5 ms·

The truth we fail to face is that, in the grueling task of caring for the elderly and all the perverse incentives to cut corners, providing holistic care is an

by tbihl 5y ago

The truth we fail to face is that, in the grueling task of caring for the elderly and all the perverse incentives to cut corners, providing holistic care is an enormous labor of love that will tend to not work well outside of family, despite all the money we throw at it.

R0b0t1 5y ago
This is far beyond that. The doctors are brazenly prioritizing "not being bothered" over the health of their patients. Over prescription of antipsychotics is still common in US psychiatric facilities, and even if not there are alternatives, like very high dosages of SSRIs or other specific medications with complacency as a side effect.
- roenxi 5y ago
  If the alternatives are a doctor who cares and a doctor who doesn't then the choice is clear. But it is really difficult staying enthusiastic about treating someone, long term, who is never going to repay any extra efforts. Caring for the elderly/infirm is a really gruelling experience. It seems quite likely that there physically are not enough doctors who have the mental stamina to do that. The options the average person faces if they can't care for themselves are going to be doctors who don't really care, or nothing.
  - mindslight 5y ago
    Also, these facilities optimize down their number of employees to practically guarantee that they're all overworked. It's impossible to care in an environment like that - if someone has spare time to do anything beyond the rubric, then that is an avenue for optimization. The only thing holding them back is state regulations, and that doesn't make for a good outcome. This article strikes a chord with me. After a long hospital stay, I sent my father to inpatient rehab (aka "nursing home") for two weeks. Before he went, they told me I could do daily visits outside his window. After he was there, they made me schedule visits ahead of time with their "activities coordinator" who told me I was lucky to get twice a week. They didn't bother to make him do any of his therapy, rather they just let him lay in bed the whole time. They put him on a bunch of new meds to make their job easier, double dosed his biannual medication, etc. It was of course impossible to get anybody on the phone to talk about any of the details of his care (and not for a lack of trying). I only discovered the meds after the fact when I requested the records (which was also its own ordeal, and they're not even complete). Administratively though, they were on the ball. The intake paperwork pushed me to sign him up for a long term stay (complete with "sign here" highlights on patently unnecessary forms; I rejected them), and they wasted no time switching his insurance billing address to their own address. His stay ended abruptly one (early) morning, when they punted him back to the hospital with a dubious story. I believe it was because they knew his Covid test was coming back positive but didn't officially "know" yet, and this way they could keep their numbers down. After the second hospital stint, I just took him home despite the extreme burden. I hired some private helpers and between them and myself being extremely involved with the visiting nurses/rehab, he did much better. I would have paid for more bona fide sessions of rehab if I could have, but that's our inflexible system. If you have a good relationship with your family and one of them is in the position of "needing" a nursing home, it behooves you to save them from these horrible institutions that are mainly geared to milk their insurance. Even at decent hospitals and not during Covid, if someone else is not there and continually advocating, their care will be overlooked.
    - vxNsr 5y ago
      I’m assuming he was on Medicare, the gold standard insurance in the us?
      - mindslight 5y ago
