Stories From Homeland, Part 3

Mrs. Diaphanous went to the hospital with severe atrial fibrillation and an ejection fraction of 18%. Her heart is not working well, and her condition is fragile. She is just barely stable. She is alert and oriented, and walking with a steady gait. Naturally she has agitated to return home since she was admitted to Homeland several days ago, and likewise agitated her daughter.

Returning from visiting her cardiologist, who thought it would be fine to go home, she expected to just pack up her bags and take off right away. However, she is being followed at Homeland by Dr. Wildman, who needs to give his permission for discharge. That's how it works in a skilled nursing facility. Whichever doctor follows the residents here has to give the okay for any orders that consulting physicians give.

This happens frequently with people who have fractures. They work with the physical therapist, who remarks that they are doing well and should be ready to go home soon. Then they go out to the orthopedist, who says, "Okay, I think you're ready to go home now." The next the nurses hear of them is when the family member leans up against the counter, saying, "My wife went home; doctor Jointz said it was okay. Is there any paperwork you want me to sign?" "Only the AMA form."

So no one in the facility has done thoughtful discharge planning yet or completed the time-consuming paperwork needed for discharge, and Mrs. Diaphanous expects to go home this minute. I phone Dr. Wildman, expecting to just get a telephone order, but it's necessary to fill out the right paper requesting discharge and fax it over.

In the meantime I fill out discharge instructions and ask the daughter which pharmacy she would like me to phone the medications over to. While I work on the paperwork and wait for the doctor's faxed order, the daughter has approached the desk three times in twenty minutes, asking what we want her to do while she waits.

"Play cards?" I want to suggest.

She cut short my discharge instructions on taking the medications, saying the pharmacist would go over all that with them.

Coda: two hours later she was back, asking to clarify the discharge instructions. "I know you couldn't wait to get rid of me," she begins.