Grandma's been in prisonBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7138.1174a (Published 11 April 1998) Cite this as: BMJ 1998;316:1174
It all began during the October holiday week. Grandma, who is now 89 and has coped very well on her own, fell during the night, pressed her alarm call button, and was admitted to the local hospital. In the casualty department everything was normal, but instead of immediately returning her home she was admitted.
We found her in the assessment ward on our return from holiday. Over the next two weeks she spent a lot of time sitting in an armchair pinned in place by a bed table and wrapped up in a rug. She made occasional sorties to the toilet, but was spectacularly inactive despite intermittent physiotherapy. There was simply nothing she needed to do. Everything was provided: meals, baths, toiletry needs, etc. We asked if the chiropodist could visit and if a hair do could be arranged, but these services were available only once every three months. It was therefore chance whether or not she would be there.
By now all existing home support services had disappeared — the home help, the gardener and general handyman, the fish man who called once a week, and the local shop owner who delivered regular groceries. Her pension would soon be altered if she was not discharged home. As she was as well as she had been before admission, we asked if discharge could be arranged. This could not be allowed, however, until a home assessment had been carried out.
Five weeks after admission a home assessment took place. Grandma was taken home and, in the presence of five observers, she was asked to make scrambled eggs. Grandma doesn't like scrambled eggs and probably hasn't made them for 20 years. She passed this test, however, and was immediately whisked back to hospital. While she had been let out from the ward, the chiropodist and hairdresser had called. She therefore missed the two useful things that might have been done for her.
Now that she had passed the scrambled eggs test, we felt that discharge must be imminent, but she had to wait to be seen by the day hospital staff. No one asked if she wanted to attend a day hospital. Coincidentally, after six weeks in hospital it was discovered that she had non insulin dependent diabetes controlled by diet. We were assured that this would not delay her discharge. A week later the day hospital saw her and then another week passed before the home help service could be reinstated.
Seven and a half weeks after the initial incident Grandma finally “escaped” to her own home. On day one of freedom she managed very well, enjoying her house again, and managing all the daily living activities that were necessary. On day two it was time to go to the day hospital. Wheeled off at the crack of dawn she spent the day there and came home tired. The next thing we know it is five o'clock in the morning and the phone is ringing at our house some 45 miles away. She has fallen again in the night. The doctor has been and she is waiting for the ambulance to take her to hospital. We plead with them to wait for our arrival so that we can tuck her up in her own bed and see if anything further needs to be done, but “No, she must go to hospital.”
By the time she gets to hospital she is fine, tucked up in bed in an acute medical ward. We discover that during her first admission she had been given benzodiazepines night and day. On discharge these were withdrawn with the resultant rebound insomnia and disorientation. No one had discussed with Grandma or us whether sedatives were appropriate, and their abrupt withdrawal on discharge had caused major problems. Now in an acute medical ward with nothing wrong but old age, the mêlée all around leaves her unkempt and disoriented. It becomes obvious that she will quickly perish if left in this environment. In discussion with her we decide that a nursing home near to us is the only solution. Her house must be sold and she agrees.
“Can we not let old people take risks with themselves if that is what they want?“
To those who work in the NHS it always seems that getting a nursing home place must be just about impossible, but the best three local nursing homes all have an empty room and could take Grandma immediately. Within three days admission is arranged.
Such events are always distressing, but if there is to be an alarm service that old people can use when they fall over there must be some support service available to them in their own homes that will tuck them up in bed and briefly settle them with perhaps a follow up visit from a district nurse the next day. Every day that an old person is out of their own home makes it less likely that they will ever return. Furthermore, the ease with which admission to a nursing home can be arranged must be a lesson to all of us working in the acute sector. When many people stay in acute beds for up to six months at a cost of £1200 a week it must be a better use of resources to buy nursing home places at £400 a week. Finally, the use of sedation without consent should be questioned. Its abrupt discontinuation on discharge may result in problems even in the young and fit. Should we not discuss with patients the use of these agents and, if it is felt they are necessary, obtain their full informed consent?
The sadness is that there is no escape for Grandma. She will be in an institution for the rest of her life. Can we not let old people take risks with themselves if that is what they and their relatives want? We should not thwart their last wishes by institutionalising and deskilling them by prolonged admission to hospital. There is still a lot of scope for saving money in the NHS.