Four of us huddle around the computer: nursing manager, nurse practitioner, family doctor, and me, an urban family medicine resident transplanted to a remote northwestern Ontario town. The meeting is part of a new initiative at this long-term care home. Every two weeks, staff sit down for a comprehensive discussion about complex patients or challenges. The doctors, nurses, and pharmacists here are concerned that understaffing has led to overprescribing, with overworked caregivers resorting to medicating patients to manage agitation and confusion. The problem is exacerbated by remoteness: Government-funded home care here is limited and, with sustainable recruitment an ongoing challenge, staff can’t take a sick day without leaving colleagues floundering.
Today we are trying to help a 76-year-old woman with advanced dementia. She often naps during the day but becomes distressed and unable to sleep at night. At this point, both she and her caregivers are overwhelmed. This problem is common in long-term care and is labelled BPSD (behavioural and psychological symptoms of dementia). A pharmacist had flagged a locum’s recent decision to initiate lorazepam—a sedative in the benzodiazepine family, which includes Valium—to help the patient sleep. We bristle with righteous indignation: This medication increases the risk of falling, can induce delirium, and chemical dependence looms. The medication administration record documents failed trials of less-offensive sleep aids, including melatonin. The patient’s medical history—which includes an abnormal electrocardiogram and recurrent antibiotic use for bladder infections— further limits our medication options for sleep or agitation.
Then we notice that she sometimes receives low doses of hydromorphone, an opioid, for back pain. This feels more hopeful: We see an opportunity to stop a potentially harmful medication. With no contraindications to acetaminophen, we order Tylenol to be dispensed around-the-clock and discontinue the opioid. But before we can pat ourselves on the backs, the nursing manager raises a reluctant hand. “I wonder,” she says, “if sometimes the nurses are choosing hydromorphone for its sedating effects.” We are back to BPSD.
“Here’s a resource that emphasizes non-pharmacologic interventions for sleep,” I say, bringing up a recently published guideline for de-prescribing benzodiazepines. The section for behavioural management for insomnia instructs:
Go to bed only when sleepy.
Do not use… bedroom for anything but sleep.
Have the resident toilet before going to bed.
With only one nurse and three personal support workers caring for more than 30 patients overnight, it’s simply not feasible for each resident to be assisted into bed at their desired time. Capacity for supervised free time or organized activities is lacking, so less-mobile residents spend most of their days in the security of their bedrooms. We read on:
Offer back rub.
Any grandmother would give the same advice for trouble sleeping: Read a story, sing a lullaby, give a back rub. Of course we’d love to prescribe a back rub over a benzo, but our health care system tends to, paradoxically, render seemingly simple solutions impractical.
“I’ll discuss the risks and benefits of lorazepam for sleep with this patient and her family. Maybe we can offer it on a strictly as-needed basis,” says the family doctor.
“I’ll reassess her agitation and stay active on our goal to de-prescribe,” the nurse practitioner adds.
The nursing manager joins in. “I see this as an opportunity for team education. Opioids are simply not first-line for pain, and are never appropriate for managing behaviours.”
It’s our best attempt at evidence-based medicine within the restrictions of our under-resourced system.
I leave the meeting with more questions than answers. Does “prescribing away” problems become acceptable when low-tech guideline-based solutions seem next to impossible? How do we avoid burnout when we are constantly reminded how far from the target we are? How do we retain health care workers in positions that have them overextended? These questions implicate underlying systemic issues: poverty, caregiver stress, the geography of inequitable service access, a profit-driven pharmaceutical industry, and the fickle priorities of politicians.
I pull myself out of this cognitive downward spiral. Here I’d met three providers dedicated to the health and dignity of their community’s frail elderly. By capitalizing on an opportunity for team-based problem solving, they were already making progress. Today, for instance, a single chart review not only resulted in the beginnings of a plan for this patient’s complicated problem, but had also helped highlight larger patient safety and resource issues. The response—to plan teaching sessions rather than enact punitive measures—was forgiving and forward-thinking. Our meeting reminded us that simple, common-sense approaches to complex problems can and should be incorporated into our care plans wherever possible. Now when I work with patients and families struggling with BPSD, I routinely make a point of encouraging the seemingly small acts of care that they instinctively provide, like back rubs, and validate them as not just therapeutic, but invaluable.
