Hospital say ready for discharge, family disagree

[Pl242]

Posting for any advice or insight which would be gratefully received.

MIL currently in hospital after a fall resulting in fractured shoulder. Also has dementia, limited mobility (now further curtailed by shoulder injury as can now longer use walker/zimmer), is incontinent and also generally very frail.

After just over a week in hospital they advised she was ready for discharge. They stated she would be fine with a care package of carers coming in four times a day to change her and move her from bed to chair then chair to bed. She would need to be confined to her bedroom at home. They said this would work as she was not attempting to move from chair/bed in hospital.

FIL, her primary carer, expressed that he was not able to cope with her coming home at this point. Prior to fall she was coming to end of 6 week care package following a minor stroke in March. He and other family members disputed the hospital assertion that she wasn’t trying to move from chair/bed in hospital. She has been. Is constantly removing sling as forgets she has a fractured shoulder. Dementia symptoms currently much worse in hospital due to delirium and drowsiness from painkillers. We all think it’s just totally unrealistic for them both to be confined in an upstairs bedroom as we don’t think she can be left alone so in effect FIL would be placed into an almost 24/7 caring role save 4 x 40 mins carer visits per day.

The hospital staff said our only option was to request a social services assessment, which we have. MIL remains in hospital whilst we wait on this. Since this there have been a few other incidents in hospital which have confirmed our view that her being discharged is unrealistic - passing out when physios try to get her to walk, pulled out a cannula overnight leading to blood loss and passing out. Doctors also saying she’s not making much progress, there are other things that have cropped up which they are investigating eg infection. Yet in same breath saying they think she should go home and would be discharged if a social
services assessment hadn’t been requested by the family. None of this makes sense to us.

Grateful for any insight on what we might expect next, tips on how best to manage decisions. FIL torn between wanting to try and bring her home vs going into a care home, but worried that if he says yes to the care at home package he’ll essentially be left alone to cope with a very difficult scenario.

Sorry this is long. Thanks for reading.

Would love a middle way re rehab etc. hospital just saying nothing available. Hoping that social services might be able to signpost some options.

we will have to do more research into privately paying options. I’m trying to urge FIL to explore options, even if he doesn’t choose to use them, but I don’t think anyone wants to face doing it as it makes the prospect more real.

which I get, but think it needs doing.

but I still can’t understand that what hospital is suggesting can be termed a reasonable workable solution even if you can say she doesn’t need medical treatment. As if we do what they’re suggesting chances are she’s just going to be back in hospital within weeks after another, fairly inevitable, fall?

@Lavenderandbrown you have summed up my concerns to a tee. Think we need to ask ourselves with research/information. It’s just a challenge to get FIL in this frame of mind unfortunately.

There are definitely NHS rehab places - my mum has had two x 5 week stretches (different places) for re-enablement after hospital admissions in the past 3 years. This was Cambridgeshire.

Tbh the hospital don’t really care about anything other than getting the bed back. As soon as she leaves, she is no longer their responsibility. A different team will be in charge of assessing whether she can actually be cared for at home, or not. She might fall again, she might not 🤷‍♀️ . That’s a problem for the future, whereas right now they have patients in corridors needing a bed. We had similar with MIL - Parkinson’s, dementia, severe osteoporosis, virtually immobile, doubly incontinent - and still the hospital insisted she could go home to 4 x carers plus FIL 🤦‍♀️. Eventually ss stepped in, but only after a meeting where DH asked whether, if his mum soiled herself overnight, she’d be left lying in it until the morning? Because FIL certainly couldn’t do that. They could only admit that yes, this was the case. So a care home was the only option.

You need to ascertain what FIL wants to do, but help him make an informed decision of what the reality will be like for him. we had to coach FIL to say her could not keep her safe at home, which was very hard for him as her felt he was betraying / abandoning her 😟. But he was doing the best thing for her.

If she’s self funding, you can look at care homes yourself. However, you need to have an idea of when her money will run out and what might happen then.

No real advice but posting to say I am going through something similar and agree that it feels quite shocking that an old person in a poor condition can be pushed out so quickly without any support.

My DM is 85, has quite advanced Alzheimer's and lives in a care home. She broke her hip 13 days ago. Admitted to hospital 11 days ago and had a hip operation 10 days ago.

She's not eating or drinking. Is delirious. In a lot of pain. Not got out of bed since the operation (save for by hoist). They want to send her back to the care home. Care home have said they don't think they will be able to manage her - not set up to drip feed / have a fluid line. Hospital say they need to take her back and if she continues not to eat and drink then see the GP.

Basically they want her out despite the terrible condition she is in.

