right to take the life of another regardless of the situation. All life is worthwhile, no one but G_d can determine its end. (This is usually backed by theological argument such as 10 commandments such as "thou shalt not kill" and others.)

Side 2 looks at the "right to choose" and is related to the experience of suffering, and the definition of "quality of life". Watching someone who is ill, who has constant pain and is able to do little more than lie in bed, may be alive by the aid of machines -- the definition of "quality of life" is subjective to the individual's experience. I had seen both sides as part of my work in health care chaplaincy. I have seen the family called to the bedside and told that this would be it, only to see the miracle of the patient to rally and continue living months or years more. I have also seen patients who are able to do little more than lie in bed, dependent on painkillers and oxygen or a machine to survive. Working in renal, I have even had discussions with patients who decide to cease treatment for their kidney failure. Often they have told me that it is the pain, the decline in their health, and the cessation of their perceived quality of life. After making this decision, and going to 'comfort care only" (meaning pain control but no 'heroic measures such as CPR or tube feed') I have met with patients who continue to survive for days or weeks. Some have asked 'why can't I die? When will this end?' I once told a man that I didn't know. (Often patients 'declare themselves', meaning they stop being aware of the world and their systems start to shut down. The body doesn't need or take in food or drink, their responses cease, and they begin the process of detaching from the world as they start the journey towards death.) I told the man that perhaps he wasn't done yet, that there might be something he was still to accomplish. I asked him to consider if he had unfinished business, if he still had a lesson to learn, or perhaps that he was to teach us something. This was not something he had considered...

The choice to live or die... not an easy one to make.

In the same paper, I found an article decrying the choice to award an Order of Canada to Dr. Morgentaler. Dr. Henry Morgentaler is best known for performing abortions illegally.

"Morgentaler is known for almost single-handedly pushing abortion rights on to the national agenda when he opened an illegal abortion clinic in Montreal in 1969. At one point, he was jailed for 10 months when a lower court acquittal was overturned on appeal.

The issue culminated in a landmark ruling in January 1988, in which the Supreme Court struck down anti-abortion provisions of the Criminal Code on the grounds they violate a woman's constitutional right to "security of person." "Cassandra Drudi, Canwest News Service; With files from The Journal, National Post and Montreal Gazette Published: Wednesday, July 02

One side of the debate argues that giving him the order of Canada has been a long time in coming. He has fought for the rights of many women who had little or choice regarding unwanted pregnancies. The other side of the debate claims that he has chosen to act against morality, to "kill" or take a human life by aborting pregnancies.

It is easy to take sides when hearing a story. But it is difficult to know what we would want when it is our situation. I wonder how many people surprise themselves by chosing something that they swore they would never do. I remember when I used think more "black and white/right and wrong", in a box. People who smoked were bad, people who drank were bad, people who got divorced were wrong. In practicing theological reflection in my everyday work, I have changed some of my theology in the 17 years since I first started my theological training. I now think that divorce is not a "sin", but hope that it is the last resort. I would rather see 2 happy people apart, then 2 (or more as children and other family members are affected) unhappy people together. I would rather people learn to relate to one another and try to have dialogue rather than discriminate due to a difference of opinion about how to live, or what to think. I would rather see people who are able to respect the beliefs and customs of others, and in turn have their traditions respected and maybe enhanced due to the openness towards those things that are new, or "different" (i.e. weird, or not like us). I would rather see love, real love (not sexual but agape

In my work, it is my task as a chaplain to "come along side", to walk with the person in their journey as a support for them in their times of health and/or other difficulties. To remind them by my presence that God is present in the midst of their struggles and seeming chaos and that S/He does care. To do this, I provide a listening ear with no judgment about their choices. this is not always easy. I might personally think one thing, but do not express this to the person, as I do not know the life experiences and perspective that leads to this choice or stage of their living. The goal is to help them make choices that will honor the person that they are, to enhance their life experience, to meet the "person" that they are -- that God knows them to be. I really don't know until it is my situation and my story.

"No one dies from having their medication stopped"

This is a comment overheard at rounds the other day. One doctor was counseling another about stopping a certian medication and then explained that during his rotation of training in England, that the chief doctor would get a referal and would review the chart and then immediately stop all medications. He would then say "let's come back tomorrow and see how they are doing". Usually the person was better the next day. The doctor went on to comment to the other that here in North America, we are fixated on medications. "When you call geriatrician over there, they stop meds, here they review the chart and probably add another one."

