There are many scholarly articles on the risks associated with the transition of care. The following is an example of this breakdown and the outcome that took its toll.
A senior man was on hemodialysis for kidney failure. He also had heart disease from hardening of the arteries and an irregular heartbeat. A pacemaker was necessary to regulate the heartbeat. He also had diabetes for many years. His diabetes required insulin to manage the blood sugar. The shunt, the device that allows the hemodialysis to occur, was not working so another catheter was inserted to allow for his life-saving dialysis treatment.
Charism was called to the table because the senior had exhausted his Medicare rehabilitation stay and was to be discharged. His son did not know what to do and where to turn. Staying at the rehabilitation facility was no longer covered by Medicare and continued stay at the rehabilitation nursing home was not of value. Most importantly, he wanted to go home.
The Charism nurse spoke to the family about the expected outcome of the conditions that this man had to deal with. The issue of end of life wishes was raised by the Charism nurse. The senior looked depressed, noted he was depressed and told his family that he was tired of living. He would give treatment one more try, and if he did not feel any better, he wanted to be placed on hospice and to live the rest of his life in peace. The physical and psychological pain were taking its toll, and he was tired.
On discharge home, the family realized that the senior was on sliding scale insulin, insulin that was to be given episodically based on elevated blood sugar. Even though the diabetes was long standing, the insulin had been in a pen. The Charism nurse “taught” the son to draw up the insulin for his father with a phone call at 8 PM the night of discharge because the discharge nurse had not recognized this need for teaching.
Three days later the son called the Charism nurse. His father was unresponsive and in the emergency department. The father had become increasingly lethargic, confused and was hallucinating at home. On investigation, the Charism nurse noted that the discharge instructions included the tranquilizer Ativan. The Ativan was to be given “4x/day PRN”. The wife did not understand that PRN meant as needed so was administering the medication four times a day leading to the hospitalization. Once dialyzed, the senior became alert again, but this was the last straw. He asked to be placed on hospice and died a few days later in peace.
Discharge instructions and transitions of care can be deadly for seniors. The communication, or lack of communication, in this area is as important as any other care delivery system. Ask, ask, ask and ask again to make sure that the family and senior understand. Do not assume that others in the healthcare continuum understand. Clarity and reinforcement of information are critical to the success of our advocacy role. Contact me to discuss how you can make the transition of your loved one easier on everyone involved.