Due to the grandstanding in the 1980's skilled care of the elderly became a political football. There grew out of this an advocacy movement on behalf of the elderly and skilled elder care became the most regulated sector of American health care. Difficult and exceedingly complex regulations, draconian inspections by regulatory agencies and harsh penalties put nursing homes on the defensive. Nowadays, in order to avoid any perception of under treatment of the elderly, nursing homes have a very low threshold for transfer to hospitals of patients with acute symptoms.
Many advance directives specify that a patient is not to be transported to a hospital. However, families under pressure to make an urgent decision often contravene these documents at the last moment. At other times the directives are simply ignored. I suspect many of these directives are drafted and signed hastily without sufficient time for education and counseling of patients and their families.
These incredibly complex patients arrive in the ER where the pressure for a quick work up and rapid disposition may drive the decision for admission. Throw in pressure from families and return to the nursing facility becomes a lost cause.
This creates a tough discharge planning situation for hospitalists. Traditional discharge criteria do not easily apply because the baseline functional status of many of these patients is so poor. Treatment endpoints are often poorly defined and may be inflated by family expectations.
What can be done? Better education and counseling of families to clarify and align treatment expectations might be helpful in reducing both the number of hospital admissions and the length of stay. This is where I see an important role for palliative care teams in the nursing home and even the emergency department.
A Perspective piece in the September 29 issue of NEJM takes a different view. This article reads like a pitch for more government intrusion, as if that sector of health care is not already over-regulated. But now the incentives would be 180 degrees in the opposite direction, favoring under-treatment, as opposed to what we had in the 1980s. Indeed there are provisions of the Affordable Care Act that can be leveraged in that direction. The authors do acknowledge potential unintended consequences.
But what struck me most about the article was the case example used to launch the discussion. It concerns a 90 year old female with multiple complex problems:
She develops a nonproductive cough and a fever of 100.4°F. The night nurse calls an on-call physician who is unfamiliar with Ms. B. Told that she has a cough and fever, the physician says to send her to the emergency room, where she's found to have normal vital signs except for the low-grade fever, a normal basic-chemistry panel and white-cell count, but a possible infiltrate on chest x-ray. She is admitted to the hospital and treated with intravenous fluids and antibiotics. During her second night in the hospital, Ms. B. becomes confused and agitated, climbs out of bed, and falls, fracturing her hip.. The episode results in about $10,000 in Medicare expenditures...
There is an alternative scenario, however, in which, when the same symptoms develop, the night nurse evaluates Ms. B. using a standardized protocol and calls an on-call nurse practitioner (NP) who visits the nursing home daily. “Late this afternoon, the resident developed a nonproductive cough and a temperature of 100.4°F,” the nurse reports. “Her other vital signs are normal, and her lungs sound clear. She isn't complaining of shortness of breath or chest pain, and there is no leg edema. I think we can watch her and call back if something changes.” The NP agrees and says she'll see Ms. B. in the morning, at which point she finds a persistent low-grade fever and crackles in the right posterior lung field. After consulting with Ms. B.'s daughter, who serves as her health care proxy, the NP orders an oral antibiotic and increased oral fluid intake. Ms. B. recovers over the next several days. The episode costs Medicare about $200..
The patient had pneumonia. Based on her nursing home residency it was health care associated pneumonia (HCAP). Maybe you don't like the HCAP guidelines but it doesn't matter. You don't treat HCAP by waiting until the next morning then starting an oral antibiotic whether the patient is 90 or 50.
So here we have authors making policy recommendations in NEJM regarding acute care of complex frail elders who demonstrate a very poor understanding of such care. Concerning.