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Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light…
Dylan Thomas
THE LIGHT IS dying, not because of actual death but rather the life being removed from older people by state paternalism.
Paternalism is usually well-meant but often misguided and harmful to those that it purports to protect. It is not lost on me that none of our current senior government ministers dealing with this crisis is older, which is a relatively new departure in politics.
At the outset let me state that there is as much medical scientific evidence that cocooning the over 70s will end this pandemic any sooner, as lying in the sun will cure you of Covid-19. Cocooning is in place for two reasons, to protect older people and prevent our medical system from being overwhelmed.
I understand the need for this, but like many geriatricians, I am concerned as many recent patient interactions have made me question the ‘enforced’ cocooning of older people. We have reached the objective in the short-term. Our ICUs have not been overwhelmed and our system is still coping. It’s time to give older people a break.
Imagine an older, healthy and active relative or friend, one of the ones who ‘never sit down’. Their generation learned to be busy from a young age. There are many older people like this in Ireland. That person is missing out right now on the most basic of physical activity, all because of their age, and nothing else.
Too much to ask
Let me be clear here – I am fully behind the public health policy and the results achieved thus far have been remarkable with exceptional co-operation, but this mandatory cocooning expectation on one sector of society is a step too far in my opinion.
I have been disappointed that many a conversation on what should re-open first focused on the likes of golf and tennis ahead of the more immediate plight and needs of older people.
In the Spanish flu pandemic of 1918-1919, the fatality rate was greatest amongst young adults. This was an era before antibiotics and many people died from secondary bacterial infection. No one at that time suggested we cocoon younger people. That’s despite many older people doing better in that pandemic, maybe as they had survived many a previous bacterial infection.
There are many over 70s in Ireland who have lived through polio epidemics, tuberculosis, a world war, deep recurrent recessions, institutional abuse and bereavement. Many have held the responsible positions that have delivered the state that we all now live in. I think they can be trusted with the facts and take on board the personal risk to themselves.
Let’s be clear, it is not primarily older people spreading this disease. Cocooning is advice, yes, for the wellbeing of older people. Any disproving looks from younger neighbours should be quenched quickly by the deserving respect and empathy due to this generation.
They lived through very tough times and for a lot longer than you and I, reared us, educated us, healed us, financed us and are still working, helping with childminding, caring for family members and net contributors to society.
I think they can be trusted to act responsibly with the facts, weigh up the personal risks and follow public health messages, and probably more so than the 20 somethings on the radio telling us about how they find on-line dating great as they ‘really got to know someone‘!
Inequality
An older friend recently tearfully told me of their frustration at wanting to follow the public health advice and feeling absolutely obliged to do so as a responsible citizen while a slightly younger friend could take a walk or cycle or call around to other people’s front gardens.
Contrast this with groups of younger people gathering for drinks parties in the nearby parks. This person ran a large educational organisation. Are we seriously suggesting an older person must absolutely and indefinitely cocoon for their own benefit? They can’t decide for themselves?
What about older people living with spouses with dementia who don’t understand or remember there is a pandemic? Many older people are ‘voting with their feet’ by going for a walk. Providing they understand the facts and risks involved, that is something we should support as an age-respectful society, just as much as we are a race-respectful society, or respecting the right-to-choice society.
I love the tales I’m hearing in my work, of friends on the phone to older relatives being abruptly cut off as they dive into a ditch to avoid being seen, or conversely ensuring they are seen outside once a day to show the neighbour they aren’t that age.
Our older people don’t need to be taught wellness and how to cope by younger people who, quite often seem to not really have lived much themselves. They need to be allowed to exercise informed freedom of choice.
Most older people have learned wellness through experience, hard-won and self-taught resilience and a deeper understanding of themselves that innately advises them what is likely to work for them to improve a situation when challenged.
I always ask my father’s advice; he’s seen more and experienced more situations than me and maybe a starting point in wellness for everyone is to seek the advice of someone older you trust if you feel in trouble.
It is important to remember, as has been stated many times and shown in evidence, that the majority of older people will not die if they contract this illness and the illness will be mild.
It’s true that mortality is greater if you are older especially if you have heart disease, but it’s also greater if you are younger and overweight with high blood pressure. The fact that many older people are dying in nursing homes is a sad reality and the variables for outbreaks such as poor infrastructural design, inadequate health governance structures to residential care in Ireland, as elsewhere, and health-worker transmission has been well articulated already.
