How do I do an "ER Dump"?

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How do I do an "ER Dump"?

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As awful as it sounds, I'm considering doing an "ER dump" :(

Previous post here: https://www.agingcare.com/questions/grandma-is-in-terrible-condition-and-refuses-to-allow-anyone-to-help-cant-aps-do-more-459712.htm?orderby=recent&page=1�

Grandma lives alone in NY state. She is 83 and we do not know her finances. She is refusing help at home, and it's not safe for her to be home anymore without any help. It's been several months of outright playing games and her refusing home aides, volunteer shoppers, and doctor appointments. No one thinks she should be at home without help. She has an APS social worker, but this has not been very helpful lately. The neighbor, Maureen, might have been given proxy. Maureen agrees that she cannot remain at home without help, and we are trying to make a plan. She cannot move in with anyone.

How do I do an "ER dump"? What do I need to know?

Should we wait until she is having a "bad day", is ranting, undressed, and unwashed, and has allowed herself to be completely out of food, and then call for a welfare check... and just hope they transport her to the hospital? Will they?

Do we need to wait until she falls again and is transported to the hospital, or can we instead have someone drive her to the ER for one of her many legitimate medical complaints?

If she is transported to the hospital, does she actually need to be admitted? Or at this point can we just say that no one is able to come back and pick her up, and she is not safe at home alone ("unsafe discharge"?)

Would the hospital arrange for transportation for her to get home? Will they allow her to get in a taxi?

Once she is at the hospital and everyone refuses to pick her up, then what happens...?

Thank you all. I'm sure this is a difficult and controversial topic, but I would greatly appreciate any personal experience, "how to" advice, or other information. I'm so exhausted and heartbroken. I think we either do this now, or all go crazy until she really injures herself and this happens anyway in one way or another in a few weeks or months.

Care Decisions Hospital Refusing Care

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The thing to understand here is that until Grandma is declared incompetent, no one can help her. She has to voluntarily say "I need help; yes, let my family help me". If she is intransigent and saying that she is fine, she gets to have her own way.

In these kinds of situations, I advise that family step WAAAAAY back and say, "fine mom, have it YOUR way".

When the SW tries to lay a guilt trip on you about how they will get YOU help you tell them "this is NOT about ME; I'm not in a position to help anyone; additionally, she will not ACCEPT our help or ANY outside intervention. GRANDMA needs help and intervention from the STATE or some entity that can force her into care." (End of sentence; don't respond to any more pleas from SW)

This is GRANDMA's choice. Let her have it.

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You always know the right thing to say Barb!

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If she calls in the middle of the night, say "call 911 grandma". I'm serious. She cannot have it both ways.

Turn your ringer off when you go to bed.

About incompetence. As CM says, there is a very high bar.

I would call the APS social worker (and have neighbor call as well) and tell them that she is a vulnerable adult who is refusing all offers of aid and is self neglecting to the point of malnutrition. Tell us that you are stepping back from any and all attempts to assist.

Stop going crazy. Tell neighbor to tell grandma calmly that she is resigning as healthcare proxy since she won't accept any assistance.

This is grandma's choice.

In my own family experience, folks who trust and cooperate get good medical care and have good outcomes.

Stubborn "feisty" people who think they know it all get crappy medical care and die miserable deaths. In the end, there's not a d@mn thing you can do about it.

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My mom was resistant to care and I almost stepped away to let her fail. But in the end I couldn’t bring myself to do it because I knew she was mentally not competent. She was simply unaware of her deficiencies and inabilities to care for herself. ERs were not helpful to me. We had many ER visits for this or that and she was sent home pretty quickly. But once she got admitted to the hospital that’s when I was able to 1) Beg for a social worker 2) assert strongly she was an unsafe discharge 3) get a Dr order to admit to a care facility that I had already picked out. The hospital discharged her to this care facility in an ambulance with a hold order on it meaning the ambulance could not stop and let her out if she said she wanted out. She was rolled into the facility in a wheelchair. This is the short version of my story. Not all details are here. But I will say that with proper care and medications mom is much better now. The first 3-4 months were rough. But now it has been 7 months and she is a different person. She is happy and seems to have settled in there. I have peace of mind that she is safe and cared for. No more emergency calls in the middle of the night. I’m glad I didn’t walk away.

