Bring a Photo to the Hospital

smiling senior friends on beach 1203192990 21Dec2020
Healthy and well before the ED visit

Bring a Photo to the Hospital

Here’s a great tip to get better medical care for your elderly relative or friend when you take him/her to the Emergency Department. Bring a photo to the hospital. Take a hardcopy photo of them when they were well, active, and feeling great to leave with their medical chart. Why the photo? Here’s the conversation in our breakroom the other day.

How the “Bring a Photo to the Hospital Conversation” Started

Last week Jennifer was upset to the point of tears because the father of one of her best friends had just been admitted again to the hospital with near-fatal lung disease. Her friend’s family was not sure he’d ever make it home again. This crisis in the breakroom sparked several conversations In addition to Dr. Darko regaling all with his Case of the Blue Man. One serious discussion was started by Sheila about saving someone’s life, getting them good and appropriate medical care, when they are admitted to the hospital.

Sheila’s Mother Got Sick – Hospital Time

Sheila said that her 77 year old mother got pneumonia. Well, that is, it eventually turned out to be pneumonia. What she got was weak and tired. Other than complaining to Sheila’s dad that she felt “puny”, her mother didn’t say anything to anyone. She felt it would pass in a few hours or days. Instead she lost her appetite and ate almost nothing for a few days, slowing getting weaker and weaker. Finally one morning she couldn’t even get out of bed without Sheila’s dad helping her, and at that point he demanded she let him take her to the hospital. She refused, saying she would be fine. At that point he called Sheila.

Sheila Jumps into the Fray

As we said, at that point Sheila’s dad called her. “Your mom’s sick and she won’t let me take her to the Emergency Department. I think she’s beyond calling her doctor’s office and waiting a week for an appointment. Can you come help straighten out this situation?” He then told the whole 2-week story of her mom feeling weak, then getting a bit worse, then losing her appetite and not eating much or not at all. He ended with the fact that, just that morning, she couldn’t get out of bed without help. “I’ll be right over,” Shelia said.

When the Daughter Needs to be Mother to the Mother

While it’s true that Sheila’s mother was giving her father grief about being ill and going to the hospital, things changed when Sheila arrived. Her mother quickly acquiesced and said, “Well, if Sheila thinks I need to go, then I’ll go.” Sheila and her dad looked at each other, neither surprised at this reply. Her dad could only shrug his shoulders. “Okay, Mom, let’s get you packed up.” Her mother was in pretty sorry shape, to be honest. She looked like “death warmed over.”

Emergency Departments Can Bring Surprises

Sheila and her dad got her mom into casual clothes, got her purse with her IDs and insurance cards, and bundled her into the car. The Emergency Department staff checked her in, the doctor slapped a stethoscope on her chest and ordered a chest x-ray. From her tenting skin the nurses knew she was dehydrated. They had already started a routine IV. They turned up the flow rate. The x-ray came back with the silhouette sign of pneumonia and a few ground-glass opacities. White cell count was way up. And, she did not look well at all. They admitted her to the hospital.

To Live or To Die – What an Odd Question

Sheila and her dad found out which ward she would be in and went there to wait. The nurses were bringing her up from the ED with bags of liquid on poles and a blood pressure cuff around one arm. They wheeled her into a “semi-private” room. In the ED they had gotten her into a hospital gown. They gave Sheila a bag with her street clothes and shoes. A nurse came in with an iPad tablet and began reviewing questions about dietary preferences, emergency contact people and numbers, and so on. She confirmed that Shelia’s mother told the ED doc that she wanted to be DNR. That grabbed Sheila’s attention. “Wait. What’s DNR?” The nurse explained that DNR was Do Not Resuscitate. It meant that if there was a “medical event” while in the hospital her mother did not want to be resuscitated.

iStock image 465193845 purchased 21Dec2020
Looks Ready to Die in the ED

What? Whoa! Wait a Minute! DNR?

“That’s not true!” Sheila said, clear alarm in her voice. “Of course she wants to be resuscitated.” She looked at her mother. “Mom, if you have a heart attack or something while you’re in here, do you want them to resuscitate you?” “Sure, yes, absolutely. Why?”, her mother replied. Sheila explained that, from the ED, they have it in her medical record that she did not want to be resuscitated. Sheila’s mother had no idea where they got that bit of misinformation and told the nurse to take the DNR out of her chart.

Happily, an Uneventful Hospital Stay

All went well in the hospital. She was diagnosed with a “community-acquired bacterial pneumonia” and treated with an IV antibiotic. After a few days she was discharged from the hospital with a week’s worth of oral antibiotic to continue at home. As Sheila and her dad were taking her out in a wheelchair her mother saw a couple of the nurses whom she had met in the ED when she was admitted. She said high and they looked blank, said a weak hello back, and looked puzzled. Sheila’s mom said her name and said, “I met you a few days ago in the ED.” Both nurses looked shocked. They brightened, big smiles, and came and gave her a goodbye hug. One said, “We’re sorry. You look like a completely different person now that you’re feeling better.”

