When I have an elderly patient who needs to go into a nursing home it generally goes like this:
I start telling the family that the patient needs a higher level of care. Maybe they are having a hard time with their meds, are unsteady on their feet despite some physical therapy, having issues with eating and drinking enough, a few close calls with the fire department after meal prep fiascos, they are lonely and depressed, etc.
The patient falls a few times. Maybe they break a hip. Or two.
I remind the family that I told them the patient needs a higher level of care. They promise me they will look into it.
The patient develops a urinary tract infection and then urosepsis with acute renal failure and is admitted to the hospital. The social worker gets the patient placed in a skilled nursing facility for “rehab” which Medicare will cover for thirty days.
On the 29th day, the facility notifies the family that the patient needs to be discharged the next day. There is a scramble for a bedside commode and a walker. A promise of home health that never quite materializes…
The patient is home alone for 4-5 days and has another fall. Fortunately the X-ray shows nothing is broken.
I remind the family again about the higher level of care need, that they must have someone present 24/7.
There is another fall in the next few days.
The family says they do not feel they can/want to provide the 24/7 care the patient needs. It all seems so overwhelming. They looked into facilities but that is going to eat up any inheritance and while they stop there, while they never actually say that they want the money for themselves, it is implied… And I understand. I do. But my duty is to the patient. I push harder.
There is another fall or maybe another bladder infection within a week or two but we catch it early enough, before the hospital is necessary.
I finally convince the family that this cannot go on. They recognize that they are spending too much time in my office and at the hospital. I may even have to throw out the Adult Protective Services threat. They say, “But they will never agree to it…” I know the patient will, though, once the family is on board. I have done this dozens of times with dozens of other patients…
I sit down with her. I hold her hand. I look her in the eye. I tell her that she cannot live like this, that she knows it is going to kill her and it won’t be something quick. It will be a terrible, lonely, lingering death. She nods, defeated. She does not want to be back in the hospital. I tell her that her only hope for living on her own again is to go into a facility for some intense rehab, but I cannot promise her that she will ever make it out of the facility. She nods. We both know she will die there. She sobs. I put my arms around her and hold her while she cries. The family stands around awkwardly. Ultimately, the patient agrees to placement.
Sometimes, though, the tears will wear a hole in a stony heart and a daughter or son catches a glimpse of their own future sitting in that chair and will step forward to say, “Ok, I will do it.” I can see there is love breaking through, a coming to grips with reality. I know they are not really sure how they will do it but they will find a way.
And then I feel like crying. But I don’t. My own turn will come soon enough.