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Case Study: Delivering Patient-Centered Care for a Medically Complex Nonagenarian

Overview

This case study highlights the dedication, expertise, and coordination required to care for an 89-year-old woman with a complex medical history and a strong preference to remain at home. Through the collaborative efforts of Visiting Physician Services and VNA Health Group, her needs were met with compassion, clinical rigor, and unwavering respect for her goals of care.

Background

The patient, an 89-year-old woman, lives at home with her husband. Her medical history is marked by multiple chronic and serious conditions, including:

  • Congestive heart failure (CHF)
  • Chronic obstructive pulmonary disease (COPD) (managed with chronic prednisone but without supplemental oxygen)
  • Atrial fibrillation post-permanent pacemaker placement
  • Type 2 diabetes mellitus
  • Hypertension
  • Depression
  • Diffuse osteoarthritis

She also has a notable oncologic history, including a lung carcinoid tumor treated with CyberKnife, uterine cancer, and indolent lymphoma currently under surveillance.

Despite this extensive history, she independently managed over 20 medications and mobilized short distances using a walker.

Acute Decline and Initial Intervention

In February, the patient contacted our team due to worsening bilateral leg swelling and redness. The Visiting Physician Services team promptly assessed her at home and found her chair-bound with significant functional decline. Her medications were disorganized, and she showed signs of fluid overload alongside superimposed bilateral cellulitis. Though her condition was serious, she firmly refused hospital admission.

The care team responded with a two-pronged clinical approach:

  • Initiation of dual antibiotic therapy
  • Adjustment of her diuretic regimen to better manage fluid retention

Visiting nurses from VNA Health Group were called in to provide essential support of medication reconciliation and management. This involved multiple home visits to sort, organize, and educate the patient and her family on proper administration, ensuring adherence to her complex treatment regimen.

Clarifying Goals of Care

Recognizing the patient’s progressive functional decline and increasing dependence, conversations around her goals of care were initiated. These discussions extended to her daughter and emphasized a shared understanding of what mattered most to the patient, remaining at home, avoiding hospitalization, and receiving care that prioritized comfort and dignity.

Her husband was also noted to be in decline, making the need for comprehensive home support even more urgent.

Clinical Progress and Persistent Challenges

Over the course of five weeks, notable clinical improvements were observed:

  • The cellulitis resolved with the antibiotic regimen
  • Leg swelling decreased
  • Medication management significantly improved

However, despite these gains, her overall health remained fragile. Her respiratory status, mobility, and general stamina were markedly impaired. Episodes of respiratory distress, edema, and even mismanagement of medications continued. Still, the patient steadfastly refused hospital care, expressing a clear desire to remain in the comfort of her home.

Transition to Hospice

Given her advancing COPD, CHF, and irreversible functional decline, hospice care was introduced as an appropriate and compassionate next step. After thorough discussions, the patient and her family aligned with the hospice philosophy and agreed to the transition.

Since enrollment, she has been receiving regular hospice visits. Her care plan is now centered on:

  • Comfort-focused symptom management
  • Weekly hospice nursing visits
  • Personal care support via a dedicated home health aide (HHA)
  • Family education and emotional support

Notably, her symptoms have remained well-controlled, and she continues her routine medications. Her family has become more involved in her day-to-day care, creating a supportive environment for both the patient and her husband.

Responsive, Coordinated Support

Recently, the patient fell from her wheelchair due to the brakes not being secured. In response, an urgent home visit was conducted, imaging was promptly arranged, and her pain was effectively managed, all without requiring emergency department intervention.

This event underscores the depth of the care team’s responsiveness and their ability to swiftly coordinate necessary services while honoring the patient’s wish to stay out of the hospital.

Outcomes and Reflections

The patient and her family have expressed high satisfaction with the care they’ve received. They feel supported, heard, and reassured, at peace with the natural process of decline and death.

This case stands as a testament to the power of interdisciplinary collaboration. It exemplifies the importance of:

  • Personalized, goal-concordant care
  • Respect for patient autonomy
  • Integration of medical, psychosocial, and logistical support systems

Conclusion

This patient’s journey reflects the complexity of delivering healthcare in the home setting, especially for individuals with serious illnesses who choose comfort and dignity over aggressive intervention. Through the joint efforts of Visiting Physician Services and VNA Health Group, she continues to experience stability, peace, and the highest quality of life possible under the circumstances.

Her story highlights not only the clinical challenges but also the profound impact of empathy, communication, and teamwork in delivering exceptional patient-centered care.