COPD Discharge With New Atrial Fibrillation: Patient Refuses SNF, and a Duplicate Antithrombotic
Mrs. K is a 74-year-old retired teacher, hospital day 3 for a COPD exacerbation. She also developed new atrial fibrillation and was started on apixaban and metoprolol. She needs 4 L/min oxygen to keep SpO2 at 90–92%; at home she used 2 L/min. She lives alone on the second floor of a walk-up apartment, uses a rollator, and her daughter lives out of state. Physical therapy reports she walks 30 feet with a walker and then must rest; occupational therapy reports she cannot safely negotiate stairs. She is alert and oriented, declines a skilled nursing facility, and says, "I've lived alone for 20 years; I'll manage." The case manager has a SNF bed 30 miles away available today. On review, she tells you she takes "a baby aspirin every morning for my heart" and has continued it in the hospital.
1. Which disciplines need to be involved before discharge, and what specific information does each need from you?
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Each discipline needs the finding that changes their plan, not the whole chart.
- PT/OT: current distance, rest requirements, and the stair assessment - they drive equipment (walker vs rollator), home exercise, and whether home PT is feasible.
- Case management/social work: functional status, oxygen requirement, absence of local support, insurance/day status, and the patient's stated preference, so options besides the 30-mile SNF (home health, assisted living, PERS) get put on the table.
- Respiratory therapy and the oxygen supplier: the order must be rewritten for 4 L/min with a target range, plus portable tanks and enough tubing for a second floor - an unchanged "2 L" home order is a readmission waiting to happen.
- Pharmacy: full reconciliation, especially the aspirin-apixaban overlap, plus affordability and adherence packaging.
- Home health: skilled nursing, PT, and oxygen safety assessment in the actual apartment.
- Prescribers (pulmonology/cardiology/PCP): follow-up timing and the anticoagulation and rate-control plan.
- Dietitian: nutrition and weight status if intake has been poor.
2. She refuses the SNF. How do you proceed?
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She is alert, oriented, and has decisional capacity - this is an informed refusal to be respected and mitigated, not overcome.
- Explore the reason first: cost, fear of losing independence, pets, distance from her daughter. The objection often suggests the workaround (e.g., home health plus a stair plan; a closer facility).
- State the risk plainly and specifically: "You cannot currently get up those stairs safely, and a fall on apixaban means a serious bleed risk." Then ask what she would need to feel safe.
- Build the safest possible home plan: home health nursing and PT, a stair-negotiation evaluation, durable medical equipment, personal emergency response system, daughter engaged by phone with permission, oxygen supplier delivery and instruction, and a follow-up contact within 48–72 hours that does not depend on a 30-mile drive.
- Give her the red flags in her own words: worsening breathlessness, palpitations or chest pain, bleeding, a fall, or inability to manage stairs means call - with a number she can actually reach.
- Document capacity, the options offered, the risks explained, her refusal, and the plan agreed upon. Notify the provider and the case manager. This is shared decision-making with documented risk mitigation, not persuasion.
3. What is the medication concern, and how should it be resolved before discharge?
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She is on apixaban plus daily aspirin, which is dual antithrombotic therapy and a substantial bleeding risk for a 74-year-old who uses a walker and lives alone on a second floor.
- Do not simply remove the aspirin. Combination therapy may be intentional if she has a recent stent or established vascular disease, and stopping it unilaterally could cause a thrombotic event.
- Verify the indication: check the history for coronary stenting or prior MI, then call the prescriber and state the concern directly ("apixaban 5 mg BID plus aspirin 81 mg - is aspirin still indicated?") and obtain a clarified, documented order either way.
- Reconcile everything else at the same time: the home oxygen order (must reflect 4 L and a target range), the new metoprolol (teach pulse checks and orthostatic precautions), and any inhaler changes with correct technique.
- Teach bleeding precautions in plain language: report black stools, unusual bruising, nosebleeds that will not stop, or any head strike - the last is critical on an anticoagulant after a fall.
- Use the pharmacist as a second check on interactions and cost, and send the reconciled list to home health and the PCP.