Abstract
In this paper, I will describe the case of Mr. Henry Spirk. He is a a 72-year-old man who has recently broken his hip and does not have the ability to take care of himself. In addition, he was diagnosed diabetes, hypertension, and partial hearing loss. However, Mr. Spirk refuses to believe in his current condition and claims that he is able to take care of himself. I will describe the discharge planning and identify which obstacles prevent us from discharging Mr. Spirk without additional home care. I will identify which health conditions need to be addressed and discussed with the patient before making the discharge placement, which team members on the interdisciplinary team are important in Mr. Spirk's case, and how the family interview and the safety assessment of Mr. Spirk's apartment influence my discharge placement decision.
Discharge of Elderly Patients from Hospitals: Mr. Spirk's Case Management
Mr. Henry Spirk is a 72-year-old who has recently broken his hip. The operation was successful, but Mr. Spirk is overweight, and he was diagnosed with type II diabetes and hypertension during his stay. His weight, diabetes, and hypertension need to be addressed before he is discharged. These issues are common risk factors in the development of cardiovascular conditions, so they need to be addressed to prevent Mr. Spirk's readmission completely or at least postpone it.
Besides potential cardiovascular issues, I need to address Mr. Spirk's vision and hearing impairment. He is currently using reading glasses, and he has 60% hearing loss in his left ear. Although these symptoms could be caused by diabetes or hypertension, I believe further discussion is necessary with Mr. Spirk and his family. Hearing loss can be influenced and hastened with improper diet habits and some ototoxic drugs. Because several old prescription drugs were found in the apartment during the safety assessment, I have several reasons to doubt Mr Spirk's claims that he has been healthy his whole life.
Most importantly, I need to address Mr Spirk's hip fracture. Fried, McNamara, Burke, and Siscovick (1997) claim that heart conditions are common in elderly people because of their sedentary lifestyle. Moderate exercise and diet changes are the best prevention method in this scenario. However, Mr. Spirk's hip injury will prevent him from physical exercise and encourage his sedentary lifestyle. In addition, it makes him dependent on other people's assistance, and Mr. Spirk does not want any assistance. Proper physical rehabilitation of this injury will allow Mr. Spirk to live without home health care and avoid future readmission.
I will need a physical therapist on my interdisciplinary team for planning an appropriate discharge plan for Mr. Spirk. The physical therapist is required to evaluate Mr. Spirk's current mobility and determine how it can be improved. The physical therapist is required to create a suitable rehabilitation program for Mr. Spirk's injury in collaboration with the patient and his family. Physical rehabilitation is the most important aspect of treatment for Mr. Spirk because regaining mobility is the only way he will be able to take care of himself again without outside nursing assistance.
Mr. Spirk needs to change his diet, so I will need a dietitian on the interdisciplinary team. This person is required to create a suitable diet plan for Mr. Spirk. The dietitian needs to educate Mr. Spirk in the importance of the diet changes for maintaining his health and regulating his current conditions. The dietitian should explain to Mr. Spirk why a proper diet will prevent his conditions from escalating into more serious health conditions and prevent further readmission to the hospital.
I will also need a pharmacist on my interdisciplinary team. Mr. Spirk is currently taking medication for his diabetes, hypertension, and residual postoperative pain. The pharmacist is required to monitor and manage the patient's intake of drugs during his stay in the hospital. The pharmacist should also learn about the drugs found in Mr. Spirk's apartment and understand how they affect his current condition. Analyzing these drugs could bring up other health conditions Mr. Spirk avoided mentioning. The pharmacist will make medication plans for Mr. Spirk accordingly and advise Mr. Spirk about medication usage outside the hospital.
Besides these three members, I would like one more member in the role of an educator. Mr. Spirk is already familiar with care procedures concerning diabetes outside the hospital, so I do not need a diabetes management nurse. However, he seems impatient and reluctant to accept that he needs daily assistance. I would like a registered nurse with a specialization in cardiovascular nursing on the interdisciplinary team to assist in the patient's education. Because of his sedentary lifestyle and current health conditions, Mr. Spirk will probably suffer from cardiovascular conditions if he refuses home health care nursing. I believe an education concerning potential problems which may arise from his current issues will allow Mr. Spirk to reconsider his refusal of outside nursing care.
