A Doctor’s Perspective on Long Term Care
By Heather Hunter
As a senior, I am filled with dread at the thought of ever having to go to a nursing home. However, I do not want to be a burden on my children if I become incapacitated. In her classic Canadian novel, The Stone Angel, Margaret Lawrence poignantly depicts the feelings of Hagar Shipley, the 90 year old protagonist, when she overhears her son and daughter-in-law, themselves seniors, planning to take her to Silver Threads nursing home. Anything to avoid this fate, Hagar promptly boards a city bus and runs away with no destination in mind. When my neighbour’s son placed his mother in a nursing home against her wishes, she found her way back home only to be returned a.s.a.p. She told me, “I’ve been incarcerated.” Another resident summed up his opinion: “Nursing homes are jails for old people.” Surely, it doesn’t have to be this way.
Nursing home wards, called home areas, generally house 28 to 32 residents and typically have only one Registered Practical Nurse (RPN) in charge and two Health Care Aides (HCA) or Personal Support Workers (PSW) on duty. Their physically demanding work includes washing, dressing, toileting, administering medications, feeding and other tasks scheduled within impossible time constraints. Stress from overwork and low pay is the underlying cause for neglect and poor treatment. A few workers, psychologically unsuited to the job, lose their patience with non-compliant or helpless residents resulting in verbal or physical abuse. With luck they are caught on camera by family members and fired.
The government’s reaction to mounting complaints has been to hire more inspectors rather than more front line workers who understand the challenges of the job but are excluded from discussion and decision-making. The ministry’s response to whistle-blowers has been to increase scrutiny of doctors, nurses and personal support workers, the scapegoats. The root cause of the systemic problems in Long Term Care is inadequate funding and staffing.
Dr. D. describes the conditions in the LTC homes where he worked for 23 years:
Malignancies are common conditions of residents of long term care. We would get “emergency admissions” who were palliative patients who couldn’t get into a hospice because those places were full. These were heavy care patients who often survived only two or three days, putting more strain on the overburdened staff. Most patients have more than one serious diagnosis; some have half a dozen. Many of our patients, had they been born a generation earlier, would not have survived this long to accumulate such a heavy burden of chronic disease.
The issue of bedsores has always been a serious problem and the main reason is not enough staff to prevent or treat them. In my homes most of the bedsores were already there when the patients arrived from the hospital, clear evidence of neglect. More than half of the bedsores on heels and backs were the result of fairly brief hospitalizations for pneumonia or broken hips; patients went into the hospital with healthy skin and came back to us with major breakdowns. They also returned having eaten nothing because they were not capable of feeding themselves and hospital staff did not assist with this.
All of the residents are incapable of any degree of independent living. Such chronically ill people, having weak immune systems, are very susceptible to contagious infections and so do poorly with seasonal influenza and now COVID-19, hence the high death rates. The losses during the pandemic are not surprising in the nursing home population given their advanced age and frailty.
NH patients are living in densities far higher than exist in the rest of the community. Four persons sitting at a small dinner table for two hours three times a day is a recipe for spread of infections. With multiple residents to a room, it is nearly impossible to isolate infected patients.
Periods of no supervision occur. For example, the RPN may be undertaking a complex sterile dressing change, while two PSWs are engaged with a patient who needs a mechanical lift in order to use the toilet and must be supervised until detached from it. The problem is that using the lift to toilet a patient or to transfer them from bed to chair takes two staff members out of circulation for considerable time, so they cannot help elsewhere. Wandering patients cannot be restrained physically or chemically and they are not under constant supervision because of low staff numbers. Bad things can happen elsewhere on the floor when everybody is busy.
Funding demands that many staff are part-time or casual because they cost less and have no benefits. To achieve full-time hours and a living wage necessitates working in two or three nursing homes. These workers are less inclined to feel a sense of duty or loyalty to a facility and their movement facilitates the spread of infections.
The high turnover of staff in nursing homes is a major problem. In one of my homes, over a two year period, the entire staff changed including management. Patients benefit from a consistency in routine and in those delivering their care. When the turnover is high, this source of comfort is denied them.
Most of the 30,000 recorded complaints or violations over the past five year period were trivial. For example, one of my homes was cited for using the word, “squares” on the dessert menu when the actual items were round, which required a multipage document to be filed with the government using up valuable management time. The anonymous snitch line maintained by the Ministry of Health and Long Term Care allows anyone at any time to lodge a complaint, no matter how trivial or malicious, secure in the knowledge that it will be investigated by “Compliance Advisors”. There are no consequences for the complainant if the allegation is an outrageous exaggeration or lie.
Dr.D.’s frustration with the government’s approach to LTC eventually culminated in his decision to retire. One good thing to come out of the pandemic is the exposure of the abysmal failures in nursing homes caused by underfunding. With public awareness, the government can no longer turn a blind eye to this national disgrace. Thankfully, the ministry has recently mandated 4 hours of direct care per patient per day to be phased in over the next 4 years which will require the hiring of thousands of people to meet that obligation in Ontario’s 630+ nursing homes. Let us hope that the caregivers will be qualified and compassionate and able to earn a decent livin