Urgent Question, need knowledgeable honest answer about rehab of elderly

[kickysnana]

Is the general trend now to spend huge amounts on procedures and totally deny true convalescent care in favor of pleasing the insurance companies (Medicare) for the elderly?

My 82 year old Dad went in on Saturday with chest pains following a week with the flu. The scheduled an angiogram on Monday at noon. He previously had two bypasses done to correct 80 and 90% occluded cardiac arteries one narrowed and the condition given the term "widow maker".

My Dad is very active. He walks an hour every morning. He bowls three times a week, plays table tennis once a week. Does his housekeeping, shopping and home repairs. Last summer he was golfing 18 holes with some fatigue.

One of the 5 year old bypasses was unsaveable but it was on the narrowed artery. They cleared the "calcified" narrowed artery with some difficulty and inserted a stent. They thought that they could have created a small infarction at the time. The second bypass tore while they were trying to clear it. They were able to stop the bleeding and put three stents in it. The third artery was at 90% but they felt they had put him under enough stress and too much dye to do anything about it. We told the clearly rattled surgeon that Dad needed specific instruction about his post op activity and he said " he might as well do what he feels he can do." My sister just called me and told me that he is expected to go home tomorrow and that he expects to go bowling that evening (because the 62 year old neighbor had a stent put in with no complications did it).

That said my Mom died January 12th. She had COPD and we were told 4 days before her death, after a crisis that her prognosis with new meds and therapies would not be terminal for at least 6 months and possibly up to 5 years.

She was given the choice of immediate home hospice or 2-3 weeks of PT/OT therapy in a care facility to help her regain her strength. She chose it without consulting any of us because "she didn't want to be a burden." We are a close supportive family. She had been living at home and taking care of herself, with Dad taking care of the house, laundry and shopping but had been terrible about seeking out treatment as her condition changed.

During a family conference I stressed that Mom needed clear guidelines during her rehab and that was echoed by the nursing home. Since there are so many of us and she was stable, better than she had been in months we took turns visiting for short periods so she could rest and build up her strength. She had said until the last day she was coming home and had projects planned.

In the hospital during the week after she collapsed she would become confused after about 15 minutes of conversation and in the evenings. She could sit up for only a few minutes after being in bed for 10 minutes two days before she transfered to the care facility. She stood one day before she was transferred and ended up walking with an empty oxygen container with the PT telling her to relax and breathe the day she was transferred.

The day before she collapsed in the nursing home I heard that they had her walking to and from PT/OT on another floor in another wing. She had not been able to walk across a room without pausing for some minutes for a month before she collapsed. She had gone in to see her doctor two weeks after this started and nothing was done to help her at that time. The evening of her grand walk she called my Dad, 10:30 at night and told him she wanted to talk to him. She told him that she was too tired and she wanted to die. Dad being Dad thought she was having a "bad day". Told no one until she was in a deep final sleep the following day.

The next morning she PTed again, went to church, ate lunch and collapsed. I called her minutes after it happened and did not recognize her voice and called the nurse and headed down. They gave many reasons that she was having a bad spell but finally one and a half hours later told us she needed to go to the hospital and be put on a respirator (she had a living will and when asked by the nurse refused this) or the family should be called. She died about 28 hours later.

While in the hospital the lung specialist told her that the respirator for about 24 hours at that point, would merely give her body a rest and allow her to heal and go on. I have no doubt that she was PTed to death. It was not what she wanted but she was such a people pleaser and Medicare has such ridiculous required milestones that and the PT people did not know her, how much grit she could put up for short periods of time that was not good for her in the long run.

I know she was going to die before long and I know that doctors predictions can be wrong but I have no doubt that the "system" PTed my mom do death, rushing her without knowing her and I am afraid the same system is about to let my Dad do too much too soon too. They did not get his clotting and other vitals stabilized until about 3 this morning. We were told that it was only clots that hold the stents in place and without the clots Dad would bleed out. They were not reckless people and both have said over and over "the doctor would tell me if I wasn;t supposed to do or not do something."

[havocmom]

1. No advice, but marking (and kicking) in hopes of you finding resources

Condolences on the loss of your mom and good wishes for your father's recovery. Will try to get hold of someone who may be able to provide help in where you can look for the information you need.