Because of his current attitude and unwillingness to accept his medical conditions, Mr. Spirk will probably not accept home care. However, we must bring up the safety assessment of his apartment and explain why it is dangerous to discharge him without home care. The access to his apartment is difficult because there is no elevator. He needs to cross two flights of stairs, but he is not in a condition to cross these stairs several times, especially if he is carrying groceries. He will need to stay indoors, and his social life will suffer. He will be alone most of the day because his son is busy and he has no other relatives to take care of him. It is difficult to maneuver in most parts of the apartment, and the bathroom lacks safety features for disabled people. Mobility and safety features should be addressed first because they are most important, but old prescriptions and the expired food need to be brought up.
Planning the discharge according to the apartment safety assessment and family interviews will be difficult. Mr. Spirk and his family are very stubborn in their opinions, and they seem to decline any medical advice proposed for adequate care once he leaves the hospital. His son thinks Mr. Spirk does not need medication, and he cannot frequently visit his father because he is under high amounts of pressure at work. According to the interview with his son and his son's wife, Mr. Spirk has no other relatives, and his son does not have the time to adequately take care of his father. With this in mind, it is impossible to discharge Mr Spirk without any advice concerning home care and apartment safety measures.
Because of his inability to leave the apartment, Mr. Spirk will have to live in social isolation. Although solitude is sometimes a personal choice, Mr. Spirk needs to recover from his injury and his surgery. He needs a person who will support him. If he does not accept home care and does not receive adequate care from his family, he will not have the motivation necessary for a fast recovery. He could also develop psychological issues, such as depression, because he will be lacking of human company.
Motivation is a very important psychological part in recovery. Just like a social environment determines psychological development of children, it can provide support in the recovery process. However, Mr. Spirk will not have any social environment to provide him with support he needs for recovery after his operation. In addition, he is currently in denial. He does not want anybody around him, and he does not want to admit that he has more health issues than he thinks. During the apartment safety assessment, several old prescriptions were found in the bathroom medicine cabinet. They could have belonged to his wife, but they could also be a sign that Mr. Spirk is not honest concerning his health. This issue needs to be brought up in the communication with Mr. Spirk and his family, so we can get a better insight into his medical history.
Although Mr. Spirk does not require end-of-life care, his current condition and the environmental settings prevent him from living without assistance. According to the National Institute of Aging (NIA) (2008), it is important to talk openly to the patient and seek alternative ways of gaining some information. Addressing financial issues is important to reach a mutual agreement on the patient's discharge placement. Mr. Spirk is clearly not willing to share all of his problems and participate actively in his home care and safety measures planning. Mr Spirk's health is currently at risk because his conditions can develop into complicated medical problems, so it is important to inform him that he will not solve the issues by claiming that he is able to take care of himself.
According to my assessment, Mr. Spirk's self-care abilities are non-existential. However, he has the right to refuse all the propositions we offer. If his family still believes that Mr. Spirk can take care of himself, there is no way to force them in accepting our recommendations. If Mr. Spirk wants to be discharged without taking our advice on home care, he can be discharged against medical advice (AMA). He will need to sign a form in which he understands that he is putting himself at risk for future readmission. We need to state his current condition in that form and explain which solutions we have offered to the patient. This is an important part because it is necessary to put some effort in patient care instead of simply allowing them to leave the hospital AMA. Although it would be ideal to provide him with home care assistance, we can only propose this as a solution. Another option is to recommend a physical rehabilitation facility until he is able to take care of himself.
Either way, according to the laws regarding acceptance and refusal of medical treatment, Mr. Spirk has the right to refuse our propositions and his rights should have been known to him since the admission day. I would rather discharge him to a rehabilitation facility or under the condition of accepting home care, but he always has the right to refuse further treatment.
References
Fried, L. P., McNamara, R. L., Burke, G. L., & Siscovick, D. S. (1997). Heart health in older
adults. Import of heart disease and opportunities for maintaining cardiac health. Western
Journal of Medicine, 167(4), 240–246. Retrieved from http://www.ncbi.nlm.nih.gov/
pmc/articles/PMC1304538/pdf/westjmed00338-0048.pdf
Naylor, M. D., Brooten, D., Campbell, R., Jacobsen, B. S., Mezey, M. D., Pauly, M. V., &
Schwartz, J. S. (1999). Comprehensive discharge planning and home follow-up of
hospitalized elders. JAMA, 281(7), 613-620. doi: 10.1001/jama.281.7.613
National Institute of Aging. (2008). Talking with your older patient: A clinician’s handbook.
Retrieved from http://www.nia.nih.gov/NR/rdonlyres/99DFC896-8E13-4BC7-9F85-
EED95AA6A293/0/clinicianhandbk11708FINALPDF.pdf
