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May 30, 2017

Wellness vs. Wishes: When Patients Decline Post-Acute Care

Each year, clinicians make 13 million post-acute referrals for Medicare patients.

With healthcare providers facing increased pressure to both lower costs and improve quality, post-acute care after hospitalization is a logical choice—it provides a safe, personalized environment in which patients can be cared for and healed by professionals.  For many patients and families, however, the choice is not so obvious.

Doctors at a Johns Hopkins facility caring for Mrs. A were faced with this challenge when she said, “You’ll have to drag me kicking and screaming out of the house if you want to put me into a nursing home.”

Despite the benefits of post-acute care, including skilled nursing facilities (SNF), rehabilitation, and in-home services, patients and families may choose to go home and end professional care against medical advice. Family members, thinking that they can provide continued care, may argue with doctors underestimating the time, skill and resources it takes to handle complex recovery. Infections from improper wound care, or even one wrong medication dosage can land patients right back in the emergency room. 

Mental capacity is another culprit of this dissension. Older patients with emerging dementia or Alzheimer’s may be unfit to make decisions. Additionally, patients, and their families, may not have a full grasp on the status of of their relative’s health and possibilities of further deterioration. But more often that not, people just want to go home.

When patients disagree with clinicians’ acute care discharge plans, the results can be costly and harmful.

It can be tough for physicians to balance patient wellness and patient wishes. Doctor seek to first “do no harm". Allowing a patient to make a decision that could be bad for their health can seem like a choice between quality of life over quality of health.

Three tips for clinicians to keep in mind when faced with the referral conversation with patients: 

  • It’s a matter of autonomy, not authority – In most cases, patients do not mean to offend doctors or assume they are smarter. Post-acute care, especially SNFs, can invoke feelings of dependence and loss of freedom. Remind patients that, at every step of the way, they are the drivers of their health. Empower and encourage them.
  • Educate through scenario planning – Simply telling patients that a choice is bad for them won’t be helpful in their decision making. It’s best to lay it all out and give them real expectations of what could happen down each of the roads they can choose to travel.
  • Talk it out and compromise – In the case of Mrs. A, her team of care providers pleaded with her on several occasions to continue her care at a nursing home. In-home support was out of the question, due to financial cost, but Mrs. A and her team were able to find middle ground on short-term rehabilitation. Although not ideal, negotiating with patients on options that are still medically acceptable can be a great stepping stone to better health.

As it turns out, Mrs. A’s aversion to nursing homes stemmed from her work as a younger woman in senior care facilities. It seems a few bad apples colored her vision for what her life would be like in a post-acute care facility. Recognizing and working with this fear is what allowed the doctors to be able to coax her towards a better decision, maintaining her dignity as the main driver of the decision.

When faced with a “wellness versus wishes” situation, it’s important for clinicians to get to the root of the issue. While it’s easy for clinicians to get wrapped up in treating patients just as bodies and numbers, practicing empathy reminds us that patients are people too, often times with rational and valid concerns.

As the Sherpa of what can feel like mountains to climb towards better health, clinicians have the opportunity to truly educate and advocate for post-acute care among patients that just want to go home.

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Tagged: post-acute care, patient autonomy, home care

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