Discharge Planning After Amputation: Medicines, Stairs and Two Wishes
Hiroshi K, 68, was diagnosed with type 2 diabetes 18 years ago. He has end-stage renal disease on haemodialysis three times a week, peripheral arterial disease, and had a right below-knee amputation six days ago. His medications include insulin glargine 18 units at bedtime, glimepiride 2 mg before breakfast, and 12 other drugs. His HbA1c is 6.4%, and he has had two hypoglycaemic episodes on the ward this week (2.8 mmol/L and 3.1 mmol/L). He lives with his wife, who has rheumatoid arthritis and cannot lift him. Their house has four steps at the entrance, a bathroom on the second floor, and no lift. His MMSE is 22/30, mostly because of memory and attention. He manages his own insulin injections but often forgets whether he has taken his morning tablets. He wants to go home; his daughter, who lives 90 minutes away, wants him to go to a rehabilitation facility. A discharge conference is scheduled for tomorrow.
1. Identify and rank the medication-related risks, and state what you would raise at tomorrow's conference.
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Ranked risks:
- Glimepiride is the most dangerous item on the list. A sulfonylurea with active metabolites accumulates in severe renal impairment, and it is contraindicated in severe renal dysfunction - he is on dialysis. Combined with insulin, it is the most likely cause of the 2.8 mmol/L episode, and hypoglycaemia in a dialysis patient can be prolonged and fatal.
- The glycaemic target is wrong for him. HbA1c 6.4% is over-treatment for a 68-year-old with end-stage renal disease, an amputation and cognitive impairment. Guidelines for frail older adults with serious comorbidity accept roughly 7.0 to 8.0%, sometimes higher. Tight control buys him hypoglycaemia, not protection.
- Insulin dose must be reviewed around dialysis days - clearance and appetite both change.
- Memory and attention problems plus a 14-drug regimen make double-dosing of tablets and missed insulin realistic. His wife must be able to supervise.
- Twelve other drugs need reconciliation: look for NSAIDs, contrast, and anything renally cleared or causing orthostasis and falls.
At the conference I would ask the physician to stop or replace glimepiride, set an explicit HbA1c or glucose target, and simplify the regimen - a nurse cannot change the prescription, but advocacy is the nursing intervention. I would also ask for a pill organiser, a single pharmacy, a written schedule keyed to dialysis days, and teach-back with his wife before discharge.
2. Reason through the discharge destination: he wants home, his daughter wants a facility, and the house is not accessible. What is your position?
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First, establish capacity, not just the MMSE. An MMSE of 22/30 does not by itself remove his right to decide where he lives. Capacity is decision-specific: can he understand the options, retain the information, weigh the risks and communicate a choice? With support and repetition he may well be able to, and that assessment should be documented before anyone plans over his head.
Then be honest about the risks at home: four entrance steps with a wheelchair or prosthesis, a second-floor bathroom, and a wife with rheumatoid arthritis who cannot lift him. Discharging him to that house tomorrow would predictably produce a fall - possibly on the steps, alone with his wife.
But 'unsafe today' is not 'unsafe forever'. The question is what would have to change:
- A temporary rehabilitation admission of a few weeks to build prosthetic tolerance and transfer skills - which also meets the daughter's concern without overriding his wish.
- Home modification: a ramp, a commode and bed downstairs, grab rails, a shower chair; application for long-term care insurance (介護保険) and a physical disability certificate.
- A care manager, home-visit nursing for wound and insulin support, and outpatient rehabilitation.
My position: aim for home, but only via a realistic interim plan. Present the options with the risks and let him choose; the daughter's view is information, not authority. Document the discussion and the agreed review point.
3. Design the teaching plan and say how you will know it has worked before he leaves.
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Content, limited to what keeps him alive at home:
- Hypoglycaemia recognition and treatment - sweating, tremor, confusion, and a plan: 15 g fast-acting carbohydrate, recheck in 15 minutes, and what his wife should do if he is drowsy. This is the first priority given two episodes this week.
- Which medicines changed and why, so he does not revert to the old regimen; a written schedule with dialysis days marked.
- Insulin technique with his actual vision and hand function - check him drawing up and injecting, not just talking about it.
- Stump and prosthesis care: daily skin inspection, what redness or breakdown looks like, who to call.
- When to call for help and the contact numbers, written large.
How I know it worked - teach-back, not 'do you understand?' I ask him to show me the injection and to tell me, in his own words, what he would do if he woke at 03:00 sweating and shaky. I include his wife in a separate session, because she is the one who will find him. I ask him to sort his medicines into the organiser unaided.
Limits and follow-up: with memory and attention problems, one teaching session is not enough. I would schedule a repeat session, involve home-visit nursing from week one, and set a review date - the planned medication changes make the first two weeks the highest-risk period.