Exactly what is expected to happen with a hip fracture that cannot be surgically fixed? Can it ever "heal?"

I am a hospice physician. I would like to say that you are not eligible for hospice services unless you have a prognosis of less then 6 months. We consider the patient and the patient's family as the unit of care. We provide the a nurse, nurse's aide, chaplain or spiritual counselor, social worker and a physician to each patient and their families. We provide 24 hours day, 7 day a week access to care through a phone number you can call and any of the previously mentioned providers can be called to come out and see the patient or the family. We also provide 13 months of bereavement care for the family. Hospice comes to wherever the patient is located nursing home, home, personal care home, or assisted living centers. We are an extra layer of care. A RN nurse is assigned to visit the patient at least once a week and then a LVN nurse usually comes a second time in the week (At least in our hospice). Then a home health aide is assigned to come out and bathe a patient at least twice a week. Most want at least 3 times a week. If the patient is having a hard time they can receive a RN or LVN visit daily especially in the last few days of life. Also there is a free to the family 5 days of respite care for putting stable at home patients in a nursing home for five days of rest so family members can rest. The there is continuous care for uncontrolled symptom management and in patient hospice care for symptoms that can not be managed by in home continuous care. The last two mentioned are for very specific symptom management and it is highly regulated by Medicare. It is not to be used for normal end of life care. You also get a social worker to help you with end of life care from anxiety in family and patient to planning a funeral or placement in a nursing home. They make an initial visit and then as needed visits. The spiritual care worker helps patients and families deal with spiritual issues around the end of life. They meet you where you are and can sit and pray with the patient and his family or coordinate spiritual care with your chosen faith. They visit initially and then as needed and you can refuse their visit. All medications related to the primary hospice diagnosis are covered by the hospice as well as medications related to pain, constipation, nausea & vomiting, anxiety & agitation. Most people who are in the last 6 months do experience pain and so yes we are aggressive at managing pain because it is not fair to die in pain even if you can not verbalize that you are in pain. The elderly often express pain in worsening delirium which means they see, hear and react to things other people can not see, hear and react to. As you age all your organs age including your stomach and your ability to metabolize medications in your stomach decreases. So giving your loved one more medications actually makes the patients stomach work harder at digesting them. So this means that a lot of the drugs and vitamins actually are not getting metabolized and are diminishing the amount of any of the drugs that are getting into the patients blood supply. It has been shown with study after study that the elderly medically fragile (anybody in a nursing home and almost anyone who is older then 65 depending on the person) need to be on less then 9 medications and that means over the counter medications and vitamins too. And most people in the last 6 months of life have lost enough weight that they no longer have hypertension and diabetes type II and therefore either need less of those medications and/or no longer need those medications. Most people who initially come on hospice have a "honeymoon period" when we stop excessive medications and the patient actually wakes up and is more cognizant and aware of there surroundings. We do not start pain medications unless there is some symptoms or source of pain. Most people in the last few weeks of life have pain as their body start to shut down and their muscles contract. We do not want you loved one to die. We just want to make sure your loved one is actually cared for appropriately. If you do not want to believe that I will talk about the economics of hospice. We actually do not want to kill your loved one because that would mean we can no longer be reimbursed for their care. (Medicare pays a set amount for every day you are on hospice. It covers the pay of all the caregivers, the director of nursing, the administrator, the pharmacy costs, the secretaries, the answering service, the physician etc. ) We have patients with varying length of stays some come on and die with in a day others come on and die 3 years later. Our hospice (Silverado Hospice) has a physician visit the patient with in 7 days of admission, to make sure the patient is appropriate and indeed has a life expectancy of less then 6 months if the disease was to run it's normal course. (This visit is not required by healthcare law) After the first 6 months patients are seen by a physician ever 2 months to re-certify that the patient's has a life expectancy of less then 6 months is the disease was to run it's normal course. (these visits are required by law) If the patient's illness has stabilized then the patient is discharged from hospice for extended prognosis. (life expectancy greater then 6 months) Our hospice location in and it has a census of about 150-160 patients with about 50 admissions per month and 50 deaths per month. We usually have 3-4 patients that we discharge per month for extended prognosis. We are happy to readmit them when their illness progresses again and that happens quite a bit, usually 3-12 months later. Medicare has strict guidelines that must be followed so the patient has to show decline each re-certification period (within each 60 day period). So that is what hospice actually does. We do not hasten death in anyway.