Peace & strength to you and your family
hm

[havocmom]

12. OK, the word from someone knowledgebable in elder care and facilities that do it:

from reply to my email that included link to this thread so she could read your OP:

Hard to know what to recommend.
They call the left anterior descending artery the "widow maker" because with that degree of narrowing, he is at risk for sudden death.

It actually sounds like the hospital offered them all the care they could. Medicare does not pay for any "in the home" care other than PT/ hospice = Also, sounds like the mother had lung disease and heart disease and they were giving her PT so she wouldn't get a clot embolizing to the lungs.

I wish I had something to offer, but there really isn't anything.

Btw, odds are he won't feel well enough to go bowling anyway - sometimes you just gotta listen to them tell you all the things they are going to do/

The person I contacted deals with these issues professionally. FWIW

[Mojorabbit]

2. My husband had a stent

inserted ten years ago at age 40. They put him on limited activity for two weeks. We sweated out the six month period needed to make sure the stent would hold. Husband did go back to work after one week. Major type A and it was more stressful to rest for him than work. I don't know if this helps or not.

[w8liftinglady]

3. having worked with this for about the last 25 years...

I have to say...it depends.Yes..there are criteria that patients have to meet to remain in an acute care hospital,and the "rehab" hospitals are very picky about who they admit.Most of my elderly patients end up doing rehab in a nursing home.To be honest-90 percent of them will not go unless it is phrased "rehab",and not "nursing home".And,yes-Medicare has strict rules about criteria for rehab.It can be modified somewhat,but does not usually benefit the medically fragile patient like your mom.Due to financial constraints and overwhelming costs,the convalescent centers of the past just do not exist...at least for most people.I see families struggle with this very thing daily.Most children simply can not care for a medically fragile parent at home...especially if they have 2 medically fragile parents.As our population has aged,it has placed a huge strain on available rehab resources,and a lot of people are simply not going into the nursing and rehab fields,especially for the elderly.I'm afraid I don't have a good answer for you,but if you have any questions,feel free to PM me and I'll try to get the answer for you.

[MannyGoldstein]

4. My Heart Is With You

We've just gone through a bout with my mother-in-law: cancerous tumor removed, a precancerous lesion two weeks later, then an MRSA ("superbug") infection, all since the first of this year.

In general, the US healthcare system is apalling. We live in Boston, which has superb hospitals and docs because of Harvard. There are a few other pockets of excellence, but the rest is awful, awful, including Long Island where my mother-in law is. Doctors missed obvious things, forgot to do important things, and so forth. Adequate care was only provided because my wife is smart and tough, and we have good connections and know how to deal with medical people.

I cannot imagine how people who don't have our resources deal with our medical system.

On the other hand, the good news is that people are living longer and longer - life expectancy has increased by 10 years over the last 30 years. We have our parents longer than folks did before, many people are living into their 80s and 90s.

Good luck to you and your family.

[tilsammans]

5. Hugs to you and your dad, my friend . . .

:hug:

I’m afraid I’m not much real help, as I have little experience with the current Medicare go-round. I lost my parents years ago, and I too, was VERY disillusioned by the so-called “care” provided.

My sincere sympathy on the loss of your mom. And best wishes for your dad’s recovery. He is very fortunate to have a child who is THERE and as on the ball as you are. I urge you to continue to question the process.

[pacalo]

6. Like havocmom, I'm unable to advise but keeping this alive in case someone with knowledge will see

your heartfelt plea. Best wishes to you, along with my condolences.

[pitohui]

7. yes it's a trend both of my parents have had multiple bypass surgery

first thing let me say i am really sorry about the loss of your mom

as far as post surgical care --

i was amazed that they kicked my folks out the door after a couple of days and pretty much left them to fend for themselves as far as PT after quadruple/quintuple bypass surgery!

