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.

Some health authorities have a 'rehab hospital'. They are like cottage hospitals used to be. Your father could be discharged to it where there ar medical staff and physios who will get your father ready for dcharge home. If they don't feel he is able to go home alone they can arrange a care package or initiate discharge to a care home. I would investigate if their is a rehab hospital and if so request he is discharged there. You say you are 'quite distant' - I'm 4 hours from mine so took a week off and went to discuss it in person.

Been through this with Mum over the last year. Now she is reluctantly in a care home. Initially she went in for 2 weeks as respite for us. We attempted to get her home with a live in carer, but that didnt work as Mums care needs are too much. So she is settling in a local care home now. Good luck navigating the system - It can be very frustrating at times!

What do you suggest? He can't stay in hospital indefinitely just blocking a bed if he doesn't need medical treatment that requires him to be in hospital. Would he go into a care home for recouperation with the expectation of going home when he is better? Or while his home is being adapted for his needs, safety rails to hold onto in corridors and bathrooms, downstairs bedroom, panic/fall alarms, etc, and arranging carers to come in to help him.

He will have to be very careful getting from lying to standing to avoid his blood pressure dropping too much, lying to sitting then wait a few minutes, sitting to standing with the help of a frame and wait a few minutes before attempting to move.

I'd start by speaking to the medical staff. Has he been medically optimised eg medication review/ alterations to try and improve the postural drop. Good oral fluid intake, although this would have to be balanced with the heart failure , where fluids are often restricted.
Things he could manage himself such as going from a lying to sitting position first, then sitting for a little while before standing. Then getting up slowly etc etc.

Local Age UK can usually support with this through advocates and a hospital discharge team who will make appropriate arrangements that are based on the older person not the system

Ask for a reneablement package which will initially set up
carers at home for you and establish whether he can cope there. You will probably have to the carers, definitely after the first few weeks. That will show you and him what’s possible and he might make more sensible decisions.

I'm sorry you are dealing with this; it isn't easy, especially from a distance.

Either his postural hypotension can be addressed (depending on cause) or it can't. If it can't, then he should be discharged. If he has capacity, he has a say in where he ends up and if he point blank refuses a care home, then he will need to be discharged with the care (temporarily, while permanent care is set up) will be organised. If there is some chance of rehab, he may be discharged to a community hospital (not available everywhere, I know) to get him back on his feet.

Being in hospital is a risk as well as a benefit. Risks of transmitted infections, muscle loss due to lack of movement and poor food, dehydration... hospitals are great for acute care but not for elderly frail people with no acute need.

Are there strategies or equipment the physios/OTs can give him to help avoid collapse? Getting up VERY slowly? Can the docs reduce some of his meds (which may help this symptoms but worsen others)? Without knowing your dad, it is hard to say exactly what will keep him safe at home (a frame? a call button?) but he is, by insisting on going home, accepting that his risk of collapse (which could be fatal) is not insignificant. It does sound like someone needs to have a VERY strong conversation with him about his risks. I know some people are stubborn and usually it takes a major crisis to change things - he may feel he hasn't reached that point but needs to understand that a crisis is likely to come, and won't be enjoyable.

Good luck.

I commented earlier but missed the part where you said he doesn't feel safe to go home. So my comment was a bit tactless sorry.

Obvious as it sounds, he needs to work out, with the discharge team, what will make him feel safe. Carers, an alarm system, care home, respite care. Staying in hospital might feel medically safe but in so many other ways it's the worst place for an older person to be.

You're right, it is like navigating a maze. Blindfold. By yourself. With different people shouting all sorts of different directions at you.

I hope you get something worked out.

@Randomchatdescription of being in a blindfold maze with contradictory instructions is so apt. There is no one right way to navigate this and how you choose to do it could be completely different from someone else. Sad to say as well, there is usually no particularly satisfactory outcome. Unfortunately it sounds like your DFs condition is a side effect of being old and or on medication. DF had similar and it’s how we got him into the care home - that and his dementia. How old is your DF ?

Maybe lurking in the background is the way to go for now. If social work or hospital get a whiff of someone available he will be out of the hospital asap. Meanwhile if he doesn’t feel safe at home but can’t stay in the hospital, the onus is on him and social care and the medical team to come up with the solution.
In parallel you can research care agencies in the area, find out if a rehab type facility exists also check out local care home availability and costs. If you do have power of attorney I would check out your DFs finances and see what he can afford as that may dictate next steps.

Good luck, none of it is easy.

A care home won't stop him falling. He needs to have a pendant so he can call for help, which will be an ambulance. The care home will do the same.