We have had similar in our family. Dementia advanced rapidly after admission due to fall, treated for chest infection but complete loss of mobility during hospital stay with minimal physio input. Discharged home to be bedbound with carers three times a day, funding for whom ceased after six weeks, and no therapeutic support since discharge. It is no way to treat the elderly, both patient and carers.

I am sorry (but sadly not surprised) to hear that others are going/have gone through similar situations. My hearts go out to you and your loved ones. It’s a damn right awful thing to have to manage.

Thank you for all the helpful replies. I truly appreciate your time.

I assume physio have seen her? You can request a journey to home assessment. So on the day she leaves she has physio accompany her to the house and if she can’t manage any of it she returns to hospital.

would a hospital bed downstairs be safer /more comfortable than her being upstairs? With a commode if necessary? The bed could have the bars raised so she can’t get out at night.

Could you broach it with FIL that she goes into home for Respite for a few months maybe- on a trial basis so that they can look after her whilst she is recovering and he can decide then whether he feels that he is able to look after her going forward once recovered. If it’s broached as a respite then it’s not permanent and he may have the option to bring her home if he feels that he can cope eventually.

I attend to a lot of Elderly fall patients as part of my job role.
It doesn’t sound like the home environment will be particularly suitable if she will be confined to an upstairs room. There’s also risk of fire etc that she would be trapped upstairs?
Is there a risk she would forget she is injured and try to attempt the stairs if left unsupervised for a few minutes such as toilet for you FIL etc?
Definitely doesn’t sound like an ideal solution at all for either of them, especially risk of depression to both of being confined to a room.

Respite would mean it’s not quite so final and FIL might then feel that the care home is more suitable once she is settled there.

It’s rubbish, but it’s important to get your head around the idea that it’s not the hospitals responsibility to provide social care for her. The hospital role is to provide hospital level care to people who need that level of care.

If she’s fit for discharge to a care home, or a nursing home, or full time care at home - then she is fit for discharge.

Trying to fight for health care, when it’s a social care issue will get you no where and just be incredibly frustrating all round.

It might help to frame it as ‘she no longer needs to be in hospital’ rather than ‘she’s ready to go home’. It’s then a question about what next after hospital.

@whynotmereally she’s not at that stage yet. They tried her on commode in hospital today (since admission bring change in and out of nappies on bed) and it took 3 members of staff to manoeuvre her and was apparently a complete ordeal. If it was going to be a hospital bed downstairs I’m not sure where my FIL would sleep. Could he be upstairs on their bed with her downstairs alone? If he needed to sleep with her they’d need to convert a room. Only a small toilet downstairs so not sure if it would work.

Thanks @Justlurking10 you make a lot of good points.

@ScaryM0nster i get what you’re saying but what they are proposing is completely unfeasible. It’s actually bordering on the negligent to convince an emotionally vulnerable elderly carer that he can fulfill what they propose imo. I get that it’s a care issue though so we need to press their needs onto social care when they get around to assessing her and do our own research on other care options and how on earth it might be funded.

She needs to go into a care home. Possibly a nursing home. It is possible the hospital know this and are pushing for a decision on the family's part. FIL won't haven't sell his home. It can all be sorted quite easily. It's unreasonable to expect MIL to keep an acute bed when a perfectly good alternative is readily available.

He can’t fulfill what they’re proposing to the standards that the family would like to maintain.

That’s technically different to a standard that’s considered sufficiently safe.

As you say, pursuing the social care assessment and looking at options in that arena is where to focus your efforts. Respite care home while shoulder heals may be a good option.

Oh jog on and stop trying to guilt trip OP. This family want their mum properly cared for and are not being unreasonable in asking questions about how. If the hospital are 'pushing for a decision' which they see as being her going into a care home, or a nursing home, which they expect her family to directly pay for, then they can come out and say so, can't they? At the moment, they are saying the care visits at home will be enough - on a pretty dubious judgement given the OP - because they know that's what the local authority prefer as the budget option. The care home option is there but to assert 'it can all be sorted quite easily' is misleading and patronising - I've done this myself and I know.

She should be open to a hospital OT (and physio), you need to speak to them. Is equipment already in the home to help transfer her? How is she transferring / on what equipment? Does she currently had ‘cot sides’ or ‘bed rails’ up in hospital? If so it’s not likely she will have these at home so they need to be lowered to give a true reflection on if she is likely to try and transfer out of bed herself. What kind of chair has she got at home, is it suitable / similar to what she has been using in hospital? Is she currently on a falls alarm / sensor or under ‘close ob’s’. Have the fire service been informed she is for ‘upstairs living’? What are her nighttime needs, are staff keeping a diary? The OT should be able to help with all of these questions.

is your mum eating and drinking much? Unfortunately whilst your mum is healing for her fracture there it is limited what ‘rehab’ she can do. In addition due to her dementia it may be questions how much she will follow instructions / be responsible for her own rehab. It’s more likely once she has attended fracture clinic and allowed to weight bear on that arm again she can get community physio coming to her home to try and progress mobility. OT’s don’t tend to do home visits from an acute setting, and follow up at home varies from area to area. It’s not great I know, but generally if a person can transfer 90 degrees they can normally go home with carers and equipment.