        Yes, but a Medicare Advantage plan through a traditional "insurance" company. I think it got him better drug coverage and a few fringe benefits. I wasn't involved in choosing the plan, I just stayed the course because it was mostly working out. I don't believe that it affected his care. There were a fixed number of hospitals, inpatient rehabs, and visiting nurse associations, and they all took his plan. And I can't possibly see their behavior being different for a different payer - the incompetence was intrinsic to their deliberate bureaucracies. The only way to rise above would have been to find providers that didn't take "insurance" at all, such that the actual customer was the patient rather than another bureaucracy. The Medicare rules were limiting by fixing the amount of rehab sessions he got per week. The length of his care would have been limited too (discharge rules), but I advocated to extend him within the system. But any bureaucracy is going to be similar, and thus the only way to fix that would be neutering the whole "insurance" cartel and forcing the industry into radical price transparency. Which is basically the line I was straddling with the private pay helpers. What Medicare really helped with is making his copays sane and giving me solid footing to push back on billing fraud. For instance, one equipment supplier sent me a bill for 50% more than it should have been, and then shamelessly stood by their story on the phone ("you owe us this amount, so you need to pay"). I presume they successfully defraud many people that way.
        vxNsr 5y ago
        In general unless your parents had tons of money you can just be honest with them, the person is 90 years old on a fixed ss income, the likelihood of you getting a single dollar is 0%. Just stop trying. Also great for advocacy in the hospital when they wanna discharge and you feel they still need to stay longer. They’re not allowed to discharge without consent, they’ll claim that you’re on the hook OOP for anything Medicare won’t cover… but if the patient has no money, who cares. The social worker can yell till she’s blue in the face about fiscal responsibility but at the end of the day, the hospital will have to eat the cost and actually perform the rehab correctly. (Speaking from experience)
  - spaetzleesser 5y ago
    "Caring for the elderly/infirm is a really gruelling experience." I can see that in the facility where my parents live. Overall the place is fine but it's constantly understaffed and people aren't paid well. This is a way harder job than my much better paid tech job. I can slack off for days when I feel like it whereas the care personnel never can escape the grind. It's sad that these people get paid so little considering how psychologically strenuous their work is and how much human benefit comes out of it.
Gigachad 5y ago
IMO its a problem that we try to keep everyone alive at all costs disregarding quality of life. I would much prefer to just die before becoming incapable of basic tasks and being kept artificially alive.
- hansel_der 5y ago
  i hear you. unfortunately there are a lot of ppl in a situation where they did not declare that in time and we can't assume they would.
  - silexia 5y ago
    Most doctors don't accept this sort of end of life care. We should stop making it the default and make it elective instead. We treat animals far more humanely, allowing them to be put down when their quality of life goes down without much hope of improvement. Right now, if I want to avoid the nightmare fate of elderly or permanently ill people, I would have to commit suicide ahead of time. I would rather have a humane system that could take care of that when I am too far gone .
    - hansel_der 5y ago
      fact remains: everyone can opt-out
grapist420 5y ago
yeah but antipsychotics severely retard every mental process and have a high risk of permanent motor and intellectual disability (it really sucks to have tardive dyskinesia). There’s absolutely no reason that should be prescribed. https://freddiedeboer.substack.com/p/the-weight https://freddiedeboer.substack.com/p/the-weight Freddie explains it in this article - he deems it worth it for him to be able to keep a job and friends, but it is in no way called for for random old folks to be disabled like that to make them easier to handle
- robbiep 5y ago
  It’s actually tardive dyskinesia (I assume you may have thought that the tardative stems from retarded as in intellectual disability). As far as I am aware, this movement disorder does not have any causal relationship with intellectual disability. I agree with the principle behind your other points though, in an ideal world we would not prescribe these medications to the elderly to ‘aid in management’
  - grapist420 5y ago
    whoops. Looks like tardive actually refers to it developing late in the course of treatment, https://www.dictionary.com/browse/tardive https://www.dictionary.com/browse/tardive and dyskinesia refers to the actual disorder of movement

