Question of the Week

For April 25, 2017

An 85-year-old woman with severe chronic obstructive pulmonary disease (COPD), hypertension, a history of strokes, and moderate dementia is hospitalized for a COPD exacerbation. This is her fourth admission in the past year. At home, she is cared for by her 50-year-old daughter and 45-year-old son, with assistance by visiting nurses and home health aides.

Respiratory failure occurs, requiring admission to the intensive care unit and intubation. The patient becomes delirious and develops ventilator-associated pneumonia, requiring broad-spectrum antibiotics.

Ten days after presentation, the patient recovers and is moved out of the intensive care unit, but rehabilitation cannot begin because she has persistent confusion. The clinical team recommends that she be discharged to a nursing home rather than to her home. They initiate discussions with the family about goals of care. The daughter is agreeable to their plan, but the son resists.

Which one of the following questions is most appropriate to address this disagreement about the patient’s discharge?

Do you feel your mother needs a higher level of care than we’ve planned for her after discharge?
Have you been unhappy with the quality of your mother’s care?
Do you understand that keeping your mother in the hospital unnecessarily increases her risk for infection?
What problems have you noticed at nursing facilities you’ve visited?
How do you think your mother is doing?