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Some social factors contributing to the prolonged hospitalization of chronic disease patients in a general… Chatwin, Mary Kathleen 1947

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Some S o c i a l Factors C o n t r i b u t i n g to the Prolonged H o s p i t a l i z a t i o n of Chronic Disease P a t i e n t s i n a General H o s p i t a l by Mary Kathleen Chatwin A Thesis submitted i n P a r t i a l F u l f i l l m e n t of The requirements f o r the Degree of MASTER OF SOCIAL WORK i n the Department of SOCIAL WORK The U n i v e r s i t y of B r i t i s h Columbia October, 1947 ABSTRACT of Masters Thesis Some Social- Factors C o n t r i b u t i n g to the Prolonged H o s p i t a l i z a t i o n of Chronic  Disease P a t i e n t s i n a General H o s p i t a l by Mary Kathleen Chatwin DEPARTMENT OF SOCIAL WORK The U n i v e r s i t y of B r i t i s h Columbia October, 1947 Some S o c i a l Factors C o n t r i b u t i n E to the Prolonged H o s p i t a l i z a t i o n of Chronic  Disease P a t i e n t s i n a General H o s p i t a l ABSTRACT In the c o n s i d e r a t i o n of chronic i l l n e s s e s , s o c i a l , emotional' and economic f a c t o r s are as important as the purely medical ones i n determining the needs of the p a t i e n t s . Since h o s p i t a l personnel b e l i e v e that pro-longed care of chronic p a t i e n t s i n a general h o s p i t a l i n v o l v e s a waste of h o s p i t a l f a c i l i t i e s , i t would be of value to discover some of the s o c i a l f a c t o r s which are c o n t r i b u t i n g to the prolonged h o s p i t a l i z a t i o n of a group of chronic' disease p a t i e n t s . Chronic diseases were defined as those which are i n s i d i o u s i n onset, progressive, u s u a l l y long term, and from which there i s never complete r e s t o r a t i o n to normal. W i t h i n t h i s meaning of chronic i l l n e s s , as a r r i v e d at through c o n s u l t a t i o n , the three r e s i d e n t i n t e r n s of the Royal Alexandra H o s p i t a l , Edmonton, s e l e c t e d a l l the chronic disease p a t i e n t s i n the medical, s u r g i c a l and c h i l d r e n ' s s e r v i c e s , on J u l y I 5 i 1946. Data about these eighty p a t i e n t s were c o l l e c t e d from t h e i r h o s p i t a l f i l e s , through correspondence w i t h the attending p h y s i c i a n s , and through a case work i n t e r v i e w , adapted to the i n d i v -i d u a l s i t u a t i o n . Long term h o s p i t a l i z a t i o n was a r b i t r a r -i l y defined as t h i r t y days s t a y . According to d e f i n i t i o n forty-two of the eig h t y p a t i e n t s were long term chronic disease p a t i e n t s . These p a t i e n t s were grouped according to the type of care they r e q u i r e d ; a c t i v e medical, nursing or c u s t o d i a l ; and the data were then analysed to f i n d what s o c i a l f a c t o r s were c o n t r i b u t i n g to t h e i r prolonged h o s p i t a l i z a t i o n . The greatest s i n g l e c o n t r i b u t i n g f a c t o r to extension of ' h o s p i t a l i z a t i o n was the f a c t that twenty ( f i f t y percent) of these p a t i e n t s had nowhere el s e to go. A combination of f a c t o r s such as, no f a m i l y , f a m i l y u n w i l l i n g , unemployment, old age, l a c k of e a r l y medical care and i n s u f f i c i e n t comm-u n i t y f a c i l i t i e s f o r t h e i r care, were found t o be c o n t r i b -u t i n g to t h i s problem. Although s t a t i s t i c a l a n a l y s i s or t a b u l a t i o n was not found p o s s i b l e , grouping according to the needs of the p a t i e n t s was i n d i c a t e d i n order to account f o r prolonged h o s p i t a l i z a t i o n , where an adequate medical s o c i a l plan could not be arranged outside the h o s p i t a l . Of the fourteen p a t i e n t s r e q u i r i n g a c t i v e medical care, f i v e were i n need of a s p e c i a l , prolonged type of care not a v a i l a b l e elsewhere; i n three cases treatment was not known; and i n s i x instances medical care was not a v a i l a b l e u n t i l too l a t e i n the progression of the disease; due l a r g e l y t o the inab-i l i t y of these p a t i e n t s to pay f o r i t . Of the t h i r t e e n p a t i e n t s r e q u i r i n g n u rsing care only; s i x lacked f a m i l y f a c i l i t i e s f o r care, and n u r s i n g or boarding home placements were not a v a i l a b l e ; the remaining seven had homes but nurs-in g care was not a v a i l a b l e to them because of the expense and the s c a r c i t y . F i f t e e n p a t i e n t s remained i n h o s p i t a l a prolonged time, though not r e q u i r i n g medical or s k i l l e d . nursing care. Nine of these p a t i e n t s remained longer than three months, and two of them longer than seven y e a r s . These p a t i e n t s required a c u s t o d i a l type of care, not only f o r med-i c a l reasons, hut because poverty made home care impossible. In s i x of the forty-two long term cases, h o s p i t a l i z a t i o n was expended because of inappropriate treatment, which was u s u a l l y due to the f a i l u r e of the p h y s i c i a n to t r e a t the pat i e n t as a whole. I t was obvious throughout that 1here i s a great need i n the community f o r f a c i l i t i e s f o r the care and treatment of the chronic s i c k , who do not a c t u a l l y r e q u i r e treatment i n a general h o s p i t a l . Perhaps more important at the present time,wis the i n d i c a t i o n of the need f o r medical s o c i a l workers to insure the use of the e x i s t i n g f a c i l i t i e s i n the community to the best advantage of these p a t i e n t s ; TABLE OP CONTENTS Chapter- Page 1 INTRODUCTION 1 ~" ( l ) Background of the chronic disease problem- nature and prevalence-studies done. (2) The h o s p i t a l ' s problem- e x i s t i n g XI f a c i l i t i e s inadequate- economic maladjustments- s o c i a l and emotion-a l maladjustments. (3) Medical S o c i a l Work as i t r e l a t e s XV111 to the c h r o n i c a l l y i l l - the medical component of s o c i a l work- f u n c t i o n i n h o s p i t a l s - s p e c i a l needs of the c h r o n i c a l l y i l l . I T SCOPE AND METHOD 1 111 LONG TERM PATIENTS REQUIRING ACTIVE MED-ICAL AND DIAGNOSTIC TREATMENT 7 need f o r medical care, s p e c i a l treatment- f i n a n c i a l i n a b i l i t y to pay- the e f f e c t s of poverty- inr adequate medical s u p e r v i s i o n . IV LONG TERM PATIENTS REQUIRING SKILLED NURSING CARE 17 l a c k of nursing care and a l l i e d s e r v i c e s - need f o r p e r i o d i c med-i c a l s u p e r v i s i o n of the m e d i c a l l y i n d i g e n t - misuse of the general h o s p i t a l as a nursing home. V LONG TERM PATIENTS REQUIRING CUSTODIAL CARE 26 no longer a medical problem- i n -s u f f i c i e n t i n s t i t u t i o n a l f a c i l i t i e s and medical s e r v i c e s f o r the aged s i c k - poor adjustment to p h y s i c a l l i m i t a t i o n s , h o s p i t a l i t i s • VI SHORT TERM AND POTENTIALLY LONG TERM PATIENTS 37 no s i g n i f i c a n t d i f f e r e n c e between the long term and the p o t e n t i a l l y long term groups- poverty- need f o r medical research and s p e c i a l med-i c a l treatment- l a c k of f a m i l y and community f a c i l i t i e s . V l l PACTORS CONTRIBUTING TO PROLONGED HOSPITAL-IZATION 43 TABLE OP CONTENTS (continued) Chapter Page nowhere el s e to go- need f o r medical care, e a r l y and s p e c i a l i z e d - need f o r nursing s e r v i c e s , v i s i t i n g nurses, nursing and boarding homes- need f o r c u s t o d i a l f a c i l i t i e s f o r the aged and i n c a p a c i t a t e d - need f o r medical s o c i a l work. v T l l APPENDICES (1) Sample of schedule used f o r the c o l l e c t i o n of data. 48 (2) The Royal Alexandra H o s p i t a l and the community served by i t . , -51 (3) Tables 57 ( i ) The d i s t r i b u t i o n of 80 chronic disease p a t i e n t s i n the Royal Alexandra H o s p i t a l , J u l y 15» 1946, by c l a s s of care required and s e r v i c e . ( i i ) The d i s t r i b u t i o n of 80 chronic disease p a t i e n t s i n the Royal Alexandra H o s p i t a l , J u l y 15,1946, according to leng t h of h o s p i t a l -i z a t i o n and c l a s s of care. ( i i i ) N u m e r i c a l d i s t r i b u t i o n , by c l a s s , of 42 long term chronic p a t i e n t s according to method of f i n a n c i n g care i n the Royal Alexandra Hospi-t a l , J u l y 15, 1946. ( i v ) L i c e n s e d i n s t i t u t i o n s i n the c i t y of Edmonton f o r the care of the Aged, I n f i r m and C h r o n i c a l l y i l l , J u l y , 1946. (4) B i b l i o g r a p h y 64 ( i ) Selected references ( i i ) General references SOME SOCIAL FACTORS CONTRIBUTING TO THE PROLONGED HOSPITALIZATION OF CHRONIC DISEASE PATIENTS IN A GENERAL HOSPITAL g Chapter I INTRODUCTION 1. BACKGROUND OF THE CHRONIC DISEASE PROBLEM Of l a t e years the students of v i t a l s t a t i s t i c s have been c a l l i n g our a t t e n t i o n to the increased l o n g e v i t y which i s having a profound e f f e c t on our way of l i v i n g . Since the beginning of the century c e r t a i n c h a r a c t e r i s t i c s of the Canadian population have changed. From 1921 to 1941 the pro-p o r t i o n of the population over f o r t y - f i v e (1) years of age has increased from nineteen (2) to twenty-five percent. I t has been estimated that by 1970 more than h a l f the population w i l l be over f o r t y - f i v e years (3) of age. This ageing of the po p u l a t i o n has f a r reaching s i g n i f i c a n c e not only (!) 6th Census of Canada, 1921, V o l . I I , P o p u l a t i o n , Ottawa, Kings P r i n t e r , 1925* (2) 8th Census of Canada, 1941, V o l . I I , Population by l o c a l s u b d i v i s i o n s , Ottawa, Kings P r i n t e r , 1944. (3) Kresky, B., & Luykx H.M.C, "P a t i e n t s are o l d e r and stay longer, H o s p i t a l s , Vol.'lS, no. 2, February, 1944, p. 22. I I m e d i c a l l y "but a l s o i n t e r l a c i n g w i t h a l l spheres of our s o c i a l s t r u c t u r e . The ever i n c r e a s i n g number of people i n the older age groups have created new problems; one p r i m a r i l y medical having to do w i t h chronic i l l n e s s , the other a s o c i a l problem having to do w i t h employ-ment and s e c u r i t y . The problem of the c h r o n i c a l l y i l l and the increase i n the o l d e r age groups has i t s o r i g i n i n the advances i n medical science and publ i c h e a l t h d u r i n g the past f i f t y years. Death r a t e s from communicable diseases have decreased s h a r p l y , as a r e s u l t of them, w h i l e death r a t e s from degenerative diseases have (4) increased s t e a d i l y . Reduction of i n f a n t m o r t a l i t y , prevention of acute i n f e c t i o u s diseases such as typ h o i d , d i p t h e r i a , small pox and s c a r l e t f e v e r , the i n s t i t u t i o n of b e t t e r s a n i t a t i o n and the improvement i n such a c t u a l f o o d s t u f f s as the m i l k supply, have a l l been f a c t o r s i n lowering m o r t a l i t y among i n f a n t s and c h i l d r e n . Improved diagnosis and e a r l y r e c o g n i t i o n of disease r e s u l t i n g i n r a p i d and e a r l y cures have a l l been f a c t o r s i n extending (4) i b i d . p. 21. I l l the l i f e span. As a r e s u l t of the f a c t o r s mentioned the numbers of persons s u f f e r i n g from chronic i l l n e s s e s continues to i n c r e a s e . Fundamentally the chronic patient d i f f e r s from the acute patient i n that the former s u f f e r s from a disease that i s of long d u r a t i o n , and the l a t t e r s u f f e r s from a disease, p o s s i b l y the same, that i s of com-p a r a t i v e l y short d u r a t i o n . One person may react a c u t e l y to a disease that makes another a chronic i n v a l i d . There i s no absolute c l a s s i f i c a t i o n of diseases as acute or c h r o n i c . Thfe degree of ,disablement i S v a r i a b l e and d i s a b i l i t y may be minimal, p a r t i a l or complete. Although damage to the human body by chronic i l l n e s s i s permanent and i r r e v e r s a b l e i t should not be considered i n c u r a b l e , since i n a l l cases medical r e l i e f can be given and i n some cases r e h a b i l i t a t i o n of the patient to the point of economic s e l f s u f f i c i e n c y i s p o s s i b l e . Fundamental to a l l medical treatment i s the b a s i c r e a l i z a t i o n that the p h y s i c i a n i s d e a l i n g w i t h the whole i n d i v i d u a l . This i s p a r t i c u l a r l y important i n the management of pat i e n t s w i t h chronic d i s e a s e s . The c h i e f IX aim i n treatment i s t o a r r e s t the progress of the disease and to enable the patient to maintain or resume h i s accustomed r o l e i n h i s f a m i l y and i n s o c i e t y . Every measure to ease the s u f f e r i n g of the p a t i e n t should a l s o be t r i e d . The confusion between senescence and chronic i l l n e s s leads to neglect and m a l t r e a t -ment . Persons between the ages of f i f t y and seventy should be regarded as s i c k not s e n i l e . In the. past i t was assumed th a t the c h r o n i c a l l y i l l needed c u s t o d i a l care and that c o n s t r u c t i v e medical care was not necessary. Recently, however, i t i s being emphasized that medical care i s r e q u i r e d i n various degrees according to the stage o f the i l l n e s s , and c l a s s i f i c a t i o n of chronic p a t i e n t s by type of care r a t h e r than by disease i s (5) suggested. Chronic diseasesare f o r the most par t , obscure i n o r i g i n . Most important are diseases of the h e a r t , a r t e r i e s , kidneys and l i v e r , organic a f f e c t i o n s of the nervous system, mental d i s o r d e r s , cancer, t u b e r c u l o s i s and non-tubercular diseases of the lungs such as (5) Boas, E.P., Proceedings of N a t i o n a l Conference of S o c i a l Work, 1939. asthma, various forms of rheumatism, diabetes m e l l i t u s , and other disturbances of the glands of i n t e r n a l s e c r e t i o n or of metabolism. • Seventy years ago these chronic diseases caused only one f i f t e e n of a l l deaths; today (6) they are r e s p o n s i b l e f o r as many as one h a l f . (7) Boas has the f o l l o w i n g to say about the -nature of the problem of chronic d i s e a s e s . "The i n f e c t i o u s diseases are recognized as a constant menace. R e l a x a t i o n of methods of c o n t r o l q u i c k l y lead to t h e i r recurrence i n epidemic proportions Chronic diseases do not present them-selves i n such c y c l i c stages; but they are a dry-rot c o n s t a n t l y weakening and d e s t r o y i n g the s o c i a l organism. There i s no r e a l i z a t i o n that they are ever present and inescapable; that they occur at a l l ages; that i f we are spared them i n our youth they w i l l almost i n e v i t a b l y overtake us i n our • older years." P h y s i c a l i n c a p a c i t y a r i s i n g from these diseases i s at f i r s t i n s i g n i f i c a n t but g r a d u a l l y assumes greater p r o p o r t i o n s . In the e a r l i e r stages of the disease the subject i s ambulant and able to work but g r a d u a l l y he becomes more d i s a b l e d and e v e n t u a l l y becomes an i n v a l i d . Chronic diseases (6) Boas, E.P., The Unseen Plague, Chronic  Disease, J . J . Augustin P u b l i s h e r , New York, 1940. p. 4. (7) i b i d . p.4. VI d i f f e r from acute diseases not only i n t h e i r e s s e n t i a l medical c h a r a c t e r i s t i c s but i n t h e i r s o c i a l and economic consequences as v / e l l . In most acute diseases the medical c o n s i d e r a t i o n s are paramount, compared w i t h them the s o c i a l and economic d i f f i c u l t i e s are unimportant. I n chronic disease the medical s o c i a l and economic elements are i n e x t r i c a b l y interwoven and of equal (8) s i g n i f i c a n c e . Because of the extended d u r a t i o n of the average case of chronic disease, the s p e c i a l requirements f o r d i a g n o s i s and treatment,, and the inadequacy of present f a c i l i t i e s , the chronic disease problem i s a major one. Accurate f i g u r e s on the prevalence of chronic diseases are not as yet a v a i l a b l e . M o r t a l i t y f i g u r e s t e l l only a small part of the s t o r y , as most deaths f o l l o w years of d i s a b i l i t y , yet the changing trend of m o r t a l i t y i s very evident. Diseases of the heart and a r t e r i e s accounted f o r 31»788 deaths i n Canada i n 1945* (270 per hundred thousand). Cancer was the second greatest cause of death, (8) Boas, E.P., The Care of the Aged S i c k , S o c i a l S ervice Review, V o l . 