Oh my, that really is a bad medical situation. Once they decide that surgery can't be done, she will not be able to weight bear on the hip, but they should be able to let her sit up in a chair. Nutrition can be a factor in pressure sores when just turning and using a specialized mattress and other pressure relieving equipment fails. Osteoporosis might and probably should be treated medically, if she could not tolerate a bisphosphonate they could at least be giving some vitamin D and calcium +/- some ranitidine or a PPI. The heart failure is probably a major determining factor. You are right to plan to be assertive with hospice, that care is to be directed towards comfort and quality of life, but not to hasten death in any way. So sorry this is happening.

wow, Carolei, I guess I really forget about any other kind of surgery for hip fracture than I guess what you're calling implant, anyway, assuming that's what mom's was called a hip replacement, which is what she had, not sure I'd say her ball was actually broken off, just that they'd been saying she was deteriorated to bone on bone for 3 yrs. prior to her fracture and needed the replacement but her doctor wouldn't give her "clearance" for the surgery, either - until she had the fracture but she didn't have the heart issues, either, dealt with that with my dad but not a fracture, rather a gall bladder removal that they then just dealt with conservatively with a week of IV antibiotics, but hardly the same thing; just to ask - again - just to be sure - are you sure she would have to have real general anesthetic, as in a breathing tube; that's just what we assumed mom would have to have for her hip replacement but they said no, it was called "managed anesthetic care", that they didn't actually put them all the way to sleep, as in with a breathing tube, like dad would have had to have had for organ removal - so just asking, just to be sure, just in case you want to ask - especially since you're at a different, big city hospital, although mom's wasn't but still, assuming you got this info from the other place? not this one? or no...we had the kidney thing as well with dad, may have something to do with what caused all the other, at 60% month before, which isn't good, is it, but was just what it was, but going down to 30 by the next month sure isn't good and really concerned the kidney doctor and he put him on shots for it while he was in the hospital, but only then, not after he got out, but did start keeping a check on him, so his blood disorder doc thought he was keeping on giving him the shot, seems like from the way things were going, though, should have been obvious he wasn't - go figure... Anyway, mom was scared of surgery, too, but more of the anesthesia thing; she'd had issues with that before but she felt better after we, at least, found out, it wasn't going to be true general anesthesia - I'd really check into that. Especially with the complications of no surgery - that's what the doc of my friend's mom said re her not having it - that typically they do end up with pneumonia, and especially if your mom already has fluid on her lung. I'm just so glad you were able to get her to an emergency room, and apparently a good one, in the big city - I just didn't know how that kind of thing worked when they were in a nursing home under medicare, if you had any authority to do something like that or not cause, yea, can't believe - well, yes, I can, after learning what happened with friend's mom - finding out she'd actually fractured hip around probably 6 wks. before and they hadn't done or said anything - but still not a wound care appt. for another week?! like going to the doctor and being told you'd had a heart attack but not being sent to the heart center for that long - or maybe not - because, yes, it is unusual for an ER doctor to admit anymore, it seems, at least we've never had it done, and especially from a nursing home and especially when it wasn't the nursing home that had her sent to the ER but then again, like you said, and I'm proud of you, maybe that is why, under the circumstances and you explaining what was going on - kudos to you! - like said, don't believe my friend or a lot of people I know, even my dil, would do that - I never even thought about the weekend thing but come to think of it, dad did go in on the weekend as well and wound care didn't come until Monday but, frankly, that was the least of my concerns with him at that time but even his first go round when he had the debridement it wasn't done by a doctor but then it wasn't quite the same situation so maybe why; wow, interesting; I'm glad that thing has loosened up - shame that it had to happen but might have actually helped keep things from getting worse, especially now that I think about - your mom must be pretty good - thinking why my dad didn't have that happen the first time is he kept picking at it - was thinking about his getting infected and you not really saying much about that, was thinking the bed sores themselves would be prone to it, what with the concern re sepsis and all but really guess that's kinda something different, that it was more his picking