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You pretty much have it right. Call when she is in need of help and out of control. Apparently, I am guessing, there is no diagnosis? But she is unsafe at home? Basically you both call the Ambulance and tell them you have found her in an unsafe condition (if this is true). She gets to the ER. You tell them right away that she is not rational and is unsafe at home (if this is true). You tell them that you will not accept her into your home, and that a discharge home is unsafe for her, and that they will be held responsible if they do this. She will then be admitted and evaluated. Her Heatlh Care Proxy will be informed of the findings. The findings will either be that she is safe on her own and they will discharge (then they should not have your consent to this, nor your agreement that you will follow up in any way; in fact you will have to say that you are unable to follow up in any way). If they discharge her, saying she is safe, then that's that. She is deemed by the medical system to be safe. IF you are doing all this then it is clearly as a last resort. If there is any other option you and health care proxy can try I am assuming it has been tried. The Social Workers will now do anything, including moving heaven and earth to get you to take her home, to agree to daily visits and they will tell you that they can help you and that you will do this together. They can't really help you, and I am imagining you already know this.
Again, the ER Dump is the last ditch effort when an elder is not safe, is not caring for herself, and refusing care, when there is no one who can safely care for her (the phrase is "I am neither mentally nor physically able to do this). You do need to understand that refusal to do the care, to "cooperate with them" does mean they may seek guardianship over her. If this occurs you will have ZERO input on where she is placed, including even the area. You will have relinquished any right to participate in her care either physically or financially.
So again, this is the last ditch effort to get care for someone you cannot care for, and someone who is refusing care. It is not to be lightly done.

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Well said.

I just want to reinforce that you should not let anyone talk you into taking her home. You have already been through it and you know the situation. Don't take her home even temporarily for any reason because you will be back to square one at that point and no one will return your calls! Please don't agree to home helpers because it will not be enough and you won't get what they are promising you - not to mention that your grandma already doesn't like outside helpers. Tell them you are unable to assume care and you are not aware of anyone else who can.

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Yes, wait until she falls again and then for heaven's sake do not get involved in bringing her home. Make sure everybody is on the same page. Refuse to participate in an irresponsible project.

I don't mean to be thick, but why are you all "going crazy"? Are people responding to grandmother's demands piecemeal, and being badgered by her; or are you still trying to get her to agree to something she has made it plain she does not agree with? If the latter, stop it.

People like to think they respect their elders' choices. But when those choices result in problems, respect flies out of the window. You have to respect personal choices even when you don't agree with them, and even when bad things happen as a result, is the point.

If your grandmother wants to live at home, social services will try to make that happen, by the way. Have a happy place ready to think of if they tell you this.

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Thank you for the advice, and I think you're right - we're all trying to force her to accept help (volunteer shoppers, home aides, doctors visits) when really, she doesn't want help. She wants us all to tell her she's perfectly fine and completely capable, and then she wants us all to go away and leave her alone (that is, until she calls us all in the middle of the night saying she hasn't eaten for days because she's refused food deliveries...) I'm having trouble balancing her need for independence with her serious self-neglect.

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Step one is to look at this objectively and decide whether you honestly think she is incompetent. It's quite a high threshold.

Another thing that occurred to me overnight as I was mulling over helping people who won't let you -

[I have a client who won't wear her falls alarm because she is afraid of setting it off accidentally. We've had a frank exchange of views about this three nights running, and petty bureaucracy forbids me to superglue it to her ear when she's not looking]

- is that when we offer help, it's got to be the right *kind* of help. It's got to be the little, unobtrusive packages of support and usefulness that a defensive, private person will grudgingly admit is quite a good idea, oh all right then, if you absolutely insist.

Not the same client, but I have another fierce old lady whose *lovely* neighbours were worried about her not eating and referred her to us for reablement. The care plan states that our aim is to get her back to normal, planning and eating reasonably square meals at reasonable times of day.

Now then. When I reminded her of this yesterday, because she demanded to know why yet another person had come to bother her, she snapped "I don't WANT to get back to normal!"

Now then. This is not true. She does, but it has to be her normal, not everybody else's normal. Everybody else expects her to have breakfast at eight, lunch between noon and one, a snack at about four, and supper at half past seven.

Well she hasn't done that for thirty years (I have to admit - neither have I). Why would she want to start now? She lives alone, she eats what she pleases when she feels like it.

The difficulty is that because of pain and illness she hasn't been eating even what she pleases, to the point where even when she does feel like eating, getting up out of her chair, walking to the kitchen, fixing a meal and eating it are far too much like hard work. It's a vicious circle.

So we're not getting her back to our normal. We're getting her back to the condition where she is *able* to please herself.

The ideal caregiver/support worker/concerned relative, when dealing with a person like this, has to be extremely self-effacing. The help has to be supplied in a way that goes almost unnoticed, by being carefully aligned with what the person when well would do for herself. Manner, actions, attitude all have to be acceptable to the person you're actually dealing with. It's no good thinking she has to be flexible, she has to change, she has to let people do x, y, z. You have to think what form you can present support in that is not going to get straight up her nose.

