OTI Online
win/spring 1985

A Hospital is No Place For a Person Who is Ill
by Jane Cowles. Ph.D.

Today, many people are unaware of the scope, depth, possibilities and availability of health care in the home.

A historical review reveals that until the late 19th century, the home was the primary location for treatment of the sick. Patients were placed in the hospital only when they were impoverished and didn't have access to high quality medical care, defined as having a personal physician, and home circumstances that would permit the patient to remain in familiar, loving surroundings. Hospital patients were rarely afforded kind and caring treatment by the hospital staff. (Unfortunately, the problem of negative medical staff attitudes remains today for all hospital patients, regardless of their economic status.) Routinely, in a hospital setting, the patient is removed from her/his familiar personal surroundings, denied her/his loving family support and good food, and is transported to an environment that is impersonal, cold and foreign. As Norman Cousins said, "A hospital is no place for a person who is ill."

One major social trend since the late 19th century has resulted in a movement towards home care. Soaring costs - both to insurers and patients - make a stay in the hospital a financial burden for almost everyone. Few people can afford a long stay, unless they are fortunate enough to have extended coverage. Aside from finances, there are other social, medical and psychological reasons to consider home health care.

Holistic philosophy has taught us that the patient with an illness requires attention beyond the focused repair of a "defective" part of the body. Sadly, the "caring, healing" aspect of medicine has diminished considerably over the years, due to several factors. Hospitals have become larger and more technically oriented, commercial and depersonalized. Fewer nurses are staying in the field of nursing as they pursue higher education and go into more lucrative and prestigious areas of medicine.

Generally, physicians must spend a large portion of their time seeing patients in the office, therefore visits to the patient in the hospital are brief. The hospital schedule is run for the efficiency of the hospital and the doctors rather than the needs of the individual patient. It has been well documented in recent literature how isolated, depressed, and helpless a patient feels in the hospital. It has also been documented that the negative emotions of fear, anger, sadness and loneliness are not conducive for healing.

In New York City, we are fortunate that the resources available for caring for the patient in the home are almost unlimited. It is now possible to provide the sophisticated care of the primary care physicians and specialists directly to the patients where they live. Nursing care can also be divided into "specialty areas" such as cancer care and cardiac care delivered by Licensed Vocational Nurses, Licensed Practical Nurses or Patient Care Technicians. It all depends on the level of need of the patient after the assessment of her/his condition.

Often, in addition to direct medical care, other resources are also necessary. Housekeeping services can be vital to a temporarily or permanently disabled mother, so that she can maintain control over her home and family. Equipment such as beds, walkers, oxygen, braces, toilets, traction units, etc. can turn any bedroom into a care center for the patient. Almost all medications can be administered in the home including I.V.s, I.V. antibiotic therapy, routine chemotherapy and hyperalimentation (3000 calorie-a-day-feeding). Computer monitoring of the patient is now available in the home setting utilizing the "state of the art" capability to hook-up the monitor to a telephone line connected to a hospital or even the physician's office.

Physical therapy can be a routine support for the patient in the home, and will insure range of motion for the patient as well as help the patient to maintain total body strength. Occupational Therapy can assist patients with their individual physical limitations in a creative manner and help the patient to be as independent as possible.

Psychologists and social workers working within the home environment have a much greater opportunity to view their patients within the framework of the family structure and see how the members interrelate within the home, rather than in the artificial confines of a hospital. A professional working with family members as a unit often can provide a level of communication and understanding that previously had not existed within the family. It is initially important for the family and the patient to be as open and truthful as possible with each other. The psychologist and/or social workers can facilitate this interactive process through dialogue.

A dietician can be most helpful by reviewing the often complicated food delivery problems that exist when one member of the family must follow a special diet. The dietician can be invaluable in either teaching family members how to shop and cook for the patient's diet in conjunction with regular family fare; or by offering advice on alternative food choices, which can include suggesting I.V. or oral dietary support.

Patients who need blood drawn, cultures or other samples taken, can do so within the comfort of their own homes. When blood must be spun down, it can be spun in the home by a technician with a portable unit. Portable EKG machines are lightweight and the results can be sent over the telephone to a cardiologist's office or to a hospital center. Home x-ray is also a reality and, in some areas, vans that contain CAT scan machines can also come to the home.

In order to provide the homecare for a family member, it is vital that the patient's family, and extended family, understand what kind of role members should play, since family members are an integral part of the care team.

Some assessment must be made prior to establishing any homecare effort. Important to know is how ill is the patient, and what level of care needs to be provided? How old is the family member who will be the leader of the homecare team and how is his/her health? Does the family have outside support in order to avoid burnout, fatigue, or stress-related illnesses?

It is critical for all concerned that a team effort be put forth, with weekly meetings about the quality of care that has been provided and what suggestions can be made for improvement. These meetings should include input from any family member or professional team member who is working with the patient at home. Such topics such as pain relief, bed sores, psychological support, observations, and discussions about equipment are a must. Often, such communication can lead to a positive experience and substantial personal growth for the family. Techniques for temperature taking, dressing changes, exercises, and massages can be taught to family members so that they feel involved in the direct care of their patient.

The basic family home life should always be respected and not inundated with traffic made up of professional team members. No visits should be made without setting up a schedule that works without intrusion. The goal is warm and personal care for the patient.

Some examples of people who could benefit from homecare would be the following:

• An older man who has a cardiac disorder and needs an indefinite amount of care

• A child who is unable to attend school due to a physical disorder

• A cancer patient who requires chemotherapy

• The patient who has a serious fracture and is in traction

• Anyone who has a distressing mental condition

• A person handicapped by arthritis and in need of physical or occupational therapy

• Anyone who is under medical distress and has no family support

• A person whose only alternative would be a nursing home

• A patient who requires long term I.V. antibiotic therapy For patients who are terminally ill and unable to care for themselves or require the kind of total, constant care that few families can handle, hospice care can be a solution.

Initially developed experimentally in England, hospice care for the terminally ill has become a growing field in the 1980s. It can be provided in either a special hospital setting or at home.

In the institutionalized setting, no aggressive medical procedures or treatments are instituted, only palliative care is given, and the rules for family visitation are relaxed. In some facilities, provisions are made for members of the family to stay overnight.

In the hospice home setting, which, if possible, is more desirable for the patient, care is instituted with 24-hour, supportive, professional help. However, families should never try to accept the burden of this type of care without an adequate and complete support network of properly trained professionals. Stories abound about professionals not trained in the area of death or dying abandoning the patient and family in the last days of the patient's life. The complete hospice team usually includes a physician, psychiatrist, chaplain, nurse, social worker, and possibly others, depending on the patient's level of need.

It is clear that the benefits of homecare are more than just the cost savings of being out of the hospital. For the patients, care in their own homes means that they have more control and independence over decisions concerning their lives. Early discharge from a hospital can become a reality because support in the home is possible. It is much less draining on the family unit to have a patient at home, as they do not have to schedule their days and nights for complicated drives to the hospital, only to find on arrival that warm and loving contact with their ill family member is restricted.

The informed consumer of health care can evaluate new ideas and adapt and implement them within the framework of what is best for their loved patient. If homecare is their decision, they will have to instigate it from their physicians - perhaps even demand it. They may have to buck traditional concepts but the' results for the patient and family are truly worth it.


JANE COWLES. Ph.D. is the nationally famous author of "Informed Consent," a guide to treatment options in breast cancer. She is presently total patient care consultant to Professional Home Visits, a members-only service providing Manhattan residents home visits by Board certified/eligible physicians 24 hours a day. For information call 212/972-0900.

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