By BRAD FLANSBAUM, DO

Grandma and me

Grandma is 93.  The matriarch of my family is in worsening health, and her decline is difficult to observe.  We all experience the travails of the US health care system at some point, and in my family’s case, ours is no exception.  The stress on my mom and aunt is considerable, and my grandmother is increasingly alarmed at her frailty and poor memory.

Through July of 2010, she was independent.  She walked daily, traveled, drove (that is another story), and enjoyed her brainteaser and crossword puzzles.  By all accounts, she was happy, albeit with the usual pangs of age.  She took no medication.

Last summer that changed when she fell and underwent a 3-day hospital stay.  Her memory was not the same and her gait was unsteady thereafter.  It was a minor stroke.

After discharge, her functional status worsened, and the vicious cycle we all witness as docs—setback beget setback—reared its head.

My mom sold the house, and grandma moved into an assisted living facility, a lovely place, but it was not home.  Her refrains, “the food and company are lousy, and I am depressed and lonely,” along with an assortment of other issues —all upsetting, given the vitality of this woman until recently—presented and intensified.  Relocation trauma is a known condition, but one you would differentiate only if you witnessed it firsthand.  I am now familiar with a (new) geriatric term.

It is also uncomfortable having “the conversation” with your grandmother—that I reluctantly had recently due to concern over her declining mood.  I asked her if she still enjoys life.  She told me that walking, her ability to read and think, and her family were her three most important joys.  Only the latter remained, and I sensed that she wished to say more, but chose not to.  Silence was all I could muster.  I would have responded differently at the hospital with a patient, but it is awkward and difficult when it is your own flesh and blood.

Two weeks ago another setback, as she fell and sustained trauma to her right shoulder.  She went to the emergency room late in the PM, and attributed the accident to an unfortunate “roll out of bed.”  We will never know the exact cause, and as hospitalists the weekly admit for “near-syncope” is the norm, and these events are just part of the rigors of practice.  An unsatisfactory ICD-9 code, but roll out of bed does not have that near-synocpe cachet.  The elusive diagnosis.  We have all been there.

I spoke to the hospitalist in the emergency room the following day, a lovely person, but as a self-aware physician, I wanted to distance my participation in her care.  We all have journeyed that road, likely on the receiving end at inopportune times, and deference to the doc in charge is central.  I learned my lessons well from years in the trenches.

However, all the axioms we hear and speak nowadays referring to our system, mainly, U.S. healthcare “overtests, overdiagnoses, and overtreats,” echoed in my mind as her care progressed, and as I spoke to my mom over the ensuing hours.  Because the etiology of the fall was unclear, she went into a monitored unit.  Not a surprise I guess.

I was afraid of what would follow, i.e., stress, echo, PPM, etc.  That is not what my grandmother would want.  Thankfully, we moved her off that floor, at the behest of my mom, and the rest of the stay was unremarkable.

On the day of discharge, however, I received this email from my mom:

“The discharge papers indicated that her Vitamin D levels were very low and she needed a large dose for 6 weeks – included with the papers was a script for 50,000 units per week.  No hospitalist spoke with me upon discharge, no instructions were given, nothing!  I don’t even know what day they gave her the first dose.  I called her GP, and of course he left for the day and would not call me until tomorrow. She was taking Citracal which has  Vitamin D so I don’t want to give her that.  How much Calcium should I give ger?  Not happy with hospitalist today. They are giving her 650mg of Tylenol for pain.”

Lessons:

This is a BOOST hospital.  I know the director for years and he is as good as they come (he had nothing to do with her care).

Due to a conversation we had on an unrelated matter last week, I mentioned her stay and Rx muddle, and he read from the EMR/discharge summary to review the proceedings.

I must admit, from the physician and quality documentation standpoint, all was well.

Nevertheless, there is the email above—front and center, along with a telemetry stay, with the potential for more care and iatrogenesis, not to speak of unwanted outcomes.  Grandma was in pain as well.

Unfortunately, it is likely no one’s blunder.  We have this system: disjointed and provider centric and it is a hulking, stubborn mass.  Change is hard.

Again, I want to emphasize that staff and physician care were lovely; but absent advanced directives or inquiries thereof (they actually exist); the slippery slope of consultants and the pens they yield; and confirmation of family insight regarding discharge instructions, we get the expected result.

The query, “what is good care” is at the fore.  More to the point, how do we upend the check box, best practice algorithm, and practice norms to meet patient expectations?

We have a long way to go.  A lesson learned firsthand.

Brad Flansbaum, DO, is Director, Hospitalist Services at Lenox Hill Hospital in New York City. He began working as a hospitalist in 1996 at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education.

This post first appeared at The Hospitalist Leader.