Whose In Charge When You are in the Hospital?

My 94 year old mother was just released from the hospital following a 13-day stay, precipitated by a serious infection.

First, the good news – the infection has cleared and she is back home,  thinner (not a good thing) and more easily fatiged, but with her memory in tact and able to engage in meaningful conversation that includes current observations and references to ongoing private jokes.   Fortunately, she has a wonderful team of home caregivers who are keeping her safe, comfortable, engaged and eating her favorite foods.

The infection could have been very dangerous, and it needed to be cleared with a course of antibiotics that could only be delivered in the hospital.  But once my mother was in the hospital, it started to look like her stay was being extended in a way that was not beneficial, and there was no one to take charge of the decision about what should, and shouldn’t be done.

For example, because my mother was mostly confined to bed, she developed some fluid on her knee, and complained of some pain.  The fluid was drained off, which resulted in signficant relief.  However, she was also prescribed an opioid pain medication, which resulted in increased confusion and severe constipation.  As with the pain, the medication prescribed to deal with the constipation did not take into account how petite my mother is, so it packed a punch that was much more debilitating than it needed to be.

When I was finally able to speak to the hospitalist, I described a scenario (which my mother and I laughed about this morning) of returning from high school one day to find my mother scrubbing the floor by hand, and complaining that her knee had swelled up with fluid.  Since I am now in my 60s, I hoped to demonstrate that my mother’s knee pain is not an acute situation that had to be addressed during this hospital stay.  I asked him to make sure to include Physical Therapy at home in the discharge order, and he agreed that, along with an 0ver-the-counter pain medication, was probably all that is needed.

The hospitalist acknowleged that my mother’s case exemplifies a situation that is very common among the elderly – she has several health issues, and a doctor for each of them.  While he is the attending phsysician for the current hospitalization, in his own words, none of these physicians is “in charge.”   Treatment by one, very well-meaning physician may be counter-productive as it relates to addressing other conditions, and when one has a question outside of his specialty, he feels that he is not the right person to ask it, so it is never asked at all. Thus, while our family was clamouring to have the patient discharged once the infection had cleared,  the doctors were all concerned about whether she would be safe at home, but no one felt like he was the party responsible for implementing a discharge plan.  My mother’s chart indicated that she lived at home with help, but not around the clock.  While we had made arrangements to increase the hours to 24/7,  no one asked if changes had been made, or even told us that that discharge was being delayed until we assured them this was the case.

Sadly, I could tell the same story about when my mother-in-law was hospitalized, in a different state, almost 15 years ago, and I described a similar situation about my mother in a blog post in 2013.

Changes in rules for medicare and insurance reimbursement designed to focus on results, rather than “fee for service,”  were supposed to address this. However, until the result to which the providers are held accountable is a well patient who can go safely home as soon as possible, and not just eliminating symptoms (clear an infection, reduce knee pain), then no one feels responsible for the patient and her wellness.


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