4, June, 1930,Pl92 V I I n e p h r i t i s t h i r d and pulmonary t u b e r c u l o s i s (9) f o u r t h . Exact i n f o r m a t i o n regarding the a c t u a l prevalence of chronic i l l n e s s e s could only be gained by a most i n t e n s i v e medical survey of l a r g e population groups. In the past f i f t e e n to ' twenty years numerous surveys have been c a r r i e d out i n l a r g e r centres i n the United S t a t e s , and Canada i n order to determine the i n c i d e n c e , nature, and needs of the c h r o n i c a l l y i l l . These surveys r e v e a l s t a r t l i n g data i n re gard to the incidence of t h i s problem and to the f a c i l i t i e s which are needed to understand b e t t e r the nature of the problems and to provide a necessary means f o r t h e i r i n v e s t i g a t i o n and c o n t r o l . Perhaps the most extensive i n v e s t i g a t i o n has been the N a t i o n a l Health Survey conducted i n 1935~3° hy the United States P u b l i c Health S e r v i c e , which was a n a t i o n wide f a m i l y canvass of sickness i n r e l a t i o n to i t s s o c i a l and economic s e t t i n g . I t was found that on any given w i n t e r day i n the United States forty-two percent of those unable to pursue t h e i r usual a c t i v i t y because of i l l n e s s (9) Canada Year Book, 1945* I V I I I or i n j u r y , are s u f f e r i n g from a chronic (10) d i s e a s e . The incidence of i l l n e s s was one hundred percent higher among the poor than among the moderately w e l l . t o do and chronic d i s a b i l i t y i l l n e s s was eighty-seven percent higher among r e l i e f c l i e n t s than among f a m i l i e s w i t h annual incomes i n excess (11) of three thousand d o l l a r s . The Committee on Chronic I l l n e s s e s of the Welfare C o u n c i l of New York C i t y made a survey of the chronic s i c k i n that c i t y i n 1928. They found that one per-cent of the population were d i s a b l e d by chronic i l l n e s s and that t h r e e - f i f t h s of a l l i n d i v i d u a l s w i t h chronic disease needed medical care, one t h i r d of these i n h o s p i t a l s . One quarter of those l i v i n g at home should have been i n i n s t i t u t i o n s . Nearly h a l f of a l l the c h r o n i c a l l y i l l persons were under f o r t y years of age, one t h i r d were c h i l d r e n under s i x t e e n years of age c h i e f l y w i t h cardiac and orthopedic d i s o r d e r s . One f i f t h of the whole number were aged persons (10) S o c i a l 7/ork Year Book," 1939. Medical Care, P. 241. (11) Medical Care, S o c i a l Work Year Book, 1939. p. 238. I S (12) of seventy years and over. This estimate Of prevalence was supported by s t u d i e s c a r r i e d out i n other c e n t r e s . The Massachusetts Depart-ment of Health i n a house to house survey i n some communities found that twelve percent of the population were s u f f e r i n g from some form of chronic d i s e a s e . I t was also found that (13) • prevalence i n c r e a s e s w i t h age. The Boston C o u n c i l of S o c i a l Agencies estimated that the c h r o n i c a l l y i l l , e x c l u d i n g those w i t h tuber-c u l o s i s and mental disease, who were r e c e i v i n g care from Welfare agencies numbered one i n every one hundred and e i g h t y - f i v e persons i n the (14) c i t y . A P h i l a d e l p h i a survey estimated that i n any American i n d u s t r i a l c i t y , one i n every two hundred i n d i v i d u a l s was d i s a b l e d by chronic i l l n e s s . I t was a l s o reported that acute general h o s p i t a l s were burdened w i t h chronic p a t i e n t s f o r whom t h e i r f a c i l i t i e s were unsuited and too c o s t l y f o r the type of care needed by most chronic i n v a l i d s . I t was f e l t that most of (12) Chronic Disease, S o c i a l Work Year Book, 193.3. P - 78. (13) Boas, The Unseen Plague, p. 7• .(14) The Care of the C h r o n i c a l l y 111 i n Montreal, M e t r o p o l i t a n L i f e Insurance, Ottawa, 1940, p. 3. these p a t i e n t s could he cared f o r i n i n s t i t u t i o n s that cost to operate about one h a l f (15) the cost of care i n acute general h o s p i t a l s . In 1940 the E a s t e r n Canada d i s t r i c t of the American A s s o c i a t i o n o f M e d i c a l S o c i a l Workers sponsored a study of the care of the c h r o n i c a l l y i l l i n Montreal. This study a l s o supported the previous s t u d i e s done i n American centres. I t was found that one percent of the population were permanently d i s a b l e d by chronic i l l n e s s and o n e - t h i r d of these people were dependent wholly or i n part f o r t h e i r support and medical (16)' treatment. This study pointed out that the problem i s not l i m i t e d to o l d age and that there i s a h i g h incidence of chronic i l l n e s s i n (17) childhood. The f o l l o w i n g i s one of the conclusions a r r i v e d at by the study committee. "The problem of chronic i l l n e s s at the present time handicaps the work which i s done i n the general h o s p i t a l s and i n convalescent homes, which were not p r i m a r i l y intended f o r such c o n d i t i o n s . The l a r g e numbers of chronic p a t i e n t s occupying the beds i n these h o s p i t a l s f o r undue lengths of time, prevents (15) What P h i l a d e l p h i a c i t i z e n s spend on medical and h o s p i t a l care, The Modern  H o s p i t a l , vol.37, no.2, p.58, August,1931. (16) The Care of the C h r o n i c a l l y 111 i n  Montreal, 1940, p. 29. (17) I b i d . p. 29. f u l l y e f f i c i e n t s e r v i c e being o f f e r e d to those w i t h acute i l l n e s s . The large-number of c h r o n i c a l l y i l l p a t i e n t s i n the so c a l l e d homes f o r the aged, i n t e r f e r e s a l s o w i t h the work of these i n s t i t u t i o n s and r e s u l t s i n numerous i n d i v i d u a l s who (l8) apply f o r admission being turned away". 2. THE HOSPITAL'S PROBLEM At the present time many types of i n s t i t u t i o n s , homes f o r the aged, homes f o r i n c u r a b l e s , almshouses, i n f i r m a r i e s and general h o s p i t a l s o f f e r refuge but sometimes l i t t l e e l s e t o chronic p a t i e n t s . There i s at present an u t t e r inadequacy and indecency of e x i s t i n g f a c i l i t i e s f o r the care of long term p a t i e n t s , as evidenced by the s t u d i e s done on the problem. "Almshouses, poor farms, and homes (19) f o r i n c u r a b l e s have no place i n modern s o c i e t y " . Whether or not the c h r o n i c a l l y i l l should be h o s p i t a l i z e d i n i n s t i t u t i o n s dedicated to that purpose or whether they should be housed i n wings b u i l t as a d d i t i o n s to present h o s p i t a l s f o r acute diseases, i s a subject s t i l l under debate. Some b e l i e v e that they should be cared f o r i n separate (20) wings of so c a l l e d 'acute' h o s p i t a l s , and (18) i b i d . p. 29. (19) Bluestone, E.M.,wThe Chronic has a Claim to Care and Cure i n the Acute General H o s p i t a l " , The Modern H o s p i t a l , V o l . 6 3 , no.3, Sept.1944, p.69. (20) i b i d . p.69. X I I others b e l i e v e that s p e c i a l h o s p i t a l s should be (21) b u i l t f o r them. In planning the. extension of f a c i l i t i e s i n e i t h e r d i r e c t i o n , i t should be borne i n mind that prevention of these v a r i o u s diseases may reduce i n the f u t u r e the number of cases that w i l l r e q u i r e i n s t i t u t i o n a l c a re. Dr. E.M. Bluestone, d i r e c t o r of the Montefiore h o s p i t a l i n Hew York, advocates a r a d i c a l break w i t h t r a d i t i o n i n order to plan a complete community program f o r the long term p a t i e n t . I f there are not enough beds f o r the care of the long term p a t i e n t s , then he f e e l s that they should be e s t a b l i s h e d i n or around the general (22) h o s p i t a l . He advises a general h o s p i t a l f o r acute i l l n e s s e s and emergent surgery; a h o s p i t a l f o r treatment of chronic diseases and orthopedic cases; and a c u s t o d i a l home f o r the permanent and s e r i o u s l y d i s a b l e d . These should be one medical (23) centre under the one c e n t r a l s u p e r v i s i o n . "Since the chronic p a t i e n t r e q u i r e s every • f a c i l i t y of the general h o s p i t a l without exception plus c e r t a i n added f a c i l i t i e s , physio therapy, occupational therapy and (21) Boas, The Unseen Plague, p. 96. (221 Bluestone, op. c i t . , p. 60. (23) McClurkin, E•, "Chronic Disease from the pat i e n t ' s point of view," The Modern  H o s p i t a l , v o l . 6 5 , no.">> November, 1945,P«78« X I T I r e h a b i l i t a t i o n therapy; i t would be c o s t l y ( 2 4 ) to d u p l i c a t e these at a d i s t a n c e . " Dr. E. P. Boas, points out that i n New York C i t y f u l l y twenty-one percent of the p a t i e n t s i n general h o s p i t a l s are s u f f e r i n g from ch r o n i c (25) i l l n e s s e s . He f e e l s t h a t many of these patients may belong i n the wards of a general h o s p i t a l , but that when study r e v e a l s that they w i l l need permanent prolonged h o s p i t a l or c u s t o d i a l care they should be t r a n s f e r r e d to a s p e c i a l i n s t i t u t i o n . He estimates that h o s p i t a l s f o r chronic diseases should contain at l e a s t one hundred beds f o r s m a l l e r u n i t s would mean greater, expense per person. Eor prolonged care and t r e a t -ment chronic disease p a t i e n t s do not i n h i s opinion belong i n a general h o s p i t a l . F a c i l i t i e s f o r treatment are not adapted to t h e i r needs and i t i s unn e c e s s a r i l y expensive type of care. I n a s i n g l e year f o u r chronic p a t i e n t s may occupy one bed that otherwise might accommodate twenty-five (26) p a t i e n t s w i t h acute i l l n e s s e s . There are few adequately equipped h o s p i t a l s f o r chronic d i s e a s e . The f i r s t r e p r e s e n t a t i v e of (24) Corwin, E.H.L., The American H o s p i t a l , The Commonwealth Fund, New York, 194o. P.9« (25) Boas, The Unseen Plague, p.35« (26) i b i d . P.35. f r y the h o s p i t a l with every modern appliance f o r treatment of the chronic s i d e i n a homelike atmosphere, was Montefiore H o s p i t a l f o r Chronic Diseases, i n New York, founded i n 1884 as a Home f o r Chronic I n v a l i d s and g r a d u a l l y e v o l v i n g as a h o s p i t a l . The new s i x t e e n hundred bed Welfare H o s p i t a l f o r Chronic Disease i n New York c i t y i s the newest i n s t i t u t i o n of i t s kind and marks the f i r s t comprehensive attempt on the part of a c i t y to provide h o s p i t a l f a c i l i t i e s f o r the chronic (27) s i c k . However i t must be understood, as (28) pointed out by Morrison that the p r o v i s i o n of chronic h o s p i t a l f a c i l i t i e s are not cheap, and the chronic h o s p i t a l r e q u i r e s f a c i l i t i e s not found i n a general h o s p i t a l . Throughout the whole of Canada, to serve over eleven m i l l i o n people there are only twenty h o s p i t a l s f o r c h r o n i c a l l y i l l persons, w i t h a t o t a l bed capacity of 3»415» a n d these are t o t a l l y unable (29) to cope w i t h the s i t u a t i o n . The f i n d i n g s of (30) the N a t i o n a l Health Survey i n d i c a t e that i f (27) McClurkin,' E., Chronic disease from the pat i e n t ' s point of view. (28) Morrison, P e a r l , "What do we mean by chronic p a t i e n t s ? " The Canadian H o s p i t a l , p.36-38. (29) N a t i o n a l Health Survey Report, conducted by the Canadian Medical procurement and a s s i g n -ment board, Kings P r i n t e r , Ottawa,1945»P«147• (30) i b i d . , p.147. c h r o n i c a l l y i l l p a t i e n t s could he t r a n s f e r r e d from our acute i n s t i t u t i o n s a considerable per-centage of the a v a i l a b l e space i n such h o s p i t a l s could be made a v a i l a b l e f o r a c u t e l y i l l persons. Fear of contagion and f e a r of b o d i l y harm have roused the community to spend huge sums of money f o r the care of pa t i e n t s s u f f e r i n g from pulmonary t u b e r c u l o s i s and mental diseases, and a l s o f o r the study and i n v e s t i g a t i o n i n t o the o r i g i n s of these diseases. The treatment of these diseases has developed through almshouse care, then s p e c i a l c u s t o d i a l home care, then treatment diagnosis and research c e n t r e s . At present chronic i l l n e s s e s are i n the almshouse care stage; the community i s s t i l l w e l l s a t i s f i e d to give c u s t o d i a l care to the .chronic s i c k . However there are a number of recent developments which owe t h e i r existence to the war and to the th r e a t of i n s e c u r i t y g e n e r a l l y . P r o v i s i o n s f o r s o c i a l s e c u r i t y are i n c l u d i n g more p u b l i c funds f o r the care of the pa t i e n t s who cannot finance themselves. The extension of v o l u n t a r y group insurance schemes w i l l confer b e n e f i t s f o r those who can a f f o r d them. Apart from these economic developments there i s i n c r e a s i n g i n t e r e s t on the part of p h y s i c i a n s , s o c i a l workers and the p u b l i c g e n e r a l l y , i n chronic XVI"' diseases and the r e a l i z a t i o n of the present inadequacies f o r care. As we have seen i n the f o r e g o i n g review of stu d i e s done on the nature and prevalence of chronic disease, there i s a close l i n k between poverty and chronic i l l n e s s . "Poverty and chronic diseases l i e w i t h i n a v i c i o u s c i r c l e which must be broken some-(3D where". I t i s f u t i l e to patch up the i n d i v i d u a l s t r i c k e n w i t h chronic i l l n e s s without going through to the ways i n which our s o c i a l and economic system aggravates the disease, or ways i n which disease b r i n g s s o c i a l d e s t r u c t i o n i n i t s wake. There are two c h i e f groups of maladjustments caused by chronic i l l n e s s e s . F i r s t are the emotional and mental maladjustments which a f f e c t both the patient and h i s f a m i l y . I f the i l l n e s s i s § prolonged the patient may become f e a r f u l of what i s to become of him and i f a good deal of - pain accompanies the i l l n e s s there i s u s u a l l y an accompanying i r r i t a b i l i t y developing. The presence of an i n v a l i d i n a f a m i l y may o f t e n determine the r e c r e a t i o n , work, and the development of the l i v e s of the other members of the f a m i l y . Prolonged i l l n e s s places a great s t r a i n on the v a r i e d human (31) Bluestone, E.M., The Emergence of the Chronic P a t i e n t , J o u r n a l of the American Medical  A s s o c i a t i o n , v o l . 2 j , noTo, p.374,(Jet. y,1943» XVII r e l a t i o n s h i p s comprised i n a f a m i l y . Parents o f t e n "become a burden to t h e i r c h i l d r e n who w i l l welcome any means of g e t t i n g r i d of them. Daughters and sons are sometimes compelled to postpone marriage i n order t o help the f a m i l y f i n a n c i a l l y , or i n keeping the home. Second are the economic maladjustments r e s u l t i n g from chronic i l l n e s s e s . When the wage earner i s s t r i c k e n a host of problems a r i s e which u s u a l l y r e s u l t i n the dependency of the f a m i l y . When i t i s the mother of a f a m i l y who i s i l l there i s an added expense, and u s u a l l y a d r a i n , of h i r i n g a house-keeper to care f o r the f a m i l y . • When the i l l n e s s i s prolonged the cost of medical treatment i s u s u a l l y more than the average f a m i l y can bear. Unfavourable economic circumstances make d i f f i c u l t the a r r e s t of the disease and the r e h a b i l i t a t i o n of the p a t i e n t . Lack of time, money, and energy to use s p e c i a l drugs and d i e t regime i s a l s o r e s p o n s i b l e f o r the development of much chronic s i c k n e s s . Because of a l l these f a c t o r s we see f a m i l y a f t e r f a m i l y d i s o r g a n i z e d , w i t h shattered morale and r e s u l t a n t d e s t i t u t i o n . These i l l e f f e c t s are often a d r a i n on the h o s p i t a l ' s resources as w e l l . X V I I I 3 • MEDICAL SOCIAL WORK AS IT RELATES TO THE  CHRONICALLY ILL Of recent years the profound i n f l u e n c e of h e a l t h , or the l a c k of i t , on a l l aspects of community l i v i n g has been more c l e a r l y manifested so t h a t greater emphasis i s now being l a i d on the medical component o f - s o c i a l work. In any p u b l i c welfare program today, chronic disease plays so l a r g e a part i n the determination of dependency, that a l l case workers need to possess a fundamental grasp of what c o n s t i t u t e s adequate medical care; i n terms of housing, d i e t , mental hygiene and other p u b l i c h e a l t h matters. R e a l i z i n g that an understanding of the patient's s o c i a l and emotional s i t u a t i o n i s important, many h o s p i t a l s have e s t a b l i s h e d S o c i a l Service Departments, to c o n t r i b u t e to a complete diagnosis and treatment of the i n d i v i d u a l p a t i e n t . Throughout the past f o r t y y e a r s , medical s o c i a l workers have been c a r r y i n g on s t u d i e s i n an e f f o r t to d e f i n e more c l e a r l y the c o n t r i b u t i o n they could make i n the medical s e t t i n g , and to improve the q u a l i t y of t h e i r work. In a statement of standards, published by the American A s s o c i a t i o n of Medical S o c i a l Workers, the r o l e of the S o c i a l Service Department has been summed up by the f o l l o w i n g words: "Medical S o c i a l S ervice has been developed i n the h o s p i t a l as a s e r v i c e to the p a t i e n t , the p h y s i c i a n , the h o s p i t a l and the a d m i n i s t r a t o r and the community, i n order to h e l p meet the problem of the p a t i e n t whose medical need may be aggravated by s o c i a l f a c t o r s and who t h e r e f o r e may r e -q u i r e ' s o c i a l treatment which i s based on(32) h i s medical c o n d i t i o n and care." By a i d i n g the p h y s i c i a n i n the treatment of the i l l the medical s o c i a l worker enhances the use-f u l n e s s of the medical care and thus helps the h o s p i t a l to achieve i t s purpose i n medical t r e a t -ment . There i s a growing awareness among medical s o c i a l workers of the needs of the c h r o n i c a l l y i l l , and a search f o r ways to r e l a t e t h e i r s e r v i c e s to these needs. The p a t i e n t w i t h a chronic disease i s l ong term and h i s i l l n e s s i s more f r e q u e n t l y c o n t r o l l a b l e than c u r a b l e . This would beshopeless p i c t u r e i f the focus were upon the disease r a t h e r than upon the patient w i t h the i l l n e s s . The connotation of the word c h r o n i c , has f o r a long time been an unpleasant one s i g n i f y i n g to many people, i n c u r a b l e and t h e r e f o r e , hopeless. But w i t h the growth i n understanding of the (32) Statement of standards to be met by Medical S o c i a l S ervice Departments i n H o s p i t a l s and C l i n i c s , American A s s o c i a t i o n of Medical S o c i a l Workers, January, 1943* P»3 XX p o t e n t i a l i t i e s w i t h i n those w i t h chronic d i s e a s e s , s o c i a l workers are no longer content to assume that because cure i s u n l i k e l y , the f u t u r e i s hopeless. I n the l i g h t of i n c r e a s i n g psycho-somatic understanding, i t i s a mistake to type pati e n t s as " d i a b e t i c s " or "cancer cases". What i s s i g n i f i c a n t to the