Guardian Angel Care Inc.
A doctor and his invisible patientsDec. 18, 2005. 07:48 AM
Dr. Mark Nowaczynski is the only person Eileen Heitlager has seen all week.
He's likely the only person she'll see all year, besides the social worker and the young woman who comes to help her clean and buy groceries.
Heitlager hasn't left her little, dim bachelor apartment for eight years, since she slipped and broke her hip. She has no friends left, no family except for a distant nephew in Sudbury. At 96, she spends most of her time lying on her dusty pullout couch, beneath a heap of blankets, trying to keep warm.
That's how Nowaczynski finds her just before noon, on the second visit of his regular Tuesday rounds.
"Hi, Ms Heitlager, how are you?" he asks, bounding into the little home like a son returning from college.
She waves hello and he sets down to practice — checking her blood pressure, listening to her lungs, checking her neck for an inflamed jugular, a sign that her congestive heart failure is flaring up.
"You are taking your pills. That's good," he says, kneeling on the floor beside her.
"Why do my hands keep so cold?" she asks, holding up an arm so thin, it is almost transparent.
"I keep telling you," Nowaczynski replies. "It's because you are not mobile. Your circulation is not good."
Since her fall, the farthest she's ventured is the pink hallway of her North Toronto high-rise. The fear of slipping again and returning to the hospital in worse condition has kept her inside her apartment, and she had been too stubborn to ask for help.
She finally agreed to allow a personal-care worker to help her bathe, dust, and shop for groceries three times a week. But only after Nowaczynski threatened to admit her to a nursing home because she wasn't feeding herself.
Before he leaves, he checks her fridge, something outside the purview of most doctors: two cans of Guinness, one small juice bottle, one egg, two fast-food packets of mayonnaise, and five bottles of condiments — a sign of her earlier life, when the local grocery store still delivered. Then, he spots the "Meals on Wheels" container on the table near her bed.
"If she didn't have good follow-up care, she'd be lost. She would have ended up dying."
He tells her he'll return in two weeks.
"Thank you very much for all the help you give me," she says. "Keep young."
Nowaczynski is among the dying breed of doctors who still make house calls. Twice a week, his office is relocated to the back of his minivan, in a plastic, turquoise bin holding files on all 150 of his housebound patients, along with a leather knapsack for his supplies — stethoscope, pressure cuff, otoscope. He drives across North Toronto visiting isolated patients — old women like Heitlager hidden up in apartment buildings and old men relegated to the pull-out couches on the first floor of musty houses.
If he didn't stop in, most of them would never see a doctor, yet they are among those most in need of medical supervision — battling diabetes, congestive heart failure, osteoporosis and, for some, mild dementia. Their coffee tables are cluttered with prescription bottles.
Most have no one left to help them. Others depend on a spouse or child to do even the most basic tasks — read their prescriptions; open a can of soup; step over the lip of the bathtub to take a shower.
Facing a bare-bones home care system, his patients are offered only a few hours of subsidized care a week, a situation that forces many to choose between having groceries delivered or getting laundry done. The only alternative is a nursing home, which few accept willingly.
"I wouldn't want to go to a nursing home," says Heitlager. "I've been to see them and they look sad."
Nowaczynski began to make house calls a few months after opening a family practice near Yonge and Eglinton. He quickly found that many of his new patients were struggling to reach his office, hauling their frail bodies up on the bus or depending on children to drive them. So he offered to come to them.
What he found jarred him. After a visit to another old woman with only one hour of subsidized assistance a week, he decided to take action. On his next visit, he brought his camera. He wanted the country to confront what it was doing to its elderly.
"You can cut home care to seniors and nobody's going to notice because this is a hidden, voiceless population," says Nowaczynski, 46.
"These are people who grew up during the Depression. When things get taken away from them, they just take it. We're forcing them to relive those privations... These are people who built our country."
Both Nowaczynski's parents are dead, which is perhaps one reason why he has such passion for the elderly. He was very close to his father, a Polish chemist, who inspired him to enter science. Nowaczynski completed his PhD in physiology, studying a protein in his father's lab.
And although he's the professional with authority, he arrives to his patients' homes like a young boy — dressed in jeans, his green Paddington Bear pea coat, both straps of his knapsack tugged over his shoulders. He speaks to them in English, French and Polish.
For many, his visits are more than just medical check-ups. They brew coffee for him, and in between his questions and prodding, regale him with stories about their earlier lives.
Many, like Anne Dydyk, call him Mark.
Up until this past summer, Dydyk was a vision of health. At 74, she still worked full-time at a plumbing wholesale business. She walked there and back — more than five kilometres — every day, even in the dead of winter. She hadn't gone to the doctor in years.
