For all the talk about reducing rehospitalizations, there seems to be a big element missing, according to the New York Times: that of talking.

There’s a good chance that an elder’s Do-Not-Resuscitate order won’t make it from the hospital to the skilled nursing facility, writes Judith Graham in a New Old Age blog post. That means as a senior’s condition deteriorates, such as trouble breathing, he or she may land back in a hospital even if it’s not what the individual, family members or primary physician wanted. Graham chronicles such a case in her blog post from the perspective of a physician.

“Rarely do nursing home doctors or nurses sit down and explain the risks of hospitalizing a frail older person who is profoundly physically and mentally compromised,” Graham writes.

As in all things mainstream media, it’s a little unfair to put the boulder of eldercare on nursing home staff. It’s not as if the majority of employees gallop around their place of work deliberately avoiding eye contact or conversations with family members. There are only so many hours in the day, and we know that many of those are taken up with paperwork.

Still, there are a lot of concrete clinical guidelines coming from vendors and providers around rehospitalization efforts that are focused on data – look at who is being hospitalized for a urinary tract infection and ask if it can be treated at the SNF, for example. Make sure that you know where your hospital referrals are going, and be able to rattle off rehospitalization numbers, the experts say. The focus on data will arguably be the biggest sea change and ideally let seniors stay in their nursing home and have end-of-life care that reflects what they wanted.  

Yet we cannot expect family members to understand why being rehospitalized is so hard on their loved one without talking to them about it. When a senor and family have gone through the difficult process of working through an advance directive or DNR, it’s up to the all the members of the healthcare team to do their best to make sure those wishes are followed.