medical s o c i a l worker i n chronic and acute cases a l i k e , i s the i n d i v i d u a l -i z e d knowledge of the pa t i e n t w i t h the i l l n e s s , and the use of t h i s knowledge toward h e l p i n g him achieve maximum adjustment to h i s i n c a p a c i t y , i n r e l a t i o n t o h i s environment. E s s e n t i a l l y the kinds of problems presented by the c h r o n i c a l l y i l l are as v a r i e d as the patie n t s themselves and are i n no way unique i n the manner i n which the s o c i a l worker r e l a t e s her s e r v i c e s . Each p a t i e n t s u f f e r i n g from long term i l l n e s s has a r i g h t to be known as an i n d i v i d u a l w i t h hopes and f e a r s for, h i m s e l f . The l i m i t a t i o n s of the i l l n e s s cannot be overlooked but they are seen as a part of the p a t i e n t , a f f e c t i n g , the whole of him but not o b l i t e r a t i n g him as a person. The one d i s t i n c t i v e f a c t o r " i n ' : s o c i a l s e r v i c e f o r the c h r o n i c a l l y i s time, and i t i s t h i s time element which makes a l l the d i f f e r e n c e not only to the medical agency but XXI a l s o to the pa t i e n t who has been i l l f o r months and sometimes years. This time element i s e s p e c i a l l y important i n the treatment of the aged, w i t h chronic diseases; who make up the l a r g e s t p r o p o r t i o n of t h i s study group. T h e o r e t i c a l l y society, provides the needy aged w i t h means of subsistence but beyond the s t a t u t o r y v i s i t s of the welfare worker, there i s no f u r t h e r o b l i g a t i o n f o r anyone to take an i n t e r e s t i n the c l i e n t . The s i t u a t i o n i s f u r t h e r complicated by the l a c k of good i n s t i t u t i o n a l accommodation f o r o l d people, who, though c h r o n i c a l l y i l l , r e fuse to end t h e i r days i n the poor house. They are oft e n r i g h t i n t h e i r stand, since adequate care i s not a v a i l a b l e f o r them i n the poor house. With t h e i r cash b e n e f i t s they could be cared' f o r i n a boarding home, or t h e i r own home; provided that a greater amount of s o c i a l s e r v i c e and medical care were • a v a i l a b l e . The volunteer worker has an important part to play here; i f d i r e c t e d by an experienced o r g a n i z e r , i n the p r o v i s i o n of d i v e r s i o n and comforts. This s e r v i c e may make a great c o n t r i b u t i o n to the p a t i e n t ' s happiness and i s i n no way a s u b s t i t u t e f o r the e s s e n t i a l case work of the p r o f e s s i o n a l s o c i a l worker. XXII The s t a f f s i n s o c i a l s e r v i c e departments i n h o s p i t a l s are o f t e n inadequate to ca r r y on the prolonged s u p e r v i s i o n of c h r o n i c a l l y i l l p a t i e n t s , f o l l o w i n g t h e i r discharge from h o s p i t a l . In the case of the Royal Alexandra H o s p i t a l , where there was only one s o c i a l worker, t h i s was seen as a l i m i t i n g f a c t o r .in the s e r v i c e a v a i l a b l e t o the c h r o n i c a l l y i l l . Follow up w i t h case work s e r v i c e , f o r the chronic p a t i e n t was impossible a f t e r d i s -charge, due t o the pressure of work, and t h e o r e t i c a l l y , the s o c i a l s e r v i c e department could give s e r v i c e only to pati e n t s w h i l e they were i n h o s p i t a l . As prolonged care of the chronic p a t i e n t i n a general h o s p i t a l i n v o l v e s a waste of medical f a c i l i t i e s , the medical s o c i a l worker was o f t e n confronted w i t h the problem of a r r a n g i n g f o r h i s care elsewhere. This u s u a l l y proved, a d i f f i c u l t task, f o r various reasons. The patient was r e l u c t a n t to leave the s h e l t e r of the h o s p i t a l ; community resources such as v i s i t i n g nurse and medical s e r v i c e , housekeeper s e r v i c e , c u s t o d i a l , boarding, and n u r s i n g homes, were l a c k i n g ; or the f a m i l y was unable to care f o r the p a t i e n t , due to poor housing f a c i l i t i e s , i n a b i l i t y , or u n w i l l i n g -ness . P r o v i s i o n of adequate care f o r the chronic X X I I I s i c k i s a complex problem because we are d e a l i n g not w i t h one disease but many. Therefore, before planning f o r the c h r o n i c a l l y i l l i n the community i t would be valuable f o r the h o s p i t a l a d m i n i s t r a t i o n to know something of the extent of the problem to be d e a l t h w i t h ; the number and types of pati e n t s i n h o s p i t a l using f a c i l i t i e s which they do not a c t u a l l y need, and some of the reasons f o r t h e i r extended s t a y . Knowing the extent and nature of the problem adequate plans could be made, f o r planning must con-cern i t s e l f not only w i t h the s t r i c t l y medical phases but a l s o take i n t o c o n s i d e r a t i o n the wide spread s o c i a l and economic i m p l i c a t i o n s of chronic disease. Therefore i t i s proposed i n t h i s study to di s c o v e r some of the s o c i a l f a c t o r s which c o n t r i b u t e t o the prolonged h o s p i t a l i z a t i o n of chronic disease p a t i e n t s i n a general h o s p i t a l . SCOPE AND METHOD Chapter I I Scope The present study was s t a r t e d at the Royal Alexandra H o s p i t a l , Edmonton, A l b e r t a , i n J u l y , 1946.(See appendix 2) At that time the h o s p i t a l a d m i n i s t r a t i o n had become concerned about the numbers of chronic disease p a t i e n t s who were stay-ing i n the h o s p i t a l f o r prolonged periods of time. Pressure was being put on the s t a f f physicians to discharge these p a t i e n t s as q u i c k l y as p o s s i b l e i n order t o make room f o r the admission o f p a t i e n t s r e q u i r i n g more a c t i v e types of medical care. The t o t a l h o s p i t a l personnel were concerned about the problem of p r o v i d i n g adequate care f o r c h r o n i c a l l y i l l p a t i e n t s and t h i s concern was becoming apparent i n the community, e s p e c i a l l y i n the C o u n c i l of S o c i a l Agencies, where awareness of the need f o r planning was being f e l t . I t was b e l i e v e d t h a t a study of chronic p a t i e n t s then i n h o s p i t a l , i n order t o determine some of the reasons f o r pro-longed stay i n h o s p i t a l , would be h e l p f u l to a planning group, and on t h i s b a s i s the study was attempted. D e f i n i t i o n of chronic i l l n e s s , f o r purposes of t h i s study, was a r r i v e d at through c o n s u l t a t i o n w i t h the A c t i n g Medical Superintendent and the three r e s i d e n t i n t e r n s of the h o s p i t a l . Mental i l l n e s s e s and pulmonary t u b e r c u l o s i s were excluded from the d e f i n i t i o n by reason of the f a c t that these ailments are t r e a t e d elsewhere i n separate h o s p i t a l s . 2 I t was f u r t h e r decided to exclude such d i s a b i l i t i e s as f r a c t u r e s , blindness and deafness, and to be concerned i n t h i s (33) study w i t h those diseases, u s u a l l y considered c h r o n i c , which are i n s i d i o u s i n onset, progressive, u s u a l l y long term, and from which there i s never complete r e s t o r a t i o n to normal. .Within t h i s meaning of chronic i l l n e s s , as a r r i v e d a t through c o n s u l t a t i o n the i n t e r n s . l i s t e d the names of chronic p a t i e n t s i n the medical, s u r g i c a l , and c h i l d r e n ' s s e r v i c e s i n the h o s p i t a l . The l i s t s were compiled on J u l y 15» 1946, and since the concern of the study was t o be prolonged h o s p i t a l i z a t i o n , no e f f o r t was made to f o l l o w up over a period of time. Rather, the subjects of t h i s study are chronic disease p a t i e n t s who were i n the h o s p i t a l on that one day. I t was found that out"of an a v a i l a b l e three hundred and twenty-two beds, eighty,(twenty-four percent) were being occupied by chronic disease p a t i e n t s . E i g h t y - f o u r percent of. t h i s t o t a l were i n the medical wards, while eight and a h a l f percent were i n the c h i l d r e n ' s s e r v i c e and seven percent i n s u r g i c a l wards. Method In order t o have a uniform s e l e c t i o n of cases, a con-ference was held w i t h the three r e s i d e n t i n t e r n s i n order to e x p l a i n the purpose of the study, and to reach an agreement (33) Boas, The Unseen Plague, p.l9« 3-among them, on a d e f i n i t i o n of chronic d i s e a s e s . They then submitted a l i s t of the chronic p a t i e n t s i n t h e i r s e r v i c e , together w i t h the diagnosis and h o s p i t a l number. A schedule was then drawn up on which to record the data about each p a t i e n t , (see Appendix 1) As much inf o r m a t i o n as p o s s i b l e was gathered from the medical chart and the general o f f i c e f i l e s and recorded on the schedule. Previous medical h i s t o r y was obtained from the i n t e r n ' s h i s t o r y on the medical c h a r t , and from previous h o s p i t a l f i l e s , where a v a i l a b l e . A case work i n t e r v i e w , adapted to the i n d i v i d u a l s i t -u a t i o n was held w i t h each pa t i e n t able to be in t e r v i e w e d , to supplement h o s p i t a l f i l e s . T h i r t e e n of the pa t i e n t s r e -f e r r e d were unable to be interviewed f o r v a r i o u s reasons; s i x patie n t s died s h o r t l y a f t e r r e f e r r a l , f o u r paients were i n the ter m i n a l stage of t h e i r i l l n e s s , and. three were discharged' before they could be interviewed and could.not be contacted upon discharge. Pour, of these p a t i e n t s , unable to be i n t e r -viewed, came w i t h i n the group of long term p a t i e n t s but i t was f e l t that s u f f i c i e n t i n f o r m a t i o n was a v a i l a b l e about these f o u r , without the i n t e r v i e w , f o r them to be included i n the study. The attending physicians were consulted i n each case i n order to ob t a i n the prognosis and the degree of i n c a p a c i t y s uffered by each p a t i e n t . Since there i s no absolute c l a s s i f i c a t i o n of a disease as acute or chronic i t was found cumbersome to attempt to c l a s s i f y the patients by type of ailment. C l a s s i f i c a t i o n by type of care r e c e i v e d , or r e q u i r e d , was found to be a simple and a more v a l i d means of d e a l i n g w i t h the p a t i e n t s i n t h i s study. Chronic disease p a t i e n t s f a l l roughly i n t o three main groups according to the type of care they r e q u i r e . The f i r s t group, Class A, are those p a t i e n t s who are i n the "acute*" or exacerbation phase of t h e i r i l l n e s s i n which they r e q u i r e a c t i v e medical and n u r s i n g , d i a g n o s t i c and. or t r e a t -ment care. The second group, Class B, i s composed of those p a t i e n t s who have passed the acute phase of t h e i r i l l n e s s but s t i l l r e q u i r e s k i l l e d nursing care f o r a prolonged period of convalescense. U s u a l l y the nu r s i n g care r e q u i r e d i s f o r r e -l i e f of pain, and mai n t a i n i n g comfort of the p a t i e n t , where nothing w i l l r e s t o r e the f u n c t i o n of the damaged t i s s u e . This i n v o l v e s c a r e f u l d i e t i n g and the a d m i n i s t r a t i o n of medication. Many p a t i e n t s i n Class A and B need the h i g h l y s p e c i a l i z e d care such as of f e r e d by the general h o s p i t a l but they need i t f o r a period of months. The t h i r d group, Class C, i s composed of p a t i e n t s who are no longer a medical problem. The disease process i s ar r e s t e d l e a v i n g the pat i e n t w i t h a permanent p h y s i c a l d i s -a b i l i t y . He may r e q u i r e some a s s i s t a n c e i n d r e s s i n g , bath-ing and e a t i n g , but no expert nursing or medical care i s necessary. This type of p a t i e n t s r e q u i r e c u s t o d i a l care o n l y . P a t i e n t s i n B and C do not n e c e s s a r i l y r e q u i r e care i n a general h o s p i t a l . Some p a t i e n t s i n Class B, and a l l i n Class C, could be cared f o r i n a good nu r s i n g home, boarding home, or i n t h e i r own home i f a v a i l a b l e . 5. On grouping the eig h t y chronic p a t i e n t s according to the" c l a s s of care r e q u i r e d , i t was found that f o r t y - n i n e percent required medical and nursing care or were i n Class A; twenty-s i x percent r e q u i r e d only s k i l l e d n ursing, or Class B care; and twenty-five percent r e q u i r e d c u s t o d i a l care o n l y , (see Appendix 3» ta b l e "So J 1) The d i s t r i b u t i o n of p a t i e n t s according to l e n g t h of stay i n h o s p i t a l was c a l c u l a t e d i n order to determine the number of pa t i e n t s who had been i n the h o s p i t a l f o r a pro-longed period of time. T h i r t y days care was chosen as the a r b i t r a r y point of d i v i s i o n between short and long-term (34) care. I t was found that forty-two of the chronic p a t i e n t s had been i n the h o s p i t a l longer than t h i r t y days. (See Appendix 3» t a b l e n o . i i ) Thus t h i s study was concerned p r i m a r i l y , w i t h f i f t y - t w o percent of the chro n i c disease p a t i e n t s i n the Royal Alexandra h o s p i t a l , J u l y 15* 1946. Through the presentation of case m a t e r i a l , and some d i s c u s s i o n of i n d i v i d u a l p a t i e n t s ; a chapter being devoted to each of the groups according to type of care r e q u i r e d ; some s o c i a l f a c t o r s which might have co n t r i b u t e d to prolonged h o s p i t a l i z a t i o n , are discussed. The cases presented are i l l u s t r a t i o n s of the outstanding s o c i a l f a c t o r s or problems presented by these p a t i e n t s and no attempt was made t o ' (34) Hundenburg, Roy, A., A study of bed d i s t r i b u t i o n accord ing to leng t h of stay, The 1946 D i r e c t o r y , H o s p i t a l s , v o l . 20, no. 10, pp. 52-54, October, 1946. 6 analyse or t a b l u a t e the f i n d i n g s s t a t i s t i c a l l y , since the data d i d not lend themselves to t h i s treatment. Although the c h i e f emphasis i n the study was on the long term p a t i e n t s , those considered short term by a r b r i t r a r y d e f i n i t i o n were not excluded from c o n s i d e r a t i o n since i t was obvious that the two groups were not e s s e n t i a l l y d i f f e r e n t . I t i s suggested that long term h o ' s p i t a l i z a t i o n of chronic disease p a t i e n t s i n t h i s h o s p i t a l i s l a r g e l y dependent upon s e v e r a l c o n t r i b u t i n g s o c i a l f a c t o r s which w i l l be discussed i n the f o l l o w i n g chapters. Chapter I I I LONG TERM PATIENTS REQUIRING ACTIVE MEDICAL ' OR DIAGNOSTIC TREATMENT Of the forty-two long term chronic disease p a t i e n t s , one t h i r d r e q u ired an a c t i v e type of medical treatment, such as i s a v a i l a b l e i n a general h o s p i t a l . I n every case t h i s need f o r medical care was the main reason f o r extended, stay i n the h o s p i t a l . Por ten out of the f i f t e e n cases, adequate medical care could not be given elsewhere. Por the other f i v e , adequate care, could be given i n a nursing home or i n the p a t i e n t s own home, i f s k i l l e d nursing care and con-tinuous medical s u p e r v i s i o n were a v a i l a b l e . I n each of these f i v e cases i t was more convenient, f o r p a t i e n t and p h y s i c i a n , to have the pati e n t i n the h o s p i t a l f o r care, because of the i n a b i l i t y of the pa t i e n t to pay a phy s i c i a n f o r home v i s i t s , and i n some cases because of the distance of the p a t i e n t ' s home from the c i t y . A l l of these p a t i e n t s , without exception, were f i n a n c i a l l y unable to supply themselves w i t h the necessary nursing care and there was no v i s i t i n g nurse s e r v i c e i n the community; though four of the p a t i e n t s were people who d i d have a home or a f a m i l y who could care f o r them. Only one pa t i e n t i n t h i s c l a s s was r e c e i v i n g care i n the pu b l i c s u r g i c a l ward; the remainder being i n pub l i c medical wards. The most common disease i n the group was diabetes which was the diagnosis i n f o u r cases. Heart and kidney d i s o r d e r s occurred w i t h equal frequency, each account-f o r three cases. Three p a t i e n t s were d i s a b l e d by asthma, 8* o s t e o - m y e l i t i s and cancer r e s p e c t i v e l y , and the c o n d i t i o n of the remaining p a t i e n t had been p r o v i s i o n a l l y diagnosed as cancer, but t h i s had not been confirmed. The number of days care i n h o s p i t a l ranged from t h i r t y days to ni n e t y - t h r e e days care, t h i r t y days being the mode, and only two p a t i e n t s being i n h o s p i t a l more than n i n e t y days. The p a t i e n t s ranged i n age between s i x t e e n and e i g h t y - s i x years, one h a l f the group being under f i f t y , and only two pa t i e n t s over s i x t y . This means that the m a j o r i t y of the pat i e n t s i n t h i s group were i n the productive years of t h e i r l i v e s , and treatment o f t h e i r i l l n e s s e s was imperative i n . order to prevent progression to t o t a l d i s a b i l i t y . Only two p a t i e n t s i n t h i s group were comfortably able to pay f o r t h e i r medical care. S i x p a t i e n t s belonged i n the marginal income group. Although they were able to support themselves they were not prepared f o r the a d d i t i o n a l expense of prolonged i l l n e s s . The remaining one h a l f of the group were e n t i r e l y dependent f o r t h e i r support, three on f a m i l y , two on the c i t y r e l i e f a s s i s t a n c e , and one on an Old Age Pension; these p a t i e n t s were unable to pay e i t h e r f o r t h e i r support or t h e i r medical care. Thus, a l l but two of the long term chronic disease p a t i e n t s r e q u i r i n g a c t i v e medical t r e a t -ment i n h o s p i t a l were not able to pay f o r the s p e c i a l medical care they