But then she strained her back doing filing work. And in July, she collapsed at her nephew's pool party and shattered her femur. It took a steel plate, metal pins, 19 staples and six weeks in hospital to repair. Now, she doesn't dare walk any farther than three houses down her street, and that's with the help of a rolling walker that Nowaczynski helped her secure.
"I've never been sick. All of a sudden, these stupid things come up," says Dydyk. "My God, what's wrong with me?"
It doesn't take much for an elderly patient's health to hurtle downhill. Just one fall. They venture outdoors less, which means they get less exercise and become more isolated. With less exercise their physical health declines. With less social interaction, their mental health declines. It's a vicious cycle.
Dydyk is at the top of that cycle. She might still make it out. She lives alone but has the support of family and neighbours. Someone drops by every week to take her laundry. Someone else takes her to get groceries. She can still cook for herself.
Unlike Manitoba, the home-care system in Ontario is only partially funded by the government. While the budget for the province's Community Care Access Centres has increased over the years, so have the number of patients requiring help. And, while hospitals have been pushed to unload patients sooner and sooner, the emphasis has shifted to "post-acute" patients emerging from hospital who with some assistance, will be back on their feet and off the medical system.
That means that while nursing care — like changing bandages and replacing IVs — is automatically covered, home-making services like cleaning are not. An elderly patient can only get that kind of help if it piggybacks atop personal-support services such as feeding or bathing.
Even then, the centres run on tight budgets, and most housebound, sickly seniors don't receive more than three hours of free help a week.
"As a system, we could do more to prevent them from deteriorating and to keep people at home. Everyone agrees with that," says Camille Orridge, executive director of the Toronto Community Care Access. "The debate is, how much should the government fund?" Most Maritime provinces cover no homemaking services at all, she says.
"A lot of people, prior to aging, were paying for housekeeping. Because they hit 65, should the government pick that up? To me, it's not as simple as, `Seniors are entitled to it or not.'"
But if we've agreed as a society to provide free education to every child — regardless of whether their family can afford to pay or not — then shouldn't we provide them the same social net at the other end of their lives, Nowaczynski argues.
He deplores the fact that bathing is used as a rationing stick for other types of care. Some of his patients were never married. They're modest. How can we expect them to strip down naked in front of a stranger?
"What good is a bath if they only have dirty clothes to put on?" agrees Susan Thorning, COO of the Ontario Community Support Association.
For most of Nowaczynski's patients, agreeing to any help at all is difficult. It signals defeat.
"Really, I don't need anybody to help me take a bath," Dydyk says.
"I hate being dependent on anybody."
Nowaczynski is up against a larger system.
The Ontario Health Insurance Plan caps the amount of house calls a doctor can make through its fee structure. The charge for an intermediate office visit is $30; the charge for a daytime house call only double that. But, once house calls take up more than 20 per cent of a doctor's practice, that $60 fee drops to $45.
`You drive for an hour in the middle of a blizzard, and maybe they'll let you in, maybe they won't. I've done assessments through mail slots'
Dr. John Ruth
`You drive for an hour in the middle of a blizzard, and maybe they'll let you in, maybe they won't. I've done assessments through mail slots'
Dr. John Ruth
Nowaczynski spends 30 minutes with most of his housebound patients — but add to that the 20 minutes it takes to drive there and find parking on their crowded streets. In that time, he could have ushered at least three patients into his office.
"The only way to make money doing house calls is the quick and dirty house call," he says.
If the system didn't dissuade doctors, the work would, says Dr. John Ruth. Up until 1995, he, too, made house calls as part of a regional geriatric program out of St. Michael's Hospital.
Once they step out of their office, all the comforts and advantages doctors have come to expect vanish. The sterile environment is replaced by musty apartments, often reeking of urine, he says. They can't call for an X-ray or make a referral to a specialist. If the patient cancels, they can't use that time to brush up on paperwork.
"It's hard work," says Ruth, who now works with acutely ill geriatric patients inside Toronto East General Hospital. "You drive for an hour in the middle of a blizzard, and maybe they'll let you in, maybe they won't. I've done assessments through mail slots."
As a result, few doctors make house calls any more. According to the New England Journal of Medicine, while 40 per cent of all doctor-patient visits were house calls in 1930, that number had dwindled below 1 per cent by 1980.
In Ontario last year, more than 43 million office visits were billed by doctors to OHIP. By comparison, only 209,000 house calls were billed.
"I'm tilting at windmills," admits Nowaczynski, who this fall became an assistant professor at University of Toronto. It's another tack — if he can't beat the system himself, he'll mould the people who soon will run it.
But he's got an even bigger foe: denial. We live in a culture that covets youth. None of us wants to think about getting old.
That forces Nowaczynski to state the obvious, time and time again, as if it were profound. He's not just fighting for old people. "This is your mother, your aunt, your grandmother and, one day, this will be you or I," he says.
