Lyle Mitchell, 84, is admitted to the medical/surgical unit after fainting and falling off his living room couch. Assessing him, you find that he's confused, incontinent, dehydrated, and unsteady on his feet. He's receiving intravenous fluids to correct his short-term problem—fluid and electrolyte imbalances. But what about his ongoing needs, including a safe environment, physical therapy, and adequate nutrition?
Patients are discharged from hospitals so quickly these days that many of them, especially older adults, require continuing care at home or in long-term care. More than 12 million adults today need help to perform activities of daily living. By 2020, more than 38 million will have a chronic condition that will limit their ability to live independently.
When a hospitalized patient like Mr. Mitchell is frequently confused and can no longer take care of himself or make important decisions, his family may need to consider long-term-care options. As his nurse, you're one of the people they'll turn to for advice and support. In this article, I'll discuss how you can best help them make good decisions during this stressful period.
Guilt and uncertainty
Families wrestle with feelings of guilt and uncertainty as they determine whether long-term care is right for a loved one. Use these tips to help them make a decision that's not clouded by their emotions.
- View hospitalization as an opportunity. Hospitalization may be a chance for the patient and his family to get much-needed help. Although Mr. Mitchell's family brought him to the emergency department because of his fall, they admit that his increasing confusion and weakness are also problems.
- Begin discharge planning at admission. During admission, consider the patient's long-term needs. Gather information about his current living situation and support system. Is he well groomed, alert, oriented, stable on his feet, and able to manage his health conditions independently? Does he live with another adult who's willing and able to take care of him? If any of the answers are no, he may be a candidate for long-term care. In the meantime, ensure that other needs, such as physical therapy, are addressed while he's in the hospital.
- Watch for unrecognized health problems. Incorporate your findings into the patient's long-term-care plan. For example, the nurses have noticed that Mr. Mitchell is dyspneic on exertion and that he has 1+ ankle edema. Further examination and testing reveal that he has heart failure. His needs for medication and a low-sodium diet are included in his long-term-care plan.
- Involve the patient and family. In plain language, share your assessment of the patient's needs with them and encourage them to voice their concerns. Although Mr. Mitchell's family wants what's best for him, they may not understand his needs and condition. For example, they don't know why he's been confused and weak. By answering their questions, you can help them recognize that his need for assistance will continue beyond this hospitalization.
- Help the family evaluate what care they can provide. Most families feel responsible for caring for a loved one and may feel guilty letting others help. Although Mr. Mitchell's wife initially says she's happy to care for him, she's frail herself. Encourage her to consider her own physical and emotional limitations. Let the family know that it's okay to ask for help.
- Detail the options. The health care team will suggest what level of care the patient needs after discharge, but the family may not understand the differences. Provide details on home health care, assisted living, long-term care, and hospices. Also give them a list of community services that may be helpful, such as the local Agency on Aging.
- Offer to organize a family conference to discuss the patient's needs. Invite the patient, family, and hospital staff involved in the patient's care, such as his primary care provider, nurses, and staff from social services, physical therapy, occupational therapy, respiratory therapy, and dietary therapy. Together, everyone can formulate a discharge plan tailored to the patient's needs and preferences.
- Be patient. Making care decisions is usually time-consuming and stressful. Families and patients need your time and support when considering their options.
- Respect their decision. The best choice for the patient is the one that's right for him and his family. Even if you don't agree with their choice, support them and their decision.
- Help them make selections. Give your patient and his family information on what they should look for when choosing a facility, a home health care agency, or medical equipment. Your hospital's social services department can provide a list of local facilities, medical supply stores, and agencies that provide visiting nurses. It can arrange for tours of facilities they're considering.
Mr. Mitchell's transition
Mr. Mitchell's family agrees that his needs will be best met in a long-term-care facility. The hospital's social services department tells them about local facilities and helps them contact those that interest them. The family seems at ease with their decision, and after his discharge, Mr. Mitchell settles into life at his new home.
Jennifer L.W. Fink is an agency nurse for InteliStaf Healthcare in Madison, Wis.
Bull, M., et al.: “Predictors of Elder and Family Caregiver Satisfaction with Discharge Planning,” Journal of Cardiovascular Nursing
. 14(3):76–87, April 2000.
Reed, J., et al.: “Discharging Older People from Hospital to Care Homes: Implications for Nursing,” Journal of Advanced Nursing
. 29(4):819–825, April 1999.