Breaking the Readmission Cycle

Abstract

Breaking the Readmission Cycle Brian Hatten I want to share the story of my difficult patient Ms. L. She has twenty-seven current medical issues. Thirty-five active prescriptions. Limited mobility requiring the use of a motorized scooter. Non-medical care gaps. And over twenty hospital admissions since 2020. I met Ms. L approximately five years ago as her hospital attending and have continued to care for her during her frequent hospitalizations. I could recite this 77-year-old female's litany of medical problems. But sufficed to say, her history is complex, with her admitting diagnoses running the gambit from cellulitis to gastrointestinal bleeding to altered mental status. But, her diagnosis and frequent exacerbations of congestive heart failure (CHF) are particularly frustrating for us both and will be my focus today. CHF makes her susceptible to fluid overload leading to feelings of shortness of breath, which progresses to respiratory distress. Like other individuals with CHF, she uses diuretics to prevent herself from becoming fluid overloaded. And, like many individuals who take diuretics, she hates them. She (un)affectionately calls her water pills "the bomb" because the effect is sudden, profound, and explosive when they begin working. The combination of the diuretic effect and her limited mobility causes significant emotional stress for Ms. L, a woman who values presenting herself outwardly as in control, well-dressed, and put together. Her dislike of the medical effect of her diuretics has led to her either taking them less often or outright discontinuing them. So, while discontinuation avoids those frustrating effects, it leads to fluid accumulation, subsequent respiratory distress, and readmission to the hospital. Her medical records mention she has memory issues. It is unclear how much her mild cognitive impairment affects her frequent readmissions. We have had many conversations where I would never suspect something was amiss. But sometimes, she can be forgetful and does not recall our recent discussions. That being said, she knows the names and uses of her medications. She can report to me her home weights when she checks them and knows what her "dry" weight should be. Yet, she does not act when her scales begin reading heavier or when she develops leg swelling. Instead, she presents to the emergency department in extremis. When directly questioned about why she lets her situation deteriorate to such a state that she requires hospitalization, she demurs. She comments that she can often be stubborn, that the diuretic effect of "the bomb" is burdensome, but always reminds me she is honest in admitting she wasn't taking her water pills. During several admissions, I worried for her survival after she had self-discontinued her medications and showed up at the emergency department in respiratory failure. For any patient with recurrent admissions, I discuss their overall goals of care to ensure we are working together toward achievable medical ends. But this conversation was essential to have with Ms. L. The possibility existed that she would present to the hospital too late in her disease process, and we would not be able to correct her respiratory failure. I wanted to ensure that the hospital staff and I respected her wishes regarding her care. Despite raising my concerns, she would [End Page 22] decline to discuss her wishes. Even worse, attempting to have her complete advance care planning documents like advance directives or a Physician Orders for Life-Sustaining Treatment (POLST) form was a futile endeavor. Ms. L was always vague and non-committal. She simply did not want to engage in those types of conversations. When asked why she declined to discuss these issues, Ms. L would reply that she was doing okay, the discussion was unnecessary, and she had family members to make those decisions for her. Caring for her during her hospital stays was a source of professional frustration for me. Her recurrent admissions made me feel like I was failing her. During each hospital stay, we would go over her medications. We repeatedly discussed how she should check her weights daily and monitor for lower extremity edema. We created multiple action plans for when to call her physicians so we could head off another hospital visit. We completed all the...