Reactive Care & Collateral Damage

By Benjamin E. Ruark

Western medicine’s shift from reliance on anecdotal accounts to evidence-based practice, however progressive it may be, nonetheless appears to have elbowed forward thinking even further from frontline medical practice. This can be said because Western medicine still maintains a rigid adherence to the concept of reactive care. A reasonable definition of reactive care comes from a Progress in Preventive Medicine journalarticle of January, 2017: The P4 Health Spectrum – A Predictive, Preventive, Personalized and Participatory Continuum for Promoting Healthspan. The authors define reactive care as: 

“initiating interventions once an individual is on the verge of or has actually suffered a negative health event.” They add, “However, with slowly progressing and often ‘silent’ chronic diseases now being the main cause of illness, healthcare and medicine must now evolve into a proactive system, moving away from a merely reactive approach to care.”

Health metrics and continuously updated evidence aside, healthcare’s singular reliance on caregivers’ monitoring to instigate further action fortifies the reactive care mode. What’s implied is that their hapless hands are tied until some next unavoidable shoe drops. Implicit from such a service bearing is a dormant mind-set in full acceptance of its own self-imposed intercession-inertia. Despite that it can lead to stagnancy of abstract thinking, in general. Therefore, inspiring a number of drawbacks in its daily wake: such as passively enabling incipient but detectable problems to gradually progress, undeterred; or to eventually precipitate due to their late-occurring nature. Such as not halting, early on, otherwise preventable complications from emerging to full-blown strength. All of which induces a rippling effect where higher medication dosages and more aggressive medical interventions then become necessary.

What routinely gets monitored are patient symptoms and reported side-effects from prevailing treatment interventions. A common denominator across most monitoring conditions is the temporal aspect: they’re currently present as reported by patients. Symptoms, then, become the major focal point and target for a patient’s medical management by healthcare staff. In a long-term care institution, such as a skilled nursing home, nurses rely on their aides to make periodic checks on patients’ symptoms. While the nurses, themselves, prepare periodic medication-dispensing rounds then made to patients in their assigned unit. Allowing for an eight hour shift to accomplish same, I would contend, leaves ample room to attend to proactive care as well.

Healthcare’s Collateral Damage Hub: Unattended to Patient Predispositions

Where do savvy practitioners turn to get reliable answers about preventive measures regarding possible biological, behavioral, physical, or psychological (bbpp) at-risk factors that patients may be prone to undergo? Specifically, any double-B, double-P threatening conditions at risk of: (1) developing sporadically or permanently in the near-/long-term, and (2) are known or suspected to correlate with a major or co-occurring health problem’s diagnosis or prognosis. The blindsiding answer is they have no place to go to get answers because those answers are out-of-mental-reach: they’re not on anyone’s mind because the underlying health problem is mainly either stealthily active or slowly emerging and mostly out of plain sight. Unseen until a patient either complains, or points to it; or the unaddressed health problem progresses to the visible extent of becoming remarkably obvious to all concerned. 

The name for this embarrassing breach of healthcare practice is Preventive Care of Patient Predispositions, a preventive intervention designed to detect patients’ predisposed co-occurring health anomalies early on so that they can be eradicated or mitigated.

Some health problems, such as Alzheimer’s disease, have over time identified and outlined their own disease-specific predispositions. However, ostensibly-known predispositions for many diseases and illness are not to be found, overtly, listed in black-and-white beside common symptoms in the countless articles that are published annually. Only through keyword searches using the term ‘predispositions’ or one of its synonyms is this searching tack likely to pan out.

‘Collateral damage hub’ refers to a copious center of inactivity due to widespread staff neglect at identifying and addressing patient bbpp-predispositions, and further allowing the insidious injury and suffering they incur to come to fruition. If a patient predisposition gets staff attention at all, it’s likely by afterthought; but presumably missed altogether by a majority of healthcare facilities. Medical staff are not oriented, nor trained, to think preventively along 3 threads: (1) patient ailments that coexist more or less under the radar, formally unnoticed. (2) Any existing co-occurring so-called ‘minor’ health problems and their possible interaction with a major diagnosed presenting health problem and/or its prognosis. And (3) which of these heretofore unaddressed patient predispositions merit keen staff attention. 

Those 3 missing threads of preventive care perceptibly infer that a much more comprehensive intake assessment will have been undertaken. Thereby yielding a clearer, fuller picture of everything going on with a particular (whole/bbpp) patient. Below, an abbreviated example is provided.

Jonathon Doe

Diagnosis/Prognosis Metastatic prostate cancer spreading to lower back and hip (pelvic bones). All cancer-targeted medication discontinued 1 year ago. Life expectancy unknown. In palliative care and treated with methadone for mitigating pain. Conventional end-of-life care emphasizes: a) physical comfort, b) mental and emotional needs, c) spiritual issues, and d) aiding with practical tasks. Patient’s outward appearance resembles that of any senior in fair health and fitness: however, this is a false-positive impression due to the power of the methadone.