required i n order to prevent the progression of t h e i r diseases. Although need f o r medical care was the main reason f o r prolonged h o s p i t a l i z a t i o n i n each case, an examination of the 9 s o c i a l background of these p a t i e n t s b r i n g s to l i g h t some f a c t o r s which may be c o n t r i b u t i n g to prolonged h o s p i t a l -i z a t i o n . In one h a l f of the cases f i n a n c i a l i n a b i l i t y to plan f o r care elsewhere was seen as a f a c t o r i n c o n t r i b u t i n g to the extension of the h'ospital stay. Tflhen i l l n e s s s t r i k e s there i s an immediate d i s r u p t i o n of l i v i n g r o u t i n e ; new emotional adjustments must be made and a d d i t i o n a l economic problems must be met. In cases of acute i l l n e s s , the d u r a t i o n i s u s u a l l y not s u f f i c i e n t to make e i t h e r the p s y c h o l o g i c a l or the f i n a n c i a l s t r a i n c r i t i c a l . A f t e r a few weeks, d a i l y l i f e becomes normal and the extra expense i s absorbed g r a d u a l l y i n t o the budget. But, when the disease i s p r o t r a c t e d , the case i s q u i t e otherwise. A chronic i n v a l i d i n a home i s always a tax on the other members of the household e i t h e r emotionally, p h y s i c a l l y or 'both. Among poorer f a m i l i e s these d i f f i c u l t i e s are accentuated. Many f a m i l i e s , not alone of the poor, but a l s o of the so c a l l e d middle c l a s s , are i n e v i t a b l y pushed to d e s t i t u t i o n by the continuous f i n a n c i a l d r a i n of chronic i l l n e s s . The f o l l o w i n g case i l l u s t r a t e s not only how poverty may be a cause of delay of discharge, but a l s o how i t may have co n t r i b u t e d t o the development of the c o n d i t i o n . Case of Mrs. A.A. Mrs. A.A., a widow, age e i g h t y - s i x , had been i n h o s p i t a l ninety-three days w i t h a diagnosis of d i a b e t i c gangrene. Treatment consisted of amputation of the great l e f t toe, and f o l l o w i n g the o p e r a t i o n , d r e s s i n g of the wound and r e g u l a t i o n and s u p e r v i s i o n of d i e t . The p a t i e n t was dependent 10. f o r her support upon an old age pension. She had no family-l i v i n g , and p r i o r to admission had "been l i v i n g alone i n a rooming house. She had been s u f f e r i n g w i t h d i a b e t e s . m e l l i t u s f o r a number of years and had been h o s p i t a l i z e d twice p r e v i o u s l y f o r r e g u l a t i o n of d i e t and medication. She was seventy-five percent d i s a b l e d by her i l l n e s s and because of her age and l a c k of f a m i l y resources, some form of c u s t o d i a l care would have to be provided f o r her upon her discharge. I t i s a f a i r assumption that the p a t i e n t ' s d e f i c i e n t income and poor l i v i n g c o n d i t i o n s may have been c o n t r i b u t i n g f a c t o r s i n the development of the gangrene. I t i s known.that i n cases of diabetes m e l l i t u s great care must be taken i n the r e g u l a t i o n of the d i e t and i n c a r i n g f o r the e x t r e m i t i e s i n order to prevent the development of gangrene. A l s o , present knowledge about the c o n t r o l of diabetes makes r e h o s p i t a l -i z a t i o n f o r the c o n d i t i o n unnecessary,.if the p a t i e n t i s able to obey the r u l e s of d i e t and i n s u l i n dosage. Although t h i s i s r a t h e r a severe case, i t i s perhaps not unusual to f i n d t h i s type of p a t i e n t i n a general h o s p i t a l . One would expect that a person eighty-three years of age would s u f f e r w i t h some breakdown i n body f u n c t i o n . However, i t i s f a i r to assume that t h i s p a t i e n t ' s most pressing problem was t h a t of securing adequate l i v i n g accommodation, which problem was complicated by her poor p h y s i c a l c o n d i t i o n and her inadequate income. Although the greatest proportion of the patients' i n t h i s c l a s s were i n the older age group, one t h i r d of the group were under t h i r t y years of age. The outstanding problem f o r t h i s 11. younger group was the securing of s u f f i c i e n t and appropriate medical treatment i n order to a r r e s t o r cure the di s e a s e . This was found to be a problem f o r various reasons; e i t h e r treatment f o r the c o n d i t i o n was not known or e a s i l y a v a i l a b l e , or the patient was unable to pay f o r treatment or s u f f i c i e n t convalesence to insure against recurrence. The f o l l o w i n g example, which i s i l l u s t r a t i v e of t h i s problem, i s the case of a boy i n need of s p e c i a l medical care and r e h a b i l i t a t i o n , yet l a c k i n g t h e . - f i n a n c i a l resources to pay f o r i t . The case of AB B i l l y , a s i x t e e n year o l d boy w i t h a dia g n o s i s of . o s t e o - m y e l i t i s , had been i n h o s p i t a l f o r seventy-two days r e c e i v i n g s u r g i c a l treatment. H i s i l l n e s s had t o t a l l y d i s -abled him f o r a-period of at l e a s t s i x months. For one year p r i o r to h i s admission he had been e n t i r e l y s e l f supporting through heavy manual l a b o r . H i s f a m i l y J . i v e d i n a d i s t a n t town and he said that i t was impossible f o r him to r e t u r n there f o r convalescent care, as there were four younger c h i l d r e n i n the home and the parents were f i n a n c i a l l y unable to bear the added burden of h i s care. His treatment con-s i s t e d of drainage of the wound and change of d r e s s i n g s . The a t t e n d i n g p h y s i c i a n reported that the boy could be d i s -charged to h i s home and come i n t o the h o s p i t a l f o r t h i s t r e a t -ment. Since the boy had no home to be discharged to t h i s plan could not be c a r r i e d out and he had to remain i n the h o s p i t a l f o r a longer period than was s t r i c t l y necessary. This case i l l u s t r a t e s the n e c e s s i t y f o r the p r o v i s i o n of s p e c i a l care f o r young people s u f f e r i n g w i t h i n c a p a c i t a t i n g 12. i l l n e s s e s . The p a t i e n t ' s r e h a b i l i t a t i o n , p h y s i c a l , p s y c h o l o g i c a l , and economic, depended upon h i s f i n d i n g a job w i t h i n the l i m i t s of h i s handicap. Work that would be too t a x i n g would a c c e l e r a t e the disease and soon lead to t o t a l d i s a b i l i t y . I t was necessary that the boy support h i m s e l f yet he lacked the t r a i n i n g to do any job that was s u i t e d to h i s p h y s i c a l l i m i t a t i o n . H i s f a m i l y was unable to h e l p and the community lacked adequate f a c i l i t y f o r h i s t r a i n i n g toward r e h a b i l i t a t i o n . Carelessness, or f a i l u r e on the part of the p a t i e n t or h i s f a m i l y to understand the true nature of h i s disease and the importance of f o l l o w i n g a prescribed program, together w i t h adverse s o c i a l and economic f a c t o r s and l a c k of medical s u p e r v i s i o n , o f t e n tended to n u l l i f y the b e n e f i t s of h o s p i t a l i z a t i o n . In a l l but f i v e cases i n t h i s group these f a c t o r s were i n evident o p e r a t i o n , i n va r y i n g extents. Some patien t s were repeatedly readmitted to h o s p i t a l because of cardiac decompensation that could have been prevented, d i a b e t i c coma that should not have occurred, and a host of other c o n d i t i o n s , that s a t i s f a c t o r y medical s u p e r v i s i o n would have averted. Although inadequate medical s u p e r v i s i o n i s some-times the r e s u l t of f a i l u r e on the part of the p h y s i c i a n to understand the whole problem, of t e n the t r o u b l e i s i n the p e r s o n a l i t y of the patient and i n h i s i n a b i l i t y to accept appropriate treatment or medical s u p e r v i s i o n . Understanding of the medical, s o c i a l and emotional f a c t o r s c o n t r i b u t i n g to the pa t i e n t ' s c o n d i t i o n i s imperative i n treatment; and under-standing of these interwoven f a c t o r s gives some i n d i c a t i o n of t h e i r c o n t r i b u t i o n t o the repeated and prolonged h o s p i t a l i z a t i o n i n the f o l l o w i n g case. The case of Mrs. AC Mrs. AC a woman of f o r t y - f i v e had been i n the h o s p i t a l s i x t y - e i g h t days. She had*a record of f i f t e e n previous h o s p i t a l i z a t i o n s i n eight years. The pati e n t was f i r s t known to the h o s p i t a l i n 1931 when she was admitted f o r treatment of dysmenorrhea. At that time she gave a long h i s t o r y of previous i l l n e s s i n c l u d i n g , measles, mumps, s c a r l e t f e v e r , and i n f l u e n z e ; and operations i n c l u d i n g appendectomy, removal of an ovary, and a perineorrhaphy. In 1934 the pa t i e n t was readmitted and t r e a t e d f o r n e u r i t i s and c o n s t i p a t i o n , both c o n d i t i o n s being considered f u n c t i o n a l d i s o r d e r s . Nine years l a t e r she returned to the h o s p i t a l s u f f e r i n g w i t h v a l v u l a r heart disease. During the next four years she was admitted to h o s p i t a l twelve times f o r the treatment and the c o n t r o l of t h i s c o n d i t i o n . L i t t l e i n f o r m a t i o n was a v a i l a b l e from the p a t i e n t about h e r s e l f and her s o c i a l background. She stat e d t h a t she was of I t a l i a n descent, born and brought up i n A l b e r t a , i n the protestant f a i t h . She had seven years p u b l i c school education, and d i d domestic work p r i o r to her marriage a t nineteen years of age. She then had two c h i l d r e n i n quick succession. When the patient had been i n h o s p i t a l two months, her husband gave n o t i c e that he would no longer be r e s p o n s i b l e f o r medical b i l l s , c l a i m i n g that he could not be he l d respon-14. s i b l e since he was not married to the p a t i e n t . This d e c i s i o n was the r e s u l t of a q u a r r e l i n the ward, on the occasion of a v i s i t , i n which the p a t i e n t s t a t e d t h a t she d i d not wish to see him again. In d i s c u s s i n g the s i t u a t i o n w i t h the husband, and i n l a t e r contact w i t h the p a t i e n t ' s f a m i l y , the s o c i a l worker discovered that much of the i n f o r m a t i o n given by the p a t i e n t , about h e r s e l f , was not t r u e . I t was found that the patient was of Ukrainian descent, and brought up i n the Greek C a t h o l i c f a i t h . Seven years before her admission to h o s p i t a l she l e f t her husband and went to l i v e w i t h the present common-law husband. Her heart c o n d i t i o n developed around t h i s period and she remained an i n v a l i d . The common-law husband paid a l l medical b i l l s , u n t i l the argument, and then decided to have nothing f u r t h e r to do w i t h the p a t i e n t . As a r e s u l t of t h i s d e c i s i o n the p a t i e n t was l e f t i n a dependent c o n d i t i o n and l a c k i n g the a b i l i t y to earn due to her s e r i o u s p h y s i c a l c o n d i t i o n . In view of the circumstances the s o c i a l worker attempted to help the patient make a s u i t -able plan f o r care i n the event of discharge. However, the p a t i e n t refused to admit that there was a problem, and r e -peatedly affirmed that there was no need to t a l k about d i s -charge since she would s u r e l y die i n h o s p i t a l . (35). As Weiss and E n g l i s h have s t a t e d , the mere discovery (35) Weiss, Edward and E n g l i s h , O.S. Psychosomatic Medicine,, p. 79. 15. of unpleasant circumstances i n the l i f e s i t u a t i o n of an i n d i v i d u a l i s no i n d i c a t i o n of emotional c o m p l i c a t i o n and s t i l l l e s s of psychogenic o r i g i n of the d i f f i c u l t y . The s i g n i f i c a n t f a c t o r s are the p a t i e n t ' s a b i l i t y to a d j u s t to such s i t u a t i o n s , h i s pattern of r e a c t i n g to them, the degree of an x i e t y i n h i s make-up, the nature and seriousness of h i s c o n f l i c t s ; as w e l l as p h y s i c a l defects and h i s patterns of p h y s i c a l behaviour. This p a t i e n t e x h i b i t e d l i t t l e i n s i g h t i n t o her problems, and a f a i l u r e to accept r e a l i s t i c a l l y her l i f e s i t u a t i o n . She e v i d e n t l y had a good d e a l of c o n f l i c t about her n a t i o n a l o r i g i n and r e l i g i o u s upbringing and she gave the worker f a l s e i n f o r m a t i o n i n a manner t h a t suggested that she b e l i e v e d i t t r u e . Since her p h y s i c a l c o n d i t i o n was made worse by emotional excitement as evidenced by her relapse a f t e r the q u a r r e l w i t h her husband, the s o c i a l worker avoided arousing the p a t i e n t ' s a n x i e t y by q u e s t i o n i n g the d i s c r e p a n c i e s i n her s t o r y . Although i n f o r m a t i o n about the p a t i e n t was sketchy, there was s u f f i c i e n t evidence to i n d i c a t e that her c o n d i t i o n had been i n f l u e n c e d by her emotional r e a c t i o n to her l i f e s i t u a t i o n , and because of her h a b i t u a l p a t t e r n o f r e a c t i o n , which had r e s u l t e d i n a complicated s o c i a l s i t u a t i o n , her discharge from h o s p i t a l had been delayed. In t h i s c l a s s of p a t i e n t s whose h o s p i t a l i z a t i o n had been prolonged p r i m a r i l y because of need f o r medical treatment there were s e v e r a l s o c i a l f a c t o r s which were c o n t r i b u t i n g to the extension of the h o s p i t a l i z a t i o n . Two t h i r d s of the p a t i e n t s i n t h i s group, while having s e r i o u s medical problems 16. to be d e a l t with., at the same time had s o c i a l problems which may have cont r i b u t e d to the development and extension of the i l l n e s s . Stated simply the most prevalent problems was poverty. I n some cases t h i s was the end r e s u l t of the i l l n e s s , but i n others i t c l e a r l y c o n t r i b u t e d to the development of the c o n d i t i o n . Lack of medical care and i t s appropriate a p p l i c a t i o n , which i s t i e d up w i t h economic s t a t u s , was found to be a c o n t r i b u t o r y f a c t o r i n s e v e r a l cases. In a small m i n o r i t y of i n s t a n c e s , i t was f a i r to assume that the p a t i e n t ' s p e r s o n a l i t y problem was r e s p o n s i b l e f o r prolongation of the i l l n e s s and consequently the h o s p i t a l i z a t i o n . 17 Chapter IV LONG TERM PATIENTS REQUIRING SKILLED NURSING CARE S l i g h t l y l e s s than one t h i r d ( t h i r t e e n ) of the long term chronic disease p a t i e n t s i n h o s p i t a l were i n need of s k i l l e d nursing care only. I n every case the disease process had been arrested or brought under c o n t r o l , but the organism had been permanently damaged, and nothing could r e s t o r e the f u n c t i o n of the damaged t i s s u e . The pa t i e n t was e i t h e r t o t a l l y d i s a b l e d , as i n the case of the pati e n t w i t h rheumatoid a r t h r i t i s who could not care f o r h i s own needs; or was i n the t e r m i n a l stages of the disease, such as the patient w i t h f a r advanced cancer which would not y i e l d to surgery arid was not amenable to r a d i a t i o n treatment. However, expert and sympathetic n u r s i n g care was necessary i n these cases to r e l i e v e the p a t i e n t ' s misery or to avoid serious complications such as the development of bed so r e s . Such care was of t e n necessary f o r a period of months and included not,only r o u t i n e n u r s i n g care, but sometimes c a r e f u l d i e t i n g and the a d m i n i s t r a t i o n of hypodermic medication. Such nursing care may be a v a i l a b l e i n a general h o s p i t a l but i t i s a l s o a v a i l a b l e i n a f u l l y s t a f f e d nursing home, or i n the pati e n t ' s own home by a t r a i n e d v i s i t i n g nurse; but perhaps most a p p r o p r i a t e l y of a l l , i n an i n s t i t u t i o n f o r chronic p a t i e n t s . Only two p a t i e n t s i n t h i s group were able to pay f o r t h e i r care i n h o s p i t a l or could a f f o r d home care. Pour of the p a t i e n t s were i n the marginal income group and payment f o r t h e i r prolonged medical care would make them d e s t i t u t e . 18. The remaining seven p a t i e n t s were dependent f o r t h e i r support, e i t h e r upon t h e i r f a m i l i e s as i n the case of three young people, c i t y r e l i e f a s s i s t a n c e as i n two cases; or Old Age Pension as i n two cases. These dependent p a t i e n t s were t o t a l l y unable t o pay f o r any type of medical care. One h a l f the p a t i e n t s i n t h i s group were over seventy years of age and one quarter were under f o r t y . Seven p a t i e n t s were without f a m i l i e s or the f a m i l y was unable to assume the care of the patient at home, because o f ' l a c k of housing f a c i l i t y , s k i l l , or poverty. S i x pa t i e n t s had f a m i l i e s who. were f i n a n c i a l l y able to care f o r them at home but who found i t more convenient to have the pa t i e n t s i n the h o s p i t a l , because of lack of nursing s k i l l or a b i l i t y or due to un-w i l l i n g n e s s to assume the r e s p o n s i b i l i t y of such care. One p a t i e n t i n the group was r e c e i v i n g p r i v a t e ward care, two were i n pu b l i c s u r g i c a l wards and the remainder of the group were r e c e i v i n g care i n the pub l i c medical wards. Pour patients s u f f e r e d w i t h c o n d i t i o n s of the h e a r t , the most common ailment; cancer was the next most common, accounting f o r three p a t i e n t s . Two pa t i e n t s were diagnosed as s u f f e r i n g w i t h s e n i l i t y and the f o u r remaining p a t i e n t s had the re s p e c t i v e diagnoses of cardiac l u e s , glomeruo-nephritis, rheumatoid a r t h r i t i s and d i a b e t i c gangrene. The number of days care ranged from t h i r t y to three hundred and eleven days, eig h t p a t i e n t s s t a y i n g longer than s i x t y days and f i v e longer than n i n e t y days. Two pa t i e n t s i n the group died w i t h -i n t h i r t y days of the date of the study. 