at his that caused it to get infected rather than the wound itself, so that really is great that your mom apparently didn't do that, because I've gotten the idea that's fairly typical for older people but, like said, this last time, even without debridement it was horribly painful so, yes, I'm so glad you've got the pain people on board as well but are they allowing her to move that hip; they had my friend's mom's boarded to her other leg so she couldn't move it, for pain, but also that was after the surgery - at least I don't think it was before as well - so also so she wouldn't move it out of place (she wasn't able to get up at first like they normally have you do) so maybe that's why but I would think they would do it for pain control for your mom. I had somewhat wondered about the whole rehab/nh thing - though not sure you'd already mentioned it - if they weren't going to do surgery but then of course I think I was hoping, without really knowing everything - that they then might and really in a way, if you find out about this anesthesia, hoping they still might, but, yes, without, don't see how there could even be rehab, not for her hip anyway, if they don't do anything. Are you sure, though, the original nursing home - and don't have it all real straight where you are in relation to both places - once she goes back there - will follow through on this plan, seeing as how they're not the ones that helped get this set up in the first place? How will she make this trip? Have they told you she's supposed to be able to move her leg? Are you sure she's moving it or it's just moving on its own because it's not completely attached - but obviously not completely detached either, which, could that happen? not that, understandably, that's really been a priority lately with everything else that happened but now that you kinda have a plan - at least, that is, until they actually start and then it may not matter again, till they get through all that; just wondering where she'll be by then with the original issue; I I mean, I realize the other needs to be take care of but then what? which is really your question, isn't it? How does she seem to be with everything - I mean, besides feeling better, now that she's out of pain - which, btw, we ended up going through over the weekend ourselves, found out Sun morn hub's mom had fallen Friday evening and we were afraid she'd broken her arm so took her for xrays - thankfully she hadn't but still she'd been in pain and not able to sleep for all that time so understand that part - but now that she is out of pain, with what she thinks she'd like to do, as far as fighting, although I know you did say she's scared of surgery but it is really the anesthesia part, more so, right? at least that seems to be the usual; at least know it was with my mom. Don't think she was trying to hang on for my sake; no, at that time, she wanted it for her sake, but, in you mom's case, what is the unendurable? not being able to move her leg? is that really that bad? of course mom didn't have that, but if she hadn't fractured it and then been able to have the surgery, I'm not sure, might have been, but didn't face it with that, but did with other issues. I am wondering about what they say, though, if that's really the way it has to be but then, even if it is, still if it really has to be that way, not like there haven't been those in that situation. But, then, true, considering the other situations, thinking about her kidneys issues, in particular, not really sure why dad's kidney doctor put him on those shots, not really sure it really was about his kidneys; he called them blood building shots, that, as I think I understood, his kidneys either could cause something to happen there or really as I understood his situation maybe in a way he actually didn't - there's that falling through the cracks thing with the doctors whole scenario - his other situation was actually causing his kidney issue, although I know it could happen anyway, or maybe it was his heart; I know all that works together but either way not sure what might have happened had he continued to keep getting them but sure don't see how it could have helped anything him not getting them for almost a year, which, when finally did them started back up, they said it probably wouldn't do any good and it didn't so basically he did have nothing done for his kidney failure that whole year, like I'm getting the idea with your mom, although I believe they still said - even though they never said 80%, like said, I think maybe, for some reason, did get back up to the 60%, actually maybe with the shots in the hospital and maybe did stay there, though not sure how or why, but still think they called his stage 3, right at borderline stage 4, which have they told you anything about what that would normally mean and do you plan to try to find out about that discrepancy between those 2 doctors? something to think about there as well but then there is the time between now and then to decide how to handle - a lot on your plate - keep us posted how things go tomorrow when the wound doc comes in - I'm dreading that from here for you - hugs

