Home, But How?

Maybe I really do not understand how hospitalization works in the Philippines.

I say this as someone who has spent most of his professional life in healthcare, although admittedly in the United States. I run skilled nursing facilities in California. I deal with hospital discharges, rehabilitation needs, nursing assessments, physician orders, wound care, therapy, insurance authorizations, and the countless details that determine whether a patient can safely move from one level of care to another. The American healthcare system has enough dysfunction of its own, and I have never been shy about pointing it out. I am also careful not to assume that everything done in America can—or should—be transplanted into a country with different resources, financial realities, and systems of care.

Still, there are questions that should not depend on the country.

My 88-year-old father was involved in a violent vehicular accident. He fell from a jeepney and was struck and dragged beneath the van behind it. He sustained severe facial injuries that required surgery. Several fingers were fractured, and three were eventually amputated. A Foley catheter was inserted. He spent four days in the intensive care unit before and after surgery.

Seven days after the accident, the “lead” doctor—the EENT specialist and lead surgeon who operated on my father’s facial injuries—wrote an order discharging him home.

Home.

It is such a comforting word until someone uses it as a destination without explaining how the patient is supposed to function once he gets there.

By then, my father had not walked. He had not stood or even attempted to sit at the edge of the bed. No physical therapist had evaluated his mobility, balance, or ability to transfer. No occupational therapist had assessed how he would dress, eat, use the toilet, or care for himself with one badly injured hand and three missing fingers. His facial injuries also raised obvious questions about whether he could chew and swallow safely.

I asked the doctor whether the discharge decision was based solely on my father’s recovery from facial surgery. It was a reasonable question. Perhaps, from the perspective of the surgeon’s specialty, my father no longer required acute treatment for his face. But my father is not a face occupying a hospital bed. The face is attached to an 88-year-old man who had just survived severe trauma, intensive care, surgery, amputations, catheterization, pain, and a week of immobility.

Could he stand?

Could he transfer from the bed to a chair? Could he walk to the bathroom? Could he lower and raise his clothing with his injured hand?

Could he clean himself after using the toilet? Was the catheter going home with him, and if so, had anyone taught the family how to care for it? Could he feed himself? Could he chew and swallow without aspirating? Would he require a special diet, a wheelchair, a walker, a bedside commode, a hospital bed, or two people to move him safely?

These are not requests for sophisticated technology or expensive treatment. They are ordinary questions about what will happen when an injured elderly man reaches his front door.

When I asked whether it was a good decision to discharge my father without first examining his functional abilities—particularly his ambulatory and toileting abilities—the doctor responded, “It’s okay that I am being challenged.”

That answer has stayed with me because I was not challenging him.

I was not questioning his credentials, his surgical skill, or his authority as a physician. I was not trying to tell him how to practice medicine. I was asking for the information any family would need before bringing home an 88-year-old man who had not been out of bed for a week.

Perhaps the word “challenge” reveals part of the problem. In healthcare, especially where physicians are treated with considerable deference, a family asking questions can easily be regarded as a family resisting authority. A request for clarification begins to sound like an accusation.

The doctor feels compelled to defend a decision when what the family actually needs is help preparing for its consequences.

I did not need the doctor to defend himself. I needed the hospital to tell us what my father could and could not do.

I understand the realities surrounding hospitalization in the Philippines. Many families are terrified of the bill growing with every additional day. Some patients receive a discharge order but still cannot physically leave while their relatives search for money to settle the account. Philippine law prohibits certain hospitals from detaining eligible patients solely because of unpaid bills, yet complaints about the practice have persisted for years.

It is a strange healthcare contradiction. A hospital may decide clinically that a patient should go home before his ability to function there has been properly assessed, then delay his actual release while the family tries to produce the money. We have somehow created a system capable of keeping a patient who cannot pay while sometimes appearing too eager to release one whose ability to stand has not even been established.

One treats the patient as an unpaid account. The other treats him as an occupied bed.

Neither sees the whole person.

I am not suggesting that Philippine hospitals keep every patient until complete recovery. That would be unrealistic anywhere. Hospitals have limited beds. Families have limited money. Resources are uneven, and therapy services may not always be immediately available. A patient does not need to remain in an acute hospital until he can function exactly as he did before the accident.

But there is a considerable distance between “no longer requires acute hospital care” and “safe to send home.” Even when the ideal services are unavailable, somebody must at least identify the risks, explain them to the family, and help create a realistic plan.

If my father required two people to transfer him, we needed to know. If he needed daily surgical wound cleaning and dressing, we needed instructions, supplies, and a qualified nurse. If he could not safely swallow ordinary food, we needed guidance before someone handed him a regular meal at home. If rehabilitation was recommended but unavailable or unaffordable, that needed to be discussed honestly. If the family would be responsible for nearly everything, then the family needed to know what “everything” meant.

In theory, this is where case management and interdisciplinary discharge planning should enter. The surgeon determines whether the surgical condition is stable. Nursing identifies continuing medical and personal-care needs. Physical and occupational therapy evaluate mobility and daily function when indicated. Case management brings the findings together, speaks with the family, and helps arrange whatever services and equipment are realistically available.

One doctor should not be expected to perform every assessment. That is precisely why a hospital is supposed to have a team.

We were fortunate that I knew enough to ask these questions, even if asking them was interpreted as a challenge. Many families do not know what to ask. They hear “discharge” and assume the hospital has determined that their loved one can safely return home. Then an ambulance delivers a bedbound patient to a house with stairs, no hospital bed, no wheelchair, no trained caregiver, and no plan beyond a plastic bag of medications and instructions to return for follow-up.

The family improvises.

Filipino families have become remarkably good at improvising. They find a private-duty nurse through Facebook. They borrow a wheelchair from a neighbor. They purchase supplies nobody told them they would need. A daughter learns wound care from a brief demonstration. A son lifts his father incorrectly and injures his own back. Relatives divide the night shift among themselves and call it family support, although sometimes it is the healthcare system quietly transferring its unfinished work to the household.

My father may indeed have been medically stable enough to leave the hospital. I was never insisting that he remain simply because I was frightened to bring him home. I wanted to know what bringing him home would require so we could have the right people, equipment, instructions, and follow-up care ready.

That is not a first-world demand. It does not require an American hospital, unlimited insurance coverage, or an expensive rehabilitation center.

It is a son asking whether his father can stand, eat, urinate, use the toilet, and make it safely through the first night.

A discharge order tells us where the patient is going.

A responsible discharge plan tells us what happens when he gets there.