19. The f o l l o w i n g case i s i l l u s t r a t i v e of the most t y p i c a l k ind of patient i n the group and points up the most common f a c t o r s which are c o n t r i b u t i n g to prolonged h o s p i t a l i z a t i o n of these p a t i e n t s , namely poverty and lack of community r e -sources or f a c i l i t i e s f o r care elsewhere. The Case of B.A. Mr. B.A. a widower, seventy-six years of age had been i n the h o s p i t a l n i n e t y - e i g h t days. Upon admission he was s u f f e r i n g from an o l d t u b e r c u l a r l e s i o n of the spine and treatment by surgery had been s u c c e s s f u l l y performed. When the p a t i e n t was nearing readiness f o r discharge, new symptoms developed and i t was discovered that he was s u f f e r i n g from coronary o c c l u s i o n . H i s treatment consisted of bed-rest and sed a t i v e s , h i s c o n d i t i o n was poor and there was l i t t l e hope f o r recovery. B.A. had a .long h i s t o r y of i l l n e s s and accidents and a l s o a h i s t o r y of frequent changes of residence and occupations since the death of h i s w i f e , twenty-seven years previous. He was dependent f o r h i s support upon an Old Age Pension. He had two sons l i v i n g i n another province but had no home of h i s own, anywhere. P r i o r to h i s admission to h o s p i t a l he l i v e d w i t h a f r i e n d , who could not take him back upon discharge, because of the nature of the care he r e q u i r e d . I n h i s c o n d i t i o n , B.A. could have been discharged from the h o s p i t a l , had he a place to go where he would.receive adequate n u r s i n g care. However, 'since such care was not a v a i l a b l e to him outside the h o s p i t a l , i t was necessary f o r him to remain, probably u n t i l h i s death. 20. Here i s an e l d e r l y man, without f a m i l y or f r i e n d s able or w i l l i n g to care f o r him; f r i g h t e n e d and demoralized by h i s i l l n e s s e s and hard l u c k , f e e l i n g that f a t e i s against him; l o n e l y ; and wanted by no one. This i s a case of human s u f f e r i n g , a r e s u l t of ne g l e c t " o f proper medical s u p e r v i s i o n when i t was r e a l l y necessary. The p a t i e n t ' s present problem i s a s t r a i g h t q u e stion of poverty,.and h i s case i l l u s t r a t e s c l e a r l y the need f o r medical p r o v i s i o n f o r the proportion of our population who are unable t o pay f o r medical care and are thus without s u p e r v i s i o n u n t i l the disease process threatens l i f e . I t al s o points up the need i n the community f o r medical s e r v i c e s , such as nursing-homes, and v i s i t i n g nursing s e r v i c e , which would be a v a i l a b l e to the m e d i c a l l y i n d i g e n t . This case i s not an uncommon one, r a t h e r i t i s the t y p i c a l type of case seen by the medical s o c i a l worker, i n h o s p i t a l clearance work. The f o l l o w i n g h i s t o r y i s a l s o a common type of case seen i n a general h o s p i t a l and i t i s i l l u s t r a t i v e of the misuse of g eneral h o s p i t a l f a c i l i t i e s . The Case of B.B. Mrs. B.B., a widow, age e i g h t y - f i v e , was admitted to h o s p i t a l f o l l o w i n g a f a l l from bed, s u f f e r i n g w i t h c e r e b r a l thrombosis, a r t e r i o - s c l e r o s i s , and s e n i l i t y . The pa t i e n t ' s daughter had been c a r i n g f o r her at home during the previous s i x months of her i l l n e s s . She was t o t a l l y bedridden by her i l l n e s s and she required nursing care and a good de a l of a t t e n t i o n . The daughter found i t impossible to continue w i t h her mother's care, and since t h i s type of.care was not a v a i l -21. able elsewhere i n the community, the pa t i e n t was admitted to the general h o s p i t a l . A f t e r seventy-eight days of r o u t i n e nursing care i n h o s p i t a l , the pati e n t d i e d . Although t h i s p a t i e n t was not i n need of s p e c i a l medical a t t e n t i o n or s u p e r v i s i o n she d i d r e q u i r e s k i l l e d bedside nursing care to keep her comfortable and to ease her s u f f e r -i n g . This type of care r e q u i r e s the s e r v i c e of a t r a i n e d nurse and i t i s d i f f i c u l t i f not impossible f o r the p a t i e n t ' s f a m i l y to give such s e r v i c e . When the f a m i l y must do so out of n e c e s s i t y i t o f t e n r e s u l t s i n p h y s i c a l or emotional hard-ship f o r some members of the household. I n t h i s case the patie n t was given home care u n t i l her f a l l from bed, a common occurrence i n cases where s k i l l e d nursing care i s not a v a i l a b l e . Since there was no other place to go, she was admitted to the general h o s p i t a l , where she remained u n t i l her death, occupying a bed which was s o r e l y needed f o r the more acute l y i l l who required the s p e c i a l s e r v i c e s a v a i l a b l e i n 'a general h o s p i t a l . In the f o l l o w i n g instance the medical s o c i a l worker was able to he l p make plans f o r the p a t i e n t ' s discharge from h o s p i t a l only a f t e r r o u t i n e h o s p i t a l check i n d i c a t e d t h a t the pat i e n t was not i n need of general h o s p i t a l care. This case i l l u s t r a t e s the impoverishing e f f e c t of chronic i l l n e s s e s and i s an example of h o s p i t a l i z a t i o n being prolonged because the patient had nowhere e l s e to go. The Case of B.C. 'Mr. B.C. a seventy year old s i n g l e man of U k r a n i a n ' o r i g i n , had been i n the h o s p i t a l two hundred and two days s u f f e r i n g 22. from apoplexy. The p a t i e n t , t o t a l l y i n c a p a c i t a t e d by h i s i l l n e s s , could not h e l p h i m s e l f at a l l . He was able to s i t up f o r a few hours at a time, h i s speech was s l u r r e d , h i s memory clouded, and he was hard of h e a r i n g . Although he was not i n need of medical a t t e n t i o n he required n u r s i n g care to keep him comfortable. The patient came to Canada from the Ukraine at the age of f o r t y - f i v e and worked as an o c c a s i o n a l l a b o r e r and handy-man u n t i l h i s s t r o k e . Although he had been a c i t y r e s i d e n t f o r twenty years, he had never taken out n a t u r a l i z a t i o n papers and was thus i n e l i g i b l e f o r an Old Age Pension. P r i o r to h i s h o s p i t a l i z a t i o n he had been l i v i n g w i t h f r i e n d s , who stated that they would be unable to take him back i n view of the amount of n u r s i n g care and a t t e n t i o n that he would r e -q u i r e . The p a t i e n t s small bank account was garnished by the h o s p i t a l f o r p a r t i a l payment of the b i l l and the c i t y r e l i e f o f f i c e was n o t i f i e d (by the c o l l e c t i o n s o f f i c e ) of i t s r e s p o n s i b i l i t y f o r the care of the p a t i e n t . The p a t i e n t was then r e f e r r e d to the s o c i a l worker who w i t h the cooperation of the c i t y r e l i e f o f f i c i a l s and the p a t i e n t was able to arrange t r a n s f e r to a p r i v a t e n u r s i n g home where he could receive the p r a c t i c a l n u r s i n g care that he r e q u i r e d . This patient was not i n need of treatment i n a general h o s p i t a l . A more appropriate plan could have been worked out through the s o c i a l s e r v i c e department of the h o s p i t a l i n teamwork w i t h the p h y s i c i a n , but t h i s wa's not done because the p h y s i c i a n d i d not understand or accept the r o l e of a 23. S o c i a l s e r v i c e department i n a h o s p i t a l . I t was not u n t i l , h i s f i n a n c i a l resources were exhausted by the payment of medical b i l l s that thought was given to the p r o v i s i o n of some more appropriate type of care. Once the patient was no longer able to pay h i s h o s p i t a l b i l l h i s case was brought to -the a t t e n t i o n of the s o c i a l worker who was able to. make a plan f o r h i s discharge. However, he was not e l i g i b l e f o r admission to a c i t y n u r s i n g home u n t i l " he was d e s t i t u t e , and under the care of the c i t y r e l i e f o f f i c e . In the foregoing cases the p a t i e n t s stay i n h o s p i t a l was prolonged to v a r y i n g extents because there was no other place where the p a t i e n t s could get the care he or she r e q u i r e d . This was f o r various reasons; such as, no f a m i l y , or f a m i l y u n w i l l i n g , or poverty, e i t h e r personal or of the community i n providing medical care f o r the c h r o n i c a l l y i l l . U s u a l l y i t was a combination of s e v e r a l f a c t o r s which complicated the s i t u a t i o n . In a l l these cases, however, the a t t e n d i n g p h y s i c i a n and h o s p i t a l s t a f f , were aware* that the p a t i e n t no longer required care i n the h o s p i t a l but discharge was delay-ed because of i n s u f f i c i e n t f a c i l i t i e s i n the community f o r the care of the i n d i g e n t , c h r o n i c a l l y i l l * I n some cases i t was found that the p a t i e n t ' s h o s p i t a l stay was extended f o r some of the foregoing reasons but was complicated by inadequate medical a t t e n t i o n . This was due to e i t h e r the l a c k of the physician's understanding of the p a t i e n t , or was the r e s u l t of the i n a b i l i t y of the patient to c a r r y out the i n s t r u c t i o n s of the p h y s i c i a n or to adjust to 24. the l i m i t a t i o n s of h i s i l l n e s s . In the f o l l o w i n g case the p h y s i c i a n f a i l e d to h e l p the p a t i e n t , because he f a i l e d to t r e a t the i n d i v i d u a l , r a t h e r concentrated upon the disease i t s e l f . The Case of B.D. Miss B.D. a g i r l of nineteen had been i n the h o s p i t a l forty-two days on her s i x t h admission to h o s p i t a l . The previous admissions had been for,- trench mouth, pneumonia, d i p t h e r i a , rheumatic f e v e r and appendectomy. The d i a g n o s i s given by the i n t e r n f o r t h i s patient had been .'personality i n s t a b i l i t y ' ; the a t t e n d i n g p h y s i c i a n had p r o v i s i o n a l l y diagnosed i t as rheumatic f e v e r , but had not confirmed i t . For the previous seven years the g i r l had e x h i b i t e d such d i f f u s e symptons as, weakness, nausea, j o i n t pains, short-ness of breath, l o s s of a p p e t i t e , and f e v e r . The p a t i e n t ' s mother had s u f f e r e d w i t h inflammatory rheumatism f o r a number of years. A consultant p h y s i c i a n reported that the rheumatic fever was now quiescent and that the g i r l ' s t r o u b l e was " l a r g e l y f u n c t i o n a l " and would r e q u i r e treatment by psychotherapy. Her treatment i n h o s p i t a l c o n s i s t e d of medication to the j o i n t s and s e d a t i v e s , to which the patient f a i l e d to respond, a f t e r a month and a h a l f . The c o n t i n u a t i o n of treatment of the p h y s i c a l symptoms alone, i n d i c a t e s the p h y s i c i a n s lack of understanding of the g i r l ' s problem; her f a i l u r e to respond suggests the inadequacy of the treatment. Prolonged h o s p i t a l i z a t i o n i n t h i s case was due to inadequate and i n a p p r o p r i a t e treatment 25. on the part of the p h y s i c i a n . The g i r l , now a confirmed i n v a l i d , w i t h a doubtful prognosis, w i l l continue to r e c e i v e h o s p i t a l care as long as her f a m i l y continue t o pay the h i l l . Although t h i s was not a common type of problem i n t h i s group, i n a p p r o p r i a t e medical treatment was f e l t to be. c o n t r i b u t i n g f a c t o r i n prolonged h o s p i t a l i z a t i o n i n four of the fo u r t e e n cases. The outstanding s o c i a l problem i n t h i s group of p a t i e n t s , was poverty.. The e s s e n t i a l d i f f e r e n c e between.this group, and the one discussed i n the previous chapter, was the type of medical care r e q u i r e d , and there was no outstanding d i f f e r e n c e i n the types of problems which were a f f e c t i n g the lengt h of h o s p i t a l i z a t i o n . I n only four cases was the need f o r n ursing s u p e r v i s i o n urgent enough to warrant continued h o s p i t a l i z a t i o n . In the remaining ten cases continued care was necessary because the pa t i e n t had no place to be d i s -charged t o . F i v e were without f a m i l y or home and f i v e had both r e l a t i v e s and home but could not be accepted there f o r various reasons, mainly because s u f f i c i e n t n u r sing care would not be a v a i l a b l e . 26. Chapter V LONG- TERM PATIENTS REQUIRING CUSTODIAL CARE The remaining one t h i r d of the forty-two long term chronic disease p a t i e n t s belonged to c l a s s C, p a t i e n t s r e -q u i r i n g c u s t o d i a l care only. These p a t i e n t s no longer presented a medical problem. In them the disease process was a r r e s t e d , l e a v i n g a permanent p h y s i c a l d i s a b i l i t y . Many needed some as s i s t a n c e i n d r e s s i n g , bathing, and e a t i n g , but no expert nursing or medical care was necessary. Such pa t i e n t s may l i v e at home i f the home i s adequate. In only two cases i n t h i s group d i d the patient have a family, both w i l l i n g and able to care f o r them at home, and i n both cases the p a t i e n t s were discharged to home care at the time of the study. Another two p a t i e n t s had f a m i l i e s who were able f i n a n c i a l l y , but were u n w i l l i n g to assume the burden of the care of the p a t i e n t i n the home. Instead they paid f o r the p a t i e n t ' s care i n the h o s p i t a l . Of the f i f t e e n p a t i e n t s i n t h i s group, only three were able to comfortably pay f o r t h e i r h o s p i t a l care; two others, although not yet d e s t i t u t e were unable to pay f o r t h e i r care without becoming d e s t i t u t e . The remaining two t h i r d s of the group were t o t a l l y dependent f o r t h e i r support; f i v e upon c i t y r e l i e f , and f i v e on Old Age Pensions, One h a l f the p a t i e n t s i n t h i s group were over seventy years and a l l were over f o r t y years of age. The number of days care i n h o s p i t a l ranged from t h i r t y - f i v e days to 2,925 days, w i t h seven patients i n the group being i n the h o s p i t a l longer than 27-two and a h a l f years. A l l the p a t i e n t s i n the group were r e c e i v i n g care i n the p u b l i c medical wards. The most common ailment was diseases of the heart which accounted f o r f i v e p a t i e n t s . Heuro-s y p h i l l i s was the d i a g n o s i s i n two cases, and the c o n d i t i o n s of the f o u r p a t i e n t s were given as, asthma, b r a i n tumor, neurogenic d i a r r o h e a , and m a l n u t r i t i o n , r e s p e c t i v e l y . I n two cases the diagnosis was given as s e n i l i t y , which meant that the p a t i e n t was s u f f e r i n g the n a t u r a l degenerative changes of o l d age and that there was no s p e c i f i c diseased organ. One patient was described as a boarder; no medical diagnosis had been made and the p a t i e n t was not i n need of care i n a general h o s p i t a l , she merely 'boarded' t h e r e . I n t h i s group of p a t i e n t s , the most outstanding s i n g l e f a c t o r c o n t r i b u t i n g to the prolonged h o s p i t a l i z a t i o n , was lack of f a c i l i t i e s i n the community f o r the care of the aged s i c k . In s e v e n t y - f i v e percent of the cases, the e l d e r l y p atient had been admitted to h o s p i t a l f o r medical treatment, and once the disease process was a r r e s t e d and the patient ready f o r discharge i t became apparent t h a t discharge would be impossible since the p a t i e n t had no place e l s e to go. The most common reasons were, poverty and i n a b i l i t y of the patient to pay f o r care elsewhere, and l a c k of p u b l i c p r o v i s i o n of c u s t o d i a l homes f o r the aged. The f o l l o w i n g i l l u s t r a t i o n s are t y p i c a l i n t h i s group of p a t i e n t s of what happens once the e l d e r l y i n d i g e n t p a t i e n t gains admission to the general h o s p i t a l . 28. The Case of C A . Mr.C.A., a s i n g l e man, aged eighty-three had emigrated from Sweden at the age of twenty and worked i n t h i s country as a t r a n s i e n t l a b o r e r . He claimed he had no f a m i l y or f r i e n d s i n t h i s country. For unknown reasons the patient had f a i l e d to o b t a i n Canadian c i t i z e n s h i p and was thus not e l i g i b l e f o r an Old Age Pension. He had, however, e s t a b l i s h e d residence i n the c i t y and was i n r e c e i p t of c i t y r e l i e f allowance, l i v i n g alone i n a rooming house. He was admitted to h o s p i t a l during an acute psychotic episode which had been p r e c i p i t a t e d by m a l n u t r i t i o n and a v i t a m i n d e f i c i e n c y . He was up and around the h o s p i t a l and d i d not r e q u i r e s k i l l e d n u r s ing care. His treatment consisted of nourishment and s e d a t i v e s . When interviewed the p a t i e n t stated that he had never been s i c k before, or had never had medical a t t e n t i o n . He had no idea of how long he had been i n the h o s p i t a l and s a i d he had nowhere to go upon discharge. He stated that he hoped he would d i e i n the h o s p i t a l and then he would be put underground and out of the way. The Case of C.B. Mrs. C.B., an e i g h t y - f i v e year o l d widow had been i n h o s p i t a l three years at the time of the study. Upon her v admission to h o s p i t a l the p a t i e n t ' s only daughter, l i v i n g i n C a l i f o r n i a , was contacted and i t was discovered that she was w i l l i n g to have the patient w i t h her. However, since the daughter d i d not have complete n a t u r a l i z a t i o n papers, the patient'was refused entry i n t o the United S t a t e s . 