I'll try to explain a few things that you questioned, debdaughter. The round "ball" part broke completely off of the leg bone (femur), so the only way to actually fix her hip is a hip implant. No other repair will work.........no pins, or any other less drastic fixes.........only an implant. She has osteoporosis in her pelvis and long bones. We were told that if they tried to push the shaft of the implant down into her femur, it's so deteriorated it would probably just shatter, unless they use an implant with a really long shaft----and that's a very lengthy, difficult surgery. There's no other way to do the surgery except by using general anesthetic, which is very risky for her. Her heart is only operating at about 30-some %. She is in congestive heart failure (I knew that), with fluid accumulation on her left lung (did not know that). The enzyme level that indicates heart damage (troponin) is elevated (also new knowledge), but not because she's had a recent heart attack. The cardiologist said it's because of the CHF. He said for her to have "clearance" for surgery, her heart would have to check out okay, and she has already "failed" that test. Even without the stress of surgery, her heart is already showing signs of stress (the troponin). So that's why no surgery can be done. Her heart and lungs would never withstand it. Also, her kidneys are impaired.........stage 4 renal failure is what one doctor said, another gave better numbers (said working at 80% efficiency) and I don't know why the conflicting reports, but I do know she went into renal failure 15 years ago when she had the heart bypass surgery and almost died. They've told us many times since, during various hospitalizations, that, whenever her body is stressed, her kidneys go into crisis, as they are so impaired it doesn't take much to push them over the edge. She is terrified of having another surgery, so in my mind, that would almost guarantee bad results. You never go into surgery in that frame of mind----it's certainly going to go poorly if you believe it will. So I've resigned myself to the fact that she simply cannot have surgery to fix the hip, but she must be protected to the extent possible from complications of full time bed rest while letting the hip heal. Some of the typical complications I've read about, that frequently cause death within the first year after a hip fracture are blood clots, pneumonia, and bed sores/sepsis. Well, she's already experiencing the bed sores, one of which is extremely bad. That was what prompted me to take her to the emergency department, to try to get wound care quicker than June 8th, the date the nursing home had scheduled her an appointment. Luckily, that worked. The ER doctor decided to admit her, which I'm learning was unusual. They said a bedsore is NOT justification for putting someone in the hospital, said they see bad bedsores all the time, but don't admit. I guess the ER doctor really went over and above to accommodate us. In fact, he said something to that effect, after I explained how things were falling through the cracks with the nursing home and her primary care doctor and the whole scenario. Luckily, I managed to convince him to admit her so wound care could see her when they came in on Monday (they don't work the weekend). The wound care nurse did see her his morning, and made arrangements for debridement by a wound care doctor either this evening, or possibly tomorrow. There's a huge eschar they called it over the wound, that has loosened up and will be fairly easy now to remove, then the wound will need debrided until only good pink healthy tissue is left. They tell me it will be excruciatingly painful, and that's why we agreed to let palliative care be a part of this whole treatment program. They'll be managing pain, both during the debridement as well as ongoing (including the pain she still has from the fractured hip, whenever it is moved). We thought we were going to get her admitted to a rehab facility in the same city as the hospital, where palliative care and wound care could both follow her, but she doesn't qualify---can't tolerate the minimum 3 hours daily of therapy. So back to the nursing home upon discharge from the hospital, but at least we've got it worked out for the two teams (palliative care, wound care) to stay involved and overseeing the important aspects of her care. She will have to make at least one trip per month to the city where they are located, though---a hardship on her, but can't really be avoided if we're to keep them in charge of this crucial care. If things really go downhill, palliative care can transition into hospice care, and then they can actually go to the nursing home to provide direct care. As I understand now, the hip will never heal, if heal means knit back together. The ends are just too far apart to ever come close enough for a callus (that's what they called it) to form around the broken ends to hold them together. Over time, it will stop being painful, but her leg bone will never be connected to her hip bone ever again. What I still don't understand is how she will move her leg, with it not being attached to the hip bone. It seems like she is still moving it (not really sure, haven't paid close attention to that), at least in some directions. She's in better spirits now that she's not in constant pain, and I assured her she could get through this current situation, but I also told her that we both know the day will come when all these health problems will eventually overwhelm her (all the doctors have talked in front of her, so she's heard just how bad of a state she's in), and I let her know that when she's weary and ready to journey on over to the other side, I will be okay....so she is free to leave, and I'll meet up with her later on. I don't want her to feel obliged to hang on, trying to endure the unendurable, for my sake. It feels like we are in as good a place as we can be, given this terrible situation we're facing. I don't look for her to last out the year, honestly, just based on all the medical issues she's got going on, but she's a real fighter and has always been a person of unbelievable determination. Who knows? Thank you for your kind words, and for your interest and concern. This is some HARD STUFF, trying to look out for our parents in their time of vulnerability and declining health.

