Convalescence: the forgotten phase of illness recovery

by Carolyn Thomas    ♥  @HeartSisters

I love the work of U.K. philosopher Alain de Botton, an explorer of the  ‘philosophy of everyday life.’  He once wrote:

“People can accept you sick or well. What’s lacking is patience for the convalescent.”  

Convalescence. It’s the gradual return to health while you still need time to recover from illness or medical treatment, usually by resting. For patients, it’s that fuzzy grey area in between feeling acutely ill and feeling 100% healthy again. The term comes from the Latin convalescere: “to grow fully strong.”

Most garden-variety convalescence is mercifully short. After spending a few days in bed with a flu bug, for example, you might feel a bit weak or shaky for a while. Not exactly sick anymore, but not yet 100%. Other forms of convalescence, however, may take weeks, months or even years of recuperation. And with some chronic and progressive disease diagnoses, everyday life can start feeling like one long endless period of convalescence – with good health merely a dim memory.  The difference: unlike the historical practice of viewing convalescence as a distinctly separate and important stage of illness recovery, today’s convalescents may simply feel like they’re being forced to very quickly adjust to the “new normal” of life.

There was a time when doctors fully accepted the need for ill people to be cared for in a way that would help them adequately recuperate.  And the number of days patients are kept in hospital before being discharged home has been steadily declining for decades. Reduced length of stay – the darling of cost-cutting hospital administrators everywhere – is now suspected of being a factor in the disturbing rates of costly and dangerous hospital readmission within 30 days after discharge home.  For example, a 2013 study from Boston University School of Public Health published in the journal Medical Care Research & Review found that for heart patients, even a 1-day increase in length of stay yielded estimated reductions in later hospital readmission rates up to 18% for heart attack patients and up to 8% for heart failure patients.(1)  Researchers wrote:

“Increasing length of stay for some patients may be a means of improving quality of care by reducing readmission during the 30-day post-discharge period.” 

It was not always this way. Consider, by comparison, England’s Royal Sea Bathing Hospital at the beach resort of Margate in East Kent. It was founded in 1791 and was in use as a hospital for the next 200 years. (After it closed, its grand buildings were transformed into private residential apartments).

In its earliest days, Royal Sea Bathing Hospital doctors believed that sick people – usually survivors of some form of tubercular infection – could benefit from the healing effects of invigorating sea bathing, brisk salt air and good nutrition that would help them become strong enough to go back home.

Similar convalescent homes built over the next two centuries provided weeks or months of respite care at the seaside, in the mountains, or in the countryside in an institutionalized yet healthful environment to people recovering from injury, trauma or surgery.

Historically, a convalescent home might have also been referred to as sanitorium. An article published in the Glasgow Medical Journal back in 1859 was called “Reasons Why Sanatoria Should Be Established On The River Clyde For The Sick Poor Of Glasgow.”  Sanatoria were for longterm illness, places usually affiliated with medical facilities.  The word “sanatorium” was derived from the Latin word “sano,” which means “to heal.”

A sanitorium (providing medical or mental health care) was not the same as a sanitarium (a kind of health resort). A well-known example of the latter was the famous Battle Creek Sanitarium in Battle Creek, Michigan, founded in 1866 by Seventh Day Adventist followers.  This sanitarium, run by John Harvey Kellogg, MD, promised “a sanitary place where people learn to stay well.”  Care included an emphasis on fresh air, sunshine, exercise and a natural diet of vegetables, fruits, nuts and grains – including a unique flaked grain breakfast cereal that was served in the Sanitarium’s dining room. Dr. Kellogg called this cereal “Granose” – but it became better known years later when a version was finally commercially available as Kellogg’s corn flakes.

Meanwhile, convalescent or sanitorium care was largely seen as a charitable kindness, especially as a break from extreme poverty and the harsh social/environmental conditions that in so many cases both worsened ill health and impeded recovery.

Although many such convalescent facilities were founded to care for the needs of very poor patients, over the decades more and more began to house temporary residents known as “the respectable poor”. And during 20th century war years, small convalescent hospitals were launched as wealthy European families opened their stately homes privately to offer ‘hospitality’ (mainly to convalescing officers) when gentlemen needed further rest time following combat injury treatments.  Think Season 2 of Downton Abbey here . . .