29. The p a t i e n t remained i n h o s p i t a l and each month her Old Age Pension cheque was turned over to the h o s p i t a l . She was allowed a few d o l l a r s each month f o r comforts. Her treatment i n h o s p i t a l consisted of r o u t i n g care and r e g u l a t i o n of her d i e t . She al s o required a hypodermic i n j e c t i o n each n i g h t i n order to prevent an asthmatic a t t a c k . However, i t was found that a hypodermic of s t e r i l e water was as e f f e c t i v e as any of the drugs used, to c o n t r o l the a t t a c k s . A f t e r two years of h o s p i t a l i z a t i o n the daughter got her f i n a l c i t i z e n s h i p papers and i t was pos s i b l e f o r the p a t i e n t to go to her. By t h i s time the patient was t e r r i f i e d to leave the h o s p i t a l and her c o n d i t i o n made such a l o n g t r i p impossible f o r her. She stated that she could not leave the h o s p i t a l and that she had not long to l i v e now anyway. At the time t h i s study was made the patient had received care f o r a year f o l l o w i n g t h i s event. The point emphasised i n these i l l u s t r a t i o n s i s t h a t adequate p r o v i s i o n has not been made i n the community f o r the care of the aged s i c k . As seen from the above i l l u s t r a t i o n s there i s no one scheme which w i l l meet the needs of the aged. In the case of Mr. C A . medical super-v i s i o n was not necessary once the acute phase of h i s c o n d i t i o n had been d e a l t w i t h . His i s a problem of poverty and neglect and i l l u s t r a t e s the inadequacy of the care pro-vided by the. c i t y r e l i e f department. I t al s o points up the gap i n our n a t i o n a l p r o v i s i o n s f o r the- aged, which does not provide f o r n o n - c i t i z e n r e s i d e n t s who are i n need. Mr. C A . 30. was i n need of adequate p h y s i c a l maintenance, the lack of which had p r e c i p i t a t e d h i s admission to h o s p i t a l . Since he was without f a m i l y and f i n a n c i a l resources he - r e q u i r e d some type of c u s t o d i a l care a t public expense. Such care could have been had i n a boarding home. Instead, the p a t i e n t was given a f i n a n c i a l allowance and he attempted to l i v e alone i n a s i n g l e room, and care f o r h i s own needs, without medical a t t e n t i o n . Although many old people do not wish or r e q u i r e i n s t i t u t i o n a l care; boarding care being b e t t e r s u i t e d to t h e i r needs; they r e q u i r e the same medical s e r v i c e which should be a v a i l a b l e to the aged i n t h e i r own homes. This s e r v i c e should i n c l u d e , out patient c l i n i c s , v i s i t i n g nurses and p h y s i c i a n s , and medical s o c i a l s e r v i c e . Although a good number of the aged c h r o n i c a l l y i l l may be cared f o r i n boarding homes, there are s t i l l many who need i n s t i t u t i o n a l care. Homes f o r the aged have long pro-vided d o m i c i l e s and s e c u r i t y f o r the r e s t of t h e i r l i v e s , to homeless men and women. However, they have o f t e n refused to take c h r o n i c a l l y i l l o l d persons who are i n need of nursing care. Since a most urgent problem of the aged i s chronic i l l n e s s , homes f o r the aged should provide, not only room and board but also simple nursing s u p e r v i s i o n and medical care d i r e c t e d to making the p a t i e n t comfortable and a r r e s t -ing the progress of h i s disease. There should be some 4 human contacts as w e l l as a p r o v i s i o n f o r s u s t a i n i n g the p a t i e n t ' s emotional and i n t e l l e c t u a l l i f e . In the case of Mrs. C.B., her l i f e was circumscribed 31. by her enforced i m m o b i l i t y . The time consumed by the simple proceedures of bat h i n g and feeding her and making her bed was so great that care could h a r d l y be given by a v i s i t i n g nurse s e r v i c e at home or i n a boarding home. Ne i t h e r of these p a t i e n t s were i n need of general h o s p i t a l care. Although they were enfeebled by degenerative d i s e a s e s , progress was so slow that vigorous medical treatment was not i n d i c a t e d . They required c u s t o d i a l care only, and due to the la'ck of such care i n the community, e i t h e r at public or pr i v a t e expense, these p a t i e n t s could not be discharged from the h o s p i t a l . The problem of c u s t o d i a l care, was not l i m i t e d to the ol d age group. The p r a c t i c e of l i m i t i n g admissions to homes f o r the aged to c e r t a i n age groups assumes that human beings age p h y s i o l o g i c a l l y . A c t u a l l y the persons age i s not always an i n d i c a t i o n of the need f o r f i n a n c i a l a s s i s t a n c e or c u s t o d i a l care. An i n d i v i d u a l w e l l past eighty may s t i l l be able t o care f o r h i m s e l f , w h i l e h i s neighbor i n h i s s i x t y s who s u f f e r s w i t h heart disease may be i n need of f i n a n c i a l a s s i s t a n c e or c u s t o d i a l care, or both. The f o l l o w i n g case i l l u s t r a t e s the s i m i l a r i t y i n the need of the chronic p a t i e n t s not yet seventy, and those who are e l i g i b l e f o r Old Age a s s i s t a n c e . The Case of C D . Mr. CD., a s i n g l e man, aged f o r t y - t h r e e , had been i n the h o s p i t a l 2,831 days. As a r e s u l t of an operation to remove a tumor from the b r a i n the p a t i e n t was bed-ridden and 32. t o t a l l y paralyzed on one s i d e . Although he was not i n need of care i n a general h o s p i t a l , he d i d r e q u i r e r o u t i n e nursing care. Previous to h i s i l l n e s s the p a t i e n t had worked as a c l e r k , and h i s savings were soon used up on medical b i l l s . He had one brother, l i v i n g i n the c i t y , who could not assume the burden of h i s care. Since care was not a v a i l a b l e elsewhere i n the c i t y , the c i t y r e l i e f department paid the h o s p i t a l $20.00 a month to keep the p a t i e n t . Although t h i s amount was not enough to pay f o r general h o s p i t a l care at the r e g u l a r r a t e s , the r e l i e f department reasoned that i f the amount was not s u f f i c i e n t , the c i t y would be t a k i n g the l o s s anyway, si n c e i t was a c i t y h o s p i t a l . Very few laymen and not enough physicians have accepted the importance of the e a r l y r e c o g n i t i o n of chronic diseases through p e r i o d i c medical examinations of the i n d i v i d u a l by h i s own p h y s i c i a n . The community as a- whole s t i l l b e l i e v e s i n seeking medical advice only when the symptoms of the disease appear and then i n withdrawing from the doctor's s u p e r v i s i o n u n t i l the same or new symptoms again become evident. In the i n t e r v a l the disease may be i n s i d i o u s l y progressing. One of the great wastes i n the f i e l d of medical care i s the p e r i o d i c h o s p i t a l i z a t i o n of persons s u f f e r i n g from a chronic disease, who during t h e i r symptom f r e e i n t e r v a l s , have f a i l e d to r e c e i v e medical s u p e r v i s i o n which might have prevented the f u r t h e r progress of t h e i r disease. Not only i s medical care o f t e n inadequate 33-a f t e r the onset of the disease, hut o f t e n the c o n d i t i o n i s diagnosed too l a t e f o r the treatment to he e f f e c t i v e . The f o l l o w i n g case i l l u s t r a t e s a lack of medical care which i f i t had been a v a i l a b l e might have discovered the c o n d i t i o n i n time and prevented the progression o f the d i s e a s e . The Case of C.E. Mr. C.E., a f i f t y - n i n e year old widower, was i n v a l i d e d i n a mine accident i n 1922. Prom that date u n t i l August, 1938, he was dependent upon h i s brother and C i t y R e l i e f f o r h i s support. He had no medical a t t e n t i o n during "this p e r i o d . He was admitted to h o s p i t a l i n 1938 s u f f e r i n g from what appeared to be a s t r o k e . Further examination showed that the patient was s u f f e r i n g from neuro s y p h i l l i s , . Although the p a t i e n t ' s lower e x t r e m i t i e s were paralyzed and he was confined to a wheel c h a i r , he was under no medical treatment. The patient had been i n h o s p i t a l 2,925 days and would long since have been discharged had he a place to go. His prognosis was poor and h i s conditon would become progress-i v e l y worse u n t i l admission to a mental i n s t i t u t i o n i s necessary. S y p h i l l i s , as cancer and t u b e r c u l o s i s , may be cured or a r r e s t e d , i f discovered e a r l y enough and adequate treatment given. Treatments f o r these disease are known, the problem l i e s i n g e t t i n g the treatment to those who need i t , and e a r l y enough to be e f f e c t i v e . In the case of Mr. C.E., medical care was not a v a i l a b l e to him since he could not pay f o r i t , and r o u t i n e medical examinations were not supplied by the c i t y r e l i e f department. Since he d i d not 34. e x h i b i t symptoms he had no need to consult a p h y s i c i a n . Had medical care been a v a i l a b l e to him e a r l y enough, he might have been saved the d e t e r i o r a t i o n t h e t s y p h i l l i s b r i n g s , and the p u b l i c might have been saved the expense of pr o v i d i n g c u s t o d i a l care f o r him. To date the pa t i e n t has spent eight years i n a general h o s p i t a l , because there was no other f a c i l i t y f o r h i s care elsewhere. Surely t h i s i s a misuse of a general h o s p i t a l . The m a j o r i t y of human ailments do not permit of such l o g i c a l therapy as salvar s a n or p e n i c i l i n i n the case of s y p h i l l i s . I n some cases the cause of the disease may be known but not the means to era d i c a t e i t . Or i t may, cause unknown/ induce permanent a l t e r a t i o n s i n s t r u c t u r e and f u n c t i o n i n many organs of the body. Therefore, i n a great m a j o r i t y of i l l n e s s e s treatment i s not s t r i c t l y c u r a t i v e but i s d i r e c t e d to r e s t o r e the f u n c t i o n a l c a p a c i t y or to remove the causative agent. Fundamental to a l l medical treatment > rs the r e a l i z a t i o n that the p h y s i c i a n i s d e a l i n g w i t h a whole i n d i v i d u a l . Often, as has been pointed out i n the preceeding chapters, the lack of proper treatment i s not wholly the r e -sult .of i n a b i l i t y to pay, or inequal d i s t r i b u t i o n of medical s e r v i c e , but i s t h e , r e s u l t of ignorance on the part of the phy s i c i a n of how to t r e a t c e r t a i n a i l m e n t s . I t i s w e l l understood by many physicians and p a t i e n t s , too, that emotions may be a f o r c e that w i l l produce sickness i n various parts of the g a s t r o i n t e s t i n a l t r a c t , but of t e n beyond paying 35. ; l i p s e r v i c e to t h i s concept, very l i t t l e o f a p r a c t i c a l nature i s done about i t . . The Case of C.F. Mrs. C ."£?., -widowed twice by f i f t y - s e v e n , was admitted to h o s p i t a l f o r treatment of diarrohea of which she had complained f o r seven years. The pati e n t had been employed as a j a n i t r e s s u n t i l two years before her admission when she had been forced to stop work because of her poor h e a l t h . The p a t i e n t gave a h i s t o r y of many g a s t r o - i n t e s t i n a l com-p l a i n t s i n c l u d i n g , u l c e r ; a l s o a u t e r i n e suspension and the removal of one ovary. At the time of the study she had been i n the h o s p i t a l e i g h t y - f o u r days, r e c e i v i n g r o u t i n e n u r s i n g care and s e d a t i v e s . A consultant p h y s i c i a n was c a l l e d i n , and a f t e r x-rays of the stomach, h e a r t , and g a l l b l a d d e r , a barium enema, electro-cardiogram and s p i n a l puncture, he reported that the patient was " s u f f e r i n g from many psychosomatic complaints". He diagnosed her c o n d i t i o n as "angina secondary to hypertension, and an abdominal c o n d i t i o n " . The patient continued to re c e i v e r o u t i n e nursing care and sedatives, and the a t t i t u d e of the h o s p i t a l attendants was that she was a nuisance, since there was nothing o r g a n i c a l l y wrong w i t h her and she was "merely" n e u r o t i c . F i n a l l y , the phy s i c i a n i n d i c a t e d h i s d e c i s i o n to discharge the patient and she appealed to the charge nurse f o r ass i s t a n c e i n arranging discharge. She was r e f e r r e d to the S o c i a l Service Department by the nurse. I t was discovered that the patient had been r e c e i v i n g r e l i e f a s s i s t a n c e p r i o r to her admission to h o s p i t a l . Her only son had a la r g e 36. f a m i l y and a small income and would be unable to h e l p her. Since the pati e n t ' s c o n d i t i o n made i t impossible f o r her to work, the worker helped make arrangements w i t h the r e l i e f department f o r t r a n s f e r to a nursing home where the pa t i e n t would get room and board. I t i s a f a i r assumption that t h i s p a t i e n t ' s h o s p i t a l -i z a t i o n has been prolonged because of u n r e a l i s t i c treatment and a l s o because of inadequate treatment i n the past. The t r a d i t i o n a l l i n e of p h y s i c a l and l a b o r a t o r y i n v e s t i g a t i o n , d i e t and medication, have been t r i e d , but no r e a l e f f o r t has been made to understand the l i f e s i t u a t i o n of the p a t i e n t . Even though the patient understands that she has 'neurogenic d i a r r o h e a ' , she s t i l l b e l i e v e s that medication w i l l answer the problem. The ph y s i c i a n a l s o seeks to accomplish a cure along organic l i n e s , s i n c e he would not know what to do or say i f the pati e n t should ask f o r t r e a t -ment by psychotherapy. 37. Chapter VI SHORT TERM AMD POTENTIALLY LONG- TERM PATIENTS Thus f a r , only the forty-two p a t i e n t s who had been i n the h o s p i t a l a prolonged time, on the date of t h i s study, have been considered. The d e c i s i o n as to what c o n s t i t u t e d prolonged h o s p i t a l i z a t i o n was made a r b i t r a r i l y thus i g n o r i n g the p o s s i b i l i t y of any of the remaining t h i r t y - e i g h t c h r o n i c p a t i e n t s becoming e l i g i b l e f o r long term c l a s s i f i c a t i o n a t any f u t u r e date. That forty-two of the eighty chronic p a t i e n t s i n h o s p i t a l happened t o be long term was dependent upon the date chosen f o r the survey. Had the check been made on another date the sample might have been markedly d i f f e r e n t . In order to determine roughly which p a t i e n t s i n the short-term group might be considered p o t e n t i a l l y long term p a t i e n t s , a check was made t h i r t y days a f t e r the date of the study, i n order to determine the d i s p o s i t i o n of the p a t i e n t s . Of the t h i r t y - e i g h t p a t i e n t s i n t h i s group, twenty-three were discharged from the h o s p i t a l before r e c e i v i n g t h i r t y days care, thus l e a v i n g them i n the group of short term p a t i e n t s . S i x p a t i e n t s were discharged a f t e r being i n the h o s p i t a l t h i r t y days, thus making, them e l i g i b l e f o r the long term group. These pati e n t s were admitted to h o s p i t a l f o r treatment of t h e i r v a rious disease c o n d i t i o n s and were discharged once the phy s i c i a n was s a t i s f i e d that treatment had been accomplished. A l l these pa t i e n t s had f a m i l i e s and homes of t h e i r own to be discharged t o . However, the f a c t that these p a t i e n t s were 38. discharged from h o s p i t a l does not insure that they were cured, nor does i t exclude the p o s s i b i l i t y of readmission to h o s p i t a l . Depending upon, the success of the treatment r e c e i v e d , the pat i e n t ' s a b i l i t y to adjust to h i s l i m i t a t i o n s and the amount and q u a l i t y of medical s u p e r v i s i o n a v a i l a b l e to him outside the h o s p i t a l , plus any number of c o m p l i c a t i n g medical and s o c i a l f a c t o r s , the p a t i e n t may or may not be readmitted to the h o s p i t a l and h i s c o n d i t i o n may e i t h e r progress to the extent of t o t a l d i s a b i l i t y , or i t may be s a t i s f a c t o r i l y c o n t r o l l e d . In view of the f a c t that there i s no h e a l t h insurance scheme or medical care plan, operating adequately i n t h i s province, the r i s k i s great that any of these p a t i e n t s may become impoverished i n paying f o r t h e i r medical care. Nine of the t h i r t y - e i g h t "short term group" remained i n the h o s p i t a l at l e a s t t h i r t y days a f t e r the date of t h i s study, d e f i n i t e l y q u a l i f y i n g as long term p a t i e n t s . Thus of a t o t a l of t h i r t y - e i g h t patients who were considered short term on the date of the study, f i f t e e n e v e n t u a l l y remained i n the h o s p i t a l a prolonged period. I t i s suggested t h a t t h i s group of patients i s not s i g n i f i c a n t l y d i f f e r e n t from those already d i s c u s s e d . In some cases the p a t i e n t ' s stay i n h o s p i t a l was extended because he required s p e c i a l medical a t t e n t i o n f o r a prolonged period due to the nature of h i s d i s e a s e . The f o l l o w i n g case i s i l l u s t r a t i v e . The Case of D.A. Mr. D. A., a s i n g l e n a t i v e born man of twenty-four, was admitted to h o s p i t a l s u f f e r i n g w i t h rheumatic heart disease, the aftermath of an.attack of rheumatic fever f i v e years 39 previous. Treatment c o n s i s t e d of sedatives and complete bed r e s t and would be required f o r a long p e r i o d . This patient was r e c e i v i n g p r i v a t e ward care and had been i n h o s p i t a l eighteen days at the time of the study. H i s f a m i l y l i v e d on a farm i n a neighboring d i s t r i c t and were f a i r l y w e l l to do. The patient had h i s l e f t arm amputated a the shoulder at the age of e i g h t , as a r e s u l t of an accident He was unable