HYANNIS – Two women in their late 80s, both alone and disoriented, arrived at Cape Cod Hospital emergency room (ER) by ambulance on the same day.
Patient 1: Didn’t know why she had been brought to the ER and could not articulate any complaints to the staff at the hospital. She was stable and the treating physician was unsure what exactly they were looking for diagnostically. Her daughter arrived hours later and said that her mother was acutely confused and yet had been playing bridge three days earlier. As soon as the ER team knew the patient’s level of confusion was not normal, they could quickly order appropriate tests associated with a change in mental status.
Patient 2: Was confused and unable to walk well. She could offer no specific complaints to her team in the ER. She had no apparent injury noted and it was unclear whether further testing was needed. About two hours later, her daughter phoned saying that her mother had been like this for two years. She had 24-hour care at home. Because there was no change in mental status, she was released.
Two similar patients had very different diagnoses and treatments, but both depended on accurate medical histories to identify the help they needed.
This explains the difficulty often encountered when the ER staff try to assess and diagnose elderly patients who are unable to communicate, said Craig S. Cornwall, MD, emergency medicine physician with Cape Cod Hospital.
“As an ER doctor, the best thing I can recommend is to have a paper copy of your health information and your living will somewhere readily accessible to EMS personnel. Something as simple as having it clipped to your refrigerator. Make sure that when an ambulance comes, the EMS personnel can easily grab your information and bring it with you to the hospital,” said Dr. Cornwall.
Your Medical History Form
The American College of Emergency Physicians has an easy-to-use Personal Medical History Form online that can be downloaded and updated as your health status changes. Dr. Cornwall recommends keeping your completed health information record on a computer and updating it, or having a family member update it, after doctor’s appointments, etc. It should then be printed out and easily accessible in an emergency.
“Keep it simple,” he said. “List medications, allergies, medical conditions, past surgeries (especially involving implants or pace makers), and physicians’ names and contact information. Make sure children’s or relatives’ names and contact information are also on the form.”
More than 15 percent of U.S. hospital emergency visits are made by patients 65 and older, according to the U.S. Centers for Disease Control and Prevention. But, according to Dr. Cornwall said the percentage of elderly patients coming to Cape Cod and Falmouth ERs is significantly higher than the national norm.
“In addition to the tourists that we see in the summer, we have a large geriatric population that resides on the Cape year-round, oftentimes without family close by,” he said.
Your Living Will
The best living wills are detailed and have been talked about with your loved ones, Dr. Cornwall said.
“It isn’t enough to write, ‘Do Not Resuscitate.’ That doesn’t tell ER doctors if you want things like advanced procedures, IV fluids or dialysis. There is a wide spectrum of things we need to know in terms of what your end-of-life care preferences are,” he said.
If you haven’t had an end of life discussion with your loved ones, then it’s difficult for them if they are asked to make tough decisions with just 10 to 15 minutes to decide in the ER, he said.
Recently, Dr. Cornwall recalled, a 94-year-old woman who came to the ER by ambulance in full cardiac arrest.
“It was clear we weren’t going to be able to bring her back to her functional baseline. Because no one came in with her and she had no living will, we had no choice but to place her on a ventilator. It’s harder on the family to withdraw life support after it’s been initiated. They came to the ER two hours later, and that’s what we had to do,” he said.
ER Tips for the Patient’s Family
Caring for an elderly person in medical crisis – especially a parent – can be extremely stressful. In addition to having a paper copy of the patient’s personal medical history and living will, the American College of Emergency Physicians offers these tips when taking a trip to the ER with your elderly parent:
• Anticipate Admission. Bring a change of clothes and some personal items in case your parent is admitted to the hospital. You can always leave them in the car.
• Convey Parent’s State of Mind. You know your parent better than the doctor. If he or she seems confused, explain to the physician what “normal” behavior is like. If the doctor is talking to you, make sure you are talking to your parent. Do your best to make sure they understand what is going on.
• Simplify Insurance Information. Have a single sheet of paper with insurance and identification information.
• Resist Downplaying: Realize that elderly patients often will talk down their symptoms to doctors or nurses and only tell it like it is to family members. Be ready to fill in the additional information if necessary.
• Bring Reading Materials. Having something to read while you wait for test results will help keep your stress level lower.
• Be Patient with Doctors and Your Loved One. Seniors tend to have more pre-existing conditions and less specific complaints, and it takes longer to work up the problems.
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