Mrs. N. will be 107 at the end of the year. She has lived for over 60 years in the same rented apartment, initially with her husband but for the past several decades on her own. She is an absolutely delightful English lady who is still gloriously mentally capable, and takes a “come what may” approach to life events with charming irony. She always tells me that my home visits are reassuring to her, even though we both know I’m not really giving her much “medical” care.
She doesn’t see well because of macular degeneration and walks around her apartment with a walker, sometimes unsteady on her feet. So much so in fact that a couple of months ago she had quite a bad fall, a neighbour called an ambulance, and she landed in hospital with a fracture of her right humerus, or upper arm.
Once I found out about the admission and went to see her, she looked like she had been hit with an improvised explosive device. She was black and blue all over her upper body including her face, and still in some pain in spite of enough narcotic medication to make her unusually confused. She was philosophical about the future in discussing getting her back on her feet: “I’m just feeling too lazy to make much of an effort. Let’s just leave things and see what happens.” I concluded that this injury was going to be pretty close to a terminal event for her.
Of course the hospital ward team of physio-, occupational therapist, nurses, geriatric medicine consultant, orthopedic surgeon, nutritionist, etc. all agreed that her chances of getting back on her feet (given that she needed the arm to use her walker) weren’t especially good. Never mind being unable to conceive of a person her age living all by herself. As her pain improved they began to make plans for transfer to a “transitional care” unit, to wait for nursing home placement. And Mrs. N. wasn’t complaining about that.
At least not until I pointed out to her that she faced a choice between somehow making the effort to get back on her feet, and spending whatever days she had left in a nursing home. This appeared to come as a surprise, and a week or two later the physiotherapist had noticed a big improvement in her mobility. She was sitting up in bed independently, standing with a two-person assist, and taking steps. When I walked her myself the main problem was pain in the right arm. I asked her whether she would like our home care team to try to get her back to her apartment and she said, “Absolutely doctor. I can’t imagine where else I would go…”
At this point our home care physiotherapist and my family practice resident attended a planning meeting on the ward, and it was clear there were two different opinions about what was possible and what was preferable. The hospital team focused on their concept of safety (which consisted in avoiding another fall that could only be accomplished with supervision in an institution), and our team was thinking and talking about what the lady herself wanted, as long as she understood the risk. About 10 days later we had come up with a clear if complex plan for increased home support, daily physiotherapy or rehabilitation assistance, supervised mobility, and good pain control with medication, all at her home.
In the meantime she had been moved to the “transitional care” unit, and the good news was a couple of weeks later the new care team there agreed to a trial of discharge home. But I got a phone call on a Thursday that she was being sent home by ambulance the next day. Friday. I got on the phone to the ward physician, an old friend, and suggested to him that discharging an unsteady blind 106-year-old home on a Friday afternoon was a recipe for a Saturday morning with the wrong medications, no assistance through misunderstood home support arrangements, no rehabilitation availability for two days, nobody available to put things right, and Mrs. N. back in the emergency department by Saturday afternoon. “She’s not acute anymore. We need the bed,” the ward administrative nurse had told me. But fortunately my colleague understood and Mrs. N’s discharge was delayed by three days.
I’ve seen her three times since then, and our physiotherapist has done a masterful job of getting her back on her feet, first with supervision. A couple of days ago when I rang her apartment buzzer, she promptly popped the front door open, and surprised my resident and me by physically answering the apartment door with her walker, returning to her chesterfield safely and independently, and then telling us a couple of entertaining stories that convinced me that her former vigour and sense of humour and completely returned. Her pain is controlled now with just a bit of Tylenol.
This dear lady won’t live forever of course, but everybody in our home care service is delighted and proud that whatever time she has left will be spent independently, where she wants to be, and living life as she chooses within her limitations. The alternative which would have rolled out and is the usual consequence for very old frail people in crisis would have been a huge and disturbing change in her life circumstances, and many of the months remaining to her spent getting used to a nursing home with its constraints of routine, indignities, and cookbook preventive medical care. We are more determined than ever to keep her away from the doors of the emergency room from now on.
I know there is no need to mention how much less our 24-hour relationship-based home-visit trust-engendering care costs.