to do heavy farm work, but was able to do carpentry work, at which he earned h i s l i v i n g * Because of h i s weakened heart c o n d i t i o n the openings f o r employment would be few f o r him. This i s the type of patient who r e q u i r e s care' i n a s p e c i a l h o s p i t a l adapted, to h i s needs. Rheumatic fever i s an i n f e c t i o u s disease of unknown cause that i n j u r e s the heart by c r i p p l i n g the v a l v e s . Although the onset of rheumatic i n f e c t i o n may be acute, i t s course i s drawn out over a period of many months and there i s a tendency f o r the i n f e c t i o n to recur year a f t e r year. The main medical problem i s to prevent i n f e c t i o n and r e i n f e c t i o n , the second one i s to spare the damaged heart harmful o v e r s t r a i n . This p a t i e n t had e v i d e n t l y not had s u f f i c i e n t medical a t t e n t i o n to prevent the recurrence of h i s disease. . Unless he i s able to continue w i t h h i s treatment l o n g enough, and remain under clo s e s u p e r v i s i o n he w i l l e v e n t u a l l y become a permanent burden upon h i s f a m i l y or the community. In the f o l l o w i n g case, need f o r medical care i s evident but i t a l s o i l l u s t r a t e the need f o r i n t e n s i v e research i n t o cause and treatment of c e r t a i n d iseases, plus, some p u b l i c 40. p r o v i s i o n f o r the treatment of those i n f i n a n c i a l need. The Case of D.B. Mrs. D.B., a widow of f i f t y , was admitted t o h o s p i t a l w i t h a h i s t o r y of swollen j o i n t s over a period of four years. Between 1936 and 1944 the p a t i e n t had been h o s p i t a l i z e d f i v e times, three f o r operations, (thyroidectomy, appendectomy, and hysterectomy) and twice f o r treatment of rheumatoid a r t h r i t i s . Although the patient had s u f f e r e d w i t h rheumatic pains and v a r i c o s e veins since 1938 she received h e r , f i r s t treatment i n 1942 when she was h o s p i t a l i z e d f o r two months. She was readmitted to h o s p i t a l i n 1945 when she received three months gold treatment. At the time of the study she had been i n the h o s p i t a l eight days, and she was . s t i l l there t h i r t y days l a t e r . At the age of f i v e the p a t i e n t came to Canada w i t h her parents, from A u s t r i a ) and s e t t l e d on a homestead i n A l b e r t a . She had no opportunity f o r education and l i t t l e or no medical care. At an e a r l y age she married a man ten years ' her s e n i o r . For twenty years, u n t i l the death of her husband,, the patient l i v e d the hard l i f e of the w i f e of a p r a i r i e farmer, where medical care was so scarce i t was considered a l u x u r y . For the ten years f o l l o w i n g her husband's death she supported h e r s e l f and three c h i l d r e n , by dishwashing and domestic s e r v i c e j o b s * At the time of the present admission the c h i l d r e n had e s t a b l i s h e d t h e i r own homes and the patient was l i v i n g alone on her farm. The expense of repeated h o s p i t a l i z a t i o n and medical treatment had drained the p a t i e n t ' s f i n a n c i a l resources and she was no long er able to pay f o r her care. In a d d i t i o n to the p a t i e n t s who required medical care t o 41. prevent the progress of t h e i r disease,-and who d i d not always have the f i n a n c i a l resources to pay f o r i t ; there were cases, l i k e the f o l l o w i n g , where lack of f a c i l i t i e s i n the community f o r the c u s t o d i a l care of the i n d i g e n t and aged chronic s i c k were the causes f o r delayed discharge. The Case of D.C Mrs. D.C, a widow, n i n e t y two years of age was admitted to h o s p i t a l i n a confused s t a t e . Her c o n d i t i o n was diagnosed as s e n i l e psychosis. At the time of the study she had been i n the h o s p i t a l only f i v e days. Because of her c o n d i t i o n and her poor memory i t was impossible to i n t e r v i e w the patient and scant in f o r m a t i o n was a v a i l a b l e from the medical f i l e . There was no record of f a m i l y or where patient, had been l i v i n g p r i o r to admission. P a t i e n t was l i s t e d as re s p o n s i b l e f o r account. She was r e c e i v i n g r o u t i n e n ursing care which would be a v a i l a b l e i n a nu r s i n g home. Her stay i n h o s p i t a l w i l l depend upon how long she l i v e s . The Case of D.E. Mrs. D.E., a widow, seventy-nine years of age l i v e d w i t h a f r i e n d and c o n t r i b u t e d her Old Age Pension cheque f o r her support. She was i n bed s u f f e r i n g w i t h rheumatism when she f e l l out of bed and bru i s e d her head. This f a l l r e s u l t e d i n her l o s s of memory and she became i r r a t i o n a l . A f t e r two days care the f r i e n d found i t impossible to give the patient the necessary nursing care, and the pa t i e n t was admitted to the h o s p i t a l . The•patient's daughter, l i v i n g i n another part of the country, accepted the r e s p o n s i b i l i t y 42. f o r the payment of the h o s p i t a l h i l l . T h i s p a t i e n t ' s stay would probably depend upon how long she l i v e s . • These two pati e n t s were not i n need of general h o s p i t a l care. Although enfeebled by degenerative disease; progress was so slow that vigorous medical treatment i n an i n s t i t u t i o n was not i n d i c a t e d . They required a c u s t o d i a l type of care such as should be a v a i l a b l e i n a home f o r the. aged. However, i n s t i t u t i o n s c a r i n g f o r the aged, to provide adequate care, must be endowed wi t h b e t t e r f a c i l i t i e s than most of the present day homes fo r ' t h e aged, yet these need not be complex and expensive. Prom these b r i e f case presentations i t i s evident that the f a c t o r s c o n t r i b u t i n g to the extended h o s p i t a l i z a t i o n of the f i f t e e n p o t e n t i a l l y long term p a t i e n t s , were not e s s e n t i a l l y d i f f e r e n t from those presented by the forty-two long term p a t i e n t s . The same types of problems, namely i n -adequate p r o v i s i o n of medical care, i n s u f f i c i e n t income, poor 4 adjustment to l i m i t a t i o n s of the i l l n e s s , l a c k of community f a c i l i t i e s f o r care and in a p p r o p r i a t e treatment were seen as f a c t o r s which were c o n t r i b u t i n g , or w i l l c o n t r i b u t e , to the extension of the h o s p i t a l s t a y . 4.3. Chapter V I I FACTORS CONTRIBUTING TO PROLONGED HOSPITALIZATION Prom an a n a l y s i s of the forty-two long term chronic pat i e n t s i n t h i s sample, i t i s evident that the greatest s i n g l e c o n t r i b u t i o n to the extension of h o s p i t a l i z a t i o n i s the f a c t that many of these p a t i e n t s had nowhere else to go. Por the most part, when these pa t i e n t s were admitted to h o s p i t a l they were i n need of a c t i v e medical treatment. Due to the nature of the diseases they required a prolonged course of care; and once the acute phase of the i l l n e s s was de a l t w i t h , they required e i t h e r a prolonged course of nursing care or an adjustment of t h e i r l i f e s i t u a t i o n to the l i m i t a t i o n s set by t h e i r i l l n e s s e s . In the case of these chronic disease pa t i e n t s t h i s o f t e n meant a l o s s of earning power and thus the pa t i e n t s greatest problem was a f i n a n c i a l one. In twenty of the forty-two long term cases the patient remained i n the h o s p i t a l p r i m a r i l y because he had nowhere else to go. I t was found impossible to analyse s t a t i s t i c a l l y and define c l e a r l y .the reasons f o r t h i s since combinations of f a c t o r s such as, no f a m i l y , unemployment, o l d age, lack of e a r l y medical care, and i n s u f f i c i e n t community f a c i l i t i e s f o r care, were c o n t r i b u t i n g to the problem. How-ever, three main groupings of these f a c t o r s were i n d i c a t e , to account f o r pati e n t s remaining i n the h o s p i t a l when no adequate medical s o c i a l plan could be made outside the h o s p i t a l . An understanding of the s o c i a l problems was best gained by grouping them according t o the needs of the p a t i e n t s , namely, need f o r medical care, need f o r nursing 44. care, and need f o r c u s t o d i a l o r boarding care. Fourteen of the long term p a t i e n t s required a c t i v e medical care which was a v a i l a b l e to them i n the general h o s p i t a l . In f i v e of these cases the patient was i n need of s p e c i a l , prolonged care i n order to a r r e s t the development of the disease. Since there was no s p e c i a l h o s p i t a l f o r t h i s type of care they remained i n the general h o s p i t a l although not r e q u i r i n g the expensive and s p e c i a l i z e d s e r v i c e i t was equipped to g i v e . In three instances treatment was hot known that would a r r e s t the disease, therefore the c o n d i t i o n progressed to the point.of death. I n s i x cases i t was evident that medical care had not been a v a i l a b l e to the patie n t u n t i l too l a t e i n the progression of the disease and the r e f o r e was not e f f e c t i v e i n a r r e s t i n g the c o n d i t i o n . This was found to be the r e s u l t of the i n a b i l i t y of the p a t i e n t to pay f o r medical care and the inadequacy of medical resources i n c e r t a i n areas, p a r t i c u l a r l y i n r u r a l s e c t i o n s . There were t h i r t e e n long'term p a t i e n t s , i n the study," who were'in need of nu r s i n g care and s i x of them remained i n h o s p i t a l a prolonged time, s o l e l y because they had no place to be discharged t o . They required placement i n a nursing or boarding home where they could r e c e i v e the nursing care they r e q u i r e d . Although the remaining seven pa t i e n t s had homes to which they could be discharged, nursing care was not a v a i l a b l e to them there; because of s c a r c i t y of t h i s s e r v i c e i n the community, and i n a b i l i t y of these p a t i e n t s to pay f o r p r i v a t e n u rsing care. With a good system of home, medical and nursing care properly organized; and the a d d i t i o n of some form of d i s a b i l i t y pension or allowance; many of 4 5 -these p a t i e n t s could remain i n t h e i r own homes. Two t h i r d s of the p a t i e n t s who required c u s t o d i a l care, remained i n h o s p i t a l because they had no place e l s e t o be discharged t o . These p a t i e n t s were w e l l enough to be on exercise but had no homes, were unable t o support themselves, and could not be forced to leave the h o s p i t a l . They u s u a l l y required i n s t i t u t i o n a l care, not f o r purely medical reasons, but because poverty, u s u a l l y brought on, or accentuated by long drawn out antecedent i l l n e s s , had made home care impossible. Improvement could not be expected i n these p a t i e n t s yet they required care on humanitarian grounds. Two p a t i e n t s i n t h i s group had remained, i n h o s p i t a l over seven years because they were without homes or f i n a n c i a l resources. This was a misuse of a h o s p i t a l and was not only economically unsound but undesirable i n other r e s p e c t s . Although lack of other accommodation was found to be the main c o n t r i b u t i n g f a c t o r t o prolonged h o s p i t a l i z a t i o n , i t was found i n a small m i n o r i t y of cases that h o s p i t a l i z a t i o n was extended due to in a p p r o p r i a t e medical s e r v i c e . This was evident both i n the past h i s t o r y of the treatment and i n the present h o s p i t a l i z a t i o n . I n s i x of the forty-two long term cases i t was evident that i n a p p r o p r i a t e treatment had contr i b u t e d to extended h o s p i t a l i z a t i o n . This was due, f o r the most part, to f a i l u r e , or i n a b i l i t y on the part of the phy s i c i a n to t r e a t the p a t i e n t as a whole. Obviously, throughout i t i s evident that there i s a need f o r more community resources f o r the care of the c h r o n i c a l l y i l l , who are not a c t u a l l y i n need of General H o s p i t a l care. Such s e r v i c e s as v i s i t i n g nurses and house-keepers, and medical s e r v i c e s ; and such f a c i l i t i e s as s p e c i a l 46. treatment centres, nursing homes and homes f o r the aged, are u r g e n t l y needed i n the community. Perhaps more important i s the need f o r more medical s o c i a l workers i n the community i n order to assure the use of the e x i s t i n g community f a c i l i t i e s to the f u l l e s t extent. 47. Appendices Sample of schedule used f o r c o l l e c t i o n of data. The Royal Alexandra H o s p i t a l and the community served by i t . Tables ( i ) The d i s t r i b u t i o n of 80 chronic disease patients' i n the Royal Alexandra H o s p i t a l , J u l y 15, 1946, by c l a s s of care r e -qui r e d and h o s p i t a l . s e r v i c e . ( i i ) The d i s t r i b u t i o n of 80 chronic 'disease p a t i e n t s i n the Royal Alexandra H o s p i t a l , J u l y 1J>, 1946, according to length of h o s p i t a l i z a t i o n and c l a s s of care. ( i i i ) Numerical d i s t r i b u t i o n , by c l a s s , of forty-two long term chronic p a t i e n t s according to method of f i n a n c i n g care i n the Royal Alexandra H o s p i t a l , J u l y 15, 1946. ( i v ) Licensed i n s t i t u t i o n s i n the c i t y of Edmonton f o r the care of the Aged, I n f i r m and C h r o n i c a l l y i l l , J u l y , 1946. B i b l i o g r a p h y ( i ) Selected references ( i i ) General references 48. Appendix 1 Sample schedule Ward P u b l i c Race White Ser v i c e Med. Sex Male Name John A l b e r t Address Edmonton B i r t h d a t e 1907 B i r t h p l a c e V i l k a v i s k i s , L i t h u a n i a • R e l i g i o n Lutheran N a t i o n a l O r i g i n L i t h u a n i a C i t i z e n -No Immigration May, 1927 alone, at the age of . twenty. ; Education 2§- years elementary s c h o o l . One year barber school. Occupation h i s t o r y Railway s e c t i o n man, l a b o u r e r . Unable to work at a l l since 1943 when-he f i n i s h e d barber s c h o o l . Income bracket Dependent Source M u n i c i p a l charge M a r i t a l s t a t u s s i n g l e Spouse b i r t h d a t e occupation i l l n e s s cause of death none C h i l d r e n none 49 P a t i e n t * s i l l n e s s h i s t o r y Date Diagnosis Duration Where h o s p i t a l i z e d 1925 Typhoid f e v e r 7 weeks L i t h u a n i a 1925 Jaundice L i t h u a n i a 1937 Acute i n f e c t i v e a r t h r i t i s 18 days R.A.H. 1943(Jan)Auricular f i b r i l l a t i o n 4 days R.A.H. 1943(Apr) Acute a p p e n d i c i t i s and rheumatic heart X-ray showed ' previous rheumatic heart disease 15 days R.A.H. 1943(Oct) R e s p i r a t o r y i n f e c t i o n Cerebral embolism 19 days R.A.H. Present I l l n e s s D u ration Since 1943 Admission to h o s p i t a l February 6, 194o P r o v i s i o n a l diagnosis Congestive heart f a i l u r e Diagnosis Congestive heart f a i l u r e Complaints Weakness, anorexia 2 years, pain i n chest, p a l p i t a t i o n s , orthopnoea, edema, some heart enlargement. R e s p o n s i b i l i t y f o r account S e l f A b i l i t y to pay able to pay part, w i l l then have no resources A c t i v e care being received Bed r e s t , r o u t i n e nursing care Degree of i n c a p a c i t y T o t a l , unable to do any type of work. Prognosis Poor, hopeless. Could care be given elsewhere Yes, r e q u i r e s c u s t o d i a l type of care but should have medical care a v a i l -a b l e . 50 Reason f o r prolonged stay i n h o s p i t a l The p a t i e n t has no f a m i l y or f r i e n d s who could care f o r him and has l i t t l e money l e f t out o f h i s savings. Requires sedatives and bed r e s t and i s unable to do the simplest types of work without t i r i n g . As there was no f u r t h e r treat-, ment a v a i l a b l e the ph y s i c i a n recommended t h a t arrangements be made f o r the p a t i e n t ' s care i n . a n u r s i n g home. Arrangements f o r discharge made by s o c i a l worker and the p a t i e n t was d i s -charged on J u l y 22, to a p r i v a t e nursing home, financed by the c i v i c r e l i e f department, (where there was no medical care a v a i l a b l e . ) "Family h i s t o r y Parents Income bracket Marginal Normal f a m i l y l i f e No Broken f a m i l y Yes how by f a t h e r ' s death when 1915 Father Occupation farmer I l l n e s s unknown Death 1915 S i b l i n g s M a r i t a l B i r t h d a t e s Sex Status Mother housewife good h e a l t h unknown 1900 1905 1903 1901 male female female male Occupation I l l n e s s Dates m. blacksmith (B.C.) good h e a l t h m. housewife (A l b e r t a ) • whereabouts and present c o n d i t i o n unknown, r e -mained i n L i t h u a n i a . 