I get a call from the hospital (this is over a year ago). They say, “Your friend is ready for discharge. What time can you pick her up?”
I reply, “Can she walk?”
“What?”
“She has three steps up into her house. Can she walk, because otherwise I can’t get her into her home.”
“Oh, uh, we will check.”
They call me back. “She can’t walk. She’ll have to stay another day.”
I knew that she couldn’t walk before they called. She could barely walk before the surgery and after anesthesia, surgery and a night in the hospital, her walking was worse. She had been falling 1-5 times at home and the surgeon knew that. He did not take it into account. The staff would have delivered her to my car in a wheelchair and then it would have been my problem.
She was confused by that afternoon, which is not uncommon in older people after anesthesia. She stayed in the hospital for six days and then went to rehab, because she still couldn’t walk safely.
Recently I have a patient, an elder, that I send to the emergency room for possible admission. He is admitted and discharged after two and a half days. Unfortunately he can barely walk and his wife is sick as well. The medicare rules say that he needs 72 hours in the hospital before he qualifies for rehab. We scramble in clinic to get them Home Health services, with a nurse check and physical therapy and occupational therapy, and I ask for Meals on Wheels. It turns out that Meals on Wheels will be able to deliver in two months.
The wife refuses to go to the emergency room. I tell her that if she does get sicker, that they both need to check in. The husband can barely walk and is not safe home alone. If one gets hospitalized, they both need it.
If you have a frail elder, be careful when you are called about discharge. Go look at them yourself, make sure that you see that they can get out of bed, get to the bathroom, walk up and down the hall. Can they eat? Do you have steps into your house or theirs and can they go up the steps? I got away with saying please check that my friend could walk because I am a physician, because I knew she couldn’t and because there was no one else to pick her up. Do NOT ask your elder. They may want nothing more than to go home and they may well exaggerate what they can do or be firmly in denial. You want them to be safe at home, to not fall, to not break a hip and to not be bedridden.
For an already frail elder, even two and a half days in bed contributes to weakness. And being sick makes them weaker. If they are barely walking when they are admitted, it may be worse even after just 2-3 days. I used to write for physical therapy evaluation and exercise when elder patients were admitted, to help them for discharge. Once I got a polite query from physical therapy saying, “This patient is on a ventilator. Do you still want a consult?” I reply, “Yes, please do passive range of motion, thank you!”
Your elder does not have to be doing rumbustious dancing before they go home, but they need to be able to manage stairs, manage the bathroom, manage walking so that they can get stronger. Otherwise a stay in a nursing home or rehabilitation facility may be much safer for everyone.
For the Ragtag Daily Prompt: rumbustious.
KO Rural Mad As Hell Blog 
No one argued with my decision to come home alone. I don’t know if it was the right decision or not, but I’m doing everything fine so far — the one thing I haven’t been able to do is find a ride back to the hospital for a “follow-up” exam with orthopedics. Following up WHAT? I was not seen by ortho the whole time I was there but whatever. It’s still a good idea, though very complicated. Home Health will be here this afternoon.
Martha, you are a young elder!
I know. My old elder friend is in a nursing home now and still — at 93 — though accepting everything in his environment except that his little dog can’t live with him — is grateful for the help and grateful he can still walk. OK, not far or fast, but every day, with his walker, I admire him with all my heart.
For a peri-prosthetic hip fracture, I sure hope someone(s) from ortho saw you! Maybe failed to identify themselves? Or, dog forfend, they only looked at the x-ray and called that seeing you.
On the other hand, when I was in the hospital, there was a note from an orthopedic surgeon agreeing with his residents’ findings and adding “I personally examined the patient”. Since I know him, I know he never examined me. I can’t guarantee he didn’t poke his head through the door while I was dozing.
No, they just saw my CT scan and X-ray, I think, but I was on morphine in the ER. I will go and hope for the best and realize it’s for my own good, but I need a ride. Physical therapy is coming tomorrow. Sadly, I have no illusions about doctors any more. There are good ones and bad ones and careful ones and careless ones and docs who are fine but who end up ambushed by their personal lives. I will do as I’m told.
That is really sound and helpful advice. Thanks.
Thank you
Thank you for this Public Service Announcement.
“Medically ready” for discharge and “functionally ready” are two very different things. I (as an occupational therapist) used to get consults to the Emergency Department (far from a “room” these days) to “clear” people for discharge home. Some were pretty simple – they were fine. Some took some creative work to test what I wanted to test in that setting. Others were obvious as soon as I had them try to get out of bed – no way could they go home. Being an old white man, the doctors and PAs tended to listen to me even when I told them what they didn’t want to hear. I’d like to think it was my thorough evaluation and concise documentation, but I suspect the color of my skin and hair, along with gender, had something to do with it.
It’s not always age. I saw a young man on a Saturday afternoon. He had a traumatic brain injury but looked fine and it was an injury that didn’t leave a clearly-visible mark (on a CT scan). They wanted to send him home but he stayed 6 days. (“Home” being a short-course dorm and he didn’t know where it was, what it was called, how to get there, or how to find any of that out; and he knew no one in town.)
Thank you and yes! It is not always age!