so, Carolei, did you just have this done, as in the last 24 hrs. as I'm seeing by the times of your posting? I'm so glad you were able to; I was asking about the pay because, yes, I was concerned you wouldn't be able to do exactly what you've done with Medicaid paying; at least it has seemed to be that way with a friend of mine but then after this last situation I think I've decided it's just her; when I spent the night with her mom for her to get to go home and all they had in her room that she'd been sleeping in was a recliner when I knew they had beds in other rooms I went and asked (well, pretty much insisted) for one while she never had and said she never would have and anything they've told her regarding her mom she'd just say whatever they thought was best; fortunately her doctor's the one who insisted on the hip surgery for the very reasons you're dealing with and now I think you see why - having said that, my mom's doctor wouldn't clear her for hip surgery that she needed for 3 yrs. - until she fractured it - 3 yrs. of misery for her - but she was still up and mobile so didn't quite get into the issues you have - but didn't understand your mom's not healing - friend's mother, turned out, who was in nursing home before - actually had fractured her hip apparently approximately 6 weeks before and nothing was said about her fall that caused it but it had already begun to heal but wrong but still....so I didn't understand about the parts not being able to be put back together - (well, actually now that I say that not sure what he meant about hers healing "wrong" because that's exactly what I understood that why it was healing is because at that point they were still together so why was even healing) - because was until she fell again - which, that's another issue, because he'd said if she didn't have surgery - which, obviously she hadn't had before - she would have to be immobilized for 6 wks., which, again, obviously, hadn't been done before, which is probably what led to the 2nd fall, which did twist and rebreak the first one, such that then it wouldn't go back together without surgery so wondering if your mom's break was like that, in which case her doctor said she would be in pain that wouldn't go away, so where did this "forgone conclusion" of yours come from if not what he was saying? I also thought the Medicaid issue might have been why you weren't getting a second opinion from the nursing home - but apparently that was a doctor issue - again, know that friend went through that with her mom - still don't know why her doc told her he was going to order tests the very day turned out he turned out not to be there - but - maybe, since in her case, just one day - that something just came up but, yes, the one on call wouldn't do anything where in my case with my dad when his doc told me he wasn't going to be there over the weekend the doc who covered for him had actually been around longer he took over even more so than the regular - didn't like this that had been done, would cause infection, ordered it removed, didn't like this that was going on because of meds that had been ordered, ordered those stopped, etc. - wow - don't think the other doc liked it too much when he got back because wasn't long then till we were being discharged - same thing somewhat happened the next time he was in only was a different doc he had, even newer one, so sweet, felt so sorry for him, he was so apologetic when came in and said he'd had a vacation scheduled for something like 6 mos., first one he was going to have had since been there but really felt his family needed it the way he'd been working, thought dad was stable, everything be ok, practically asked me if I'd be okay with him leaving, so fine - and possibly would have been - except some things the icu docs were trying that somewhat expected to just be routine - but had been brought up might not be - turned out to not be - which led to some questions - which I was going to ask - but I see your statement that your mom is still fighting so do want to ask then - how was she through all of what she's gone through - but first how was she to begin with with not having the surgery on her hip? would have thought by that that she wouldn't have gone along with that to begin with - that's what icu doc thought at first about my dad, that that would have been his attitude - he couldn't actually tell us, though, because he'd been unresponsive, like what happened with friend's mom after her surgery, so we had different situations, but certainly not getting that idea from you re your mom, but in reality I didn't feel that was the case because of things he'd told me but also because of some things that had already happened not too long before all of that that that doc didn't know about and honestly hadn't slowed down long enough to ask - the last time he'd seen him he'd been far different so he was basing his direction on that but when he found that out along with what had happened with what he was doing everything began to change and the palliative care and hospice options began to be brought up although they didn't use the term palliative care, they just said hospice but the way they first brought it up later began to be begun to believe that's what was being talked about they just didn't know the exact different terminology to use; we could have not gone that route but they were saying he could no longer - at least not for much longer; he'd been in icu at that point a week - stay there; he would need to be transferred to a facility 2 hrs. away - how far away is your mom now? where we are we have a "larger city hospital" about a hr. away from where friend's mom was but for some of the reasons already stated we opted not to do that; we had also found that my dad had CHF that also collected fluid around heart or lungs - but not in his limbs, which seemed to throw the nurse - go figure, didn't understand that - and he already had a blood disorder that was making him anemic that I knew about but his new primary didn't and since the original docs didn't he hadn't gotten that info until he came after a while after he'd been in there; now his icu doc had at least somewhat known from before but then otoh not really sure he had gotten the word either, so, yes, also know about the "comedy of errors" thing - there'd already been that going on between him and his doc who did know, who, we'd found out, no longer came to that hospital from the time when he was in there before and did then and ordered tests that we thought had been sent to this doc but had found out they hadn't been and they never realized he thought they were suppose to have been - again, go figure, and we, too, also found out he had elevated cardiac enzymes being told then by the new cardiologist they'd also just gotten on staff that that indicated he'd had a heart attack within the last 10 days, which, ended up finding out he'd been found the day before he wound up in the hospital with classic symptoms but nobody had been notified until he then was found collapsed the next day. It did somewhat begin to be investigated and got pretty hairy there for a while and then when it happened again....and with this time, wound care being brought in....

