John’s aging parent, Mary, 90, lives in another province. One day, he gets the call he has long dreaded: his mother has fallen, broken her wrist, and has been taken by ambulance to the hospital. She has had surgery and her arm is in a cast.
Is she ready to go home? Not so fast. John is told that his mother is showing signs of mild cognitive impairment and that the discharge planner wants an assessment. John must call the doctor for more information.
John manages to talk to the doctor later that day. He learns that Mary is doing very well physically, but the doctor is concerned about the possibility of dementia and has referred her to the Geriatric Team. John asks if he should take time off work and come. The doctor advises him to wait a few days until the outcome of the assessment.
During the next few days, John calls the hospital for updates. He talks to: the Registered Nurse on the unit; the Head Nurse on the unit; the Relief Nurse on shift; and the Discharge Planner.
John is confused. Some of these professionals believe that Mary has signs of dementia while others are not sure. The discharge planner is concerned that Mary may not be safe to return home; John worries, because Mom has refused previous attempts to talk about moving to assisted living.
Later, John hears from the Geriatric Case Manager that, for now, they have not confirmed dementia. His mother had delirium because of the injury, pain, unfamiliar environment and anxiety. Mary is moved to a transition unit.
Soon after, Mary calls John to tell him that she is discharged and will get home care. John wonders if she will accept strangers coming into her house because she has refused previous offers of household help.
John takes a week’s vacation time and goes to help his mother. During his time there, he meets: the community care (home care) coordinator; the home care nurse; a home health aide; the transition coordinator; the geriatric case manager; and an occupational therapist. Collectively, they offer the following advice:
- Arrange for Meals on Wheels
- Make changes for safety at home: get a bathroom grab bar; remove scatter rugs; add a night light; get Mary an emergency response system
- Mary should accept home care services for help with bathing
- John should get Power of Attorney to look after Mary’s finances
- Mary should write a Personal Health Care Directive
John is told that they will follow-up to monitor his mother’s safety at home. If she is not safe, the team will encourage her to move into assisted living.
John returns home and stays in daily phone contact with his mother. Contacting the health care professionals is difficult, given time zone differences and work schedules. They encourage him to talk to his mother so she can keep him up to date. But John senses that Mary is avoiding detailed questions. He assumes that she wants to appear to be doing well so that she can stay at home instead of living in a care home.
- Who am I supposed to talk to?
- How do I reconcile different opinions from the various professionals?
- Why is the medical team so guarded about what to tell me?
- When should I go help my mother – right away or when she is discharged? Will I have enough warning to arrange vacation time and travel?
- Why is Mom moving to another unit in the hospital?
- What is her diagnosis? What will she need from now on?
- On the medical team, who is responsible for what? Why are so many people involved?
John finds out that interacting with so many different health care providers makes the process complex. He appreciates each professional’s expertise, but wonders who is managing the overall situation. The doctor seems quite forthright with information, but John notes that the hospital staff seems guarded about what they can tell him on the telephone.
Despite knowing that everyone is trying to do what is in Mary’s best interests, John sometimes feels left out of the plans.
He begins to realize the value of planning ahead, including making sure Mom has prepared her enduring power of attorney and personal health directive.
What does John want to pass on to others who find themselves in similar situations? First, understand the “go-to” people on the health care team:
- Keep in touch with the physician. The doctor is responsible for the medical diagnosis and often knows the overall plan.
- In the hospital, keep in touch with the discharge planner. This person communicates with members of the team about the discharge plan (including the services that will be needed at home).
- Once outside the hospital setting, keep in touch with the case manager (who might also be called community care coordinator).
Here are more tips from John for staying on top of the situation:
- Start a notebook with names and phone numbers of all the professionals involved. Ask them to explain their roles.
- Negotiate specific times for telephone calls. Ask about communicating via email.
- Be assertive in asking for information. Ask your parent to inform the health care providers that they can talk to you (if your parent is willing to do so).
- Ask about the limits of confidentiality and privacy. What can you, as a family member, be told, according to legislation in that particular province?
- Expect to live on a ‘roller coaster’ and to adapt to frequent changes in the plan as your parent’s condition and level of functioning changes.
- Recruit help from family, neighbours and friends. You will need information and support.
If your aging parent(s) live on their own, and particularly if you live at some distance away, it’s best to have some planning in place BEFORE a trigger event becomes a crisis. It can help to know ahead of time what to expect and what might be expected of you.
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