Patient Story: Guiding Family Through Difficult Transition

Patient Name



91-year-old Male


Prior to acute admission, William was residing with family on the second floor of a 2-story house with 14 steps to enter. Patient was independent for activities of daily living and modified independent with mobility utilizing a 4-wheeled walker. He also had the following DME: left bed rail, cane, wheelchair, and commode. His granddaughter helped with instrumental activities of daily living such as preparing meals and using the telephone. He was also being monitored by the family with cameras.

Medical history

Relevant comorbid medical conditions: Dementia, CHF, A fib, hypertension with CKD.

The Prospero Impact

The patient, William, fell and sustained a right hip fracture. He underwent surgical repair of the broken hip two days later. William was discharged to a skilled nursing facility (SNF) for rehabilitation. His stay was complicated by acute on chronic kidney failure secondary to diuretics.

The initial discharge date was set for the first of the month, however a change in medical condition required the SNF stay to be extended. The family requested William be discharged home with family with Home Health services just a few days later. The naviHealth Skilled Inpatient Care Coordinator (nH SICC) informed the family that William would require a stretcher to get up the stairs to his home and would require 24/7 caregiver assistance. The family stated that they would have the necessary resources to support him at home. The nH SICC provided Prospero information and referral was sent to Prospero prior to SNF discharge. It was confirmed Prospero would be coming out within the week of William being discharged.

At the time of discharge, William required physical assistance with all self-care and mobility activities which the family was equipped to support at home.

Four days after arriving home, William was seen for an initial visit by a Prospero NP.  Upon initial assessment, his immediate medical and psychosocial needs were identified and addressed. He was requiring total daily care and his intake had reduced drastically. His family had hired a 24/7 live-in aide who was getting highly burdened and was planning on quitting.  His bed alarm kept setting off because he fidgeted constantly while in bed all night long and he looked uncomfortable. His primary caregiver/granddaughter wanted to send him back to the ED. The enrolling NP started in-depth serious illness discussion with family, and they eventually agreed that William would be safer at home and could be managed in place with 24×7 assistance by Prospero.

On initial interdisciplinary team review, William was stratified in the High Palliative risk level, and we designed and executed a plan of care that was focused on optimizing comfort, maintaining patient dignity and avoiding further harm to the patient. We stopped unnecessary medications (eg for high blood pressure and cholesterol) and discussed non-drug (e.g. turning on his favorite radio station, using electric fan) and mild calming agents to help with anxiety and insomnia. We introduced the concept of hospice philosophy and hospice service to the family. The son who was the durable power of attorney agreed with hospice services, however the granddaughter who had been William’s primary caregiver was opposed to it.

Because of William’s frail condition and the family’s divergent ideas about hospice, the NP scheduled a joint visit with the MD and family. The team focused on William’s known wishes, the family’s goals of care, William’s clinical decline and poor prognosis. The team addressed the family’s concerns, including the fear that William will die of starvation and their worry that his medications will cause his demise. After 2 hours of meeting with multiple family members the family finally agreed that a team that is trained to focus on providing comfort and dignity at the end of life would be best for their loved one, and they agreed with the plan to meet with hospice.

William was admitted to hospice service 5 weeks after enrollment to Prospero. He was very comfortable in the last few days of his life and died in his own bed with all his family at bedside. Days after his death, the son/DPOA called the Prospero NP to thank her and the team for guiding them through this difficult transition and helping the family make the right decision.

Note: The patient’s name has been changed to protect his privacy.