okay, in case you don't read through all that - I'm hoping you'll skip down to this - PLEASE let us know what happens with wound care -
that was the worst part of what happened with dad - even with him being unresponsive he definitely responded to the pain from that because, yes, he definitely went through the same thing as far as the debridement - his tissues were definitely necrotic - but now, having said that, not entirely sure he was actually having debridement on necrotic tissues because seems like the necrosis came later after he'd been in the icu bedridden for a week but thinking they had one of those air mattresses on the bed in there and that he had the other stuff although his necrosis was mainly on his foot but hadn't sloughed off; what they were telling me would happen; don't believe anything about his calves; his main wound care was his back, which was draining - another thing -

ASK WOUND CARE - about microbial pads - that's what they used on my dad's draining back but they said they were a sample that had been given them by the company to try - not sure but what they said dad was the first patient they'd had to use them on and they loved them - they don't have to be changed as often - they're much more absorbent - so that they're not nearly so painful - BUT - they are more expensive for a hospital to buy - and hate to say, so don't know if Medicaid would be a factor or not - dad wasn't on it, but then like said they were samples anyway, so not even sure if the hospital decided to start buying them or not anyway although I did tell the CEO how so good they were - but would be so much better for your mom so PLEASE at least ask about them - and if they don't know what you're talking about please feel free to msg me or something and I'll get in touch with dad's hospital and find out more about them;

not really sure dad's back sore were actually that deep and down into the muscle but they were still painful enough - can hardly imagine what your mom may have to go through - but then actually not really sure he really was having to have actual debridement then - that may have come from yet another earlier incident where he fell and cut his head when we went to wound care on an outpatient basis and pretty sure they did then - would go in and pick out where it would be beginning to scab over, etc. but that wasn't nearly like somewhere where it would get down in your muscle, although even then it was painful enough, at least seemed to be at the time, but nothing like the back deal later that wasn't even like that but with the back he was having to be turned - and was being - every 2 hrs. - and even that was painful even when they didn't do anything else -

so are they even saying anything about the hip at this point at this new hospital or has that been "overtaken by events" as my husband would say?

but to go back I think they were trying to be careful at that point re pain meds especially with him being unresponsive otherwise especially because at that point they were still hoping he would come out of it even though it had been well past the usual 72 hr. time period by like probably double at that point; like said, had been a week, which seems to be why, at that point, they started talking about palliative and hospice and keeping him comfortable but also like said earlier we - well, I - somewhat based on things dad had already said based on his other earlier known conditions - which sounds like you didn't already know about these other chronic health problems they've found your mom to have, which we'd found out about them with dad 2 yrs. before - were past fighting mode -
having said that I was in your position - although not the exact same issues - with my mom with her hip - she wanted to fight so as long as she wanted to I fought right alongside her but...

