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Inteview: Ian Donald, geriatrician

04 February 2022

‘I wanted to give permission to older people to say no to another test, another pill’

My father, grandfather, and great-grandfather were all doctors in Leith, in Edinburgh — three generations; so medicine was in my genes. My sister also studied medicine and joined my father in his practice.

I was attracted to hospital specialty medicine. Geriatricians have many similarities to GPs, being generalists, but working in hospitals which nowadays are full of old people. And a doctor during a student elective showed me that you could practise a mixture of emergency medicine and ward medicine for elderly people, and buzz off to visit them at home as well. He’d been a cardiologist, but became disillusioned with the technical aspects, and liked what he saw as a more person-centred approach in the small town of Elgin.

The current GP contract expects that people over 75 and those on multiple medications will have a regular review of what they’re taking. There were many prescribing guidelines, but they didn’t take into account the specific issues in those living with frailty. So I developed national guidelines for the most common drug types, split into advice for those with mild, moderate, or severe frailty.

It’s amazing just how often someone with frailty feels better on fewer medicines. I wrote With A Light Touch to explain how health care — particularly medicines or spells in hospital — carries significant risks, with diminishing returns, for those living with frailty, and health care can sometimes become a burden rather than a blessing in the last years of life. I wanted to give permission to older people to say no to another test, another pill, or another spell in hospital, and explain the benefits of receiving care at home.

We all lose reserve in most of our bodily systems as we age. Doctors identify “frailty” when the loss of reserve is so much that a minor stress or illness upsets that system: one system fails, leading to a domino effect, upsetting the whole person, until equilibrium is restored again.

In practice, we recognise frailty when a simple fall or simple infection causes upset, such as being unable to manage on your own without help for a time. By the age of 85, about half of us have a degree of frailty.

The big change in my lifetime is that the average age on the geriatric ward is now probably about 90. When I started, patients were in their seventies and eighties. But there’s a different tolerance and capacity to recover in a 90-year-old to a 75-year-old. To give you the best chance, we need to give you our wonderful emergency treatments to get you back on course again — but then get you home as soon as possible, with augmented support for two or three weeks. Post-Covid, the social-care support just isn’t there, and it has a very big impact, because people are gradually getting weaker while they’re in hospital.

My book is for older people, and their children, who often assist with their hospital visits and decision-making; but, actually, many health-care professionals also need to understand this “light touch” — perhaps those who are frightened of being judged ageist.

The Lifetime Achievement award from my hospital trust was in recognition of 32 years of what they called unremitting enthusiasm and energy to serve older people in the county. But you’d really have to ask the staff who voted for me about that.

I’ve tried to describe ways that my style of practising medicine reflects my faith and the example of Jesus. The book picks up on some of these — such as focusing on what matters most to that person, or seeking, if possible, to restore and respect the person’s identity, and not necessarily follow the rules or current guidelines. Many geriatricians would do the same, and I think it’s interesting that this approach finds its origin in Jesus’s ministry.

It’s difficult for anyone to predict the distant future. The trends we are seeing today are that healthy living and the benefits of modern health care mean that we acquire frailty later in life. The average 80-year-old today is healthier and more able than 20 years ago, and we’re living longer. But for those extra years of life, we’re adding more extra years of disability and frailty rather than years of full independence and health. Sadly, the years free of any disability are not increasing as fast as the years with some limitation; so the proportion of our retirement spent in full health is actually falling.

It does irritate me when I see headlines like “New heart drug will save 10,000 lives” — when probably what’s meant is that death will be postponed. At the moment, that postponement may result in extra years lived with frailty or perhaps dementia.

And then around that corner is a public clamour for euthanasia. And the prospect for a generation living with more obesity is not good.

I think we can live productively with frailty, still loved and valued by God, and that dependence upon one other is intrinsically human. And, yes, I believe that God has set eternity in our hearts — one way he’s calling to us to believe. But we must let go of this earthly body first.

I was brought up in Edinburgh, and the family attended the local Church of Scotland. Outside school, my teenage years were split between music — learning the organ and bassoon — and golf, under the tutelage of my father. My wife is a part-time priest in the Church of England in Gloucester diocese. Our three sons are grown up and married, and we have two lovely granddaughters.

As a Christian in the NHS, it’s frustrating that you can’t pray for your patients or witness more openly. Two years earlier, at a New Wine conference, a prophecy was given to me that a new ministry was opening for me in hospital work.

I volunteer in the Christian bookshop in the hospital since I retired last year. It’s called Books Plus, and started in Heath Hospital, Cardiff, 20 years ago. When they asked Gloucester churches, 15 years ago, if they would be interested in supporting a bookshop in our hospital, I became the chairman. After two years of fund-raising, we were able to open a shop in our hospital’s new building. It’s now the only Christian bookshop in Gloucestershire, in the heart of the hospital at the main entrance. People love coming in and spending time there, even if they don’t know why.

The first time I experienced God’s presence was probably hearing a talk on Peter’s denial at the Christian Union in Cambridge. My experiences occur most often when I’m worshipping him, and I’ve been privileged to be involved with leading worship over very many years. Music and creation are two amazing ways God has given us to connect with him.

Knowing that foods are being transported across the world that grow perfectly well in the UK makes me angry. I used to get angry about the lack of resources in hospitals, particularly when patients were obviously suffering. Emergency departments are very tough: I couldn’t have been an emergency consultant staying calm in that chaos. I’m glad to have let go of that now.

A seven-iron shot hit to a few feet from the flag is wonderful. Cooking and serving up a lovely meal for the family. And I’m happy when I see a patient back at home who feels so much better now they are off half their old tablets.

Achieving a hole in one at golf would be great. And growing more of our own vegetables.

The pandemic’s given me time since retirement, and, against expectations, I’ve learnt a more relaxed daily routine; but I still get ribbed by the family about getting through my list for the day.

I love the sound of a little stream in the hills. I could sit listening to that for hours.

My hope is that our forced interdependence upon one another across the world, whether by Covid or the climate crisis, will make us less selfish.

I pray most for my wife, Philippa, in her church ministry. I’m so proud of her. And for our children and their wives to live faithfully for God.

I’m quite an introvert; so probably I would prefer to be locked in a church with my Roland keyboard and a great sound system.


Ian Donald was talking to Terence Handley MacMath.

With a Light Touch: A guide to healthcare in frailty is published by Onwards and Upwards at £11.99 (Church Times Bookshop £10.79); 978-1-78815-929-6.

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