I wonder about this. Interesting comment that it is. There are some patients that benefit from certain drugs treatments but most would probably do fine without. Years ago, we didn't do so much treatment with drugs, (of course someone might argue that years ago, we didn't have the diseases that we do now.)

I thought it was an interesting comment on the evolution of healthcare.

Article about Seniors/ Healthcare

llness can accelerate trip to residential care

Gillian Shaw, Vancouver Sun

Published: Saturday, November 03, 2007

Dr. Janet McElhaney wants to see B.C. seniors age well.

The head of geriatric medicine at the University of B.C., holder of the Allan M. McGavin chair in geriatric research at UBC and head of geriatric medicine for Providence Health Care, sees prevention as key to keeping seniors independent and active.

McElhaney is also behind VITALiTY, a research orientation to support healthy aging which stands for the Vancouver Initiative To Add Life to Years.

The point, she said, "is that we need to be looking at transitions in the health of older individuals and really understand how we manage risk to get preventable loss of independence.

"We can do that through vaccines, we can do that through a more comprehensive approach . . . a more goal-centred approach to the care of seniors, for instance, in the emergency department."

Going into emergency could be one transition point of risk.

"One in every three persons over the age of 70 admitted to hospital is discharged at a higher level of disability than before they got sick," said McElhaney, citing a U.S. study, but one she said probably translates into the Canadian experience as well.

"There has got to be something preventable there."

McElhaney said while people usually think about frail individuals when they think of geriatrics, geriatric specialists must also concern themselves with the task of preventing disability in the majority of older people who are out there and active in the community.

"There is a thing called catastrophic disability," she said. "This is, by definition, you lose up to three of your basic self-care activities of daily living -- like bathing, walking and toileting.

"The leading causes of those things are heart attacks, heart failure, influenza and pneumonia and strokes."

McElhaney said older people can lose up to five per cent of their muscle power for every day they spend in bed, typically with their legs most affected. So even a bout of influenza can be catastrophic.

"If you are in hospital 10 days and spend most of the time in bed you have lost 50 per cent of your strength," said McElhaney. "It doesn't take long to figure out how we get to this catastrophic disability.

"It is shocking. I think that every older person needs to understand the risk when they get sick."

Illness can accelerate the path to needing residential care, said McElhaney, who points to diet, exercise and vaccinations as key primary prevention strategies.

She said the job of geriatric health care won't fall only to the geriatricians, but to others in the health care system and the community as well.

Canada has 180 to 200 geriatricians -- probably about one-quarter of what it needs -- but among those, she said, many are not practising full-time but instead divide their time between research, administration and other academic roles.

"We have to get the whole health-care system to understand this requires a different kind of approach than we have in the past," McElhaney said.

There is a shift taking place here to a more collaborative practice among different health care disciplines, she said. "To keep people walking, to rehab them, requires more than a nurse-physician model."

McElhaney said there are initiatives aimed at making it easier to care for the frail elderly, but with the very brief exposure students get to it, the training period is too short.

Instead of tackling the entire issue of geriatric medical care, McElhaney said focusing on the transitions, such as entry to the hospital, is the first step.

The acute-care-of-the-elderly unit at Vancouver General Hospital is based on a successful model of care developed in the U.S., she said.

There is also a focus on seniors in the emergency department to ensure their needs are fully understood.

"It is to try and provide a little more comprehensive assessment in the emergency department to serve the needs of these individuals," said McElhaney. "You can't just hand them a prescription and send them home."

Elderly patients in major centres such as Vancouver may have better access to services, but outside of those centres, access can be sadly lacking.

"The challenge is that they [the elderly patients] usually have quite complicated needs and the treatment is difficult to access locally," said Dr. Chris Frank, president of the Canadian Geriatric Society.

"Multi-disciplinary approaches tend to be easier to access in larger centres and it leaves people having to travel quite far for treatment."

Frank is director of the Care of the Elderly program, clinical director of the Southeastern Regional Geriatric Program in Ontario, and an assistant professor in the medicine department at Queen's University with a cross-appointment in family medicine.

He recalled a recent patient who was in the hospital for "fairly basic physiotherapy and fairly basic occupational therapy," that wasn't available in his community.

