Modules

Complexities of care of the elderly

Part 7

A team meeting has been convened to discuss discharge options for Jack. Dr. Edelman decided to ask Craig Stevens, the primary care provider, to attend. Jack and Penny will join them after the team has had a brief discussion. Linda Speakman, a social worker, is chairing the meeting.

  • Linda Speakman: Before the patient and his daughter come in I thought it would be useful to review the case. Mr. Jack McTeer was admitted six weeks ago with delirium secondary to an infected leg ulcer. Drs. Edelman and Sakowski attended to treat the infection and recommended amputation of the leg. Mr. McTeer was initially very resistant to the amputation. Dr. Edelman was concerned about possible depression and decision making capacity and consulted with psychiatrist, Dr. Ormerod. Dr. Ormerod thought that Mr. McTeer was capable of consenting to treatment and with time, Mr. McTeer agreed to the operation. The amputation was done five weeks ago. Mr. McTeer’s supportive daughter lives far from him and his ability to care for himself given the rapid decline he experienced prior to hospitalization, is cause for concern as we near his discharge back into the community.

    So. We’re all here today to talk about a discharge plan for Mr. McTeer. There are concerns that he won’t be able to care for himself and would need supports in the community, like homecare.

    So. Does anyone have anything to contribute before we let Mr. McTeer and his daughter come in? Things that we feel shouldn’t be said in front of them? Dr. Edelman, you are his primary hospital physician. Why don’t you start.

    Dr. Edelman: Sure. Well I have come to know Mr. McTeer fairly well. He is a stubborn, tough farmer who really values his independence. When I first saw him he was clearly delirious. When that cleared and we were into getting consent for the amputation, he said yes, and then no, and then yes again and so forth. And he has so far been unwilling to consider housing options. I think he understands the possible consequences of going home. However, I do not believe that he is ready. And I’m not at all sure that making the poor decision of wanting to go home indicates that he is in fact competent. He and his daughter have had some arguments about this, with no resolution as of yet. On a positive note, well, he is stable and on oral meds, that helps.

    But, I’m also worried about his daughter, Penny. She seems to have become more anxious and is caught between feeling responsible to find a solution, and not having a plan. She’s going to need as much support as her father.

    Linda Speakman: So, Dr. Edelman, if Mr. McTeer insists on going home, can we refuse him?

    Dr. Edelman: No, no, we can’t. We can point out all the problems but ultimately it is his choice.

    Linda Speakman: Okay. How about his ability to cope independently? Jennifer, you have assessed him.

    Jennifer Taylor: Yes. As the occupational therapist on this case, I have assessed his ability to cope independently, although I haven’t seen his home. He has better skill at transferring than I thought he would. He is still quite strong in the upper body. However, he is not stable on crutches. I’m not sure he could manage food preparation, and of course he can’t drive, so he would need home care support for a lot of his daily activities. I did assess his ability to cook, to tend to his hygiene and to dress himself and he would need lots of support. I think he could potentially be safe at home but only with the adequate support. And I do agree, he is very stubborn. And he is unwilling to consider any alteration to his lifelong routine.

    Linda Speakman: We could put in medic-alert systems and hire personal support workers. That would cost money though. We’ll have to talk about that with Mr. McTeer. Craig, you’ve known him for longer than any of us. Do you think he can cope?

    Craig Stevens: Well, I would like to thank you for asking me to come to this meeting. So often we get the discharge letters without having given any input. I’m a little more optimistic about Jack. He was able to take his medication, and now that he is on oral rather than injection, that helps. And also we have reasonable home care in our area. I’ll be able to check on him by phone, I could even do the odd home visit. And you know what, I agree about his daughter seeming more anxious.

    Linda Speakman: Thanks, Craig. I have the information on discharge options here. So, let’s invite Jack and his daughter in to review them together.

    Linda Speakman: Hello Mr. McTeer. Mrs. Simons, we’re really grateful you can come as well.

    Penny: Well I did take a vacation day.

    Jack: So, what’s all this about? The inquisition?

    Linda Speakman: By no means, Mr. McTeer. Since you are recovering well, we thought we should all have a discussion about what the next steps in your recovery are. We call it discharge planning.

    Jack: That’s easy — I want to go home. No discussion necessary.

    Linda Speakman: We know that’s your wish Mr. McTeer. However we have some real concerns about your safety, and your ability to care for yourself now. Have you thought about how you would cope?

    Jack: I can get around alright in this wheelchair here at the hospital. I can do the same thing at home.

    Linda Speakman: Mrs. Simons, before your father got sick you were visiting about what … every two weeks or so? If he needed more help would you be able to cope?

    Penny: Oh I don’t know. It takes me the whole day just to drive over, do the laundry, get groceries, do a bit of cleaning. Dad, have you thought about someplace else to live? Maybe a retirement home close to me so I could visit more often?

    Linda Speakman: Yes, we have talked about that. There are some nice places. They do cost money. However, putting in personal support care workers at home is also costly. And you would have to buy a wheelchair.

    Dr. Edelman: And Mr. McTeer, it will to take a while for you to get a prosthesis and learn to walk again. Umm, I just don’t think that you’ll be safe living at home alone until then.

    Jack: You’re all ganging up on me. What you don’t understand is that a retirement home sounds worse than death to me. You don’t know what it’s been like for me in this hospital. I’m very grateful but I just want to go home.

    Jennifer Taylor: We understand, Mr. McTeer, but there is a lot of support available. And we will certainly give you as many resources as possible.

    Dr. Edelman: Your daughter, and all of us here, we just basically want you to be safe and well, Mr. McTeer.

    Linda Speakman: Let’s see if we can find a solution. We could put in support services at home and you could see how you could make out for a trial period. That would let you experience the difficulties and then you would see how you would cope. You may have to pay for some of this, Mr. McTeer. Also, would you be willing to visit some of the retirement homes in your daughter’s area? It’ll give you the chance to talk to some of the folks there. They might be better than you think.

    Penny: Well I could take some time off and come with you, dad.

    Jack: Okay. We can talk about it and we’ll see how it goes.

    Penny: That’s great. Where do we start?

Commentary

This scene is similar to the last scene in “Communicating with adolescents,” and some of the exercises in that module apply here as well. You might want to review those exercises and see how they apply to this module.

A major difference between the two modules is that in “Communicating with adolescents,” the patient has more family support than Jack does. In addition, Jack will require substantial support services to be provided, and he will have to pay for some of them. Despite these factors, Jack insists on returning home.

Given that patient safety is the primary concern, and resources are limited, what other considerations play a role in discharge planning? Given the scarcity of resources for community health care, to what extent should the discharge team be influenced by issues of resource allocation? If this case were in your province or territory, what resources would be available for Jack? Readmission/failed discharge due to lack of support is another potential concern.

 

Resources

Reflective exercise 4

The team was able to agree on a suitable discharge plan for Jack. For each person around the table, list the compromises they made to find a workable and mutually acceptable solution.


 

Next: Conclusion

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