What Are We Going To Do With Dad?

Every Medicare patient has coverage for 100 lifetime SNU days if the criteria outlined in thousands of pages of regulations are met. Past the first few weeks or so, these criteria usually can no longer be satisfied -- not because the patient recovers; very few get well in the SNU -- but because the patient is "no longer making progress." No documented progress, no Medicare reimbursement.

Much of the time, there is no "progress" except toward the grave. And the next way station is chronic custodial nursing home care. Family members will soon discover, if they haven't already, this essential fact: There is no Medicare coverage for long-term custodial nursing home care. Unless, of course, an elderly loved one is destitute, in which case he might qualify for some state-sponsored Medicaid assistance.

And typical of our government, even as many medical practitioners are using SNUs more and more in answer to the "What are we going to do next?" question, Medicare has cut the reimbursements to these units drastically (but not decreasing the benefit to the patient, of course, which might anger the consuming public). As a result, many hospitals are closing them. My own unit shrank to half its size before being shut down by its sponsoring hospital last year, even as I was working on this article. Although the CEO told me that this was done because my hospital needed more "acute care beds" -- certainly true -- closing the SNU coincided with the change in Medicare reimbursements that made it financially advantageous for acute care hospitals to jettison SNUs in favor of more acute care beds.

Three years ago my father, a longtime heart patient, was admitted into the hospital with congestive heart failure. This is the hospital in which I have made rounds almost every day since the mid-1970s. The CEO is my friend and patient. My father's physician is one of my young associates, well trained and eager. I was confident that my father would receive the best medical care available in America today. Yet I would not leave him alone in his hospital room. If my brother or mother or I could not be there, I had a hired sitter by his bed.

It's rarely talked about, but hospitalizations are the most dangerous times for the elderly. Even if they have never manifested any signs of disorientation, it is in the hospital -- in a strange and threatening environment, under the influence of anesthetics, pain pills, anti-emetics and soporifics -- that many elderly will meet their match. Add to this the treatment mishaps (caused by the "normally expected" side effects and complications of standard medical procedures) and the human errors (mistakes in drug dosing, the right medication given to the wrong patient), now multiplying in our modern hospitals like germs in a Petri dish, and it is almost a miracle that any elderly patient gets out relatively unscathed.

Every night, I slept in the reclining chair by my father's bed. I got up when he did; ran interference with bedrails, side tables and IV poles; guarded his every move to the bathroom; looked at every medication and every fluid-filled bag plugged into his arm. Yet each day, my father descended deeper into paranoid confusion. He was restless, and intermittently unsure of who I was. At first I could calm him with my voice, talking about the old days, reminding him of our fishing trips on the Chesapeake Bay when I was young. Then he needed the physical reassurance of my hand on his arm or shoulder at all times. Finally, so that he could get some rest, I got in the bed and held him, comforting him as he once -- in a long-ago life -- did me.

After four days and nights his doctor told me that his heart failure was better and that his dementia evaluation did not show a treatable or reversible cause. But he didn't like the way my father looked -- agitated, sleep-deprived and deconditioned, a perfect candidate for time in the SNU. And, after all, here I was, his senior associate, the SNU medical director. Surely, my dad would get good care there.

Instead, I took my father home. I knew that if I didn't get him out of the hospital at that moment, he would never come home again. The SNU would have been a way station to a custodial nursing home. I arranged for a home health agency to provide my father with physical therapy and to assist him with his bathing, dressing and grooming -- something Medicare covers, but for only a limited period.

I went to the pharmacy and filled the eight prescriptions he was given as he left the hospital. Then, when I realized that my mother was having trouble reading the labels and following the instructions, I went back again to buy a plastic container divided into daily dosing compartments. How long, I wondered, had this been going on?

When I visit my father these days, if he is not asleep, I sit down beside him and talk at high volume into his hearing aid, if he has remembered it. Our conversations go something like this:

"How are you feeling today, Dad?"

"Not so good. You ought to come around more often."