"Realistically, if he had lived in Kingston he would have come to our out patient clinic a couple of days a week," he said. "Instead, his wife had to drive 21/2 hours each way twice a week, and at one time she had to sleep in their car because they were financially strapped. They were both in their late 70s."

Frank said when nursing staff learned of the woman's dilemma, they stepped in to help her find sleeping arrangements to get her out of her car.

gshaw@png.canwest.com

Article

I found this article today. Considering that I work with a lot of the "elderly" population, I was intrigued by the headline. It is true that a lot of people come into contact with others who might make them sicker, but some times, the GP isn't trained to see all the possible problems that arise. This article is yet another statement about how the medical profession has changed, how the shortage of physicans in certain areas is affected yet another large cohort of our population.

Key to elder care: Avoiding Hospitals

We need to keep the frail elderly 'happy and comfortable and home,' says Dr. John Sloane, who has one of the last house-call practices

Gillian Shaw, Vancouver Sun

Published: Friday, November 02, 2007

TODAY: A plea for proper medical home care as a far better option than hospital care.

SATURDAY: Home-care options that help keep ailing seniors where they want to be -- in their home.

It's a sunny fall afternoon and 82-year-old Rose Sorrenti turns her attention away from her afternoon television to point to a swollen and gaping wound on her calf the size of a baseball.

"My sister-in-law saw it and she said, 'you'd better get hold of your doctor and let him see that,' but I knew you'd be here," says Sorrenti, gesturing to Dr. John Sloane, who is perched on a nearby stool, his tablet computer open and ready for the scribbled notes that will record his patient's condition.

It's a somewhat complicated condition, as it is with most of the frail, elderly patients who make up Sloane's practice.

It is a practice that has taken him from an office to his Mercedes, appropriately enough a geriatric model itself, in which he tours around Vancouver seeing patients where they live.

In an age where "doc-in-a-box" drop-in clinics have replaced trusted family doctors making house calls, Sloane is from another era. And while a program out of Vancouver Coastal Health promises to continue serving his patients when Sloane retires in the new year, medical students aren't lining up to follow his lead.

Instead, many of them will end up being the doctors who see elderly patients when they land in emergency rooms and hospital beds, an outcome Sloane says is exactly counter to what the frail elderly need.

"As funding for reasonable coordinated home care of house-bound people has fallen, the venue of default has remained the emergency room," he said. "If you are in trouble, you push 911.

"Bang, in comes the ambulance and the person is hustled out and the next thing they know they are a bed-blocker in an emergency room.

"The truth of the matter is, the service of an acute-care hospital can't help the frail elderly, they just don't benefit. We have a frail elderly person occupying these terribly expensive and much-needed acute-care beds, and those people aren't benefiting.

"It all boils down to [the need for] an effective strategy for keeping the frail elderly out of the hospital."

"Frail, elderly" isn't defined by age as much as health.

"Once a person goes through a gate which we call frail, there is a linear deterioration punctuated by dying," said Sloane.

"Once they go into that situation, all of this preventative stuff, everything we do in hospital, most of the investigations are actually counterproductive and useless.

"What we need to be doing for those people is keeping them happy and comfortable and home. Nobody wants to spend a nickel on home care, but boy, is it cheaper than sending Granny through emergency."

People become frail through the irremediable inability to perform the activities of daily living. Many people may suffer that inability at one time or another, either through illness or an accident, but what separates the frail is that they will not get better. There won't come a day when they will be able to fend for themselves again.

If you fix stuff and the person goes right back to being normal like you and me, they are not frail," said Sloane. "Frailty and homebound-ness approximately coexist.

"My practice is homebound. All of my patients are frail and all of my patients are homebound and it is about the same group."

But when it comes to medical care, often the frail 85-year-old is treated as if he or she was 39 and all that is needed is for that broken hip to repair, or the heart problem to be stabilized and they'll be back up and running almost like new.

That doesn't happen. The 85-year-old stranded in the emergency department may suffer some form of dementia along with the ailment that landed him in hospital. He could already have several diseases from diabetes to Parkinson's to respiratory problems to a range of conditions -- a complexity that can overwhelm a medical system geared to dealing with what is wrong with a patient, not seeing the whole person and all the underlying issues.

