How hospitals consistently fail vulnerable patients

An 85-year-old woman is being sent home from hospital today. She had pneumonia, spending five days on oxygen. It was complicated because she already had heart failure and diabetes. Her medications were adjusted. She needs a walker. She lives alone. Her son is a two-hour drive away. She’s scared.

A version of this story plays out in hospitals across Canada every day. Our hospitals are failing to provide what patients truly need when they leave; the tools to reclaim personal responsibility.

A hospital admission works on three assumptions:

  1. Patients come to hospital for a perceived health need that cannot be managed elsewhere;
  2. Triage protocols weed out those who do not require hospital care; and
  3. Patients, if capable, will reclaim personal responsibility when they leave.

When a patient satisfies the first two assumptions, requiring hospital admission, a temporary dependency is created. This results in a transfer of responsibility from the patient to the hospital, for their immediate and future health. The vehicle for this shift is trust. Hospitals willingly accept this, as they house talented professionals who’ve spent their working lives preparing for these situations.

After their hospital stay, a patient ideally returns home, resuming independence. Doing so requires satisfying the third assumption. However, transferring responsibility back is not so easy. In hospital, responsibility is spread across multiple actors, all adept at their craft. Upon discharge, responsibility is placed solely on the patient and, if fortunate, their informal caregivers. The vehicle for this transfer is not trust; it is empowerment.

This is where hospitals are failing. They are right to assume that patients reclaim personal responsibility, based on the principle of autonomy. They are wrong to expect this will be done willingly or easily. The result of inadequate empowerment is a patient being woefully unprepared to manage themselves at home. More importantly, it leads to preventable human suffering.

What prevents hospitals from empowering patients? An overwhelming focus on money. In our publicly insured system, governments carry the financial risk for hospital care. To control spending, governments legislate hospitals to balance their books, working within constrained budgets. So, hospitals cut costs. Common tactics include closing beds, cutting staff, and reducing length-of-stay. Patients are sent home as soon as possible. There aren’t enough staff with enough time to help patients understand their transition home.

Lack of control over the entire spectrum of care is another challenge for hospitals. Frail elderly patients often require home care, convalescent care, or nursing home care after a hospital stay. Hospitals are at the mercy of third-party agencies, who control these resources. Staff can never be sure what a patient will be offered. Instead, they hope that a patchwork of services will materialize following the patient’s departure.

There is opportunity on both sides of the responsibility gradient. Patients must accept that hospitals cannot solve all of their health problems, and, so long as they remain capable, the onus for ongoing health maintenance will fall back to them. Funders and health professionals can help with this messaging. It should also be understood that although one can freely choose not to take responsibility, such a decision does not obligate anyone else to accept it.

On the hospital side, a critical eye should be cast on the alignment between stated values and daily reality. The search would quickly uncover routine instances where patients are not the foremost concern. Leaders must confront what is found with integrity and the desire to do better.

In a nation that prides itself on publicly funded health care, it is understood that society protects the health of its citizens by carrying the financial risk. This allows individuals to act without concern of financial ruin from health crises. This costs governments tremendously, but it is a business they ought to be in. The final opportunity is at this level. Governments are uniquely positioned to redirect the focus from balance sheets back to patients. If done, hospitals could properly afford to empower patients, resulting in healthier citizens and a more productive society.

Wellness Reductionism

Let’s begin with a subtle distinction between terms that are often conflated; well-being vs. wellness. I proposed a definition of well-being in a previous post. In short, it’s the sense of fulfilment, satisfaction, happiness, or alignment that we all seek. Wellness refers to the things we do to move toward well-being.

This is important to recognize, as there is an inherent conflict between the holistic and individualized context of well-being and the piecemeal wellness products we are sold.

The Wellness industry, like all others, exists to make money. The Global Wellness Institute estimated a market size of $4.2 trillion in 2017. The industry is overwhelmingly concentrated on nutrition (weight loss), fitness (gym memberships/subscriptions), and aesthetics (spa/anti-aging). Throw in some mind-body (yoga/retreats) for good measure.

The marketing is simple and effective: buy our stuff – feel better. And buy it we do. The trouble is that we don’t stop to think, during our hurried lives, that these wellness products are extrinsic, while the well-being we truly seek is intrinsic.

The Wellness industry applies a reductionist approach because it is profitable. It focuses on things we can change with products: what we eat, when and how we exercise, what we wear, etc. While optimizing these can improve our health, they do not address the foundations of our well-being, including our values, goals, purpose, self-identity, expectations, relationships, and more. This is the inner work, unique for each of us. Even harder to accept is that there is no quick fix on offer.

The pursuit of well-being is common to all of us. Our feelings about whether we are, or are not, achieving it form the essence of the human experience. What an incredible opportunity to explore and share our storied paths. The journey begins with awareness; awareness that our well-being cannot be purchased in shiny wellness packaging. Do the inner work. See the products for what they are. It might not be obvious at first, but you are the only one who knows what you need.