Home Again for Sheila’s Mother – But A Scary New Revelation

The threesome headed home, and her mother was glad to be back in her own house and her kitchen. A few days later Sheila came over and helped her mother set up an online account with the hospital so that she could download her medical record. Her mother downloaded her medical record and printed a copy for Sheila. That’s when the trouble started. As Sheila read it she saw something that both angered and terrified her. The DNR order, the “No Not Resuscitate” order, was still in the record as valid. It appeared that it had never been taken off her record. If her mother had had a stroke or something in the hospital they would have let her die! Sheila, her mother, and her dad were furious.

Trying to Hold the Hospital Accountable

Sheila had her mother call the hospital to demand the DNR be taken out of her record. From the printed record it appeared that an ED doc had put the DNR order in the chart. No one had ever removed it. No one had removed it despite her mother making it clear to the admitting nurse on the floor that she DID want to be resuscitated in case of some medical event. The phone robo-triage got her to the ward where she had been a patient. They said she had to talk to the ED people since the doc there had put the DNR order in the chart. The ED staff said she had to talk to Medical Records, and transferred her call. Medical record said she could not change a DNR order over the phone. She had to come to the hospital and talk with someone.

Back to the Hospital – Well and Healthy This Time

The whole entourage, the 3 of them, Sheila and her parents, went to the hospital. Her mother was armed with her driver’s license, her Social Security card, her Medicare card, and her Humana Medicare Supplement insurance card. She was ready to show that she was she. They went to Medical Records. The staff sent for a senior-level nurse to come talk with them. From there it was actually really simple. Sheila’s mom told the nurse that she did not want to be in the hospital records as DNR. The nurse said fine, no problem, they would remove it.

Well, Okay, Maybe, But What Went Wrong?

The nurse helping them did not know what went wrong. The doctor in the ED had put the order in. It would be assumed that he had talked with Sheila’s mother, confirmed that she wanted to be DNR, and put the order in her record. But it was just a checkbox in the electronic record. One checkbox for yes, one for no. Maybe he just checked the wrong box. The nurse also could not explain why it was not taken out when they asked for it to be removed when they first got to her hospital room that day. In any case, it was out of her record now, with apologies.

The Solution Is Not Obvious – Bring a Photo to the Hospital

When they got home her mother logged in and checked the record to make sure the hospital had changed it. Thank goodness, the DNR order was gone. A few weeks later Shelia’s dad told the whole messy story to a retired nurse he knew from the local YMCA. They were in an Arthritis Aquatics swimming class together. The nurse said she had heard this story before. A patient will come into the ED looking more dead than alive. The doc, based on appearance or maybe by accident, will check the DNR box. Hey, the ED is busy. There are times when the doc thinks he talked to someone but didn’t. When someone looks almost dead people maybe they shouldn’t be resuscitated.

Well, That’s Pathetic Practice for a Doctor – So Bring a Photo to the Hospital

This experienced, retired nurse offers people this advice. Whenever you’re taking an gravely-ill older relative to the ED, take along a hardcopy recent photo of them. It should be a picture of when they were well and feeling great, just before they fell ill. Tell the staff to put the photo in his/her medical chart. Then, confirm very clearly and assuredly that the patient wants to be resuscitated. So often an elderly ill person comes to the ED looking so “half-dead” pathetic. It’s hard to believe that they were in active in life and in robust good health just a few days earlier. The photo gives the staff, even hurried staff, a better idea of the person, not just of the patient.

Well, I’ll Be Damned! – Bring a Photo to the Hospital

“Well, I’ll be damned!”, Jack exclaimed at the end of Sheila’s story. Jack had come in to the breakroom shortly after Sheila had started talking about her mother. He got a Coke out of the machine, sat down, and sipped and listened. Hey, he was on break, after all. It’s better than working! But at the end Jack and Jennifer were both amazed and dismayed. For one, how would a doctor accidently make a patient DNR without permission. And, how could a hospital leave the person on DNR status after she says no, please do resuscitate me. But best and finally, how simple a solution! Take a hardcopy photo. Show that my Mom or Dad was riding horses last week, or gardening, or skiing. They are not about to die. Save them. Get them back to where they were. Make them well again.

Helpful links:

The National Heart, Lung, and Blood Institute on pneumonia

American Family Physician on Community-Acquired Pneumonia

The New England Journal of Medicine on Antibiotics for Community-Acquired Pneumonia

Centers for Disease Control and Prevention on Community-Acquired Pneumonia

The Mayo Clinic on pneumonia