"So what do we do with frailty is, you talk to them and get them to understand what is going on in their life," Sloane said. "We treat their illnesses from a medical point of view, we treat their disabilities, and we look after them psychologically.

"We do it at home and we do it on a primary-care level."

That, argues Sloane, is where the money should go and where the care should go.

"That kind of shutting them off from the acute-care system is the opposite of abandonment," he said. "Just ask any old person who has been in emerg in the last six months, or who has ever spent a couple of nights in hospital.

"They don't ever want to go back."

Sorrenti appears to share that sentiment.

"Oh, I hate that hospital," she said, recounting a litany of ailments from broken bones to heart troubles that have landed her in one hospital or the other -- some getting a better report from her than others and one clearly a target of her wrath: "I call it murdering hospital," she said.

Sloane ignores the jibes and, persuading Sorrenti to turn down the volume on the television, carries on his questions and examines the angry-looking wound. He calls in a prescription to the pharmacy from his cell phone and calls to arrange for a public-health-care nurse to come by to change dressings and monitor the infection.

Sorrenti, who looks younger than her 82 years -- "You should see me with my makeup and you'd think I was even younger," she says -- has definite ideas about checking out of this life and it doesn't involve hospitals.

"My mother had the perfect death," she said. "She went to sleep at 99 and didn't wake up."

At 88, Mary Goulah manages with the help of some home care, but she doesn't stir far from her chair in her living room -- certainly not far enough to get to a doctor's office.

"I had trouble with my feet for one thing," she said. "That was when he (Dr. Sloane) first started coming to see me.

"I wore him out, that's why he is retiring," she said with a laugh, her sense of humour clearly not dimmed by a range of ailments. "It's too much for me to go out to a doctor."

Sloane will likely be retiring before one of his patients, Jim Steele, does. The 91-year-old isn't quite ready to calls it quits with the wholesale bakery business he took on as a retirement project after his retail bakery closed.

One of Steele's sons was in school with Sloane in Kerrisdale from kindergarten on, and the elder Steele remembers the doctor as a young lad at class events.

Steele's balance is unsteady and he leans on a walker, but asked how he negotiates steep stairs at his premises, he is indignant.

"I walk up them just like any other human being," he said sharply when asked about the stairs Sloane aptly describes as "breaktakingly steep."

Paul Steele, another son, doesn't think Sloane can be easily replaced.

"It's going to be difficult if not impossible to replace people like John," said the younger Steele. "To find people with that experience in family practice and in gerontology, and who care enough to do this."

Watching Sloane care for his father, Steele is convinced that the health-care system would save money if there were more doctors ready to take on the care of homebound seniors. But it won't happen, he said, unless public policy makes it a worthwhile option for doctors.

"You have to make it attractive," he said.

gshaw@png.canwest.com

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What happens to our aging seniors with too few doctors to provide medical care?

The elderly are the fastest-growing segment of the Canadian population

Gillian Shaw, Vancouver Sun

Published: Friday, November 02, 2007

At a time when Canada's aging population means that seniors are Canada's fastest-growing population group and the fastest-growing segment is 85-plus, Canadian medical schools are barely turning out a handful of geriatric specialists every year.

Even young people are having trouble finding a family physician.

Where then does that leave the frail elderly, often with complicated medical issues that require much more time than the fee-mandated few minutes of an office visit?

They often find a visit to the doctor's office virtually impossible, and instead end up rushed by ambulance into overcrowded emergency departments when a health crisis hits.

Once in hospital, the situation can go from bad to worse. During a week in a hospital bed, they can go from being mobile to being unable to stand, let alone get themselves to the bathroom or do any of the things that were so vital to their independence.

The more fortunate elderly will have family to help navigate their way through the medical system.

But that takes its toll, with caregivers burning out. One elderly Ontario woman recently had to sleep in her car overnight while her husband was being treated for the after-affects of a stroke. They simply lived too far from the only centre that could provide the rehabilitation he needed, and she couldn't afford a hotel room.

The stress can bring out old grievances and sibling rivalries as the debate rages over just how to care for mum or dad. As one doctor points out, if your kids didn't get along when they were 16 and 17, they'll still be fighting at 50.

Medical care for the frail elderly doesn't stop with the doctor. Best practices suggests it takes a team, with nurses and social workers involved with doctors and specialists who get to know the patient and their circumstances and liaise with family or other caregivers. But unless you're fortunate enough to live in centre that has the services, plus live long enough to get to the top of the waiting list, you might be out of luck.

