Rose has chronic lung disease which is gradually worsening and limits her activities to staying near or within her own apartment. Her family is aware that her health will deteriorate and sometimes assume that a dip in her health can not be restored. Over a period of two weeks I got calls from family and caregivers for confusion, shakes and not eating and was able to respond to calls of concern by bringing the medical evaluation to the home instead of sending Rose to one of the three nearest emergency rooms, two of which would have had no past medical records for her.
Rose had a reversible metabolic condition superimposed on her chronic lung disease. Emergency room physicians and specialists who are not trained in geriatrics would have viewed Rose in the simplest way possible. This is just a confused 93 year old with advanced disease and a family with high expectations. These health care providers had no prior knowledge of her past resiliency recovering from a hip fracture, pneumonia and a skin ulcer. They would not have viewed her medications which had gone from being a good idea to treat symptoms in the past to contributing to her present acute metabolic problem. In a hospital Rose would have been stereotyped as “nothing more we can do.”
That’s not what I saw. I know that one day I will have to say to her two sons, “I will be here until the end, because we can’t reverse the disease,” but this time I could distinguish that reversing the delirium was achievable. In order to do that, I made home visits weekly including one on a Sunday afternoon with four family members and two caregivers which lasted three hours and was followed by daily proactive follow up phone calls. Three days before her 94th birthday, I called Rose and she said, “My birthday? That was last year.” Even with a delirious mind, Rose herself wasn't sure she would live to her next birthday but she and her family put trust in an old fashion primary care relationship with a doctor skilled to know that we can treat this and we can do it at home.