"You are not looking at an exotic species from another world. You're looking at your future."
Nowaczynski pulls up to a small, semi-detached home lit with Christmas lights. This is one of his newest patients — 91-year-old Don Sutton. He was referred by a social worker, after his long-time doctor refused to make a house call.
It's a complex case that's been stumping Nowaczynski for a month.
"He'll sleep a bit as long as he's in a chair. But the minute you put him in bed, he's a Jack-in-the-Box," his wife Alex tells Nowaczynski, as he peels off his Blundstone boots at the door.
"I haven't slept for three days."
Don sits ramrod straight in the corner sofa chair, dressed in a green robe and blue pyjamas. Glaucoma and cataracts have robbed him of most of his sight. Over the past month, he's become more agitated and less coherent.
Blood tests show nothing abnormal. His urine test results were also clear. Kneeling beside Don now, Nowaczynski listens to his breathing. It's fine.
Geriatric medicine often requires detective work. Symptoms that clearly surface in a young body are less obvious in an elderly one. Increased confusion, for example, can be the only obvious sign of a urinary tract infection or pneumonia.
"Would you term this as senility or Alzheimer's?" asks Alex, a former nurse who, at 86, is still razor sharp.
The two were married 62 years ago — six months before Don left to drive trucks for the Canadian Army during World War Two. When he returned, he became the man around the house. But this past year, their relationship has changed. She's become more of a mother, tending to him full-time — cooking, helping him dress, resting beside him on the sofa.
Last spring, after she had retreated to the garden for a few minutes, he panicked and left the house to search for her. He used his TTC bus pass and rode away, arriving at their confused in-law's home.
Since then, she hasn't dared to venture out. Her only respite is for two hours a week, when a burly personal care worker comes to help bathe him, something the 104-pound Alex discovered she could no longer do herself.
She can't afford more help and she's not willing to contemplate the alternative: a nursing home.
"It would break his heart to give up," she says. "I would be discarding him."
Since 2002, the provincial government has added 20,000 nursing-home beds to the system, bringing the total to 75,000. Each one costs taxpayers $124 daily — enough for at least five hours of home care.
Home-care advocates lambaste the system as both economically and morally backward. Why put people in institutions, when it's cheaper to keep them at home where they're most comfortable?
"It's incredibly counterproductive from the perspective of everybody but the nursing-home industry," says Ernie Lightman, an economist who teaches social policy at the University of Toronto. "When you build a nursing-home bed, there's a continued commitment to fund that bed. With home care, you always have the option to shut off the tap."
In Toronto last year, 1,200 of the beds were empty — an obvious signal that few people are willing to fill them.
"People don't often come out of nursing homes, and they know that," says Mary Schulz, a director at a social services agency for seniors called SPRINT.
The decision is also wrenching for loved ones.
Just 12 days after Don Sutton's check-up, he collapsed on the landing outside his bedroom and, unable to lift him, his wife called 911. He was admitted to Sunnybrook hospital.
When he comes out, Alex says she will admit defeat.
"I wanted to do my best I could for him. It didn't work. I'm going to have to put him in a nursing home. I just can't cope," she says. "I'm ashamed to say it. I feel like I'm letting him down."
It's often the little things we do as afterthoughts that make the difference between living alone at home and going to a nursing home.
For Vera Robinson, the little thing is grapefruit. Her shaky hands can no longer scoop out the sections for her breakfast. So each morning, a worker arrives to her little bachelor apartment to do it for her.
Robinson is one of Nowaczynski's success stories. She just turned 95 and still lives independently in one of city's few supportive seniors buildings, meaning it has support workers stationed there around-the-clock. For Robinson, all it takes is an hour every day — someone to pick up her laundry once a week, deliver her groceries, help cut her vegetables. Her immaculate apartment shows the care.
Using her walker, she can still do some things for herself. She makes her bed every morning, taking the better part of an hour.
The doctor comes to check in on her angina every other week.
"If it wasn't for the help I'm getting here from SPRINT and from Dr. Nowaczynski, I wouldn't be able to stay here," she says.
When she called one night wheezing and sputtering, he dropped everything and came immediately. Nowaczynski's on call like a hospital worker. The way he sees it, if he catches something early and can help, he'll prevent a crisis situation and an emergency trip to the hospital, from which the patients rarely recover.
It's seven o'clock, and Nowaczynski's work day is finally ending. Before rushing home to his own young family, he drops by a pharmacy to order a prescription for Don Sutton and then steps into a retirement home next door to use the bathroom. He works here one day a week.
So, what does he plan on doing when he gets old?
Grey has already begun to creep into his ginger sideburns.
"I don't know," he says.
Even he avoids thinking about the inevitable. It's too depressing.