What is not as well articulated is that many older people in residential care are very frail with naturally very limited life expectancy. This is not permission to ignore and accept, but rather a recognition of gerontological reality.
We must also recognise that older people, like younger people, are not a homogenous group in any setting and care must always be appropriate and not dictated by age. Surely this also applies to public health advice and older people can be trusted as much as younger people to interpret the advice responsibly.
Professor Rónán Collins MD FRCP (Lond) FRCPI FESO is a Consultant Physician in Geriatric and Stroke Medicine at Tallaght Hospital. Follow him @ronancollins7.
My dad had a pacemaker fitted at a Dublin hospital, an overnight stay turned into 3wks as he was one of 3-5% who suffer pneumothorax during the Op. We honestly thought that we were going to lose dad due to the pain/suffering of having a chest tube inserted for 19days.
On the final day out of the blue the Consultant came to visit dad to give him the once over before discharging him. During this final examination the Consultant without prompting or being pressured offered a full unreserved apology for HIS personal mistake during surgery which led to dad’s pneumothorax.
He didn’t have to say a word and risked everything including a huge claim by admitting a mistake. We thanked him for his apology and not another word was spoken about it.
Always tell the truth.
There are some honest doctors.
@Martin Holohan: sorry is so important. An old boss once said to me: “the only way to avoid complications is not to do any surgery”. Complications don’t mean negligence. But, you have illustrated how important it is for care givers to just acknowledge what happened.
@Mrsuperiority: absolutely agreed and thank you for your comment.
@Mrsuperiority: absolutely agree but people/patients seems to forget that no matter how learned you are your still human and can make mistakes, and if you do your sued, and possibly end your career…wouldn’t do it!
@Martin Holohan: yes. Acknowledgement and accountability in most cases goes a very long way on so many levels.
Well said!
Unfortunatly we live in an age where people expect perfection and the media crucify you if you make a mistake.
@Brendan Cooney: even more unfortunate is we live in a country where the mortality rate post surgery is one of the highest in Europe
@Martin Hession: is that due to out poorer initial health, our unwillingness to take good medical advice?
@Martin Hession: stats please?
@daveyt: if you look up Ireland Post op death rate for non cardiac procedure we are the fourth highest in Europe, only doing better than Latvia, Poland and Romania! Our rate 6.4% in the UK its 3.2% and in Iceland 1.2%. Thats’s a lot of people. While everyone is obsessed with numbers on trolleys, these should be the figures we should be focusing on
@Brendan Cooney: I can’t speak for the thousands of other people who died post sugery (6.4% Ireland vs UK 3.2%) but I know of one case for certain it was neither.
@Martin Hession: the death rate following surgery in Ireland is not 6.4% or anywhere near that. That’s 1 in 15 patients. Again, please quote your source.
@Peter Moran: http://www.irishhealth.com/article.html?id=21091
@Martin Hession:
This mortality rate (6.4%) is incorrect and based upon an incomplete dataset. A separate study looking at the complete dataset on Irish patients during the exact same time period reported a mortality rate of 2.3%, well within reported international rates.
https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(13)62685-9.pdf
@Peter O’Leary: glad to hear that, I’m not someone who likes arguing on the Internet. But would the same criteria be used across all countries in the original study? Also interesting that when I put up the link not one
@Peter O’Leary: glad to hear that, I’m not someone who likes arguing on the Internet. But would the same criteria be used across all countries in the original study? Also interesting that when I put up the link not one
@Martin Hession: ^not one thumbs up, but when you posted the link that refutes the euro study four people gave it a thumbs up! So you have to ask did those people know about both studies or does it confirm a bias? But I do hope the Irish study for all Irish patients
Great article Dr O’Connor.
Unfortunately, many still won’t understand but I commend your effort.
Keep up the good work
@Disgruntled Doctor: I think most people understand the concept mistakes and imperfections in every field, even in critical areas like medicine. I think most doctors understand that family anger is the norm when things go wrong. And everyone understands fear of harsh blame. What we don’t understand is that the culture of denial and cover up is not being systematically tackled from within. In aviation, for instance , it’s all about ‘hands up’ from day one, and this is constantly pushed with reasonable success. If this became the cultural norm in medicine, insurance etc would have to adjust to a new business reality.