Our health care system is staffed by compassionate people, but working within its restrictions can easily breed cynicism. In rural Ontario, I experienced many moments where the simple solutions seemed beyond reach. But I also saw providers teaming up to close the gap between optimal care and current circumstances. They asked: “When more is not available, how can we do better with less?” I am by no means suggesting that we accept the status quo. Quite the opposite—I believe that redressing systemic health inequities requires looking beyond the traditional scope of health care to address societal injustices including under-housing, inequitable access to education, the racialization of incarceration, and reconciliation with Indigenous peoples. The mission is massive and demands unprecedented collaboration. I’ve learned, however, that while feeling overwhelmed and dissatisfied may be inevitable for health care providers, hopelessness is not.
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The 13 years I’ve been a nurse I struggle so hard with the “How can we do better with less.” And when I say struggle, I mean it makes me unbelievably angry and sad. Since my first two years as a nurse I’ve been looking for a way out. I love caring for people, but “doing better with less” in the richest freaking country in the world is just stupid. While I certainly appreciate your professionalism, I’m tired of those of us in healthcare being cool, calm, and collected in the face of such atrocities. We need to stop referring to the current state of healthcare as “challenging” and be more brutally honest about it….like with some major cuss words and descriptors that pain this nightmare as it is.
Weve been looking through your articles or blog posts on this site for at some time. This really is our very first comment. Your current blog is very helpful for me and it supplies top notch content material.
An excellent article. This isn’t about under-resourcing, more about bringing together the caregivers to think and discuss what’s going on with the patient and what happens in the care setting.
I take issue with the headline that assumes we are under-resourced. We know our system is actually well financed. We spend lots of money but there are problems with how it is spent, where it is spent etc. Spending more money in a system that doesn’t address those challenges simply means we spend more money and get the same results.
Your article shows how some thinking, coordination and compassion can make improvements without raising the fight about money. Well done.
The family involvement is a good idea, giving a back rub, keeping the family member/patient more active during the day ie. walking or being more engaged. I like the behavioural management of insomnia Would the patient then be more appropriately ready for sleep? ( not napping during the day) Offering more fluids during the day might get away from recurrent bladder infections.
This is beautifully written to describe a problem so true in long term care. It is easier to prescribe a pill than to implement any non drug measure. As a pharmacist, I have work with various long term care facilities to reduce use of antipsychotics. I found it most effective to engage the PSW who know the residents at a personal level. It’s a lot of talking and discussion to realize pill isn’t the answer but scarce resource also prevent giving each resident individual attention for back rub, talking or social interaction. It is even more work to deprescribe.
You have articulated the issue beautifully! I will share with my colleagues and team members in geriatrics in Calgary as I think what you have written will resonate with them.
Here is the ugly truth, if there is no family actively caring of the individual and helping out we will never have enough staff to take care of individuals. It is pragmatically impossible.
People are trying to outsource basic care like back rubs and social interaction to someone else. This is a deeper issue here that is plaguing the mindsets here in the west.
We are trying to force staff to act like family and friends. That is impossible or unsustainable and unfair.
We can’t keep expecting providers to be superheroes or miracle workers. I know many of them who are and then they burnout. It’s unfair and oppressive.
Ali, thank you, you nailed it! I used to be a practical nurse in nursing homes, working 12 hours shifts back-to-back for over 5 years, when my health started to fail me. The TRUTH is, indeed, people are “outsource” onto a system half the number of patients, and growing smaller, without so much as a question: “what can the family do to help?”. There is only the expectation for the system (There is the thinking aloud that sais: they are paid for it, after all) to “manage or fix” their problem, without family involvement. Which of course, is totally insensitive but mostly totally unreasonable.
The second truth is, … many of the patients have … no family, at all. I will probably be one of these statistics!? Then, the “system’s” expectation for shared involvement becomes … redundant!
It’s sad, and quite complicated. The reality is, if the government doesn’t create a comprehensive & STRATEGIC (based on country’s logistic needs) open doors policy to immigration, Canada’s over 50s today’s population is going to be in great trouble in another 20 years, maybe sooner. No amount of feelings, compassion, can cope with overwhelming numbers of people that will effectively “innundate” homes with no one to care for them. This is not “looking at the glass half-empty”, but a call to action, as the facts have already started to show up, for the past 10 years.
Loved this piece. Evidence-based common sense.
Practising in remote, under-resourced environments keeps us tertiary academic physicians humble and reminds us of the paramount responsibility in advocating to better the social determinants of health.