Faced with such an urgent demand for geriatric specialists, you'd think students would be lining up to fill the spots. They're not. Geriatrics is a poor cousin to the more lucrative specialties like cardiology or neurology. Students graduating with crippling loans have to maximize their incomes to pay them off -- not see one patient in the same time their cardiology colleague sees six.

Yet while students are steering away from a geriatric specialty, the reality is the average doctor will see more seniors than anyone else.

"Except if you are a pediatrician, the classes graduating now will spend 50 per cent of their time with people over the age of 65," said Dr. Laura Diachun, a geriatrician, associate professor of medicine at the University of Western Ontario and co-author of a study pointing to a shortage of doctors who practice geriatric medicine.

"Although 50 per cent of their time will be spent looking after people who are the age of 65, the amount of training they get in medical school is negligible."

Dr. Janet Gordon, a professor in geriatric medicine at Dalhousie University, did a survey of medical schools across Canada and found that students were exposed to anywhere from seven to 200 hours of geriatrics.

"In medical school, people do close to two years or more of classroom learning and then clerkship, on the floor-clinical learning," Gordon said. "Only half the schools have people do geriatrics even though all have them do pediatrics."

Gordon said in problem cases set for medical students at her university, she found only seven per cent of the cases had patients over the age of 65 and none included patients over 70.

"I think there is a belief geriatrics is too complicated to teach them early on," said Gordon.

Geriatrics is a complex and challenging field. It's not like a 40-year-old landing in emergency with a heart attack or pneumonia. Treat the problem in the younger patient and chances are the patient will be up and on his or her way.

For an 80-year-old, one ailment may be complicated by a range of other conditions. Is the confused patient suffering dementia or is the confusion coming from an infection and dehydration? If he's sent home after days in the hospital, is there someone there to ensure he eats? Takes medication?

In medical school, students spend days and weeks gaining pediatric experience. They spend only hours with the elderly. Yet the reality is that when they graduate, they are much more likely to be caring for old people than for children.

"The bottom line is this is not a sexy place to be," said Lynn McDonald, director of the Institute for Life Course and Aging and a professor in the faculty of social work at the University of Toronto. "It is not glamorous like brain surgery or saving children who are dying from leukemia.

"We live in an ageist society; there is the feeling, 'who cares?' They are going to die anyway. . . . There is no prize, no glory.

"It is hard, hard complicated work and it is work that requires many disciplines. It is an interdisciplinary team approach. Older people don't just have one problem, they have many problems, it is very complicated and there is a special knowledge base."

McDonald said when she first went to work in gerontology in 1970, no one even knew what the word meant. "Society is catching up, but not fast enough in my opinion," she said. "I think it was in 2001, seven doctors went into geriatric medicine in all of Canada -- we need hundreds."

Geriatrics is also lacking in nursing training, McDonald said, but the curriculum is so stretched there is little room for geriatric medicine.

"Maybe we get three or four nurses in the program a year," she said of a multidisciplinary program at U of T in aging, palliative and supportive care.

"That's not very many when you think most old people end up on the medical wards in hospitals and they end up in long-term care.

"Who's looking after them? People off the street -- that's who is looking after them, with a nurse in charge if you are lucky."

McDonald says in the United States, the John A. Hartford Foundation, dedicated to improving health care for older Americans, is putting millions of dollars into training professionals in nursing and social work in geriatric medicine.

"They know they are going to have an age wave," she said. "They are preparing and they are throwing money at the problem big-time, and it works.

"If you start to pay students for doing it, they are a lot happier than if they are doing it because it is noble."

Drawing on the Hartford example, McDonald wrote a proposal for a national centre of excellence in aging focused on the three professions that provide social, psychological and physical care to Canada's older population, the National Initiative for the Care of the Elderly.

We were shocked when we got this letter saying 'congratulations,' " said McDonald of the success of her proposal.

But the dollars are not lavish. While Hartford is pouring $25 million into a single profession -- nursing -- McDonald said that in Canada, by the time overhead is paid, there will be $1.6 million left for four years.

The centre has put together academicians and practitioners working with older people and is focusing on best practices, with the aim of providing community agencies and institutions across Canada the tools they need to work with them.

