Joan, a widow, was on her fourth hospitalization of the past eight months. Each time she was discharged, she was weaker than the time before. It was hard for her to live independently. She had several medical problems, none of which were life threatening, but combined, they seriously diminished her ability to do the things she wanted to and her quality of life. Joan was frustrated because she was not getting better and did not understand what the future would hold for her. She was tired and did not want to live like this: moving between hospital, rehabilitation facility and home, never recovering sufficiently to live the way she wanted.

Joan needed a better understanding of her medical prognosis and a discussion about what she wanted the goals of her care to be. She needed better symptom management. She needed emotional and spiritual support and help getting home. Joan’s son, Sam, who lived in California, needed to understand how he could best support his mother and her wishes, and he needed assistance managing her care from so far away.

Sam contacted the patient representative at the hospital, who suggested that Joan might benefit from a meeting with the hospital’s palliative care team. The nurse practitioner from the team met with Joan – and then with both Joan and Sam – and explained all of Joan’s medical issues and treatment choices in plain language that both of them could understand. Joan said that she didn’t want to be hospitalized again and wanted to be home. She understood that declining to be hospitalized again might shorten her life, but she wanted her care to be about helping her enjoy her life – at home, spending time with family and friends. Together with Sam,  Joan decided hospice care was the best way for her to live the way she wanted to, and the palliative care team was able to connect her with different hospice organizations so she could choose the right one for her.