my dad nearly died because of the bleeding and had to go to the ER and had to have most of his blood replaced == they gave him the wrong medicine (a relative of aspirin), many older folks apparently develop the aspirin allergy only in old age -- same thing happened to his dad and for that matter to my husband's dad so keep on top of the bleeding and if it continues once your dad is home, get him back to an ER immediately and don't take no for an answer


both my parents were exercise fanatics and exercised/walked over an hour a day prior to the bypass surgeries, both of them SLOWLY built up on their own to walking again, as my dad is now fully retired and in his 80s he sometimes walks up to 3 hours a day HOWEVER please be advised that they didn't immediately jump out of their beds and start walking/hiking/swimming for the full hour

i don't think your dad should be bowling right away because of the lifting involved

he should try walking first, a bit every day, until he is back to his normal hour or so

the bowling should wait until any stitches are healed and a doctor gives the OK

this is just my opinion and my experience obviously, in our family, we family members had to take off work and take turns spending a couple weeks with our parents while they recovered, insurance was not going to pay for a trained health care professional to do this

honestly i don't think your dad should hop out of bed and over to the bowling alley, he does need to give himself permission to rest, but the walking is probably an excellent idea, my mom started walking as little as 5 to 10 minutes a day, it sounds silly, but it's a start

both of my parents have made a full recovery but it's scary, you sort of walk a tightrope between not wanting to have any dangerous bleeding and the patient being used to being active and not being at all good at staying home to rest

on the bright side, once the stitches are healed/bleeding properly controlled then these patients can have a very good chance of having more good quality years

[pleah]

8. My thoughts are with you.

I hope you find some answers. My father passed away less than a year ago. He went through 7 operations and 3 staff infections, plus an anerism (that he was not supposed to survive) and throat cancer. He lived 4 years after all that with just 1/4 of his heart working. I'm sure there is someone out there who can help you.

[Warpy]

9. The medical folks would always rather choose to attempt

to preserve function in the elderly, even if that function is limited to what we call "household ambulation," that is needing a wheelchair outside the front door but not inside their homes. Preserving function means preserving independence as long as we can and that's really the name of the game for older folks. Your mother said she didn't want to end up a burden and that means she wanted to preserve as much independence as possible. Rehab wasn't a mistake. Her collapse was likely due to an undiagnosed co morbitiy. Did you have an autopsy?

As for your dad, rehab for cardiac patients starts immediately these days. Research taught us that leaving them on bedrest "to rest the heart" only led to worse complications than the original insult to the heart. According to what we know at this point, your dad is getting the best care available. I'd discourage him from going bowling. Show up at his door with dinner reservations or something, make him an offer he can't refuse, talk to him about taking walks for a couple of weeks before he attempts anything more strenuous.

I know where you're coming from, though. Honoring my parents' wishes at the end and letting them go in their own way was one of the toughest things I've ever done. They were the only family I had.

[kickysnana]

10. Thanks to all for the thoughts and ideas.

I just heard from my sister that Dad has had atrial fibrilation since the proceedure, not uncommon, but needs to be addressed as strokes could occur and it could develop into heart failure. They will try medication and do an intervention if that fails.

I will pass the information on to my siblings in case he goes home tomorrow. I have had my own cardiac tests scheduled for over a week and will be tied up almost all day.

[damntexdem]

11. There are many issues here.

Regarding insurance, often very-expensive procedures are authorized while less-expensive needs go rejected. An acute-care bias still exists, even though elders are more likely to need long-term stability in chronic illness.

Medicare has always had an acute-care bias, which translates in chronic illness into coverage of acute exacerbations of chronic illness, and rehabilitation to recover to former status, while disallowing long-term coverage of care needed to maintain stability over the long haul.

This adds up to a 'get them rehabbed and get them out' post-hospital mentality, complementary to the 'quicker and sicker' hospital-discharge philosophy.

That said, there are nevertheless quality standards as to care planning and delivery that should, but often do not, prevent rehabbing residents to death. In short, a nursing facility resident, and anyone in post-hospital care at home or in any other venue, should not be subjected to rehab efforts that do not fit with the resident's condition.

Another issue has to do with a patient's prognosis, particularly if longer-term survival is unlikely. In particular, if a patient has a prognosis of less than six months of survival, then palliative care, particularly hospice, should be considered. The issue is then not to 'cure' nor to 'rehab,' rather to make the patient's last months more comfortable, and more dignified. Again, this goes against medicine's curative ideology; or more importantly, against an institution's interests in maximizing revenues from high-cost procedures. I don't know whether a short-term prognosis was the case with your mother or would be for your father; but it is something to be considered. If, by contrast, longer-term survival is possible, then good rehab is essential, but to be good it must be appropriate to a patient's condition.

One thing you might consider if you can afford it is seeking a second medical or rehab opinion from a disinterested provider.