Because she was in observation, the hospitalist informed the family that he had written a discharge order. The family requested more time, given the fact that she was extremely confused, was hallucinating, and had not kept anything down by mouth; the hospitalist then changed Sheila to inpatient status for ongoing care. By Saturday, the vomiting and diarrhea were much better controlled with medications, but she had not taken anything by mouth other than a few sips of liquid. She was given a regular diet and kept a few bites down. The rounding hospitalist (the third in three days) told Tara he had consulted gastroenterology but that they were no longer needed and Sheila could be discharged. Tara requested that they fulfill the GI consult instead of discharging Sheila, given the length of time of the illness (now almost three weeks), the fact that she was nowhere near her baseline status, and the lack of diagnosis.
In the meantime, when one of the nurses from the assisted living facility called Tara to check on Sheila, she pointed out that she had noticed her mother’s Alzheimer’s medication “looked different” starting about three weeks ago, which coincided with the onset of the diarrhea. With this information, the GI consultant took a good history, looked at the imaging and lab testing, and told the family he strongly suspected the diarrhea had been caused by a change to generic from brand name, a decision that had been made due to the cost of brand name. He recommended stopping the medication, and, if no improvement was seen in the diarrhea within 48 hours, he would expand his workup.
The next day, a Sunday, the same hospitalist rounded early and wrote discharge orders. When Tara’s sister, Michelle, arrived, the nurse told her of the discharge order. Michelle asked another logical question: “But do we know what is wrong with her yet? Has the diarrhea stopped?” The nurse recounted “only a few bowel movements” over the course of the night and no vomiting. Michelle pleaded with the nurse to at least see if her mom could tolerate breakfast before discharge. She then talked to the hospitalist, who recounted that Sheila had told him that morning that she had not had any diarrhea all night. Michelle asked another logical question, “But you know she has Alzheimer’s, right?”
Sheila did well with breakfast, and, after several hours without diarrhea, she was discharged back to her assisted living facility with Michelle. The PCP never called, home health was never ordered, and the low-cost medication was still on her discharge paperwork.
Throughout all this, my sisters asked me and others so many logical questions during the three-week illness, such as “Don’t they review the medication list before a patient goes home?” and “Why didn’t the ED contact the PCP? He works in the same hospital, right?” Being hundreds of miles away, and knowing both how the system should work and how it does work, I found it sobering to see all the typical breakdowns happening to my own family. I felt disappointed and dismayed, but not the least bit surprised.
The one person who truly made a difference was the nurse at the assisted living facility, who used common sense (“The medication looks different”) and compassion (“Hi, just calling to check on Sheila”) to help us determine what was wrong. She saved us all additional diagnostic tests and unnecessary visits.