Relevant Predispositions

Physical 1) Lower back is susceptible to acute pain surges in the 8-10 range. Pinched nerve in patient’s neck, sporadically triggered, causes acute (10 level) pain.

Biological 2) Oversensitive stomach lining (14+ years on medications) with occasional nausea and queasiness; dry heaves if on empty stomach for 30+ waking minutes (snacks kept on hand). Stomach and prostate are sensitive to carbonated drinks, citrus drinks, caffeinated beverages, overly spicy or rich foods, and over-/undercooked meals—which (along with stress) lead to digestive problems, IBS.

Physical 3) Wrist of right hand has tendon (possibly nerve) damage, making prolonged handwriting and certain practical tasks acutely painful.

Behavioral 4) Pattern of shallow breathing can sporadically induce borderline panic attack, shortness-of-breath, and claustrophobic tendencies.

Psychological 5) Patient is only relaxed under relative conditions of physical comfort, courteous/compassionate staff, and isolated from facility ‘hot spots:’ loud ambient noise from neighboring TVs and ‘animated’ special needs patients suffering from dementia and hearing impairment, with both them and staff being clamorous beyond acceptable—hence, highly stressful and IBS-inducing).

Care Implications for Staff 1) Patient shall refrain from: prolonged stooping; strenuous activity (e.g., changing bedding) of more than several minutes; and carrying objects 5/more lbs. over five meters. Staff will be alert to take over.

2) Patient to be administered medications only with meals. Kitchen staff are to serve bland meals, neither over-/undercooked.

3) Staff to preopen all lidded containers (except mail) of items delivered to patient (actually, all patients as sound policy). Staff are also alert to react to this patient as if his right hand was in a sling.

4) Patient is advised to ‘go for a walk’ and ‘start breathing deeply’ if he feels a sense of panic or claustrophobia developing.

5) Patient has been reassigned to quieter quarters, clearly away from loud ambient noise sections of his respective care unit; including from loud third-shift staff/activity late at night.

In this example, we have a patient who’s come to terms with his own mortality. His vulnerabilities weren’t life-threatening in themselves, but if they’d gone unattended to, they’d most definitely have been end-of-life harrowing. Now imagine patients who’re not as personally well-informed about their own health-related predispositions. Imagine them not being as articulate about various cause-effect and other pertinent factors surrounding their health-related predispositions. Imagine how long-term care staff are going to miss out on detecting many, possibly all, of those dots. Fail to connect them as needed. Imagine what that means for patients living out their final months. Worse, final years: a whole new layer of grief and hardship atop what they’re already suffering from, coping with. All because healthcare staff have failed to formally install and implement preventive care of patients’ predispositions as a new and formidable arm of their operation.

If reactive care weren’t so institutionally-ingrained—that is, it if were to afford preventive care relatively equal representation inside facility doors—then we could expect to see two lists of symptoms, instead of one, accompanying a patient’s care plan: per convention, their presenting problem’s symptoms and side-effects on one list. Next to that, the patient’s specifics on related bbpp-vulnerabilities as a second list. The second list would include how those susceptibilities get translated into staff actions and non-actions (based on the nature of a vulnerability) to be taken. No rational practitioner would argue that a preventive focus on patients’ predispositions isn’t every bit as valid and of prudent concern as conventional care’s reactive posture with patients’ existing symptoms. And by extension, that bbpp-preventive actions by staff need to be integrated into their patients’ daily functioning. Then we could expect significantly fewer patient sprains, reports of high stress levels, acute pain flare-ups, bouts of IBS, miscellaneous accidental injuries, GI complaints, extended pain and exceeded pain thresholds, and provocations of recovery-impeding moods, for example.

So, consider this new and fresh perspective-on-care to be the missing link that it is, in current healthcare practice. The hope is that enough newfound champions will coalesce to turn it into a mandated long-term care component in every patient’s treatment plan, regardless of facility type. 

As for researchers, this article’s premise invites the obvious research question for patients suffering a chronic illness or disease: what percentage of patients within a studied treatment population at some point exhibit unexpected or exacerbated ‘complaints’ or ‘complications’ that can be traced back as direct descendants of some heretofore unacknowledged predisposition?

References

Sagner, M.; McNeil, A.; Puska, P.; Auffray, C.; Price, N.D.; Hood, L.; Lavie, C.J.; Han, Z.; Chen, Z.; Brahmachari, S.K.; McEwen, B.S.; Soares, Marcelo, B.; Balling, R.; Epel, E.; and Arena, R. (2017). The P4 Health Spectrum – A predictive, preventive, personalized and participatory continuum for promoting healthspan. Progress in Cardiovascular Diseases, 59(5), 506-521.