"Fragmative" Healthcare – A Personal Experience

I suspect that the opposite of Integrative health is "Fragmative" health for lack of a better term. I experienced this first hand when my family was confronted with what turned out to be harrowing end of life experience in a hospital in New Jersey. In brief, my 87 year old mother-in-law was taken to the emergency room of her local hospital suffering from a severe rash and swelling on her face and tongue which made it hard for her to breathe. The working diagnosis by the ER doctor was shingles, a painful viral infection. It appears that my mother-in-law’s immune system was so compromised that her presenting condition led to a positive test for viral encephalitis. She was treated intravenously with a strong anti-viral drug that affected her kidneys. This led to us having to make a decision regarding whether to have her put on dialysis while she underwent a 4 to 6 week in-hospital treatment with the anti-viral. At his point she was no longer conscious and was unable to speak for herself. Fortunately, she had an advance directive and living will which stipulated that she did not want medical interventions if her chances for survival with a reasonable quality of life were very low, which we felt they were. We followed her directives and had all therapeutic treatment stopped and moved to comfort care only. She was transferred to a hospice unit within the hospital where she died about 6 hours later.

I am sure this experience is quite common and many families have or will face similar situations. However, in reflection, the fragmentation of care was palpable. For the most part, the "system" of care in the hospital functioned as planned. During the course of 6 days, 7 or 8 different doctors provided diagnosis and treatment and an equal number of nurses and nursing assistants contributed to her care. All of these caregivers were complete strangers. Her long-time primary care physician and cardiologist were no where to be seen. This is not because they didn’t care about her, but rather this is the new paradigm of care when one is hospitalized.

So the key question for us was "Who is coordinating the various players on the team?" After asking this question in an assertive manner, the nursing director of the inpatient unit stepped up to assist. From a medical point of view, we were told that the coordinator was the "hospitalist" on duty at that moment. A hospitalist is a doctor or group of doctors hired by the hospital to care for inpatients. In the past, your own primary care physician would visit you in the hospital and direct your treatment. Now your primary care physician stays in his or her office and very rarely comes to the hospital. Under ideal conditions, the hospitalist sends information about your in-hospital treatment to your PCP, however, there is very little contact during the course of your in-hospital stay. Many times, your PCP doesn’t even know that you are in the hospital.
Since the "hospitalists" work as part of a group, the "on-duty" physician changes daily by shift. It is not even worth trying to remember their names. In the end, the relationship is with a "System" that consists of many players, each compassionate in their own right. In truth, the coordination of care falls to one or several members of one’s family. The experience of dealing with multiple clinicians, each with their own specialty, and not really talking to each other is the epitome of our "fragmative" care system.

It may be that in the highly intensive inpatient level of care, "fragmative" care is unavoidable. However, one should never have to experience this fragmentation when being cared for outside the hospital setting. Based on this experience, I gained a greater appreciation for Integrative care.