"Just please let me go home. I don't care if I die, at least I'll be in my own home." Her words still haunt me. We did not follow her crying pleas to go home, instead we sent her to a skilled nursing facility. Her primary care physician admitted her directly after an appointment in his office. The arthritis in her knees was not benefiting from outpatient treatment and she could barely walk around her apartment. She refused to live with her children or have additional paid caregiver assistance even though finances were not a consideration. Her family was also concerned about her living alone but could not imagine a nursing home, "She grew up an orphan in an institution and we cannot imagine sending her back to one at the end of her life."
So here's the dilemmia... do you allow someone to go home as they wish despite knowing that they will likely die? Or do you send them to a place where they can live safely and yet potentially miserably?
In this case, the skilled nursing facility (SNF) felt like the right decision as the patient continued to demonstrate decreased insight into her deficits and ability to care for herself. "I'll be fine, I don't need anyone there," she's say despite spending less than 8 hours out of bed per week and needing an assist to walk or transfer to a chair. Her primary care physician will follow her and if she is miserable, she can... go home.
