Tips for expediting hospital discharge?

[NotThisWeekSatan]

Hi all, hoping for some collective wisdom 🤞

84 year old DF has been in hospital for 8 weeks. Initially a bowel obstruction, now resolved. But in that time he has become v weak (mobility wasn’t great beforehand) and now needs physio plus building up physically before he’s in a position where DM can look after him at home.

They had paid careers at home before due to his poor mobility but now he’s far worse, and DM now has terrible sciatica so even with lots of care, she couldn’t cope with him how he currently is.

So he’s supposedly having physio which seems hit and miss (I’m sure not all the hospital’s fault; he can be quite stubborn, plus is often asleep when they come. Though I do think they need to be firm here and make him do something!)

But at the mo he’s just getting weaker and weaker. He has next to no appetite - plus is on soft foods so diet is really unappealing which doesn’t help.

I’ve got ideas from other threads re good food to take in - rich chocolate mousse, custard etc, calorific things - but there’s no fridge and DM is reluctant to give them at visiting time as then he won’t eat his dinner.

She can’t stay until after dinner time as the hosp is about 40 mins from home and she doesn’t like driving in the dark.

Meanwhile he just seems to be fading away.

Any suggestions to help? We’re at a bit of a loss.

Can you pay private physios to come into a hospital does anyone know?

It feels that with more intense physio and better nutrition he could start to get better, but the hospital don’t seem bothered that he is just left there plateauing/getting weaker.

Individual staff are lovely and clearly working really hard but nothing seems to hang together and nobody seems to have any real drive to get him better and home.

Sorry it’s long and thanks for any advice or suggestions.

I think my first question is, what is keeping him in hospital? Have the team talked you through the process in his case?

Also what are the realistic expectations they have? I'm reading your account and seeing someone who has had a serious illness (what triggered the bowel obstruction?) is sleeping a lot, not swallowing very well, not much appetite... none of it sounds too good in terms of real recovery.

Having said that, I think talk to the physios. Is there an exercise programme that visitors can help out with getting him to do? Can you/a private carer take him off the ward at times and get him interested in life again?

Thank you for replying Permanent.

He’s been declared ‘medically fit for discharge’ or whatever the term is.

What’s stopping him really is the fact he can’t be cared for at home. So for instance, before he was in hosp this time, he could sit up. So if he needed a wee in the night, he could wee in one of those bottles.

Now he can’t sit up on his own, so DM would have to come down in the night - many times, he has prostate issues - which is just not feasible. He is moved from his bed to a chair with a hoist in hosp, I’m not sure whether this is possible at home with carers?

DM’s sciatica currently means she has to wake at 5am and take painkillers so it’s tolerable for her to get up - this can take 2 hours. So she couldn’t get up to him first thing or on demand.

We have looked at a nursing home that offers ‘hospital to home’ care in case that had better food/care etc but it didn’t seem to offer a lot more than the hosp, though we could have paid for a physio to go in. But he’d have been isolated in a v basic room and overall we thought it was no better than the hosp.

So basically what’s stopping him is that he’s not able to do anything more than sit in a hospital bed under his own steam 😔

He has previously had cancer - his bowel has been hacked about quite a bit, and he has a hernia, which I think both contributed to the obstruction.

You’re right, he wasn’t in great health before, but enough better than this that he could live at home with help.

The idea of trying to take him out of the ward and engage him with life is a great one - I’m at the other end of the country so can’t visit often - and two weeks ago when I was last meant to go, they’d both caught covid! - but I’m going up at the weekend so might suggest that.

DM could def help with physio. The problem is he tends to sleep through a lot of her visit - he isn’t very invested in his own recovery which I think is at least half the problem.

The hosp’s plan is to move him to a rehab ward but there are no beds there. I’m not sure whether that would mean more physio/attention or just the same in a different place?

Thanks again for replying and your ideas.

'He isn't very invested in his own recovery'

Yes.
I'm sorry, he does sound very frail. It does get extremely hard when someone is dealing with multiple problems, all of which contribute to the others. He is medically fit in terms of there not being anything else the acute hospital can do, but yes things have changed a lot.

I don't want to sound like someone who is writing your Dad off, I don't know him at all. But the sleeping so much is one of the things that happens when some is getting nearer to the end of life. Though it can be quite a long way away from that moment still.

Again I would say try to have a frank phone call or two with the physios and particularly the occupational therapists. Ask them their view - what has he said to them about what he'd like, what do they think is realistic for him, could you try extra private therapy, all of these questions.

Does DF have mental capacity and does he want to go home? How does DM feel about having him home- would she have any family support locally as you’re some distance away.

