Attorney Sanford Mall, CELA, CAP, VA Accredited Attorney, spoke at the 1st Annual Elder Law Conference, sponsored by the State Bar of Michigan through the Institute of Continuing Legal Education in September 2015. His presentation centered on nonlegal advocacy that attorneys can engage in with all patients to promote better quality of care. Top quality-of-care patient issues he identified were: a) unsafe living environment; b) absence of a patient advocacy; c) misdiagnosis of mental health and other conditions; d) unqualified practitioners and caregivers treating the patient; e) inadequate care and treatment plans supporting good medical decision making and continuity of care; f) poor discharge planning; and g) medication errors (Mall, 2015, p. 1). I had an opportunity to pursue his recommendation to work in collaboration with healthcare providers in ensuring all patient and family needs were being addressed. The following case took place in a hospital, but the idea behind patient advocacy and nonlegal advocacy applies to all patients.

My client was the daughter of patient (HR) who died on her third day in the hospital. The family was adamant that this death could have been prevented. They had no interest in filing a formal legal complaint but wanted the case seriously reviewed for ways to improve perceived and actual deficiencies in: a) communication between the healthcare providers and between the healthcare providers and family; and b) clinical medical decision making and continuity of care between the home, nursing home, Emergency Department (ED), and admitting unit at the hospital.

HR was an 89-year-old woman who had been in stable health for her age until her admission to a nursing home, and then subsequent admission to the hospital. Prior to this episode, she was still driving and lived alone in her own home. She was diagnosed with atrial fibrillation and heart arrhythmia in her later years, and treated conservatively with Digoxin. She was routinely seen by her cardiologist of 10 years, who saw her strictly as an outpatient. In December 2014, HR started falling more times than usual for her. She was admitted to the nursing home to complete a rehabilitation program, including physical therapy. The goal was to make her comfortable in ambulating with a walker so she could return home.

HR presented to the nursing home with lower-extremity edema, wounds on the bottom of her feet, chronic stasis dermatitis, chronic edema, and chronic varicose veins. No other complaints were identified. Important findings leading to her hospital admission were:

1. HR fell at the nursing home and injured her back and leg;

2. X-rays of her right femur showed no fracture or dislocation; however, she had back pain and her thigh hurt and was bruised;

3. HR developed upper respiratory congestion and a cough.

The nursing home attempted to manage these complaints. On December 29, 2014, the family decided to take her to the local hospital to rule out pneumonia and further evaluate her leg complaints.

While in the ED, HR was administered two doses of Albuterol within a 10-minute timeframe. This was in spite of warnings by the family that HR was very sensitive to medications. Further, the ED staff had not taken an adequate history and physical to establish what was really wrong with her before starting respiratory treatments and prescribing medications. HR's cardiologist was not consulted at any time during the admission. As a result of this and pain management administered in the ED, she became unstable and was admitted. The hospital team was not able to stabilize HR, and she died 3 days later. The discharge summary listed no concrete diagnosis for the admission, and a resident rather than an attending physician signed the death certificate.

The family asked me to review all the medical records, from which I identified 22 quality-of-care questions and/or issues. I then arranged for the family and me to meet with the Medical Director of the Quality Improvement Committee at the hospital and the Director of the Quality Improvement Department. The purpose of this nonlegal advocacy meeting was to have a better understanding of what happened to HR. However, the family also wanted the following areas addressed to ensure a different and better outcome occurred for the next family:

1. supervision and oversight by the attending physician;

2. the need to act before thinking by the clinical team;

3. seamless care continuity between the ED and admitting unit;

4. the need for clinical providers to talk with each other;

5. the need for clinical providers to communicate better with family members and engage them and the patient in the medical decision-making process.

Although the hospital representatives had to be assured multiple times that the family had no interest in pursuing any legal remedy from HR's death, the actual meeting was very productive. The Medical Director agreed to:

* present this case at a future grand rounds so all clinical staff could review the clinical presentation and treatment plan to learn from what happened to HR;

* refer this case to the Pharmacy and Therapeutics Committee to identify medication protocols and contraindicative indicators between medications and diagnoses;

* review end-of-life communication protocols between clinical providers and family members to be more sensitive to the emotional factors involved in this decision-making process;

* review general communication protocols and attending physician assignment policies to ensure clinical staff are properly identified and important clinical information is communicated to the patient and designated family members; and

* review clinical staff assignment schedules for holidays and high-volume times of the year to ensure complete coverage to support optimal quality of care.

The top quality-of-care issues that Mall identified as reasons to support nonlegal advocacy were present in HR's case (Mall, 2015). Home healthcare patients need this same type of advocacy to preserve their highest quality of life. The American Association of Retired Persons (AARP) created 35 questions to ask the aged in order to assess their needs and advocacy issues. Questions to assess the home are: is your home still appropriate for you now that you are getting older? can you manage the stairs? and, should you think about living somewhere else? (AARP, 2010).

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