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Second Opinion

Second Opinion

‘Hospice? No, Hospitalist!’ Confused Seniors in a Complex System

Leap, Edwin MD

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Emergency Medicine News: May 2014 - Volume 36 - Issue 5 - p 14
doi: 10.1097/01.EEM.0000449780.60234.d5

    I was working overnight in Tiny Memorial Hospital, located in scenic Rural America. My call room there was a converted patient room, and my bed was a hospital bed. Lying there one night, I rolled to the side and raised the head of the bed using the button on the rail. The blanket was standard hospital fare — stiff and thin. And the television remote, fully two pounds and connected to the television by cable, was the latest NASA technology from 1965. I contemplated my surroundings, and noticed the nurse call button on the remote. I had a strange desire for Jell-O and my old cardigan, but I shook it off.

    I began to imagine what it was like for the older patients in the facility. And what it would be like for me one day, when I might be hospitalized or placed in a nursing home. Admittedly, given my tendency to run my mouth and forget the contents of my carry-on, I'm probably more likely to be Tazed to death in an airport in my late 80s ... or 50s. But one wonders about the future.

    Tiny Memorial, which sees around 5000 patients a year in its emergency department, admits a small number of patients who are mostly seniors. The 25-bed inpatient side has the feel of a nursing home. Some of those admissions are called “skilled care,” which generally means they aren't strong enough for home but don't meet the criteria for a nursing home and can stay considerably longer without acute illnesses.

    Watching those folks, walking by their rooms every day, and talking to their families as they are admitted, I realized once more what I've seen over and over in emergency medicine and of the startling changes affecting all of medicine. And it's this: seniors don't understand many of the changes they're facing. Frankly, I don't either.

    But I do know that everything has become much more complex in the 20 years since I left residency. You know what I mean. Back in the day, we could admit people who needed it. We all knew that some of these were social admissions. Admitting physicians, who then often knew their patients, understood that it didn't really matter what Mrs. Reid's sodium was or whether the x-ray showed a hip fracture when she had fallen and couldn't get up. They knew her daughter lived 1000 miles away in Omaha and that she lived alone with her Chihuahua, Pierre. And he knew that she had no options except a couple of days of strengthening, but would neither go to a nursing home nor be able to afford it.

    Fast forward. Now I see Mr. Bowen, who is 90. He worked until last year cutting trees, and could use a chain saw from dawn till dusk, leaving his grandsons in the dust. Now? He fell and broke several ribs over the summer, and since then he has been declining. Yesterday he fell in the living room and has facial fractures (they'll need surgery eventually) and a broken right wrist. His son, who is 60, brings him in, and I have the inestimable pleasure of telling him, “Mr. Bowen, there's no indication to admit you to the hospital. Here are some numbers to call for follow up.” His son and daughter-in-law say, “But we just want to check him in for a couple of days until he can get stronger. He's too weak, and he's in a lot of pain!” His sweet wife pets his forehead, and is herself too frail to care for him intensely at home. I sit down. I say, “I understand, but Medicare won't pay for it!” They tell me that they are very disappointed. Mr. Bowen just looks sad and tired. “Well, take me on then.”

    I think intently, and inform them I'll talk to the hospitalist, who doesn't know him from Adam's housecat, as we say down here. “Sir,” I tell Mr. Bowen, “I'm calling the hospitalist.” This gets his attention. “Calling hospice? Why?” His son and wife look up. “No, hospitalist. The doctor who admits people.”

    “My doctor is Dr. Chapman,” he says weakly.

    “I know, but he doesn't admit anyone anymore,” I say. (What I don't tell him is that Dr. Chapman is dead, and has been for about five years). The hospitalist has zero interest in this situation. “Try orthopedics,” he suggests. I tell him that my patient's sodium is 129. “Yeah, but it has to be lower than that. I'd love to help, but administration is all over us about inappropriate admissions.”

    I call the case manager, who interrupts her untold other attempts to justify admissions and looks over the chart. “Sorry. He doesn't meet criteria. You can observe him, but it's all out-of-pocket.” I tell him about the case manager, but he doesn't understand. In the end, he goes home. I hope he can navigate the complexity of office visits; perhaps he can have some home health visits. His family members shake their heads. They just don't understand.

    Neither do I. Nobody understands the rules, most of all the elderly who were fed false promises of the care they would receive when they were older. They remember a time of “checking in” for some rest, the days of doctors they knew, the days when a prescription wasn't $500. (I explained to my well-insured mother how much my son's insulin cost, and she was incredulous. She has always had prescription coverage, which my expensive insurance doesn't.)

    Our seniors get sick, but have a hard time being admitted. They get admitted, but have a hard time staying in the hospital. They have a hard time getting into the nursing home, and they have a hard time staying there because every sniffle, fever, bruise, or fall results in a mandated ED visit by ambulance, whether they want to go or not, whether they have a DNR or not.

    They don't get hospitalists, length-of-stay rules, rehab days, or any of the complexities imposed by a system with lots of nice ideas and ideals but with nowhere near the money to pay for all of it nor any real interest in doing so.

    To be fair, sometimes the expectations of our seniors are too high. They want the best (don't we all?), but they want it to be covered at little extra cost. Those days are gone. But then again, they believed the line: “The government will never stand between you and your doctor.” What poppycock.

    We'll have to adapt to doing less with less. Unfortunately, that will be hardest on our seniors who have spent their lives working and raising children and fighting wars and keeping the country running while we had existential crises and wondered if our expensive educations were fulfilling enough.

    For better or worse, I don't think they'll be around long enough to understand the ever-changing nuances of our shrinking, complex system which, in many cases, may be their undoing.

    Dang it, where's that Jell-O?

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