I’ve had this process with my parents, strokes , cancer and now look after my mum at home with carers coming in. Dad went from an acute hospital, following a stroke, an hour away to a cottage hospital locally and got physio daily and meals in a conservatory off the ward. He got more sleep as no one was wired up to any machines so no bleeping in the middle of the night and gradually built up his strength.

I let the hospital guide me to a degree as it’s in their interest to move patients on quickly but any eventual discharge home has to be safe and occupational therapists came to the house with Dad to
monitor what he could do.

Could your DM request a meeting with the ward manager to see if they can give a prognosis? You can sometimes get a more accurate picture from the HCAs on the ward than from the doctors!

Take a look at Carer’s UK online forums. Age UK also have lots of factsheets.

I agree with @PermanentTemporary. The illnesses he's had in the past combined with his current health issues will have taken their toll on his body. In my NHS Trust, patients like this will be sent to a Discharge to Assess unit, either within the hospital or elsewhere. This is so that his care needs can be fully assessed, which is harder to do in hospital.
I would be asking the ward staff about this. He really didn’t ready to go home.

Thank you 😊

I think DM was planning to try and speak to the OTs tomorrow so I’ll definitely encourage her to do that.

I think on one level he’d love to be at home but he’s become a bit institutionalised and used to being in hospital so he’s not really connecting having to eat up/comply with physio with getting home, IYSWIM. So I’m not sure he’s articulated what he wants out of it, he’s just doing what he’s told (or not, some days 😬).

I also think he’s just bored to death in hospital - there’s no TV, no proper mealtimes to break things up, at least not with food he wants. So he’s becoming a bit disengaged. It’s all quite depressing.

But thank you, we will talk to the OTs and maybe I’ll explore taking him out of the ward at the weekend. And try and get him to realise that he needs to take part a bit if he wants to get home 🤞

Please don’t underestimate the impact covid will have had on him and your dm- likely to have really reduced energy levels.
is getting home realistic? There is a huge shortage of carers in the community.

Generally they’ll try and send people home with a care package if possible so possibly your dad needs a bit longer in hospital. Carers can use a hoist but you’d probably need 2. You can get overnight visits, live in carer etc but obviously more costly. Also can be supplied a medical bed, hoist etc. overnight he could use an incontinence sheath and bag. But I think it really does depend on dad, he may just want to be looked after and rest in hospital and there might not be improvement at home. Might be quite stressful for your mum too?

Is there wifi in the hospital? Could you get him an iPad to watch and enquire whether you could order takeaways?

I would speak with the OTs and physio and see if they think he may have rehab potential. If so they normally suggest a placement which bridges the gap from hospital to home.
However the way your describing your father it sounds like he might not have rehab potential. The sleeping lots, the poor swallow, the reduced appetite is something that happens when your body is ageing and becoming weak.
A bowel obstruction is a massive thing for anyone to recover from never mind a 84 year old frail man.

Definitely see if they think he has rehab potential, if not this may be the new normal and continue to decline and need a plan in place for this.
It's so hard to see our loved ones decline

Thank you Fluffy

Does DF have mental capacity and does he want to go home?

See above - yes and no re going home, he does want to on one level but seems to have got a bit too used to being in hospital.

He is getting increasingly confused the more he is in there unfortunately - generally he is ok and last time I saw him he was reading the paper and talking politics but I think he is just a bit insular now.

How does DM feel about having him home- would she have any family support locally as you’re some distance away

Unfortunately no family, I’m the closest. But they did have carers x3 times a day after he broke his hip last year. They’d be happy to do this again. I think getting him out now would involve 24 hour care which DM isn’t keen on but might be needed if they decide going home is what’s needed to give him a chance.

Your cottage hospital route sounds perfect, I’m not sure there’s anywhere like that near them but there are other care homes so we can see if any of them could do the same thing - but better than the one DM looked around which didn’t seem great.

DM does try quite hard to get info from the staff but it’s all quite hard going, again I might try when I’m up at the weekend. Thanks for all your suggestions.

Also with recently having covid this could have a massive impact on his health as well everything else going on

Thank you all, a flurry of replies while I was typing! I do appreciate all your thoughts.

I haven’t heard anyone mention a “Discharge to Assess unit” but will ask or ask DM to.

I think I’m just finding it hard to accept that people can just be left to live in hospital with no real endgame in terms of discharge - maybe I’m v naive but I just didn’t realise that happened.

I think DM would find it incredibly hard and stressful to have him home as he is, but equally she is thinking this might be what’s needed to stop him just wasting away where he is.

Some sort of halfway house maybe sounds the best bet and we need to work a bit more on that. Money isn’t an issue - within reason - care home or 24 hour carers would be possible, it’s just what’s the best (or ‘least worst’ 😬) option.

