Geriatric Care Manager: K. Paggi

Death by Hospital

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Elderly Woman

As a professional geriatric care manager, client death is an occupational hazard. I try to maintain a level of professional “distance” from my clients in order to see the situation objectively. Occasionally there is a client who becomes especially dear to me in spite of my good intentions. One such client recently died.

In this particular case, my client had no nearby family. I was her frequent companion, her friend, a surrogate family member when one was needed for a particular event, her health care coordinator, her advisor. I arranged for her day-to-day finances to be managed, although she never lost the ability to direct her investments. When she had a health crisis, I took her to the doctor or the ER, monitored her hospital and rehab care, and supervised her return home. She had multiple health problems, including COPD (chronic obstructive pulmonary disease), emphysema (even though she never smoked), type 2 diabetes, Atrial fibrillation (an abnormal heart rhythm), osteoporosis and chronic heart failure. She had had a radical mastectomy thirty-seven years ago, when her right arm and shoulder were stripped of a massive amount of breast and muscle tissue as well as her lymph nodes; as a result, she had chronic swelling, known as lymphedema, in her right arm. Her right shoulder had gradually become frozen due to the effects of the surgery and arthritis.

She had been a client for several years. Together we fought to maintain her independence and dignity, but there was a gradual erosion of what she was able to do comfortably. Her only brother died early in the fall; I feared it would be a mortal blow. In December she caught the intestinal bug going around her community and did not fully recover. Because of the stomach problems, she stopped taking her medications reliably. Since she managed her medications independently, it was difficult to track what she had taken and when.

By mid-January it seemed obvious that something had to be done to stabilize her health. She drifted off to sleep in the middle of sentences, stopped getting up and dressed, stopped going to activities, and had become forgetful. Fluid had accumulated in her chest, probably due to missed medications. She was not physically uncomfortable but she was definitely not herself. Her physician recommended a brief stay in the hospital to monitor her medications and reduce the fluid in her chest. We all agreed that this was the best course of action.

She never came home. The fluid was removed and medications stabilized. She went to rehab for re-strengthening. After several days she fell and was sent back to the hospital. More tests were run to determine the cause of her fall while she spent several more days in the hospital. She returned to rehab, so weak that she was afraid to take a step without assistance. A few days later she was sent back to the hospital with an irregular heartbeat; a pacemaker was implanted, and she returned to rehab. Three days later she was found non-responsive during the night, and was once again transported to the hospital, where she died. (She had an Out-of-Hospital DNR, but that is another story, which I’ll discuss in my next post.)

I’ve thought back to the initial decision to send her to the hospital so many times. What might have happened if we had made a different decision? The fact of her death is not an issue. The problem I have is that she died in a hospital, in a strange bed, away from her comfortable home, surrounded by her familiar things. Could her death have been different? Is there something I, as her primary caregiver, could have done that would have made her death easier? Is there a lesson here for all of you who have loved ones with pulmonary or heart problems?

I consulted with her physician recently, and am much comforted by his advice. When an older person is living independently, managing his or her own medications, there are a lot of unknown factors. In order to have a good clinical picture, it is necessary to know what medications have been taken and when. The only way to get that information, in my client’s case, was in the hospital. Once hospitalized, there was never a time to say, “Wait! She wants to die at home.”

The clinical picture is known when an elder’s medications are managed by someone else, so a hospital stay might be avoidable even if the situation is otherwise similar to my client’s. If that person accumulates fluid, it is likely due to a change in the heart or lung conditions and not the medications, as was the case with my client. If the elder remains at home rather than going to the hospital, fluid would probably continue to build up and the patient would go to sleep more and more frequently until, finally, he or she just would not wake up.

Posted in Dealing with Grief & Guilt, Geriatric Care Management: Kay Paggi, Hospice Care, Hospitalization

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One Response to “Death by Hospital”
  1. Suzi Anderson, RN Says:

    Dear Kay,
    I am sorry to read that you lost your dear friend. You have my deepest sympathies. I wish for you that with time, your sorrow yields to fond and gentle memories.
    Suzi

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