Discharge Planning After Hip Fracture With Conflicting Family Wishes
Mrs. A is 78, five days after ORIF of a left hip fracture. She lives alone in a two-storey rural home 45 minutes from the hospital, uses a walker, and has mild cognitive impairment (MoCA 22/30). Her daughter lives three hours away and wants her placed in long-term care; Mrs. A insists on going home. Home care can provide two personal support visits per week and no physiotherapy for six weeks. She takes apixaban, metoprolol, and acetaminophen; her only pharmacy is in town and delivers weekly. There are uneven steps at the front door, no grab bars, and a bedroom upstairs. The team must decide today whether to discharge tomorrow or delay. She scored 22/30 on MoCA last week and sometimes forgets her apixaban dose. The physiotherapist reports she needs supervision for transfers and has not yet climbed stairs.
1. What is the priority discharge-planning action, and why?
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The priority is not to choose home versus long-term care by opinion; it is to obtain an objective, in-home functional and medication-safety assessment before discharge. Mrs. A needs supervision for transfers and has not climbed stairs, so the current home is not yet proven safe. The nurse should arrange an OT/PT home visit, confirm who will manage apixaban (blister pack, delivery, supervision), increase home-care visits, and discuss interim options. This respects her wish to go home while meeting the duty to discharge safely. A capable patient may accept risk, but the team must first know and document the actual risks. Delay discharge if the assessment cannot occur tomorrow.
2. The daughter demands long-term care and says her mother is unsafe. How should the nurse respond?
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First clarify whether Mrs. A understands the risks and can weigh them; capacity is decision-specific. If she is capable, her refusal of long-term care must be respected, even if her daughter disagrees. The nurse should hold a family meeting, explore the daughter's fear and caregiver burden, give concrete information about home supports and warning signs, and involve social work. If Mrs. A lacks capacity for this decision, follow provincial substitute decision-maker rules. Avoid siding with the daughter or coercing the patient; document the discussion and the plan for reassessment.
3. List the minimum home supports that must be confirmed before discharge.
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Minimum supports include increased personal support (at least daily initially, not two per week), a medication plan for apixaban with delivery and supervision, main-floor sleeping and bathroom access, grab bars or rails, physiotherapy for stairs and transfers, hip and wound follow-up, ordered bloodwork, an emergency response plan, and a named contact. Confirm the pharmacy delivery and a plan for missed doses. Without these, discharge tomorrow is unsafe; a short interim assisted-living placement may be the least restrictive alternative.