"That's turning out to be a big winner," she said. "People don't have that information in one spot."

The institute also has a mentorship program for students in gerontology from the three professions, and it pays their way to an annual knowledge exchange.

McDonald said one way to get people involved is to offer scholarships and money for students to do research.

"Once you start to do it you love it," she said. "People who are in gerontology and geriatric medicine love it.

"It really is a challenge; it is really exciting when you can make a difference for an older person and their family."

gshaw@png.canwest.com

GERIATRIC CRUNCH

- Adults 65 years of age and older are Canada's fastest-growing population group.

By 2021, Canada will have 6.7 million seniors; by 2041 it will be 9.2 million and nearly one in four Canadians.

- The fastest-growing numbers among seniors are those aged 85 and older.

- Life expectancy for Canadians is rising, now at 82.5 years for women, and 77.7 years for men.

- The median age of Canadians has been rising steadily since 1966. In 2006, it was 38.8, a record high, up from 37.2 in 2001.

- The proportion of people aged 80 and above increased by 25 per cent between 2001 and 2006 to reach one million, second only to the rate of increase of those aged 55 to 64.

- During the same time, there was a 22-per-cent increase in the proportion of centenarians in this country.

- Kelowna has the oldest population of any Canadian city, with 19 per cent being elderly.

- There are fewer than 200 geriatricians in Canada, but the estimated need is more than 600, a number that is expected to skyrocket as the number of people over age 65 doubles in the next 25 years.

- On average, four to nine residents enter a geriatric medicine specialty training program every year.

© The Vancouver Sun 2007

Being sick, especially on one's day off, is not fun. I was at work on Saturday doing the usual flow of the day. Spent a lot of time on one floor where a patient was dying. The family had asked that I do the service and assumed that it would not be long seeing the way the patient was failing. I told the family member that I would be back on Tuesday and she could contact me then about future arrangements. When I went home, I felt slightly nauseous, later with acute onset of nausea, vomiting and diarrhea. It lasted a little over a day. I have not had symptoms since returning from the doctor's. (Of course, one does not have symptoms... just like when you take the car to the mechanic...) But nonetheless, I have Norovirus Just as I suspected. I had been told by nursing staff that they had a few cases. This is fairly common occurrence in my workplace, happens 1-2 times a year. So as a result, I am not allowed to return to work until 72 hours after the last symptom. Which from what I can tell was earlier this morning. Of course, I haven't really eaten anything either.
So I was "resting" when I remembered that I had not yet called the church re: the memorial service. So I called to find out if I am allowed to have services for non-members, and the time, etc. Called the family member, gave more info, and my home number as I will not be at work tomorrow as previously stated... The patient is still with us.

You know, it is interesting. The dying process. There are certain generalizations and certain elements that are unique to each person. But inevitably, I will hear a question... why is this happening? What happens when it is all over (morgue and funeral protocol) when will this end? How long does this take? It is interesting really. It is different for every person. Some continue to fight/hang on.. while others declare themselves. One of my ladies decided to stop dialysis treatment, shocking many. The pain was too great for her, the quality of life not good, so she decided that enough was enough. I was visiting her on her last days. She asked me to deliver some items to some staff members "when I die tomorrow". Die tomorrow? don't talk like that.. No, she was firm. Tomorrow. And she was right. It is different with everyone. Every case has different issues, but in the end, the results are the same. Whether they were younger (50-60's) or at the end of the life span (80-90s). Life and death are interesting. And in the end, a soul is lost from us to join those who have gone on before.

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This morning, my husband and I went to the notary to begin the process of writing our will. We do not yet have children and there aren't too many assets to deal with, but it is better to write it sooner than later. One of the questions is whether a living will is be included. A will is a legal document, a living will is not, and hence a guideline for others to follow in the event that you cannot speak for yourself. My husband said if there is no brain function, than pull the plug, otherwise I want to live. For me, it is not that simple. I work in a hospital and see the various options. I understand the concept of quality of life (QL), and it means different things to different people. One man told me that QL for him was being to do his job... having his mind, another man's idea of QL was being able to go in the outdoors and go hunting.. his possible amputations would not be good QL. Irony is that despite this knowledge I haven't really defined what QL would be for me, nor have I written an advanced Health directive (aka living will), nor have I had a will. But then I'm young...