I'm sorry to say I think you have unrealistic expectations regarding how much improvement he can make.

Not eating much, sleeping lots, unable to sit unaided are all signs of a significant decline in his health. At 84, although he may improve, it's unlikely to be to the stage he could manage at home.

My focus would be on finding a good care home.

Is he still in hospital as they are hoping to rehab him or just stuck? Unfortunately the weekend is the worst time to get answers to your questions, none of his doctors will be there and the nurses will all be incredibly busy.

If you were offering to take him home with a private care package (very few people actually need 24 hr care and the NHS provides it even more rarely), physio going in regularly and all his meals provided, they would likely rip your arm off.

It sounds as if he is in a vicious cycle where he gets more deconditioned, eats less, gets delirium and it all goes round again.

If the central idea was 'he wants to be at home and everyone is realistic that he may not recover but this is absolutely what he wants' this would promote some movement.

At the moment it sounds as if his rehab potential is limited and even more limited in hospital as he doesn't like it, plus they are too busy. He might not rehab that much at home but at least he'd be happy.

BungleandGeorge there is WiFi but it’s rubbish, we did think of that but I think it would be painful unfortunately. Plus he’s a nightmare just trying to make calls on his phone so I think an iPad would just drive him crazy. It’s a real shame, they took all the TVs away due to covid and they never came back.

And unfortunately he’s on a soft food diet otherwise I think he’d love a takeaway!

To PPs who have mentioned covid, I think you’re right and we’ve probably underestimated this - he had no symptoms other than tiredness so we almost forget he had it, but it almost certainly will be contributing to his lethargy (and occasional brain fog).

A good care home will try and get him out of bed for activities etc, and encourage physio. There will be more going on than on a hospital ward and should be better food. It may be the compromise. Ask the hospital about continuing healthcare funding.

Another thing re: 24 hr care.

How many people does he currently need for transfers/mobilizing?

If it is 2, then you are looking at a care home, not home care as you would be having to fund 2 carers not one, which makes the cost extortionate.

Realistically do you really think that going directly home is an option? Have you considered a decent care home where he can go for respite care ? Has he been referred to a dietician,SALT to assess his swallow.
It’s really hard for you OP and the last problem you want is for your Mother to end up off her legs as well .
Hope you get sorted .

OP I am a bit confused

he needs a hoist from bed to chair but you want to take him outside, you mean just for some air? It might not be the best use of what sounds like limited time.

I totally see why patients lose strength in hospital. Are you paying for a rehab or care place?

mum is in respite care after a fall and hospital stay. Having her own room and more attention is helping. But today my sister was told by social services that a home visit and ordering home equipment is a long wait. So we are going to sort it ourselves.

I am not an expert but the impression I get is if you can pay for it, or sort it, then that's the best route. Mum has no medical needs but would have been stuck in hospital for weeks I think, if we hadn't been lucky enough to be able to pay.

her GP is chasing up on physio but I will be surprised if he gets anywhere. Things have gone downhill a lot since I dealt with social services for dad.

Is he still in hospital as they are hoping to rehab him or just stuck?

Bit of both I think - ultimately DM wants him home but not imminently due to her sciatica. So her thinking is: he needs to be rehabbed a bit anyway, and hopefully that will give time for her to recover enough to have him home, with them potentially paying for as much care as they need - that’s the thinking, led by DM and with the hospital in agreement I think.

He might not rehab that much at home but at least he'd be happy. This is increasingly what I’m thinking.

Thanks Emma.

he needs a hoist from bed to chair but you want to take him outside, you mean just for some air? It might not be the best use of what sounds like limited time.

PP above suggested we try and take him out of the ward (in a wheelchair) to remind him of the outside world and hopefully spark a bit of enthusiasm for being rehabbed. Which I thought sounded a nice idea.

We can pay and I think some sort of private arrangement is definitely sounding increasingly preferable to staying in hosp indefinitely.

He needs 2 weeks in a rehab hospital then home with care package and physio going in. Unfortunately it is not unusual for an elderly person who is hanging on to coping by the skin of their teeth to go downhill when a medical problem takes them into hospital.

Mischance when you say a rehab hospital, do you mean a rehab ward in the hosp he’s in or would this be a separate place (as in, something different to a hospital)?

He’s waiting for a bed on the rehab ward at the mo but it doesn’t seem forthcoming.

I'm a control freak so this colours my reply

1. will he be comfy in a wheelchair?

2. how many of you are going? What are the hospital rules about taking him out in a wheelchair?

3. is it at least two people going, so one person can do all the inquiries about what's happening?

I agree with pp that if you offer to take him to a care home and pay, you will expedite release. Have you researched care homes?