my heart goes out to you with this wound care stuff though - it was bad....but necessary if she wants to get well - but maybe with palliative working with wound management on pain management she'll make it through and everything will now work out - hope so for you both -

let us know

I sincerely appreciate all those who responded to my questions, and I feel I was given some really good advice here, especially at a time when I was frightened and confused and not sure where to turn. Yes, I do realize that bedsores are preventable, but at the same time, the nursing home did in fact order an air circulating mattress, also brought in some various types of cushions and cushioning devices for her legs (Prevalon? boots, I think one of them was called), but on constant bedrest, made necessary by the fractured hip, and the fact that it took a week or 10 days for them to get these things ordered and delivered, things just got out of hand too quickly. Add in some break in physician coverage (her primary went on vacation, and the backup was reluctant to authorize anything new), no real direction at all from the ortho specialist, and lack of clear communication between the nursing home floor nurses, their wound care nurse, and myself, and it's clear how this situation went from bad to worse to tragic in very short order. My mom is now inpatient in a larger city hospital, and they have assured me I did the right thing by insisting she be brought there, as they are extremely concerned about the state of the bedsores, and have also found other serious problems, some of which I was totally unaware----fluid on her left lung (from congestive heart failure) and severe anemia. She also had elevated cardiac enzyme and another one that typically indicates blood clots (they called it D-dimer). All of this is being investigated. She was put on IV antibiotic, and is to see wound care first thing tomorrow morning. We met with their palliative care doctor today and it does sound as if they are going to work on pain management in conjunction with the wound care team, as wound treatment will include very painful debridement of deep necrotic tissue, way down in muscle tissue. I explained how all this came about to the palliative care doctor, and she said it almost sounds like a "comedy of errors, " not that there is anything funny about any of it, and unfortunately, my mom has inherited the cumulative results of all the different people who dropped the ball, in one way or another, from the aides who failed to turn her frequently enough to the doctor who left on vacation at a critical juncture in her care. We discussed discharging my mom to a rehab facility when she is ready to leave the hospital, that is part of this same health care organization, where she will probably stay for several months to (hopefully) get the bedsores healed, improve her overall health status, and get the fractured hip resolved as best it can be. So she won't be going back to the nursing home most likely, at least for several months, and possibly never. We'll just have to see how things go. Everything I read about the prognosis for elderly people with the types of chronic health problems she has who sustain hip fractures is very, very troubling. The palliative care doctor mentioned that their service begins when patients have the kind of problems my mom is having, but they can transition into hospice service if things deteriorate. I told her I am adamant that my mom not just be given higher and higher doses of morphine and Ativan as I've heard some hospice organizations do, to bring about terminal sedation. She appeared to understand that I will be closely watching to make sure my mom is kept comfortable, especially during the painful debridement procedures, but not be given more than needed to ease her on out of this world. My mom is still fighting, and as long as she has the will, then I plan to fight right alongside her.

carolei, I hope this all goes well, but I have a suspicion the second opinion may recommend referring her to Hospice. If bones won't heal and skin degrades into bedsores, time is short.

Medicaid is paying the nursing home, debdaughter...........curious why you are asking? Would it make a difference, somehow? Update: I talked with my daughter (smart girl, does medical coding so knows a little about medical stuff) and she has helped me reach a decision to have my mom taken to ER at a larger city hospital about 25 miles from here, to have pressure sore and entire situation evaluated. Maybe they will keep her and at least get her on IV antibiotics until wound care specialists can see her and hopefully get an action plan in place for the bedsores. I am scared to death that if things get postponed much longer, it is going to go so bad that she could lose her leg! :(

You and your Mom are in a difficult position. First, bed sores are never acceptable. There are specialized treatments to get these things to heal up. Including inflating/deflating air bags for the legs, resting is different positions, using of extra cushioning and pressurized chambers with pure oxygen; all of which may help. Secondly, sounds like the doctor did not expect her to live this long after the fall. But she stubbornly refuses to die. Living with a fractured hip is not living, and tack on pressure sores on top of it: miserable. I reviewed the literature out there and this seems to be the site that has the best explanation about the fracture itself for you: http://www.drugs.com/health-guide/hip-fracture.html . I don't think they want to talk about failed outcomes..these folk usually die of pneumonia or blood clots or other complications. I guess I'd get a second and third opinion from other orthopedic surgeons and a wound care specialist or two. I suspect the two potential outcomes are either get Mom in good enough shape to withstand the surgery or understand that her remaining time is going to be brutal until death finally takes her. Sorry to be so plain spoken, but you are in a real problem situation there.
As far as pushing the nursing home to act: put your demands in writing and send it certified mail to the nursing home. Report them to the agency that supervises nursing homes in your area for the pressure sores. Kick them where it hurts and keep kicking until you get what you need for your mom. They can kick you out I suppose but maybe that's not a bad thing. Bed sores are unacceptable. Start laying down a trail of paperwork. Every conversation should be in writing. If they only talk to you, the YOU write a letter back to them saying what they told you and insisting that if the letter is incorrect they send you written notice. iN other words, get your self prepared for legal action. Prays for you and your Mom.

