PUMPING IRONY: Epic Fail?

One of the more useful mantras seniors can employ when navigating the murky morass that passes for our healthcare system is a simple statement of fact: Doctors don’t always know what ails you.

This truism helps to explain the checkered history of a confounding nondiagnosis, “failure to thrive,” and it highlights — often in stark terms — just how difficult it is for elderly Americans to get the care they need. Writing in STAT News, Eric Boodman characterizes the term as a type of medical placeholder doctors often use when they don’t want to spend the time and energy to pinpoint what exactly is ailing some frail octogenarian who might be losing weight, showing signs of depression, displaying some cognitive dysfunction, or simply not thriving.

Martha Spencer, MD, a geriatrician at St. Paul’s Hospital in Vancouver, tells Boodman that older patients are tagged with the FTT label more often than she’d like. When it occurs, a colleague will often tell her the patient is probably fine — just old. The upshot: She should still check on them, but there’s no hurry.

That may certainly be the case for some carrying the FTT label, but Spencer says she’s found that it can dramatically delay needed treatment. “I’ve seen multiple cases where I’ve gone down and the person has actually had a heart attack, or they have an active infection, or they have a broken bone — and [have] not been fully investigated because of this label.”

Parents may be more familiar with the moniker — it’s been applied since the early 1900s to newborns suffering from neglect or battling certain diseases — but it’s not exactly new for seniors. Doctors have been using it for nearly a half century whenever they noticed their patient was declining but couldn’t really figure out why. In 2021, Boodman reports, some 126,000 elderly Americans had been thus classified — often unknowingly.

And, while Spencer and other FTT critics bemoan the effects of such a lackadaisical approach to treating elderly patients, others cling to the label as a way to secure a hospital bed — and payment — even in lieu of a specific diagnosis.

As insurers became more scrupulous (or unscrupulous, in some cases) in their review and rejection of claims, doctors increasingly found that an FTT  “diagnosis” ensured payment more reliably than confessing they didn’t know what was up with the patient. “Without a clear, concrete diagnosis,” says University of North Carolina geriatrician Kevin Biese, MD, it’s hard to reply to hospital administrators or insurers when they ask whether the patient should be admitted. “If there’s not an answer to that, they’ll say, ‘Don’t admit the patient, send them home.’”

Once they’re in the hospital, however, the care they receive can be sketchy. In a 2020 paper published in BMC Geriatrics, Spencer and geriatric-medicine resident Clara Tsui, MD, noted that 88 percent of patients who had been admitted with an FTT designation between 2016 and 2017 were discharged later with acute medical conditions.

It’s those sorts of cases that have sparked so much criticism over the past 25 years. Catherine Sarkisian, MD, a geriatrician at the University of California, Los Angeles, proposed revising the protocol in a 1996 paper published in the Annals of Internal Medicine. Her argument went nowhere, of course, and Sarkisian still chafes at the FTT label. Geriatricians are trained to determine what their patients need and clearly articulate it, she tells Boodman. “If someone is not eating enough, say they’re not eating enough! If they can’t take a shower anymore by themselves, say they can’t take a shower anymore by themselves!”

U.S. government insurers eventually took notice of Sarkisian and other critics, and in 2014 they demanded an actual diagnosis before agreeing to fund hospice care. The move, however, illustrates how the FTT tag may be valued more by some than others. When a patient is clearly declining and the symptoms are more of a muddle than a specific cause, FTT helps people pay for a hospice bed, notes palliative-care specialist BJ Miller, MD. “That code was there to catch folks whose bodies weren’t playing by the rules.”

It can also be a lifesaver for people who struggle to find the resources they need when caring for an elderly spouse. Boodman tells the story of Elizabeth Costle, who cared for her husband after he suffered a stroke in 1999. Eleven years later, he was declining precipitously — refusing to eat, get out of bed, or take his meds — and a visiting nurse finally diagnosed him as failing to thrive. The resulting insurance payments for the nurse’s visits made only a small dent in the exorbitant cost of his care, but it helped.

You can argue, I suppose, that a functional, humane healthcare system would place enough value on the elderly that Costle and the thousands of other Americans providing in-home healthcare to ailing loved ones would receive the support they need without capturing some arcane billing code. But the FTT conundrum is simply another symptom of a system that’s not designed to serve older Americans.

“When an older adult is called ‘failure to thrive,’ we see a lot of ageism come in, and we see the healthcare system start to ignore their problems,” says Sharon Brangman, MD, chair of the geriatrics department at the State University of New York Upstate. “It’s used to totally disregard a person. That’s kind of the ageist approach. You lump everyone in one basket, and then you don’t take care of them.”

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