by tbihl 5y ago

R0b0t1 5y ago

This is far beyond that. The doctors are brazenly prioritizing "not being bothered" over the health of their patients. Over prescription of antipsychotics is still common in US psychiatric facilities, and even if not there are alternatives, like very high dosages of SSRIs or other specific medications with complacency as a side effect.

roenxi 5y ago
If the alternatives are a doctor who cares and a doctor who doesn't then the choice is clear. But it is really difficult staying enthusiastic about treating someone, long term, who is never going to repay any extra efforts. Caring for the elderly/infirm is a really gruelling experience. It seems quite likely that there physically are not enough doctors who have the mental stamina to do that. The options the average person faces if they can't care for themselves are going to be doctors who don't really care, or nothing.
- mindslight 5y ago
  Also, these facilities optimize down their number of employees to practically guarantee that they're all overworked. It's impossible to care in an environment like that - if someone has spare time to do anything beyond the rubric, then that is an avenue for optimization. The only thing holding them back is state regulations, and that doesn't make for a good outcome. This article strikes a chord with me. After a long hospital stay, I sent my father to inpatient rehab (aka "nursing home") for two weeks. Before he went, they told me I could do daily visits outside his window. After he was there, they made me schedule visits ahead of time with their "activities coordinator" who told me I was lucky to get twice a week. They didn't bother to make him do any of his therapy, rather they just let him lay in bed the whole time. They put him on a bunch of new meds to make their job easier, double dosed his biannual medication, etc. It was of course impossible to get anybody on the phone to talk about any of the details of his care (and not for a lack of trying). I only discovered the meds after the fact when I requested the records (which was also its own ordeal, and they're not even complete). Administratively though, they were on the ball. The intake paperwork pushed me to sign him up for a long term stay (complete with "sign here" highlights on patently unnecessary forms; I rejected them), and they wasted no time switching his insurance billing address to their own address. His stay ended abruptly one (early) morning, when they punted him back to the hospital with a dubious story. I believe it was because they knew his Covid test was coming back positive but didn't officially "know" yet, and this way they could keep their numbers down. After the second hospital stint, I just took him home despite the extreme burden. I hired some private helpers and between them and myself being extremely involved with the visiting nurses/rehab, he did much better. I would have paid for more bona fide sessions of rehab if I could have, but that's our inflexible system. If you have a good relationship with your family and one of them is in the position of "needing" a nursing home, it behooves you to save them from these horrible institutions that are mainly geared to milk their insurance. Even at decent hospitals and not during Covid, if someone else is not there and continually advocating, their care will be overlooked.
  - vxNsr 5y ago
    I’m assuming he was on Medicare, the gold standard insurance in the us?
    - mindslight 5y ago
      Yes, but a Medicare Advantage plan through a traditional "insurance" company. I think it got him better drug coverage and a few fringe benefits. I wasn't involved in choosing the plan, I just stayed the course because it was mostly working out. I don't believe that it affected his care. There were a fixed number of hospitals, inpatient rehabs, and visiting nurse associations, and they all took his plan. And I can't possibly see their behavior being different for a different payer - the incompetence was intrinsic to their deliberate bureaucracies. The only way to rise above would have been to find providers that didn't take "insurance" at all, such that the actual customer was the patient rather than another bureaucracy. The Medicare rules were limiting by fixing the amount of rehab sessions he got per week. The length of his care would have been limited too (discharge rules), but I advocated to extend him within the system. But any bureaucracy is going to be similar, and thus the only way to fix that would be neutering the whole "insurance" cartel and forcing the industry into radical price transparency. Which is basically the line I was straddling with the private pay helpers. What Medicare really helped with is making his copays sane and giving me solid footing to push back on billing fraud. For instance, one equipment supplier sent me a bill for 50% more than it should have been, and then shamelessly stood by their story on the phone ("you owe us this amount, so you need to pay"). I presume they successfully defraud many people that way.
      - vxNsr 5y ago
        In general unless your parents had tons of money you can just be honest with them, the person is 90 years old on a fixed ss income, the likelihood of you getting a single dollar is 0%. Just stop trying. Also great for advocacy in the hospital when they wanna discharge and you feel they still need to stay longer. They’re not allowed to discharge without consent, they’ll claim that you’re on the hook OOP for anything Medicare won’t cover… but if the patient has no money, who cares. The social worker can yell till she’s blue in the face about fiscal responsibility but at the end of the day, the hospital will have to eat the cost and actually perform the rehab correctly. (Speaking from experience)
- spaetzleesser 5y ago
  "Caring for the elderly/infirm is a really gruelling experience." I can see that in the facility where my parents live. Overall the place is fine but it's constantly understaffed and people aren't paid well. This is a way harder job than my much better paid tech job. I can slack off for days when I feel like it whereas the care personnel never can escape the grind. It's sad that these people get paid so little considering how psychologically strenuous their work is and how much human benefit comes out of it.

Gigachad 5y ago

IMO its a problem that we try to keep everyone alive at all costs disregarding quality of life. I would much prefer to just die before becoming incapable of basic tasks and being kept artificially alive.

hansel_der 5y ago
i hear you. unfortunately there are a lot of ppl in a situation where they did not declare that in time and we can't assume they would.
- silexia 5y ago
  Most doctors don't accept this sort of end of life care. We should stop making it the default and make it elective instead. We treat animals far more humanely, allowing them to be put down when their quality of life goes down without much hope of improvement. Right now, if I want to avoid the nightmare fate of elderly or permanently ill people, I would have to commit suicide ahead of time. I would rather have a humane system that could take care of that when I am too far gone .
  - hansel_der 5y ago
    fact remains: everyone can opt-out

grapist420 5y ago

yeah but antipsychotics severely retard every mental process and have a high risk of permanent motor and intellectual disability (it really sucks to have tardive dyskinesia). There’s absolutely no reason that should be prescribed. https://freddiedeboer.substack.com/p/the-weight https://freddiedeboer.substack.com/p/the-weight Freddie explains it in this article - he deems it worth it for him to be able to keep a job and friends, but it is in no way called for for random old folks to be disabled like that to make them easier to handle

robbiep 5y ago
It’s actually tardive dyskinesia (I assume you may have thought that the tardative stems from retarded as in intellectual disability). As far as I am aware, this movement disorder does not have any causal relationship with intellectual disability. I agree with the principle behind your other points though, in an ideal world we would not prescribe these medications to the elderly to ‘aid in management’
- grapist420 5y ago
  whoops. Looks like tardive actually refers to it developing late in the course of treatment, https://www.dictionary.com/browse/tardive https://www.dictionary.com/browse/tardive and dyskinesia refers to the actual disorder of movement