Adult Social Care need to be involved who will do an assessment, it doesn't matter what the ward staff say, it matters what ASC think

But no one can MAKE him take a care package he doesn’t want

But he won't be left for hours until the next care visit which is what often triggers a hospital admission rather than a help up and a cup of tea.

The care packages for discharge can include a stay in a community setting, a care home or community hospital, 6 weeks

I had this nearly exact same situation decades ago as a young physio having to go up against a consultant ( albeit a much younger person who you couldn’t just ship off to a NH and who just needed a couple of extra days on the ward to recover). Having worked with a lot of elderly people in hospitals and the community over the years I still despair at the lack of skills in dealing with discharge planning. You need a discharge planning meeting to go through the options which would usually be A. Is the person likely to resolve these medical issues within the near future B. Could they go home with a maximum care package and a very limited ability eg. Aiming for bed to commode/ chair transfers only , wears a fall alarm etc C. What intermediate care facilities are there in your area….this may be eg. Temporary respite in a care home or dedicated step down ward/ unit , with/ without an enablement package to allow them to return home as and when they are fitter D. Is this part of an ongoing decline where ultimately this person may be needing long term care that can’t be provided at home. ….ultimately where your Dad has capacity he has the right to choose to return home even if this potentially has risks for him. Hospital discharge and availability of intermediate care / community care facilities are hugely postcode dependent hence why you have to sit down with someone in the know and see what could be asked for.

I had to be really firm when they wanted to discharge my friend. His flat had had to be cleared and he had no furniture. It was the start of lockdown so couldn’t go and buy it. He also had no current account and I was not putting it on my credit card. It took a strongly worded email from his son to shut them up. He was discharged to a nursing home in the end.

@mids2019 You should have been in touch with the discharge team. Sometimes it’s a private company. They have recommendations from OTs and other professionals. They will also contact social services if he’s staying at home. They will offer max of 4 visits a day. It’s your responsibility to say yes or no. If no, you need to be firm that it’s a care home and work out how he pays. Most councils won’t help and if hes got assets, you pay.

I strongly suggest you take leave and sort it out. No one else will. They just want to discharge but you need to sort out where to. Urgently by the sound of it. And yes, it’s hard.

@mids2019 i forgot to mention one thing , do the staff know what your parent was capable of before they were admitted to hospital? Someone who was previously in good health eg. Fully independent in self care, mobility, shopping etc is very different to someone where medical conditions are starting to cause frailty and loss of ability to self care or mobilise . Hospital staff often see an older person unwell in a bed and make all sorts of presumptions as to what they can’t do . These days I’m seeing plenty of people in their late 70’s and 80’s who are still working ,volunteering etc ( even 90’s for the volunteering !)

I can understand that. What's his financial situation like, could he afford live in or frequent carers? Is his home manageable in terms of home hygiene and toiletting.

As an aside what are the hospital doing about his blood pressure and is he drinking enough?

No care home helps people get up. They call an ambulance as they aren't allowed to lift.

@Cheese55 Of course care homes help people get up! That’s the care you are paying for!

What does he the patient think should the solution should be?

@Namastename My DM was a very good at telling hospital staff what she could do. Mostly lies. They did eventually speak to me. Old people say anything to avoid a home. I could not believe what my DM had told them. She wasn’t ok to go home. Nursing care is next to nothing. 4 visits a day of 15 mins is nothing. They just sit and wear nappies. A home is significantly kinder and they actually have a doctor who comes in once a week! Amazing. They keep a close eye on health and it’s way less worrying. Older people who refuse a care home when they clearly cannot cope really do not think about their dc. It’s nothing but a roller coaster and it ends in disaster.

@MeetMeOnTheCorner of course, the person themselves isn’t always honest about their capacity, that’s not unusual, but it’s not a reason to presume every older person is telling lies and think a care home is right for every situation. Good discharge planning should always have a concern for family members as many carers jeopardise their own health to look after their family members, it’s certainly not about being blind to all the family dynamics and complications that come with people ageing . Personally I’d far rather have a shorter life and still stay in my own home than eke out a few extra years existing in a NH….but I know full well the pitfalls of not downsizing in time, not accepting help, not putting in place POA’s or thinking about if endless life extending treatments are in our best interests, not communicating with your children or expecting them to step in. We should all plan ahead and not put our heads in the sand.

Care homes definitely do help people get up, they have with several residents I've known, a well run home will have the appropriate equipment to help. The care in a home also reduces the risk of falls due to dehydration/not eating etc.