@Greg Blake: aviation and medicine are totally different, I know what you are trying to say that check lists and double sign off are gold standard which is fine with an aircraft of 300 healthy people and where the pilot and copilot are ultimately responsible for everything, they coordinate everything they do with a computer not a human being, if something goes wrong they can turn off the computer and fly by themselves, in medicine you have no computer (other than the windows 98 version that has never been updated) and each patient is different, with different signs and symptoms and very much different expectations not your bog standard 737 which pretty much takes off and lands by itself. And if pilots mess up they rarely have to deal with the consequences as they die with their passengers
I work for a gastroenterologist (NOT this one), some doctors can and do make errors, being so pressurized and overworked it’s almost inevitable…people forget they are human FFS, wouldn’t do the job for love nor money, the responsibility would wear me out!
@Jun Stone: then cut the salary and have more people.
@Conor Kleaver: you’ve done it! You’ve solved the consultant recruitment crisis. The answer was there all along – reduce the salary even further. Genius! Get this man into politics.
@Conor Kleaver: A figure of 6.4% mortality for noncardiac surgery is totally incorrect. The rate would only apply to the most dangerous procedures in the sickest patients,
@Conor Kleaver: Cutting the salary has not worked very well for Irish general practice.
@Vincent McDermott: http://www.irishhealth.com/article.html?id=21091
@Conor Kleaver:
Why cut the salary? And have less incentive for people to do an already highly pressurised, very difficult job a majority wouldn’t do? You make no sense.
thanks for speaking out. excellent article
@Joan walsh: Agreed. And like others above my son, as a baby, was in a certain unnamed hospital where he suffered a medical error leaving him with a small scar. The paediatric consultant sat my wife an I down from the outset and told us what happened, apologised profusely, and told us we had the right to take legal action if we so wished. We didn’t. We both felt they had saved his life and this was unwarranted.
No right thinking person goes to work with the intention of doing a bad job, no matter what their profession. Sometimes you just lose thought or get distracted and that small lapse in concentration will come back and bite you. Pressure and over work can kill/ ruin a job.
A really interesting read on this subject, ‘black box thinking’ by Matthew Syed, compares the medical and aviation approach to analysis of errors, worth a read
The report misses the wood for the trees. All the major errors were caught by the audit . Therefore a second blinded reading of the scans would have prevented all these errors. This is the most obvious conclusion of this review. Yet they scapegoat the radiologist because they can’t deal with the truth.
@Martin Schranz: the audit was actively looking for mistakes and given the time to look for them, 46000 scans is a monumental amount of scans to report on in a year, try looking at 46000 children’s paintings and see if you are 97% accurate at what is depicted, the human body like a child’s painting is different to everyone that reads it, there’ll be stuff you see and stuff you miss, the hope is that you see the detrimental signs to the patient, after all the patients health is all we are in this business for
@daveyt: thats why all scans should be double read. To protect the patient but also the radiologist. Wasn’t that my point ?
@Martin Schranz: my point was that the workload was ridiculous and if you want it to be double read then we need more radiologists, but that is not in our governments priority of providing mediocre health care at minimum instead of maximum health care as a basic human right
@daveyt: That is what I am saying , the HSE should be accountable for not double reading the scans. While this will be expensive it will still be much cheaper than running reviews and paying out compensation, and would safeguard both the radiologist and the patient.
@Martin Schranz: I am a radiologist in a hospital where we double read mammography and CT Colonography. The former because of the frequency of breast cancer, and the frequently subtle findings, the latter to keep up expertise. Despite that we have not achieved perfection. In the case of UHK where there were 11 significant misses out of over 46,000 interpretations, and there is a shortsge of staff to read studies even once, there is no possibility of recruiting enough staff to do this. There is an international shortage of radiologists with 10% of posts in Northern Ireland and 8% in the U.K. vacant.
Even if you instituted such a policy, I can guarantee there would still be a rate of misinterpretation. It would be a profoundly wasteful deployment of resources.
As for the usual cry of “This much never happen again”, I can guarantee you, it will, for the reasons detailed in Anthony O’Conner’s fine article, with which I completely agree.
@Martin Schranz: I can guarantee that the audit also missed some findings. Because that’s the nature of the business. I have occasionally reviewed studies I previously read and made a new observation. Same study, same radiologist, different date. Once while working in the US I picked up a difficult to see lung cancer hidden behind the heart on a chest X-ray, that had been missed by a number of radiologists. A few days later at a meeting with the clinical team, they asked me to review a chest X-ray and I thought it normal. It was the same X-ray on which I had detected the cancer a few days previously….
These things happen when you are working at the edge of human capabilities.
The best policy is to come clean from the very start.
I bet none of these hospitals are short of managers or the latest IT equipment.
Good piece
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