Severe Neglect, Anosognosia, and a Discharge Plan That Won't Work
A 69-year-old retired teacher is on hospital day 3 after a right MCA infarct. NIHSS is 12: dense left hemiplegia, severe left neglect, and striking anosognosia. She lives alone in a two-story house; her only daughter lives 3 hours away. Before the stroke she was fully independent - driving, managing her own finances, and gardening. She is medically stable, saturating 97% on room air, with a nasogastric tube for dysphagia and urinary incontinence. Physical therapy documents that she cannot sit unsupported and requires two assistants to transfer. She says she 'feels fine and wants to go home tomorrow.' The daughter wants 'the best rehab available.' The case manager asks you to sign a plan discharging her to a skilled nursing facility.
1. What post-acute setting is appropriate, and how do you reason through it?
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Home is not safe, and neither is an automatic SNF placement - this needs an inpatient rehabilitation evaluation.
Reasoning across options:
- Home: she cannot transfer, has dense neglect and anosognosia, an NG tube, and no local caregiver. Discharge home tomorrow would be unsafe, and she cannot reliably recognize her own deficits.
- Inpatient rehabilitation facility: she is medically stable and plausibly has rehabilitation potential. IRF criteria require the need for intensive therapy (generally 3 hours/day, 5 days/week), 24-hour rehabilitation nursing, physician oversight, and a reasonable expectation of measurable improvement. An NG tube and incontinence are not exclusions; inability to tolerate 3 hours of therapy may be.
- SNF: appropriate if she cannot yet tolerate intensive therapy or if an IRF bed is unavailable; she can transition to IRF later.
- LTACH: no ongoing complex medical needs at present.
The decision should be made by the therapy team after a formal tolerance trial, not by the case manager's default, and it should be documented with functional data.
2. She insists she is going home tomorrow. How do you handle the anosognosia in safety planning and goal setting?
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Do not argue with the denial of deficit; work around it and test capacity formally.
- Anosognosia is a neurologic deficit, not stubbornness. Confrontation produces resistance, not insight.
- Use objective, self-referential demonstrations: ask her to stand, walk, or prepare a meal in a safe simulated setting, so the limitation becomes visible to her. Videotape with consent if your program does so.
- Build external safety structures that do not depend on her insight: supervision, locked kitchen, removal of car keys, medication management by a caregiver, and a plan for the stairs.
- Treat the neglect actively: visual scanning training, limb activation, cueing to the left, prism adaptation if available, and staff cueing to attend to the left side during ADLs.
- Because she rejects the recommended plan, formally assess decision-making capacity for discharge. If she lacks it, proceed through the surrogate (daughter) with the state's process; document your reasoning either way.
- Set goals in functional terms she can accept ('shower independently with one person'), not in diagnostic terms.
3. What are your clinical priorities for the next 5–7 days? Choose three and justify them.
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Choose based on what changes outcomes within this admission.
- Venous thromboembolism prophylaxis. She is immobile with a dense hemiplegia. Use intermittent pneumatic compression plus pharmacologic prophylaxis once the infarct is stable and hemorrhage has been excluded; recheck the plan if a nasogastric tube is placed or if swallowing changes.
- Shoulder and positioning care. Support the flaccid left arm in neutral, avoid overhead pulleys and pulling on the arm, and prevent dependent edema. Prevent contracture in the wrist, hand, and ankle with positioning and splints, and start range of motion early.
- Swallowing and nutrition. Keep NPO until a formal swallow evaluation; do not rush a diet upgrade because a family member is anxious. Reassess in a few days, because a nasogastric tube is a bridge, not a destination.
Also address depression screening (she is at high risk and less likely to self-report), bladder and bowel continence training, and family education for the daughter, who will be the long-term support. Spasticity intervention with chemodenervation is premature now; positioning prevents the deformity that makes it worse later.