While reviewing a pile of referrals recently, a few stood out as remarkably futile, at first glance and I was reminded of a recent NY Times article about sending old people, seemingly at the end of their lives, out for skilled rehabilitation services.

If you’ve been in the acute care system for a few years, you know the answer and I gave up chasing windmills long ago, so you’ll have to draw your own conclusions.

The data on very ill, very old people in skilled facilities is not compelling with regard to successful outcomes and even for simple survival. I came to the community hospital system in 1984, the introductory year for DRG implementation, which was a three-year ramp up, as I recall.

The reimbursement system was overhauled from retrospective to prospective payment, a challenge on a par with putting men on the moon and every bit as heroic. Chaos ensued but the world didn’t end after a few years and the health policy wonks rediscovered the health care money train- three days (actually nights) in the hospital then up to 100 days in a skilled nursing facility.

Serendipity, the great maker of the right things at the right time, wove advances in American medicine with short hospital stays and long rehabilitation episodes.

The results are impressive: death from the big killers of Americans- heart disease, stroke, diabetes, and even pneumonia went way down over a 20 year period. The catch is that people still get the diseases but live with them for much longer.

That’s the dicey place we’re in these days: my residents have an average of 3-5 chronic medical conditions (co-morbidities) after age 85. Each time one flares up, it usually tips one or more into the problem range and the resulting hospitalization requires masterful medical management.

But then, the traditional rehabilitation as in a return to a pre-morbid level of functioning seems elusive. I prefer a more descriptive term like recuperation, having qualitative but identifiable outcomes. Then an adjustment in lifestyle, often in assisted living, where we compensate for whatever you’ve lost and not regained, in exchange for your compensating us for our services.

The movement is upon us- care and comfort; no more heroics, and variations on the themes that empower people and their families to define their expectations and outcomes when offered an aggressive intervention. There’s almost always time to invoke #butwhy?