1. Firchow, Nancy MLS


When Medicare has no answers, a nurse buys a family the time to consider the next step.


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My father called me at work on a Monday morning. "Beth is at the emergency room. She fell. " I told him I'd meet JoEllen, my sister-in-law, at the hospital and manage things. At the ED I found my 92-year-old grandmother, tiny and bent with the kyphosis and compression fractures from osteoporosis, lying quite still, obviously in pain. She had not so much fallen as gotten stuck on the toilet. Too weak to stand, Beth had lowered herself to the floor, pressed her medical call button, and waited for the paramedics. The pain, her constant companion, had finally overpowered her oral morphine.

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Beth's eyes opened at my greeting, and she gave a weak smile. Yes, she hurt. Yes, they had given her something, but it wasn't working yet. Her eyes closed again. I looked at JoEllen, who had arrived before me. For the past three years, the two of us had been helping Beth out-shampooing her hair, shopping, giving her weekly Procrit injections for anemia, arranging for someone to clean her house and provide meals.


Now we were at a crossroads. Beth, living independently until this day, could not go home alone. In fact, we had discussed the possibility of an alternative living arrangement with Beth just two days ago but made no plans. We thought we still had time.


Nurses bustled in and out of the cubicle. Another Dilaudid pill. Some ice chips. One tall, blond, cheerful nurse paid particular attention to Beth's comfort. Was the bed adjusted as she liked? How was her pain? We queried the physician about Beth's care plan. Pain control, he said, adjustment of her usual oral morphine dose, and then discharge.


JoEllen and I exchanged a look. "Please, could you admit her?" I asked. "We need time to figure out what's next." The physician shook his head regretfully. Beth didn't have indications for admission to acute care, he said. With help, she'd be safe at home. I knew he was right but persisted. "Please, she can't go home. We're not prepared." The physician understood, but his hands were tied.


Time passed. Beth's pain receded, and she rested. JoEllen left to pick up her children; I stayed and worried. The social worker arrived, and I peppered her with questions: What are our options? Home care or a nursing home, she said. What will Medicare pay for? Nothing. What will we do? The social worker understood, but her hands, too, were tied. The eldercare system is a patchwork, not really a system at all. She left me with a list of local home care agencies and little else.


Later still, Beth stirred, needing a bedpan. Her nurse brought it, but Beth was too weak to lift her hips for the pan to be placed. The pain, quiet when she was still, cut sharply upon movement. The nurse considered the situation and then asked, "Could you manage a bedside commode?" Beth agreed to try. The head of the bed was raised, Beth's feet swung carefully over the edge. I watched, silent. This was the same woman who had been mobile with a walker two days before.


But the bed was too high, even at its lowest level. Another nurse came to help. Beth screamed in pain. Her body could move only with gentle, slow care. The commode, snug next to the bed, was just too far. Two more nurses eased her back onto the bed and into a diaper, while I sat helpless. All I heard were Beth's gasping howls, coming despite the opioids. All I saw were professionals unable to help her without hurting her, and I knew I needed time. I dropped my head on my crossed arms next to Beth on the bed, exhausted with worry.


"They're sending her home?" the tall nurse asked. Of all the nurses she'd seemed the one most aware of Beth's limitations and my own. I nodded, unable to speak. "What will you do?" she asked. "You can't manage this." As she left, I shook my head and lowered it back onto the bed. It wasn't an option to take Beth home with me and neither could anyone else in the family.


A few minutes later, the ED physician pushed back the curtain. "I give up. She can stay." The tall nurse came in grinning. "I told him he could not send her home." I cried with the relief of knowing I had time, if only a day or so more, to work out the options for the next, and possibly last, stage of Beth's life. Beth's admission, I realized, was solely due to the compassion of one nurse. Clearly the fractured eldercare system isn't designed to handle sudden changes in independence or to allow families the time to weigh unfamiliar alternatives.


During Beth's two-day hospitalization I had frank discussions with a case manager and with Beth, who was certain she'd improve enough to resume self-care. I had to tell her that she wouldn't, that the only option was a nursing home. She didn't want to hear it-but she knew I was right, and finally acquiesced. She died six days after she entered the nursing home.