by Nick Jacobs

Kathy's husband passed away about a year ago after a short run with cancer. Hence, her kids decided that she needed a complete physical, took her to a local hospital and found out that she had a blockage leading to her kidney.

She went in for a stent and had a heart attack. A few weeks later she had open heart surgery, and the stitches leaked. Consequently, she had it again the very next day, and was then placed in a drug induced coma for about a week.

When she regained consciousness, her children had to tell her that she had a stroke during the second surgery causing her left leg and left arm to be weak. A few days later she was transferred to a specialty long stay hospital where she was diagnosed with C diff, an infection.

After about three weeks, she was transferred to a specialty care unit of a nursing home where she became less and less mobile until she could barely stand. She was nearly in a vegetative state from the fifteen different medications that her five different physicians had prescribed for her. Her weight dropped to 90 pounds. Although the MRI revealed that there were no signs of damage from the stroke she became more and more disabled.

After a series of phone calls with the children, none of whom lived near Kathy, followed by consultations with two pharmacists, two physicians and a social worker, all of whom were not directly involved with the case, Kathy was taken off seven of her fifteen meds, at least two of which were completely redundant and many directly conflicted with each other. One of the others, as noted in the literature, had severe side affects and, because two weeks into the prescription the patient was not exhibiting any signs of the progress that this drug might have produced, should have been discontinued months ago.

Today, the family is waiting and for their mother to walk again and eventually be able to leave the nursing home. The seven drugs had, according to physicians who advised in this case as friends of the family, gorked her out!

And today, I sit in my health care leadership chair, and wonder how often this scenario is repeated in the U.S. health care system.

She was not ever our patient. We were only involved as observers and friends, but we were involved. Short of being family, we tried everything to get the professionals involved to take notice of Kathy and her condition; her care givers, her physicians and the administrators. As an Insider it causes me much grief that this scenario has played out this way. Why were her medications not closely monitored? Why did her continued, non explainable deterioration not draw the attention of her care givers? How many people in our system of health care are without patient advocates and are destined to deteriorate and die prematurely due to a similar lack of interest?