Questionable Discharge Decisions
During rounds today we ran into a problem. There is a patient with a right CVA, left hemiparesis and impaired cognition who is insisting on returning home at discharge. While that is an ideal discharge plan for most patients, it isn't realistic for her at this time. She is dependent for mobility, has severe left neglect and lives alone. She also denies she has any impairment and accuses the rehab staff of undermining her independence. She tells us she can do anything she wants but doesn't want to when we ask her to show us.
In other words, we have a discharge nightmare. The only blood relative lives out of state and refuses to get involved. She doesn't want to argue with her mother. It's obvious placement will be required. It's also obvious the patient will not agree to it. What's less obvious, but just as important is the patient isn't capable of making that decision. Therein lies the problem. The patient is able to make basic decisions about day-to-day matters. She can decide on her menu and what to wear. She is able to dial the phone. What she can't do is make a decision about discharge plans and no one has been able to definitely state why.
I did some research into the subject. According to several sources, the patient must be able to understand and describe her condition. She must be able to verbalize and clearly explain each option including the pros and cons of each. Finally she must be able to verbalize a plan that accommodates her present needs and safety concerns. The only plan this patient will verbalize is going home as soon as possible. She won't entertain any other idea or suggestion. Since there are no other relatives, the facility is going to have to request guardianship be awarded to an independent third party. In the meantime, the patient will stay in the facility and receive therapy. Her participation is intermittent at best. Continued therapy may not increase her functional status enough to eliminate the problem.
The situation got me wondering how many other patients are in the same situation, but it isn't so obvious? The elderly can present challenging discharge circumstances. Patients with cognitive problems learn to mask them early on. I wonder how many have talked themselves out of the hospital and into a bad home situation. I wonder how many have convinced family that no assistance is needed when it really is. Many of those patients probably end up back in the hospital in worse shape than they were previously.
I checked with some of my OT friends. They tell me there really isn't a cognitive test they do that would identify something like this. Even the MMSE is ineffective for this. I'm not sure what can be done because patients have the right to make their own health care decisions. I don't think anyone really wants to put someone in a facility unless absolutely necessary. I talk about discharge arrangements with my patients. I guess I'll now be thoroughly documenting those conversations. At least now I know what to ask and what responses to look for.