Experiences of hospital discharge discussions when an elderly parent is unsafe at home

[mids2019]

I just wanted people's experience of anything like the below.

Elderly parent in hospital with heart failure, collapsed king and large blood pressure crops upon standing. He has been in hospital for around a week now and there are some staff pressuring for a discharge despite it being quite apparent parent would not be safe in their own home and there is a likelihood of readmission.

There are some staff (physios) saying the parent is not able to be discharged safely due to risk of collapse/fall but other staff who feel as there is no longer potential emergency intervention there should be a diacharge.

Has any one else been in involved in conversations like this with hospital staff and how did they go? Especially interested in a nursing/medical perspective.

If agree with others working with hospital discharge team for home with package of care.

Have they been able to improve the BP drop? Maybe there’s not much they can do as it could be caused by medication which is essential for him, I’ve seen this in a couple of people.

He will need to try home and then, as he has capacity, make his own decision about whether that’s sustainable. No one WANTS. A care home but many people do come to realisation they NEED to go somewhere to be looked after

My Mum was discharged after dialysis stopped working . She came to me and everything was arranged by the hospital . All the equipment she would need including a hospital type bed was sorted in double quick time . She couldn't stay in hospital as it would be classed as bed blocking .

parent refuses to go into a care home

But also knows he isn't safe to go home- unfortunately he might not have another option - most care packages are not 24 hours, and it doesn't sound that four times a day will be enough.

I'm sorry, it is a shit place to be- my advice is always

Decide what you can offer, and stick with it.

I take it there's no convalescent home type place available, as there are in some areas? My elderly relative was in one a couple of years ago for about 10 days. Not a long term solution obviously.

The staff are saying that it would be unsafe to discharge him to his own house because he lives alone . How long do you think the hospital should keep him in ? Is his condition treatable so he will eventually be able to live alone ?

It's shit op. I'm sorry. And it's daunting when it happens for the first time and you haven't a clue what to do.

What will he accept? Does he just want to go home by himself, understanding the risk of falling again and ending up back in hospital?

Sometimes we just have to let people make bad decisions and then be there to mop up the consequences.

DH’s nan has this exact same situation currently so agree with this poster.

Nan has a package of 4 carers but has had falls overnight so been stuck, and then yeah has had ambulances called and been back to a&e, only to be discharged back to the same situation.

If he refuses a care home then there is not much else you can do. I get it, it’s an awful situation. No one wants to go into a care home. But running out of options otherwise.

I would make sure to document and record your concerns in writing. If there is a clear paper trail flagging concerns - particularly where those concerns are shared by professionals involved in someone’s care - you have much better chance of a safe discharge. Those involved will weigh up the costs of keeping the patient in hospital v the cost of defending a law suit.

Push for a discharge to a nursing home. Unless family are prepared to become full time carers make it clear that you can have no involvement in ongoing care at home.

I missed that bit. In our case due to the discharge email I got a really sensible consultant on side who had a conversation with DF and convinced him he needed to go into a home. In your DFs case logically where does he think he should be if he isn’t safe to be at home ?

Does he have enough money to self fund a care home ? It may sound brutal but ultimately this is the exam question. He will need to demonstrate either savings or property worth 2 years of fees so around £200k. If he has this then medical staff will be more persuasive about suggesting he go there if that’s what he needs to get him out of the hospital bed. Ultimately he will probably still shuttle between hospital and care home a bit, but at least it will be on them to manage it.

You need to get on this now. Ask for a meeting with the complex discharge team and get the ball rolling.

I was in a ward where around thirty percent of the patients had relatives like you and some of them had been in for months - it is absolutely not a place to let your relatives languish away, and they really get their mental state back fully if you do this.

You can have up to four visits a day from post hospital carers for up to six weeks and then it needs to be funded by other routes. That or look into what rehab wards are available.

But is he medically fit? It doesn’t sound so. Obviously blood pressure drops when standing isn’t normal, have they investigated all treatments?

Who would the law suit be against? If the EP has capacity and is refusing a care home or carers do you think the hospital should keep him in hospital forever?

it’s threats like this that end up in the threads “it’s a disgrace my 89 yo mum is stuck in a corridor on a trolley because nurses say ‘no beds’!”

But there is a massive difference between medically fit to leave hospital and medically fit.

Sadly he isn't going to get better, but that is what care homes are for, people fear care homes but the vast majority are better than a long stay on the elderly ward at hospital.

Its not up to a Physio to say if your parent is medically fit or not, i do not understand this in your OP.
OTs and Physios will have input (mdt) but its up to the Senior Dr/Consultant.

Care packages take weeks, months in some areas to arrange, if they are medically fit but cannot toilet themselves, then a care home will be the only option - IF Med Fit (to discharge) & its not as if these are plentiful either.

Social Care is an utter mess.

So if he refuses a care home, it’s home he goes with or without carers. IME he will refuse to pay for help, hence further fall/crisis and back to hospital in a worse state than before. Nurse of very many years.
This is partly why ambulances are queued up, A&E is full and beds are blocked.
What were his plans for coping as he aged?

A physio can certainly state that a patient has a significant physical safety issue with a medical cause. Up to the consultant on what the medical plan is to manage that. Any decent physio will make their case if they think a patient could benefit from further medical review.

Actually physios are one of the key teams involved in hospital discharges… and often lead.

We complained to pals for a unsafe discharge. That got physio to asses the home and give adjustments. Also to get some physio after discharge. That only added a extra 4 days stay but was what was needed to prevent another fall at home.

NHS doesn't save beds or money if your back in a few days. It was already the second fall in two weeks.

The partner would never have agreed to respite in a care home and no possible way for children to step in. So if pals hadn't helped the only alternative was for it to play out. Relative has given LPA to someone the children don't know. So nothing much more could be done.

But if the risks flagged can be mitigated by a care home or carers and he is refusing this because he wants to remain in hospital? Then yes they can discharge him once it has been documented that he has been made aware of the risks and is ignoring them.

I didn't realise i said anything different?

It will depend on the patient and their issues, the OP stated medical reasons were the issues with her parent.

Physio's wont normally be assessing a home and getting adjustments done either.

I'm a carer to elderly mum, and cared for dad through dementia, with numerous hospital stays.

As you are remote, clearly you can't offer care. Your hospital should have an early discharge team, who will arrange up to 4 visits at home a day for up to a month - its up to them to facilitate getting patients home.

whilst that is ongoing his GP will have a care co-ordinator available who's role it is to sort out on-going care, which will likely involve an assessment by the LA, they will be keen to keep him at home.

Unfortunately hospitals are under massive pressure to free up beds.

Can you frame the care home stay as temporary respite to get him ready to go home?

Look, either way you and he need to put a plan in place. He can’t stay in hospital indefinitely, even if they keep him in for now because the consensus is that it’s not safe, then you face the same discussion one week later. You might as well put a care plan in place now if it’s becoming apparent that he can’t manage at home anymore, anything else just delays the inevitable.

What does he think will work? Could he have a live in carer?

As you predict, he will likely go home with a package of care and then will fall.

He may be fine and someone (ambulance, falls service, neighbours) will get him back on his feet; or he may break something in which case given his heart failure etc it will likely either be a slow painful recovery in 24/7 care or it will be a slow and very dependent death.

If this is the risk he is happy to take then you can only put in whatever safeguards you can - falls alarm, mobility equipment etc - and wait for the inevitable.

Can I just think everyone for their informed posts at this time. It seems like navigating a maze currently.