"Lack of discharge planning"

My father was discharged after a 4 week stay in hospital following radical surgery for cancer. After suffering such a major life event he was keen to get home but the planning and communication around this was lacking. Prior to his cancer diagnosis he was completely independent, living in his own home and full time carer for his frail wife who has dementia.

 For a week or so before his actual discharge my Dad was being told that he would go home ‘soon’ that was until the Monday when the discharge date was announced as the Tuesday or Wednesday. My Dad, being a typical older Scottish man, told staff that he would be fine and didn’t need any help at home, despite the fact that he was going home with a new PEG, on insulin and considerably more frail that when he was admitted.  Obviously this caused us some distress, how would he go up and down the 2 flights of stairs to bed or down to the toilet at night, was a bed needed down stairs, how would he be kept safe at home alone? This was made worse by the fact that 10 months before he had resorted to calling an ambulance when he couldn’t get up from the floor after falling out of bed. 

I had asked the ward nurses repeatedly when he would be seen by OT but in the end I called the department myself to ask for involvement. By this point we had already rushed to buy a bed for downstairs, order a key safe, video doorbell and ensure that a community alarm would be fitted, within 2 days. When it became apparent that these safety measures couldn’t be in place with 48 hours notice , his discharge was delayed until the Thursday.

It concerns me that there was no reading between the lines or discussion with family. I was repeatedly told that he had capacity and so there was nothing that could be done; as a nurse of almost 30 years I find this incredible.  His speech has been severely compromised by the surgery and so having a full conversation is difficult , I don’t really understand why no one had a frank conversation with him, asked to include family  or acknowledged the impact of his recent experiences on his health. 

The final frustration was that we had to wait until 7pm on the Thursday for his discharge presentation, again the reason for such a delay is unclear, particularly as the discharge had been planned for the day before. Despite not getting home until around 8pm, effectively making it an out of hours discharge, he did settle in quickly and had a reasonable nights sleep in the downstairs bed that we had bought. He has realised that showering will be difficult and so we have arranged for a private carer to help him for one hour a day in the short term.

It’s so frustrating that what was an entirely predictable event, discharge from hospital, was so rushed and ill considered.