In which patients, not doctors, get a vacation from the hospital

Let’s talk about the idea of going on vacation from the hospital. Not for the doctors, but for the patients.

Every morning here in Whakatane we start our day with a group round. In the lounge room at the end of the hall are about twenty chairs surrounding a large table. Sometimes the table will have an unfinished puzzle sitting on it, worked on by patients and family members. At times the TV in the lounge (the only one for patients on the wards) will be turned onto the morning news show and we’ll switch it off. Just before 8 am, in file the rounding doctors for the day, the residents on duty, Nurse Managers, Social Workers, Physical and Occupational Therapists, Maori Health representatives, Respiratory Therapists, and Pharmacists. We go through the patients who are in the hospital with brief presentations so any of the support staff who need to see the patient are aware of them and their needs.

On the Friday of the first week I started working, we gathered for our usual morning rounds. About halfway through going through patients, we came to Mrs. Smith. “Mrs. Smith is going on leave this weekend,” reported her doctor that day.

“Leave?” I thought to myself. “I must have misheard.”

But, no, on he went and there was another patient who was also going on leave, which meant they were given enough pills from the hospital dispensary to take what they would need for the weekend and then were going to go home for a few days and come back on Monday for a reassessment. The physical and occupational therapist sometimes would go to the patient’s house with them to see where the deficiencies lay or at least reconvene on Monday for a discussion to see if they needed additional equipment or support.

Since then I’ve learned this is a commonplace occurrence. I had a patient who was ill with an infection and required IV antibiotics every eight hours. He was improving but still needed IV medication. On Friday, when I saw him, he asked, “Do you think I could go to church on Sunday? I usually play the organ for the choir.” I couldn’t think of a good reason why not, and off he went on Sunday between doses.

Other patients I’ve had have gone on leave as well while they wait for procedures that we can’t get easily as outpatients. A prime example is an echocardiogram, or heart ultrasound. An outpatient echocardiogram can take between one month to a year depending on how urgently it’s needed. Even at our facility we can only get them on Tuesdays and Fridays, and only four can be done on those days. If someone is generally well on say a Wednesday but really needs the test sooner than a month, we will keep them in the hospital but let them go on leave for times so they’re not stuck in their rooms.

I had another patient who was quite ill, also with an infection and was less stable, with worrisome kidney function and so weak he was unable to walk. However, his grandfather with whom he was very close had recently died, and the three-day funeral was starting the next day. Could he go on leave for the funeral activities?

This is utterly unheard of in the US, at least where I used to work. (If you’re a US based doc and this is a normal thing for you, please let me know, I’m curious.) The reasons are vast, starting with litigation. God forbid if something bad happened to someone while you’d let them leave the hospital, you would guarantee a lawsuit even if you’d gone over potential risks beforehand. People here also seem to have more family around who are able to help and stay with their loved ones – there almost always seems to be at least a few (and usually quite a lot) family members who live locally and help out regularly. We also have midlevel facilities in the States, which we don’t have here, called Skilled Nursing Facilities (SNF for short), for patients who don’t necessarily need hospital-level care but aren’t quite well enough to go home. Length of stay in the US is also typically pretty low because of that and because of financial pressures, so you’re in the hospital only as long as you can’t get the same level of care somewhere else, and then off you go. There is a stark dividing line between home and hospital – either you’re sick enough to stay in the hospital or you’re well enough to go home, and if you’re in between, then off to a SNF you go.

I get that mentality, and it took me a while to get used to the idea of leave, but I’ve grown to see it as an excellent idea. Sometimes, elderly people who seem highly dysfunctional in an unfamiliar hospital environment will do far better in their own space, where they’ve likely adapted their surroundings to work for them. A trial of a few days with family supervision seems far preferable than making a permanent decision of nursing home placement directly from the hospital setting.

It can be mentally healing as well. I had one patient who had not been doing well from a mental health standpoint. He’d been quite depressed in the hospital and just not getting much better. It looked like he was heading for permanent nursing home placement as he couldn’t get any stronger. His family said that if he could just go home for a few hours, sit on his couch, pet his dog, he’d be much improved. Despite my American doctor sensibilities, I acceded to their request. You know what? They were right. He came back with new enthusiasm and was able to be discharged home the next week.

For my patient who wanted to attend the funeral despite his own serious illness, it was clear that to miss the funeral would be something he would regret forever. Despite the risk, his family was able to arrange wheelchairs and transportation and he was able to attend at least for a few hours daily. Could something bad have happened? Sure, but we talked about the risks, he and the family accepted. Again, they made sure to time their visit around his medications so no doses were missed or late. It’s not a medically litigious society and people overall are far more comfortable with understanding that they’re taking a risk and living with it. I see some decisions like this as working with people to address other needs than just the physical, which overall impacts health.

I know this isn’t something I’ll be able to do at home, it’s just not accepted practice. But I have to wonder for people who are in the hospital for long periods of time whether a little break, a little return to normalcy and the outside world doesn’t provide a lot more benefits than I can give through an IV line.

-s

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