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Elderly COPD sufferer won't let you admit him

Case

history

Frank is aged 78 and has a long history of COPD. You are called to his home because he has an acute exacerbation. He has increased sputum production and is very dyspnoeic. Examination reveals him to be very short of breath, pyrexial with widespread wheezes and crackles. On the evidence available you diagnose an acute exacerbation of COPD. He refuses to go into hospital. He lives alone, his daughter lives 130 miles away.

Why may an elderly person refuse hospital admission?

When a very ill patient refuses hospital admission our reaction is usually a mixture of anxiety and dismay. In my experience it is usually the elderly who refuse admission and it is this group of patients who often need admission for social as well as medical reasons. To resolve this I start by exploring their fears.

lThey may be frightened of dying in hospital. It is worth spending some time explaining the reason for the admission and the fact that they may only be going in for tests that cannot be performed at home. I try to give an estimate of the expected duration of stay.

lSometimes the patient is worried about their spouse. It never fails to amaze me that some elderly couples have never spent a night apart.

lIf relatives live a long way from home the patient may be worried about them having to travel to visit them in hospital.

lThe welfare of the dog or cat can be equally worrying and family or neighbours can help with this.

lThe patient may be genuinely worried about crime. This is often with good reason and again family and neighbours can help.

lIf a patient has lost a loved one on a certain ward I promise that I will at least try to avoid sending them to the same one.

Sometimes the patients may over- estimate our clinical skills and wish to remain under our care. This can be worrying if we have no diagnosis. My response to this is to look them in the eye and say: 'I would dearly love to look after you but I'm afraid that I don't know what is wrong with you.' This often has the desired effect but try not to say it too many times to the same patient!

On the other hand a patient may well know what is going to happen. If they have had the condition for many years they may be fed up with the same old routine. Frank, for example, may have had dozens of blood tests, painful blood gases and long waits in X-ray etc only to be discharged the very next day. We owe the patient the benefit of their experience and if they really do always settle after the same medical intervention we should agree to try that at home.

Does Frank need admission?

A purely clinical assessment would say that he does need admission.

In an infective exacerbation of COPD the following questions can be asked. If the answer to more than four questions is 'no' then hospital treatment is indicated:

lAble to cope at home?

lAbsence of cyanosis?

lNormal level of consciousness?

lMild breathlessness?

lGood general condition?

lNot receiving long-term oxygen therapy?

lGood level of activity?

lGood social circumstances?

Other psychosocial factors obviously come into this such as excessive family anxiety or a recent very severe exacerbation. Perhaps you failed to diagnose the patient as having pneumonia the month before and dare not make the same mistake again.

What if Frank still refuses hospital admission?

You must examine your own feelings at this stage. Would Frank's admission actually have been rather convenient and avoided close follow-up? Are you under-confident in this situation? Having warned Frank of the dangers of staying at home it is now your duty of care to give him the best possible treatment available at home.

Discuss the case with your partners and the district nursing staff. Involve social services for emergency home care. Your local hospital may have an outreach COPD nurse who can help follow up Frank.

The sudden increase in dyspnoea and sputum would suggest an antibiotic is indicated. Amoxicillin or a macrolide would be the usual choice. (Bacteria are isolated in 40-60 per cent of acute exacerbations of COPD. The three most common isolates are Haemophilus influenza, Streptococcus pneumonia and Moxarella cattarhalis.)

You may want to give Frank a course of oral prednisolone (particularly if he is known to be steroid responsive). Regular high-dose bronchodilators through a spacer device can replace a hospital nebuliser. If you cannot clinically exclude concomitant heart failure start him on diuretics with an initial IV dose.

The key to this case is follow-up. Many patients respond to steroids within a few hours and you should revisit him later that day. Warn your local on-call service about the situation and revisit him early the next morning. Further investigations can then be arranged. These cases may seem worrying and inconvenient. However, they also give us the chance to practise acute primary care medicine in its purest form. Seeing a patient recover in their own home can be extremely rewarding.

References

BTS guidelines for the management of chronic obstructive pulmonary disease –

thorax.bmjjournals.com/content/vol52/suppl_5/

Community management of lower respiratory tract infection in adults –

www.sign.ac.uk/guidelines/fulltext/59/index.html

Neil Brownlee is a GP trainer and partner in Saltburn-by-the-Sea, Cleveland

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