51. Appendix 2 The Royal Alexandra H o s p i t a l , • Edmonton, A l b e r t a . The Royal Alexandra H o s p i t a l , Edmonton, i s a general h o s p i t a l of 572 beds i n c l u d i n g an i s o l a t i o n u n i t of 102 beds. I t i s approved by the American College of Surgeons, maintains membership i n the American H o s p i t a l A s s o c i a t i o n and the A l b e r t a H o s p i t a l A s s o c i a t i o n , and i s approved f o r i n t e r n s h i p by the Canadian Medical A s s o c i a t i o n . I t i s a teaching h o s p i t a l a f f i l i a t e d w i t h the U n i v e r s i t y of A l b e r t a , F a c u l t y of Medicine, Edmonton. The School of Nursing which was e s t a b l i s h e d i n 1905» 'is a c c r e d i t e d by the Senate of the U n i v e r s i t y of A l b e r t a and i t s graduates are e l i g i b l e to take examination f o r r e g i s t r a t i o n i n the province. The h o s p i t a l i s owned by the c i t y of Edmonton and governed by the Edmonton H o s p i t a l Board of 15 members, which i s appointed by the c i t y - c o u n c i l . The present b u i l d i n g was opened i n 1911 and the plant was enlarged i n 1920 and again i n 1929. The h o s p i t a l provides s e r v i c e s i n general medicine and surgery, 258 beds; p e d i a t r i c s , 64 beds; o b s t e t r i c s , 80 beds; contagious diseases 65 and pulmonary t u b e r c u l o s i s 37 beds, i n the I s o l a t i o n U n i t . I t a l s o provides s e r v i c e s i n cancer, dermatology, d i a b e t i c s , gynecology, neurology, opthamology, orthopedics, s y p h i l l i s and urology. S p e c i a l departments i n c l u d e , x-ray, c l y n i c a l and p a t h o l o g i c a l l a b o r a t o r y , p h y s i c a l therapy and s o c i a l s e r v i c e . There i s no o u t - p a t i e n t department i n the h o s p i t a l , and p a t i e n t s cannot be admitted to the h o s p i t a l f o r s t a f f care. The medical s t a f f i s • not d i v i d e d i n t o s e r v i c e s , r a t h e r each patient whether pu b l i c or p r i v a t e comes i n t o the h o s p i t a l under the care of h i s own p h y s i c i a n . For each medical s e r v i c e there i s a r e s i d e n t graduate i n t e r n who i s r e s p o n s i b l e , to the p a t i e n t ' s p h y s i c i a n , f o r the medical care and treatment of the p a t i e n t i n h o s p i t a l and i s a l s o i n charge of the s u p e r v i s i o n of the undergraduate i n t e r n s . S o c i a l Service Department. E a r l y i n 1944 the S o c i a l S e r v i c e Department was e s t a b l i s h e d by the h o s p i t a l board, on the 52. recommendation of the Edmonton C o u n c i l of S o c i a l Agencies. One s o c i a l worker w i t h experience and considerable s k i l l i n the c h i l d , f a m i l y w e l f a r e , and p s y c h i a t r i c f i e l d s was appointed. Rather l i m i t e d o f f i c e f a c i l i t i e s were set up i n a c e n t r a l l o c a t i o n i n the h o s p i t a l and the o r g a n i z a t i o n and development of the department was l e f t very much to the worker. A number of r o u t i n e tasks p r e v i o u s l y preformed by the superintendent and other members of the s t a f f a u t o m a t i c a l l y became the r e s p o n s i b i l i t y of the department. One of the f i r s t problems was the ' h o s p i t a l clearance' of a number of aged and c h r o n i c a l l y i l l , and a few whose only i l l n e s s was r * h o s p i t a l i t i s n and l a c k of any place to go. This n e c e s s i t a t e d a search i n t o community resources f o r the care o f such p a t i e n t s , and the f i n d i n g s of inadequacies i n these resources s t a r t e d the C o u n c i l of S o c i a l Agencies on a survey of the care of the aged and s i c k . As the medical and nursing s t a f f s became aware of the b e n e f i t s to the p a t i e n t s of t r a i n -ed s e r v i c e d e a l i n g w i t h s o c i a l emotional and p s y c h o l o g i c a l problems, there was a steady increase i n the number of such cases r e f e r r e d to the department. Success i n i n t e r p r e t i n g t h i s l i n e of the work so e f f e c t i v e l y was, due to the s k i l l , t r a i n i n g and p e r s o n a l i t y of the worker. In a d d i t i o n to the h o s p i t a l clearance and case work s e r v i c e s , the worker has been re s p o n s i b l e f o r the c l e r i c a l work of the depart-ment, s u p e r v i s i o n one day a week of a student nurse, l e c t u r e s to s e n i o r and intermediate nurses, a s s i s t a n c e w i t h c l i n i c s and seminars f o r i n t e r n s and medical students on psychosomatic cases, l e c t u r e s to u n i v e r s i t y students i n the School of • Nursing and A r t s ' f a c u l t y , committee membership on problems a f f e c t i n g the h o s p i t a l and i t s needs, addresses to groups i n the community and c o n s u l t a t i o n w i t h s t a f f members on personal emotional and p s y c h o l o g i c a l problems. S t a f f E xecutive 2, Medical s t a f f 134, Nurses 274, D i e t i t i a n s 3, Interns 12, O r d e r l i e s and ward aids 46, Technicians 20, C l e r i c a l workers 39, S o c i a l worker 1. 53-F i n a n c i a l D a i l y r a t e s - P r i v a t e 15.00 - #7.00 Semi-private #4.50 Ward - #3.00, Operating room fee - #3.00 - #10.00 D e l i v e r y room fee - #5»00. Operating cost percentages - A d m i n i s t r a t i o n 12.6^, p r o f e s s i o n a l care 40.9^» k i t c h e n and d i n i n g room care 20.8^, house and property 22;4%, maintenance Operating cost per pati e n t day #4.35 ( l ) Revenue per pat i e n t day #4.27 Government grants (2) Mu n i c i p a l - m u n i c i p a l i t i e s are l i a b l e f o r the p u b l i c ward charge per day of the-h o s p i t a l only i n the case of indigency, and l i a b l e f o r not more than #2,000.00 i n any one year from date of admission.' P r o v i n c i a l - The maximum per diem allowance per patient as provided by the A l b e r t a H o s p i t a l s Act i s 50^ 45^ " per day i s the rate p r e s e n t l y being paid. ( l ) f o r the e i g h t months previous to J u l y , 1946, f o r month of. J u l y the cost was #5* 15 P e r patient day. . (2) D i r e c t o r y of H o s p i t a l s i n Canada 1942 p. 146. The Community Served by the Royal Alexandra H o s p i t a l Edmonton i s the c a p i t a l c i t y of A l b e r t a , one of the newest provinces i n Canada and i n s p i t e of i t s population o f n e a r l y one hundred thousand i t s t i l l has many aspects of the f r o n t i e r town. The c i t y covers an area of 42.5 square m i l e s . Of a t o t a l population of 93»ol9 (3) 62,775 are of B r i t i s h e x t r a c t i o n (3) 1941 Census. 54. 29»955 other European and 6,070 Ukranian (many of whom have a language d i f f i c u l t y . 30,925 i n h a b i t a n t s are f i r s t generation immigrants although 69$ of the population are protestant there i s a l a r g e Roman C a t h o l i c m i n o r i t y of 29% and a great number of smaller sects and denominations. Although r a p i d development i n s i z e has continued, s o c i a l s e r v i c e progress has been slowed by the c u r t a i l e d f i n a n c i n g imposed by drought and depression. The Co u n c i l of S o c i a l Agencies i s s i x years o l d , and.the Family Welfare bureau has been g i v i n g s e r v i c e f o r three y e a r s . P r o v i n c i a l w e l f a r e and c h i l d care s e r v i c e s are understaffed and inadequate. The " C i v i c R e l i e f and Children's A i d department" of the c i t y government dispenses r e l i e f to the c i t y ' s needy i n h a b i t a n t s . General Medical F a c i l i t i e s There are four general h o s p i t a l s i n Edmonton w i t h a t o t a l bed c a p a c i t y of 1504. A d d i t i o n a l - h o s p i t a l f a c i l i t i e s a r e ; two p r i v a t e h o s p i t a l s s p e c i a l i z i n g i n the care of maternity cases and unmarried mothers, 112 beds; a dominion government t u b e r c u l o s i s h o s p i t a l f o r Indians, 250 beds; the P r o v i n c i a l Mental I n s t i t u t e , 425 beds providing c u s t o d i a l care f o r the over-flow of 'chronic p a t i e n t s ' from the p r o v i n c i a l mental h o s p i t a l ; and two p r i v a t e h o s p i t a l s f o r i n c u r a b l e s , 140 beds. Medical p r a c t i t i o n e r s i n the c i t y i n c l u d e 131 physicians (one to each 716 persons). The me d i c a l l y needy may rece i v e care from the out-p a t i e n t department of the u n i v e r s i t y h o s p i t a l which i s maintained as a separate c l i n i c i n a c e n t r a l l o c a t i o n i n the c i t y . There are a number of nursing homes and i n s t i t u t i o n s i n the c i t y which w i l l provide convalescent or c u s t o d i a l care f o r c e r t a i n types of p a t i e n t s (see t a b l e one). These must be l i c e n s e d by the c i v i c r e l i e f depart-ment, under c i t y by-law 1082, i n order that the c i t y may be reinbursed by the p r o v i n c i a l government 50$ of the amount paid f o r care of indige n t p a t i e n t s placed i n them. When a pa t i e n t i s an Old Age Pensioner, the reimbursement to the c i t y i s $0% over and above the pension.. However the c i t y s t i l l only pays $30.00 a month f o r n u r s i n g home care of i n d i g e n t s , and the p r o v i n c i a l grant which was intended to improve the care of the 55-c h r o n i c a l l y i l l has j u s t cut i n h a l f the cost of such care to the c i t y . The f o l l o w i n g are the standards of l i c e n s i n g as explained by a c i v i c r e l i e f o f f i c i a l . The b u i l d i n g i n s p e c t o r judges the s a f e t y of the b u i l d i n g and over-crowding, the f i r e department i n s p e c t s f o r f i r e hazards, the h e a l t h department judges the general h e a l t h standards, s a n i t a t i o n and q u a l i t y of food, and the r e l i e f department judges on grounds of general w e l f a r e . This i n s p e c t i o n i s done at the time of the annual a p p l i c a t i o n f o r l i c e n s e and there i s no p r o v i s i o n f o r checking to see i f the standards are maintained. There have been serious complaints of abuse and neglect against these homes made by pat i e n t s admitted to the Royal Alexandra H o s p i t a l . The c i v i c r e l i e f depart-ment has f a i l e d to check up on these complaints. I n s t i t u t i o n s c a r i n g f o r chronic p a t i e n t s At the time of the study the Royal Alexandra H o s p i t a l had under c o n s t r u c t i o n a b u i l d i n g to provide s i x t y beds f o r c h r o n i c a l l y i l l p a t i e n t s , which was t o be known as the "chronic wing". Apart from t h i s there were i n the community only two i n s t i t u t i o n s which would accept c h r o n i c a l l y i l l p a t i e n t s f o r care. S t . Joseph's h o s p i t a l which i s run by a Roman C a t h o l i c s i s t e r h o o d provides care f o r convalescents, i n c u r a b l e s , aged, and a FEW CRIPPLED CHILDREN, without r e s t r i c t i o n as to age, denomination, or n a t i o n a l i t y . This h o s p i t a l i s s e l f supporting and does not r e -ceive a p r o v i n c i a l grant, however, i t does get $125-00 annually from the c i t y . There i s some t r a i n e d n u rsing care but the s e r v i c e i s mostly c u s t o d i a l . Y o u v i l l e Convent at S t . A l b e r t i s an Indian School but as the government does not send enough c h i l d r e n , at present, to keep the large b u i l d i n g i n use, the ground f l o o r i s used f o r - t h e care of o l d people, mostly Old Age pensioners. The s i s t e r s p r e fer to accept persons who are not bedridden and who can care f o r themselves. However, arrangements can be made by the c i t y to admit a c h r o n i c a l l y i l l : person r e q u i r i n g c u s t o d i a l care. There i s no r e s t r i c t i o n as to race or r e l i g i o n and pa t i e n t s may leave when they please. There are no o l d 56 f o l k s homes or i n f i r m a r i e s maintained by the p r o v i n c i a l government. Several s e r v i c e clubs i n Edmonton maintain as t h e i r p h i l a n t h r o p i c e f f o r t small cottage type i n s t i t u t i o n s f o r o l d f o l k , and arrangements can sometimes be made f o r the c h r o n i c a l l y i l l p a t i e n t , who i s married and i n the appropriate age group; 57. Appendix 3 TABLES Table i The d i s t r i b u t i o n of 80 chronic disease patients i n the Royal  Alexandra H o s p i t a l , J u l y 15, 1946, by-class of care required  and h o s p i t a l s e r v i c e . S e r v i c e Class A Class B Class C T o t a l % Medical 33 14 20 . 67 83 S u r g i c a l 2 4 mm 6 .7-5 C h i l d r e n 4 3 mm 7 8.5 T o t a l 39 21 20 80 Percentage of t o t a l 49# 26f0 25^ 100% Table i i The d i s t r i b u t i o n of 80 chronic disease p a t i e n t s i n the Royal  Alexandra H o s p i t a l . J u l y 15. 1946. according to length of  h o s p i t a l i z a t i o n and c l a s s of care. Length of Stay Class A Class B Class C T o t a l Under 30 days 25 7 6 3.8 30 - 59 8 5 2 15 60 - 89 4 3 4 11 90 - 119 1 3 * 4 Over 120 1 2 9 12 T o t a l 39 20 21 80 Table i i i Numerical d i s t r i b u t i o n , by c l a s s , of forty-two long term chronic  p a t i e n t s according to method of f i n a n c i n g care i n the Royal Alexandra  H o s p i t a l , J u l y 157 1946. ~ A l l Cases Class A . P r i v a t e l y financed P r i v a t e ward P u b l i c ward 6 P u b l i c l y financed M u n i c i p a l i t y 1 O.A.P. 1 Part pay 1 No pay 5 T o t a l 14 Class B Class C T o t a l 1 1 2 6 5 17 1 2 4 4 5 1 - 2 4 3 12 13 15 42 Table i v Li c e n s e d f f i i n s t i t u t i o n s i n the c i t y of Edmonton f o r the care of the Aged, I n f i r m and C h r o n i c a l l y i l l , J u l y , 1945 Name No. of Monthly Type of Manage-P a t i e n t s Rates $ Care ment H o s p i t a l P r o v i n c i a l per diem Grant Type of Pa t i e n t Eventide home Men*s H o s t e l Women1s Ho s t e l S t . Josephs x General H o s p i t a l Y o u v i l l e 50 20 95 357 50 none none C u s t o d i a l S a l . Army It 11 M no 45 - 60 , Medical none day r a t e s Medical R.C* S i s t e r s of Providence no R.C. S i s t e r s of C h a r i t y 30 - 40 C u s t o d i a l R.C. S i s t e r s Gray Nuns yes no aged homeless men homeless women inc u r a b l e s general aged - no bedridden # C i t y bylaw 1082 x Refuses to take c i t y charges as the C i t y R e l i e f Department w i l l not pay adequate f e e s . C i t y w i l l pay only $30.00 per month. Table i v (cont'd) Name No. of Monthly Type of Manage-P a t i e n t s Rates $ . Care ment H o s p i t a l P r o v i n c i a l per diem Grant Type of Pa t i e n t Craven 3 30-35 Hildebrandt 5 25-30 Payne 17 3 0 r 4 0 Wickhurst 4 30 Porgan 5 40-60 Nursing P r i v a t e n 11 » M no no no no no convalescent unmarried mothers convalescent & chronic convalescent convalescent ON ro 63. Appendix 4 BIBLIOGRAPHY SELECTED REFERENCES• 1. Bluestone, E. M., "The emergence of the Chronic p a t i e n t " , J o u r n a l of the  American Medical A s s o c i a t i o n , October 9, 1943, v o l . 123, no. 6, p. 374, A short magazine a r t i c l e which points up the s p e c i a l problems i n the medical care of the chro n i c p a t i e n t . 2. Bluestone, E. M., "The Chronic has a c l a i m to care and cure i n the acute general h o s p i t a l " The Modern H o s p i t a l , V o l . 63, no. 3, September, 1944, PP. 67-69. The case f o r the care of the chronic pa t i e n t i n a wing of the general h o s p i t a l . 3. Boas, Er n s t P., "Chronic Disease", S o c i a l Work Year Book, New York, R u s s e l l Sage Foundation, 1933, 7 8 - 8 l, A d e s c r i p t i o n of Organized a c t i v i t i e s i n S o c i a l Work and r e l a t e d f i e l d s . 4. Boas, E r n s t P., "Convalescence and Chronic I l l n e s s " , i n Convalescent Care, Pro-ceedings of the Conference held under the auspices of the Committee on P u b l i c Health R e l a t i o n s of the New York Academy of Medicine, New York, The Academy, 1940. 5. Boas, Er n s t P., The Unseen PlaEue, Chronic Disease, J . J . Augustin, P u b l i s h e r , New York, 1940. An A n a l y s i s and des-c r i p t i o n of problems p e c u l i a r to chronic d i s e a s e s . A case i s made f o r the establishment o f s p e c i a l h o s p i t a l s f o r the c h r o n i c a l l y i l l . 6. Boas, E r n s t P., "The C o n t r i b u t i o n of Medical S o c i a l Work t o Medical care." S o c i a l  S e rvice Review, December, 1939* V o l . 13, PP.~t)2t5-633, U n i v e r s i t y of Chicago Press, Chicago, 111. 64. 7• The Care of the C h r o n i c a l l y 111 i n Montreal, P r i n t e d by the M e t r o p o l i t a n L i f e Insurance Company, Ottawa, A p r i l , 1940. A study of the f a c i l i t i e s a v a i l -able f o r the care f o r the c h r o n i c a l l y i l l i n Montreal, Quebec. 8. Cox, Donald M., "Desirable, features i n a Chronic Disease H o s p i t a l , " The Canadian  H o s p i t a l , V o l . 23, no. 4, p; 30-32, A p r i l , 1946. 9. E l l i s , W i l l i a m J . , "How New Jersey i s Car i n g f o r i t ' s Chronic S i c k " , The Modern  H o s p i t a l , August, 1931» V o l . 37, no. 2, BP. 53-58. 10. F a i r f i e l d , L e t i t i a , "Care of the Chronic S i c k " , The Lancet, V o l . 245, no. 6267, PP. 455^457, October 9, 1943-11. Hundenburg, Roy., "A study of bed d i s t r i b u t i o n according.to length of s t a y " , H o s p i t a l s , V o l . 20, no. 10, Pages 52-54, October, 1946. 12. Jensen, F., & Weiskotten, H. G., & Thomas, M. A., Medical Care of the Discharged  H o s p i t a l P a t i e n t , The Commonwealth Fund, New York, 1944. 13. Kretschmer, Herman L., "The Problem of the C h r o n i c a l l y 111 P a t i e n t " , The Journal of  the American Medical A s s o c i a t i o n . V o l . 127, no. 16, PP. 1025-1027, A p r i l 21, 1945. A comprehensive report of the s p e c i a l problems of the c h r o n i c a l l y i l l , together w i t h an a n a l y s i s of the v a r i o u s , methods of meeting these problems. 14. McClurkin, Eleanor, "Chronic Disease from the p a t i e n t ' s point of view", The Modern  H o s p i t a l , V o l . 65, no. 5» pp. 78-79, November, 1945* 15. Morrison, P e a r l , "What do we mean by Chronic p a t i e n t s ? " , The Canadian H o s p i t a l , V o l . 23, no. 10, pp. 36-38. A statement by the matron of a chronic disease h o s p i t a l , who s t r e s s e s the importance of d i s t i n g u i s h i n g between p a t i e n t s who r e -65* q u i r e medical treatment i n h o s p i t a l , and persons who require only c u s t o d i a l care. 16. 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W., "Better p r o v i s i o n needed f o r the c h r o n i c a l l y i l l , " The Canadian  H o s p i t a l , v o l . 23, no. 1, p. 3 4 •» January, 1946. A Canadian physician's statement on the extent and seriousness of the problem of chronic d i s e a s e s . Ward, Percy, "How much h o s p i t a l i z a t i o n i s r e a l l y necessary f o r the C h r o n i c a l l y 111," The Canadian H o s p i t a l . V o l . 23, no. 1, p. 35» A h o s p i t a l a d m i n i s t r a t o r r a i s e s the question of the need f o r f i r s t determining the numbers of p a t i e n t s who r e a l l y r e q u i r e h o s p i t a l care, before planning f o r the care and treatment. Warren, M a r j o r i e W., "The Care of the Chronic S i c k , A case f o r t r e a t i n g the chron i c -s i c k , i n blocks i n a general h o s p i t a l , " B r i t i s h Medical J o u r n a l , no. 4329, pp. 822-23, December~2j>, 1943. 67. GENERAL REFERENCES 1. B a r t l e t t , H. 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