Thank you @Holesintheground , appreciate your defence to my family’s apparently unreasonable reaction to this incredibly “easy” situation.

The whole scenario screams care home to me too. Sorry. You have to be realistic about ‘rehabilitation’. On almost no front does taking her home seem like a feasible option.
Sadly this scenario is being played out by the hundreds of thousands up and down the country. As a nurse of over thirty years and ex district nurse I’ve seen it again and again. This is what we save for all our lives. To ensure we are safe and cared for in old age. The rainy day is here.
Sell it as respite but thinking long term I would be considering what’s best for all parties including FIL and wider family and looking for a care home asap.

There needs to be some proper discharge planning.

We all know that bed blocking is a problem, but someone in this condition cannot just be sent home without a proper care package.

She needs a proper OT assessment and installing the right equipment in her home. But frankly she sounds to me as though she needs nursing home care. I looked after my late OH, who got PD youngish, and care at home became more and more challenging till he had to go into a nursing home. There really is no way someone in your MIL's condition can be cared for at home by an elderly relative. Even carers going in does not work as you can bet your life she will fall/soil herself just as they walk out of the door.

She needs round the clock professional care.

I’m afraid that sometimes you just have to be obnoxious. The hospital tried to send my 85 year old mum home with a broken bone in her back. Assumption being as two reasonably able daughters we’d be able to manage. We said no. Then repeated it again and again until, like a miracle, a place was found in a rehabilitation place.

The NHS has these resources, they just don’t pony up if they think there’s a way out of providing them.

If you can ask to arrange a meeting with the discharge manager in person or the OT on the ward, either will be best placed to advise you on the options post discharge.
each area will be different, funded by a different council so may offer slightly different options.
note that rehab beds are only for rehab - in my area anyway, a person will have rehab goals to achieve and dementia patients often cannot retain information or follow instructions making them unrehabable therefore they won’t meet the criteria for a rehab bed - not saying that’s the case with your mum, just that it’s sometimes the case.
is mum weight bearing on her arm? This will make a difference too.
Upstairs living where mum may wander does not sound at all safe, she’s at huge risk of falling down the stairs. Can a bed be moved downstairs for her? This is what the OT may suggest.
she sounds like she needs a further period of assessment to assess her ongoing needs while she fully recovers. This could be offered if a patient isn’t currently safe at home, usually in a care home setting and usually for up to 6 weeks. These places can take a while to source and mum should remain in hospital while this takes place.
Good luck, it’s such a worrying time for relatives.

We had similar when MIL had an accident and was immobile for a few weeks. She had no dementia, but FIL did, and she was his carer. They were self-funding but also keen to avoid paying more than necessary. The hospital and SS assessment said they'd be OK at home with two visits a day to prepare food and help MIL to the toilet (they would automatically fund six weeks of that post-hospital without means testing). We tried that and it lasted two days - totally inadequate. We then hired a private live-in carer who stayed for about six or eight weeks. Very expensive but a good solution.

I think in theory the hospital could fund a period of free stay in a respite home, but I imagine the bar for that would be very high, as so expensive. I suspect your best bet might be to pay privately for either respite residential care or live-in care. You're right that there's a possibility that a respite home would become permanent, though, depending on how she gets on.

@Pl242 I think you need a list of all possibilities (even if you think they're a complete no go) and then against each, you write the feasibility.

So options might be:

Care at home in upstairs room - DF trapped
Existing bed moved to lounge/dining room - is there space?
Hospital bed moved to lounge/dining room - is there space? Can DM be left alone at night?
Discharge to care home - can DF afford it?
Rehab - does it exist/is there a space?
Move in with you - do you have space/time/capacity/ability?

From there, you'll be clearer when you talk to the hospital/SW.

Do not accept a bad discharge. It doesn't matter that she's physically not in need of acute treatment. If it's not safe, it's not safe.

Have you spoken to your local
Alzheimer’s society? I work in a related field and hospitals are generally hopeless at knowing what is available if it’s not from the NHS. My local authority has an emergency dementia home care service which almost no one in the hospital refers too as they keep forgetting it’s there