Discharge Home to a Spouse Who Cannot Lift Him
A 68-year-old woman with C3 AIS C tetraplegia from a fall 6 weeks ago has completed acute rehabilitation. Her tracheostomy was removed, and she uses nocturnal noninvasive ventilation. She needs one person to assist with sit-to-stand transfers and two people for bed mobility. She wants to go home to her 72-year-old husband, who has knee osteoarthritis and a lumbar fusion and says, 'I'll manage.' Their house has two stories, a 28-inch bathroom door, and no ramp. Insurance approves 12 hours per week of home health aide. Her PHQ-9 is 14, and she says, 'I don't want to be a burden.' She is alert and has decision-making capacity.
1. What domains do you assess to determine whether discharge home is safe, and what is your recommendation?
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Assess mobility and transfers, bowel and bladder management, skin, respiratory status including nocturnal ventilation, medication management, home accessibility, equipment needs, caregiver physical capacity and availability, financial and insurance hours, and patient preference and capacity. My recommendation is not to discharge home as currently planned. Two-person bed mobility with a 72-year-old spouse who has knee osteoarthritis and a lumbar fusion is unsafe, and 12 hours per week is insufficient for a C3 AIS C patient using nocturnal ventilation. Options include more aide hours, home modifications such as a ramp, a main-floor bed and bathroom, and a 36-inch door, a trial home visit with training, or a supervised setting. Use a team conference and a documented home safety evaluation.
2. How do you address her PHQ-9 and her husband's statement?
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A PHQ-9 of 14 indicates moderate depression. Ask about item 9, suicidal ideation, as well as anhedonia, sleep, and pain. 'I don't want to be a burden' is a risk marker for depression and for unsafe caregiving. Treat with psychotherapy and an SSRI, mindful of autonomic effects, and involve the husband in a caregiver assessment such as the Zarit Burden Interview. His statement 'I'll manage' is a red flag: he may hide his limitations. Provide transfer training, respite, and a backup plan, and do not make him the sole caregiver. Also screen for adjustment disorder and cognitive effects. Reassess mood after discharge and ensure mental health follow-up.
3. If she insists on going home, what are the ethical and practical steps?
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She has capacity, so her preference carries weight, but autonomy is not absolute when discharge would create foreseeable harm to her or her husband. Convene a family meeting, document the risks and benefits, and offer alternatives. If she insists, create a safe discharge plan: increase aide hours, complete home modifications, place a hospital bed on the main floor, provide a commode, and write an emergency plan. Ensure the husband is not asked to do two-person transfers alone. Consider a trial home visit and a follow-up call. If there is evidence of neglect or the husband cannot provide care, involve social work and adult protective services as appropriate. Do not abandon her; continue outpatient follow-up and reassess.