I used to have a favorite discharge diagnosis I used that got straight and to the point:
Catastrophic noncompliance.
Then I was alerted to my next favorite admitting diagnoses: TOTGH. It stands for Too Old To Go Home. It goes along with another popular and growing problematic diagnosis a pulmonologist once alerted me to: TFTB which stands for Too Fat To Breath.
Some days it seems like my entire service is filled with patients who are TFTB and TOTGH. I'll even occasionally get the patient who is TFTGH. What are hospitalists supposed to do with these folks? They're growing older and larger and more homeless by the day. Their families don't want them. Even the nursing homes can't support their needs.
You know it's bad when we can't even send hospice patients to nursing homes because of their barriers to palliative and hospice care. The Medicare National Bank (MNB) has, in some ways, turned into a giant Merry-Go-Round of pin the tail on the hospice donkey. And to make matters worse, starting in 2013, the MNB is going to demand money back if we can't keep these patients who are TFTB, TOTGH and TFTGH from bouncing back into the hospital within thirty days of discharge.
Perhaps the solution lies in a creating a new breed of physician at the front lines of palliative emergency medicine. I call them the pallERtive care doc. They are there to help grandma get off the Merry-Go-Round for good. What better place to put a pallERtive care doctor than in the ER, home base central for the nursing home Medicare Carousel of Life. At first glance, what usually looks like an emergency when it comes through those double doors, isn't. It's actually natural death diverted for another day, week or month. Emergency rooms aren't for emergencies any more. They are some of the most expensive hospice agencies the Medicare and Medicaid National Banks can buy.
Since there are no longer emergencies in the ED, what better way to transition into the new reality of American health care than to start staffing EDs with pallERtive care docs. They'll staff the ED between 9 pm and 7am. Why? Because the only folks who ever come in during those hours are folks who should get off the Merry-Go-Round but can't. They need someone at the front lines to take control of the process and make it happen once and for all. TFTB? TOTGH? Don't worry, the pallERtive care doctor is here to help you.
Addendum: I've been alerted to yet another admitting diagnosis: TDTB or Too Drunk To Breath.
Addendum: I've been alerted to yet another admitting diagnosis: TDTB or Too Drunk To Breath.