She's in a nursing home that doesn't have a wound care doc who calls in regularly? Can you find a facility that does?

again, who's paying?

My mom id 89 yrs old and has a 91% fracture of the lumbar area of her spine. She's been told that another fall might cause her to be either paralyzed or wheel chair bound. It could not be fixed because her osteoporosis is so bad. That was over 2 years ago and while she was ambulatory with a walker for a few months afterwards, and had physical therapy, she has been totally ambulatory and without pain ever since. AND she is still non compliant about not doing things like climbing on the kitchen chair to get up in the cupboard...but that's another story about her personality. At any rate, I am not understanding why your mother cannot at least be up in a wheelchair? And I agree about getting another doc outside the facility and asking for a care conference and a treatment to address the bed sores. Bed sores are ONE thing that is really frowned upon in a nursing home by the authorities. You would have a place to complain to through the State Health Dept if you do not feel that nursing home staff....basically the RNs and the Director of Nsg or Supervisor of Staff are not seeming to be concerned. Whether or not they want to push the resident doctor there for equipment or supplies to help her, they need to do so....Medicare will pay for certain treatment and supplies if ordered by the MD who sees her there. If that MD is not being aggressive about treatment for those bed sores, and how to improve things so she can be out of bed, I would be getting another opinion from a private doctor outside the facility. I realize this is a can of worms, because then, it's possible the home will not want to order her meds through that consulting doctor and other things....it's best to get the two doctors to talk to each other after you've gotten an opinion from another. A wound that is going down into the muscle can cause a systemic infection that could increase your Mom's chances of dying too.

who's paying the nursing home?

Seems like I think of something after I think I've thought of everything.

I would also be requesting a care conference to discuss a thorough plan of action and contingency plans. If would help if you have another family member or friend, just to even out the numbers. Sometimes there are so many staff members they outnumber the patient's representative significantly.

Make lists of issues, proposed action, who will be taking it, interim results, and alternate plans of action. Put them on the spot, gently but firmly.

Bedsores: my mother developed one on her heel, it wasn't being treated by the SNF doctor who said "most of them heal on their own" and didn't do anything. We did some research and took her to a wound care doctor, but he was worse. We kept researching and eventually found a podiatrist who came to the facility and medicated the wound, which eventually healed.

I don't at all like the sound of your mother's bedsores or what I would consider negligence in allowing these to occur. She should be on a rotating pressure mattress and turned regularly and frequently. Or they can put inflatable calf cuffs on her lower legs.

I would find my own doctors, getting referrals from someone you trust and not rely on the nursing home. Try to find a reputable wound care specialist as well as an ortho doctor for a bone scan. That's a good idea to determine if anything else is going on.

Nonoperable hip fracture: If there are multiple other issues, I can understand that surgery would be dangerous. I'm not a medical person, but it seems that if the fracture isn't set, it would heal in the position it's in. But i don't have any experience on this issue. My mother was, however, on nonweight bearing status for 6 weeks because of the nature and position of her fracture. It's been about 15 years and I don't recall what kind of PT she got, but if she did get it, it was in bed.

If the fracture isn't healing, the consulting ortho doctor should at least advise you what will happen. I'd search for someone outside the nursing home and get a second opinion.

I think sometimes it's easy to feel that the doctors at the rehab facility can be relied on and you don't need your own doctors. We learned quickly that's not the case. (I also caught one defrauding Medicare; we documented, I reported him, and Medicare eventually did concur with my finding.)

And BTW, I'd be documenting all the conversations and interaction you have with the medical staff. I hope I'm wrong, but I see problems on down the line.