When a tuberculosis epidemic swept through North America in the early 1900s, many cities advertised themselves as ideal destinations for those diagnosed with “the white plague”. There were many convalescent homes in the dry, sunny state of Arizona, for example, modeled after European non-urban resorts of the time like the Royal Sea Bathing Hospital. By the year 1920, over 7,000 people had come to Tucson alone to recover from tuberculosis. So many patients with TB arrived there, in fact, that a form of tent city sprang up to take advantage of the area’s dry climate and plentiful sunshine, both recommended by physicians as curatives. The Desert Sanatorium and Institute of Research was a non-profit 120-bed Tucson medical and research center operating during the 1920s. Its brochures advertised care for those living with the chronic diseases of bronchitis, asthma, emphysema, sinusitis, arthritis or polio.  The Arizona Sanatorium and Touring Company, Inc. provided basic tent accommodation, and included a touring company which would take patients on outings and camping parties. 

What, I ask you, ever happened to that wonderful concept of convalescent care?

There are facilities that do indeed still call themselves convalescent hospitals. Many of these are nursing homes or assisted-living care homes for those – particularly frail seniors – who cannot function back at home on their own after hospital discharge.

But the reality for almost all of the rest of us discharged hospital patients remains a frightening wasteland. We’re all too often booted out the hospital door with few if any specific plans in place for home care or ongoing medical support while we continue to convalesce at home.  See also:   Goodbye, hospital. Hello, home! And other scary things.

We are in fact expected and applauded for being able to snap right back to good health as if nothing has ever happened to us.  In an era of growing concerns about hospital re-admissions, one need look no further than the disgraceful gap in care to figure out why. 

I’ve been personally witnessing this care gap first hand while visiting a seriously ill friend who was recently sent home from hospital following a five-week long stay.  Her homecoming was fraught with distress and anxiety as she worried how on earth she could possibly cope at home. But she was deemed well enough to no longer need acute care in hospital, even as she still faced debilitating symptoms and a severely impaired ability to function.  It was clear to all of us who visited her at home that she was not at all well enough to manage this “new normal” on her own. No wonder she felt so frightened and isolated.

Despite the visits of concerned family and friends to help out as much as possible, the orderly trajectory of her diagnosis-treatment-discharge-recuperation seemed to start fraying badly once she got home.

While at one time a patient in her fragile condition, both physically and emotionally, would have been a good candidate for convalescent care before being sent home alone, today we have a health care system that ignores this uniquely important adjunct to healing.

As Dr. Wayne Sotile described what he calls “the homecoming blues” in his excellent book Thriving With Heart Disease:

“You’re now home from the hospital, and you’re expected to surf a bewildering wave of emotions, anxieties and procedures. No longer are nurses and doctors checking, monitoring and calming you.  Now you have to decide what you can and cannot do, and you may feel under-qualified for the job.

“What used to be simple is suddenly unbearably complex.  Making the bed, a doctor’s appointment or even a tuna sandwich can overwhelm you and bring you to tears. You feel childish and emotional and terribly alone – no matter how many people surround you at home.”

Isn’t this exactly when the time-honoured medical tradition of convalescent care would help so many of us?

* Image:  University of Michigan, Nursing History Society

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(1) Kathleen Carey et al. Medical Care Research & Review, vol. 71, 1:pp. 00-111. October 16, 2013.

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See also:

Handling the homecoming blues

Study: “91% discharged from hospital without care plan”

The simple tool that predicts how well you’ll do after discharge from hospital

When drugs that help turn into drugs that harm

Cardiac care for the whole patient – not just the heart

“We are all patients.” No, you’re not.

Where’s the “survivorship” model for heart patients?

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NOTE FROM CAROLYN:   I wrote more about the important topics of recovery and recuperation in my new book, “A Woman’s Guide to Living with Heart Disease” (Johns Hopkins University Press).  You can ask for this book at your local library or favourite bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from Johns Hopkins University Press (use their code HTWN to save 30% off the list price when you order).

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Q:   Have you ever had the opportunity to experience convalescent care between hospitalization and being discharged home?

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