Today's topic is not so much about oxygen as geriatric assessment.
The doctor who did the bad job on the assessment outlined in Oxygen part 12 was back on Friday. She arrived as the patient was getting ready for physio. She stayed long enough that the physio appointment had to be scrapped - and there is no physio on the weekends. Which means three more days of lying in bed despite the doctors constantly telling her she has to get up and get moving.
The doctor, a specialist in geriatrics, did her best to tell the patient that the next step had to be an extended care facility - she would not be able to go to rehab because she couldn't walk.
Except the patient can. She has been doing physio in the bed and has graduated to doing the parallel bars in the gym. She can walk if she has adequate support. For some reason this is discounted by the doctor doing the assessment. (Keep in mind that this is a geriatric specialist who did an assessment without checking first for visual or auditory impairments, so we already have a precedent for discounting the patient.)
Another element that is not mentioned by the doctor is that there has been a recent change in heart meds, because the physio noticed that the patient's heart was responding erratically to exertion and it was impeding her progress. So the meds were adjusted this past week - which means she hasn't had a chance to prove a faster rate of progress under the adjusted medications.
This is significant, because the patient was living in an assisted living facility before she fell - and she needed to use a walker even then. It is possible the fall was caused by one of the "blackouts" related to her heart's response to stress - and in theory that has now been addressed through the minor adjustment to the meds. She was managing quite well with minimal daily care - most of it provided because of her blindness and to give her some stability for the more complex tasks like showering.
She still needs help getting out of the bed - and this is not a surprise, since she has been in the hospital for 11 weeks and for much of the first month she was not able to get out of bed because of the combination of the treatments for her achalacia and the expected strains and bruises from her fall. Then, when she was deemed well enough, staffing shortages complicated her schedule: she is too heavy for a small person to help out of bed, and so some days she didn't sit up at all because no-one was available.
Staffing shortages also played a role in the catheter situation: the patient does not want to lie in a soiled bed, but the nurses are too short-staffed (especially on weekends) to take the time to help her to the bathroom. There is a story about the commode - initially the patient had a commode, but it came apart twice when she used it. The staff said the commode itself was the problem - it was broken - but instead of exchanging it for another one, they took the expediency of a catheter - with the patient's consent. Why did the patient consent? Because she had become accustomed to waiting up to 3 hours for staff to answer a bell.
Back to the geriatric specialist.
This doctor, who did such a bad job the first time she came, showed up on a Friday morning without any warning, and told a 93 year-old woman who has slowly been making progress that she had to make plans for going into extended care. No prior contact with the family. Not taking into consideration that this is a patient with a history of anxiety issues (controlled at home through occasional use of Ativan/Lorazepam). She pre-empts the physio that the patient knows is crucial to proving she can return to her home. And she keeps stressing that the patient has to have a plan.
The patient has a plan. Her plan is to continue the physio, get back on her feet, and go home.
There was a family member present when the doctor was there on Friday - a visiting granddaughter from Vancouver. The doctor wouldn't know this, but the granddaughter has only been in contact with this side of her birth family for the past 8 years, and has spent maybe a total of two weeks in her grandmother's company over that time. She is not an authority on her grandmother's routines or abilities.
This is significant, because the doctor called my other half this morning to press the need to plan for extended care. The doctor said she understood that the patient had barely been managing at the assisted living facility.
Barely managing? Hm. She went down for dinner every day - with someone to help her change to the portable oxygen tank (a task that tasks less than 2 minutes) because she can't see very well. She was a regular at the knitting club, church, and the singing group. True, because of her visual impairment, someone administered her pills and made her breakfast. Much of her day was spent in her apartment, knitting, listening to the television or recorded books, talking on the phone. Compared to many of the residents in the facility - the ones in wheelchairs, the ones who have no vision at all, the ones who have Alzheimers - this woman is quite highly functional.
Until she went into the hospital, she was mobile and alert and taking an active role in the community. It is a tribute to her strength and determination that she has survived the hospital.
The other thing the doctor said was that she had not prevented the patient from keeping her physio appointment. This may be her impression, but it is not true - and we have witnesses.
When my other half expressed her concern that the geriatric specialist seemed to be acting on wrong information, the response was that the conversation was not getting them anywhere, and the doctor ended the call. This was similar behaviour to the behaviour the patient reported: when the patient tried to tell the doctor about the obstacles to getting better when doctor orders aren't followed, when physio is withheld etc. According to the patient, the doctor dismissed those concerns as if they were immaterial and returned to theidea of a plan for extended care.
In other words, the doctor has made her decision and does not want to hear that the decision has been made on the basis of incomplete - and wrong - information.
Is my view coloured by a false view of the patient? Or is it an assessment based on 18 years of knowing this woman?
Given the lack of follow-through on the physio/rehab by the staff at the hospital, and the way in which the geriatric specialist conducted herself in the three contacts she has had with the patient and the patient's family, I don't think the patient has been treated ethically. She is showing progress in rehab - unless the medical team can guarantee that an extended care facility will continue to work toward recovery, they ought to be planning rehab.
When all the dust settles, an extended care facility might still be the place where her needs can be met most effectively - but that is a decision that should be arrived at through ethical means, not through the patient having been hamstrung by the system and pushed there by a doctor whose agenda does not reflect the best interest of the person who is lying in the bed.
NEWS FLASH
So the main doctor in charge of the case has called for a meeting tomorrow at 1 pm. He said only the plan to go to extended care will be discussed and there is to be no criticism of the medical staff or the meeting will be stopped.
