The Home

It happens most nights in the ER. One of the many nursing homes, that channel their residents to my hospital, calls about a pending transfer. GGB (geriatric go boom)? Difficulty breathing, fever, chest pain, vomiting and or diarrhea, altered mental status are all possible reasons. The first thing the ER staff wants to know is the patient's code status. DNI, DNR, DNH. It is not unusual to get a patient that the NH says is a full code who is actually a do not resuscitate. If the patient recently arrived in the NH and the DNI/DNR forms haven't been signed by the NH doctor, the patient, despite the patient and family's wishes is sent to me as a full code. DNH patients are essentially on hospice care. They are not to be transferred to a hospital without the consent of the health care proxy. Surprise, the NH staff sends the patient without calling the family.

Many NH patients have multiple medical problems and frequently have some degree of diminished mental functioning if not diagnosed dementia. This makes it difficult for the ER staff to get any history as to the presenting complaint's onset, progress or associated symptoms. For a patient with dementia, the trauma of being taken from their bed, loaded into an ambulance and transported to the hospital is frightening and disorienting. The patient's agitation may make the patient violent towards the ER personnel.

EKG's, IV's, rectal temps, catheter placements, examinations, hard stretchers, lights, and noise all add to the stress on the NH patient. This is usually occurring in the middle of the night. The disturbance of the patient's normal sleep schedule is an additional factor in their discomfort.

For me, it is now personal. My elderly, somewhat demented mother resides in a NH. The facility is clean, well staffed and offers stimulating programs for the residents. My siblings and extended family visit my mother frequently. She is still able to use a telephone to call family and friends. As with most patients with dementia, my mother's demeanor can change rather suddenly. Her lack of short term memory leads to her attempting to make sense of changes in her environment. She can become angry and lash out verbally at her children and the NH staff. Other times she is her usual sweet and loving self.

I admit that I do not see my mother as often as I should. Distance and my own health issues limit my visits to at most a once a week schedule. Being a physician, I cannot help but observe the physical condition of the the other residents of my mother's NH. Her tablemate for meals is a fairly young person who has both physical and mental limitations. Traumatic brain injury, post encephalitis, and multiple sclerosis are all possible etiologies. This patient is also delightful. Smiling, laughing and singing are this person's usual responses. My mother's roommate is sadly not very lively. This patient has had what appears to be a dominant hemisphere stroke and is aphasic and hemiplegic (nonverbal and paralyzed on one side).

Other residents are limited by arthritis, minor residual stroke symptoms, severe lung disease or congestive heart failure. One young person is clearly the victim of a traumatic brain injury, brain tumor or hemorrhagic event. I can see the evidence of a craniotomy on this patient's scalp. A few residents defy my powers of observation as to why they reside in a skilled NH facility. Chronic mental health issues may be the issue that led to them being patients in this NH.

As complicated, challenging, and frustating as these patients can be, they are still human. The care given by the ER techs and nurses is amazing. I think we all see our own elderly family members and even our future selves in these patients. My mother, in a very lucid state during yesterday's visit, told me something that may be a common desire in NH patients. She said that the staff was very good, even the food was OK, but that this was no life for her. Her wish and prayer is that at age 91, she wants to go to sleep and not awaken.