Older Patients, Wiser Care
How to Avoid the Perils of a Too-Soon Hospital Discharge
Dear Dr. K,
After my dad's heart attack, I was surprised when the hospital wanted to discharge him after less than a week. He still seemed weak and disoriented and has slight dementia. I was hoping they'd monitor his diabetes and high blood pressure, too, as these had been giving him trouble. Sure enough, the day after he got home he fell in the night and broke his hip! Should I have fought harder to keep him in the hospital -- and if so, how??
Without knowing the specifics of your father's case, it's difficult to say whether it would've been better for him to stay longer in the hospital.
The time right after a hospital discharge is *always * dicey, because it's common for older people to find themselves in a condition similar to your father's:
"¢ Weak because they've just survived a major illness, and usually have been much less physically active than when at home.
"¢ More confused than usual, a very common problem known as delirium. Hospitals are especially likely to bring on delirium in people who already have a dementia such as Alzheimer's.
"¢ Medications for chronic illnesses such as diabetes may have been changed, or stopped. This is often intentional; major medical problems often require a temporary change in the management of some chronic diseases. However, follow-through on chronic illnesses sometimes "falls between the cracks."
Although many hospitals are trying to do a better job preparing older patients for safe discharge, you should always assume that your loved one will need extra help and supervision during the weeks after a hospitalization. Even under the best-case scenario, it usually takes at least that long for an older person to get back to his or her usual self.
At the same time, it's important that hospital staff make sure that an older person is reasonably ready for discharge. Here's what the hospital is supposed to do:
"¢ Make sure the patient is medically improving and no longer needs daily care from doctors and nurses.
"¢ Develop a safe discharge plan. If the plan is to send an older person directly home, this generally means that the hospital expects family and other people will be able to provide a certain amount of care and supervision. The discharge plan also usually includes home health services such as in-home physical therapy, occupational therapy, and some nursing visits.
So should you have insisted that your father wasn't ready to come home? Perhaps. It all depends on whether you feel the hospital did a reasonable job of matching his post-hospital needs with the amount of care and supervision your family was planning to provide at home. It's certainly possible that the hospital may have overestimated your father's ability to be safe at home. Or perhaps they didn't communicate well with your family about what to expect.
It's always a good idea for family caregivers to actively participate in discharge planning with hospital staff, to ensure appropriate care. After all, a sick elder is often not able to speak up effectively and accurately about needs at home. If you're ever concerned that a hospital is pushing an unsafe discharge plan, be sure to speak up.
My prescription for caregivers about hospital discharge:
"¢ Monitor your loved one for delirium during hospitalization, and make sure any underlying causes for worsened confusion have been treated. "¢ Expect your loved one to be weaker than usual in the weeks after hospitalization. If the hospitalization worsened confusion, don't be surprised if it takes days to weeks for your loved one to return to his or her usual self. "¢ Make sure the hospital staff understand what kind of care and supervision you'll be able to provide at home. If you aren't comfortable with what the hospital seems to expect of you, ask for more information about alternatives, such as a short stay in a rehabilitation facility. "¢ If you aren't comfortable with the discharge plan, insist on a review (i.e. a second opinion) before allowing your loved one to be discharged. Know that by law, you can appeal the plan, and keep the discharge on hold until the plan has been further reviewed. "¢ To better negotiate a hospital discharge, prepare yourself by reviewing a hospital-to-home discharge guide for caregivers.
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