So with grandma: it may be too late, it may by now be residential care or bust; but just out of curiosity - what sort of food deliveries has she been rejecting?

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Hi CountryMouse,
Your post is insightful, compassionate, and realistic. It's going to help me going forward with my mum, who was always a lovely (and stubborn!) person. She's in assisted living with mixed dementia. She's been on Respiradone since September, which has made a world of difference to me, reversing the paranoia and false accusations which had started suddenly. Hygiene has become a bit of an issue, and it's challenging to find a way to deal with it. She can't work up any motivation to cooperate, let alone remember. Or maybe she just doesn't want to be bothered, and it's her lifelong stubbornness coming through. Your comments are helpful; I have to admit that this issue is more about my embarrassment at my mum's decline than her physical well-being.

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I went back and read your other posts.

Grandma is mentally ill. BPD folks are notoriously hard to help because they lack the ability to trust.

You and Maureen are going to have to stop helping, stop showing up to pick her up, if she is going to get help.

Sounds cold and cruel. But its grandma's choice.

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Mama, is your mom mentally ill?

In answering this particular question, from this poster, the fact that the client has a long standing ex of a personality disorder makes getting her help really tough.

IF grandma were physically ill or injured and was admitted to a hospital, yes, then you can work with discharge to get the client into care.

But if she is "merely" self-neglecting, and the powers that be see a responsible-looking grandchild or neighbor showing up to cart them home, no one is going to interveve.

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Yes, NPD with anosognosia, apathy, and short term memory loss. In other words, a very difficult personality topped with early stage dementia. As a caregiver you know it is just a matter of time before a resistant to care elder ends up in a hospital bed. In my mom’s case it was a skin infection that needed IV antibiotics. I had plenty of people tell me to adopt a hard line walk away “it’s her choice that she won’t accept care” attitude. Told me it couldn’t be done. Well, I persevered because she’s my mom and it was hard there were times of great despair. There were several failed attempts to get an ER doc to help. Each failure was a learning experience. I read a lot here. I asked many people for advice. In the end, I it worked out for the better which is why I replied with my story. The OP can decide for herself what the takeaway is from my story.

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I’ve called APS on my mother. It didn’t do me any good. They told me if my mother was competent, paying her own bills, taking her own medicine, taking call a bus to get groceries then there is nothing they can do about it. She can live in her hoarded mess and sleep in a folding chair in the bathroom. She sleeps there every night. She calls the shots. She said she wants to die in her own house. My son and I were helping her out because of the corona virus. She hasn’t been out so we went grocery shopping for her. The nursing homes are full of corona virus patients. She really won’t go into a facility now. But lately I go see her once a week and my son goes 3 times a week. Dumping my mother at the ER won’t work. She does well on their cognitive tests. She will take a cab home. So she does. But funny how she hasn’t been in the hospital since since the end of March. Before the corona virus she was in the ER once or twice a week!! Mainly for anxiety!! She also would call 911 because she would have panic attacks!!

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My friend Richard is still pretty mentally competent, his physical issues are the problem. To make sure he has what he needs, he has a mini fridge within arms reach stocked with drinks including ensure, snacks like cheese n cracker packs, and I got him a Hot Logic Mini which is a neat little warming box, it will gently keep a meal warm for hours. I can place a Lean Cuisine box in it at noon and it will be warm and ready to eat any time between 4 to 7 pm. Keep a few paper plates and plastic untensils right there at his chair too. He can get food, drinks, etc. All without rising from his recliner. The only time he needs to walk is for the bathroom. He has a portable commode, but is too embarrassed to have it out in plain sight. This may not help your situation, but it could extend the time before your loved one needs full time care. Often our elderly will go without eating not because they are not hungry but because the process of going to the kitchen, fixing a meal, and then eating it is just too much trouble.

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With Richard, it is not that he is resistant to care, rather it is not wanting to be a " bother" to anyone. He lived with his son for a few months, but the situation was not workable because the family members expected that he would ask for help, tell them what he needed, etc. While He expected that they would "just know" or "use common sense" about things like aiding him to walk to the bathroom, changing his clothing, taking a bath. They were very disorganized and did not have any sort of set schedule for meals, he would get upset about having "fast food or pizza at ten o clock at night". He is diabetic, if he does not eat on a schedule it messes him up. I keep him on a fairly loose schedule, I get to his place at 9, remind him to read his sugar and take morning meds, fix breakfast, accept delivery of his Meals on Wheels lunch, then leave a frozen dinner set up in the Hot Logic. He knows I am here to help him, so he is not "bothering" me when he asks for help with changing clothes or walking to the bathroom. It is all in how you present the help.

How do I do an "ER Dump"?

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