One in three patients over 70 leaves hospital less able to care for themselves than when they arrived. I am an internist. I have taught that number to my trainees. This fall, I watched it happen to my father.
Hospital-associated disability is not a rare complication. It is the expected output of how we run acute care. When researchers put accelerometers on hospitalized older patients – most of them able to walk short distances independently – they found patients spent 83 per cent of their time lying in bed, with a median of 43 minutes a day standing or walking. In low mobility carried roughly six times the odds of losing daily function or entering a nursing home; bed rest was ordered in a third of patients, with no documented medical indication in nearly 60 per cent of episodes. For healthy older adults – mean age 67 – reduced knee-extensor strength by 13 per cent, stair-climbing power by 14 per cent and maximal aerobic capacity by 12 per cent.
Hospital-associated disability is not a rare complication. It is the expected output of how we run acute care.
My father is 82. He is not a healthy 67-year-old volunteer.
In March, he was found to have a 15-centimetre mediastinal mass and large liver metastases. Prior to his diagnosis, he was swimming four days a week.
What followed was Canadian health care at its best. Thoracic surgery saw him within days, and he was referred promptly to the cancer centre in Edmonton. On pembrolizumab, the mass in his chest shrunk from 15 centimetres to three, with a partial response in his liver. We had been bracing for three or four more months with him. Metastatic thymic carcinoma is rare enough that his oncology team can no longer estimate his expected survival.
What will limit my father’s quality of life now is not his cancer.
A few weeks ago, at a routine oncology appointment, his oxygen saturation was in the 70s. He had pneumonia. An ambulance took him to hospital, where he waited more than 72 hours in the emergency department for a bed. Physiotherapy had been ordered, but no one could say whether physio sees patients in the ED or only on the ward. He was in limbo.
At the hospital where he waited, Alberta Health Services’ own weekly reporting shows only one in 10 admitted patients getting a bed within eight hours. In January, Edmonton emergency physicians called for a public health state of emergency, noting that admitted patients wait more than 70 hours for a ward bed. The province disagreed, opting instead to expedite discharges. The irony: a system measured on moving patients out is probably manufacturing the patients it cannot move.
When physio finally came to see my Dad, three days into his stay, he miraculously walked a lap and a half around the inpatient unit. Relieved, I went back to Toronto to work. Over the next 12 days, my father remained bedbound apart from two 10-minute physiotherapy sessions days apart. Much to my surprise, when I returned he had an evolving pressure injury and staff were asking me about an air mattress. To develop such an injury, a person must completely stop moving – the odds rise roughly fivefold once mobility becomes very limited. Roughly six in 10 hospital-acquired pressure injuries are judged avoidable.
His chart explained why. He had been deemed low priority for physiotherapy because of his cancer and his age. Each time we told a team member that he had been independent for walking, toileting and feeding, they seemed not to believe us. His tumour had shrunk by 80 per cent but his cancer was still being used, over and over, to justify leaving him in bed – and to discourage the one thing he asked of us, which was to take him home.
Best practice is not ambiguous. MOVE ON, the mobility program developed in Ontario and spread to Alberta, asks that patients be assessed within 24 hours and mobilized at least three times a day. The Hospital Elder Life Program, the delirium prevention model in use since 1999, specifies ambulation three times daily. On an Edmonton unit, a 2025 quality improvement project aimed to have patients dressed by noon and sitting in a chair for all three meals. My father got 20 minutes in 12 days.
The same holds for the critically ill. In a randomized trial of mechanically ventilated ICU patients, those given physiotherapy and occupational therapy from the first days of critical illness were far more likely to walk out functionally independent – 59 per cent versus 35 per cent. Delirium lasted half as long; across 498 therapy sessions, there was only one serious adverse event.
Palliative patients benefit, too. A 2023 meta-analysis of 14 trials and 1,034 adults with cancer receiving palliative care found exercise improved capacity and quality of life and reduced fatigue and pain.
What does not exist is any obligation. No Canadian accreditation standard and no national guideline requires that a hospitalized 82-year-old be mobilized. Australia’s delirium standard, which is tied to mandatory accreditation, directs clinicians to “perform mobilization activities at least once or twice daily.” Canada has no equivalent sentence anywhere. No one was uniquely accountable. Nurses told us to ask the doctors. Doctors said to ask physio. Physio told us nursing also should mobilize patients.
Out of frustration, we hired a private physiotherapist to see him after hours and on weekends. Canadian hospitals do staff physiotherapy on weekends – but at an 88 per cent reduction in service, triaged to chest physiotherapy and imminent discharges. The care manager told us this wasn’t permitted and posed a liability risk. Instead, the care team began questioning our visitors to establish whether any were “secret” physiotherapists. We were told we could no longer mobilize him ourselves because of liability. More institutional effort went into stopping us from getting our father moving than into moving him.
By then a pattern was obvious. Everything that went wrong was attributed to the cancer. Everything that went right was considered beside the point.
I don’t blame the physiotherapist who deprioritized my father, the physician who didn’t notice he was always in bed or the nurse who told my mother she was not allowed to help him sit at the edge of the bed. In a 2024 survey of Health Sciences Association of Alberta members, 67 per cent reported inadequate staffing and 89 per cent said the system is in crisis. Budget 2026 raised health spending 5.8 per cent overall – but diagnostic and therapeutic services, the line that pays for physiotherapy, rose three per cent, below the six per cent the Canadian Centre for Policy Alternatives calculates is needed to keep pace with population growth, aging and inflation.
Everything that went wrong was attributed to the cancer. Everything that went right was considered beside the point.
None of this is difficult to fix. Across 14 Ontario academic hospitals, MOVE ON was associated with a 3.4-day shorter median length of stay; when it was spread to four Alberta community hospitals, six per cent more of the older patients got out of bed. Here are five things every acute care hospital should do, especially for patients over 70:
Make mobility a vital sign. Every patient is “up as tolerated” by default unless there is a documented reason otherwise, and ensure this is recorded daily.
Fund the people who do it. Physiotherapy, occupational therapy and mobility aides are not discretionary. Staff them to the needs, including weekends.
Treat boarded patients as admitted patients. Anyone waiting days in the emergency department needs the same allied health care and accountable physician as a ward patient.
Make families partners, not suspects. A hospital that cannot deliver physiotherapy needs a clear, supervised pathway for family-arranged support – not a care manager at the bedside policing it.
Count the harm. Hospital-acquired disability is not in CIHI’s national hospital harm indicator and Alberta does not measure it. British Columbia has a provincial deconditioning program; Alberta has none. Discharge targets without function targets reward the wrong thing.
My father will leave hospital dependent for every activity of daily living that he could have done himself three weeks ago. I know this was preventable. But nobody loses sleep over an 82-year-old cancer patient losing his independence to a system that never believed he deserved it in the first place.
We will hire round-the-clock care and physiotherapy and try to give him back some of what those 12 days took. Even if he has only weeks or months left, we want them to be his.
Most families cannot resource this. Most don’t have a physician in the family who knows what to demand or the money for what the system won’t provide. If this can happen to my father, in a large urban centre where I trained, it can happen to anyone’s.
Alberta’s health-care system gave us a miracle in shrinking my father’s tumour by 80 per cent. Surely it can find someone to help him sit up in a chair.
