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.