What is the best course of action for a 75-year-old female patient with chronic obstructive pulmonary disease (COPD), significant cognitive and visual impairments, and difficulty managing her medications, oxygen therapy, and daily self-care tasks?

Immediate Transition to Higher Level of Care or Structured Support Services

This patient requires immediate evaluation for skilled nursing facility placement, home health services with daily visits, or hospice care—she cannot safely remain at home without intensive support given her inability to manage medications, oxygen, and ADLs combined with cognitive impairment and three recent hospitalizations. 1

Critical Safety Issues Requiring Urgent Action

This patient presents with multiple red flags indicating she is unsafe for independent living:

• Medication non-adherence due to cognitive impairment poses immediate risk for COPD exacerbation, hypoglycemia from erratic insulin use, and respiratory failure 1
• Inability to manage oxygen equipment with documented episodes of "running out of oxygen" creates life-threatening hypoxemia risk in a patient already on 4L NC 1
• Three hospitalizations in one month (most recently within the past 3 weeks) indicates failure of current outpatient management and high mortality risk 1
• No caregiver support combined with visual impairment and cognitive difficulties means she cannot execute basic self-care tasks 1

Immediate Care Coordination Steps

1. Assess Decision-Making Capacity and Initiate Advance Care Planning

• Evaluate whether patient has capacity to make medical decisions given reported "worsening confusion" and inability to identify current medications 1
• Initiate advance care planning discussions immediately while patient is in stable state, as ATS/ERS guidelines emphasize these conversations should occur before crisis situations 1
• Discuss goals of care, preferences for intensive care, and end-of-life wishes given her advanced COPD with recurrent respiratory failure 1
• Document advance directives and identify healthcare proxy if patient lacks family 1

2. Arrange Immediate Structured Care Environment

Option A: Skilled Nursing Facility (SNF) Placement

• Most appropriate for patients unable to manage ADLs, medications, and medical equipment 1
• Provides 24-hour supervision for oxygen management and medication administration 1
• Addresses cognitive impairment with structured environment 1

Option B: Home Health Services with Intensive Support

• Requires daily nursing visits for medication administration and oxygen management 2
• Hospital-based home care programs reduce emergency visits and hospitalizations in COPD patients on long-term oxygen 2
• Must include respiratory health worker or nurse case manager with frequent contact 1
• This option is only viable if patient demonstrates some capacity for self-care between visits 2

Option C: Hospice Evaluation

• Consider given three hospitalizations in one month, oxygen dependence, and inability to manage self-care 1
• Hospice provides comprehensive support for end-stage COPD including symptom management, equipment, and caregiver support 1
• Does not require patient to forgo disease-modifying treatments initially 1

3. Optimize Medical Management Before Transition

Oxygen Therapy Verification:

• Confirm current oxygen prescription is appropriate with arterial blood gas measurement 1
• Long-term oxygen therapy (>15 hours daily) reduces mortality only if PaO2 ≤55 mmHg or SaO2 ≤88% 1
• Arrange reliable oxygen delivery system (concentrator preferred over cylinders for home use) 1
• Patient's reported episodes of "running out of oxygen" suggest inadequate oxygen supply or delivery system failure 1

Medication Reconciliation:

• Obtain complete medication list from pharmacy records given patient cannot identify current medications 1
• Simplify regimen to once or twice daily dosing where possible 1
• Assess inhaler technique (likely impaired given visual and cognitive deficits) 1
• Consider nebulized medications instead of inhalers if technique cannot be mastered 1

Insulin Management:

• Erratic insulin dosing creates severe hypoglycemia risk 1
• Consider transition to long-acting insulin only or discontinuation if patient cannot safely self-administer 1
• This requires immediate intervention as hypoglycemia can be fatal 1

4. Arrange Pulmonary Rehabilitation Referral (If Appropriate)

• Pulmonary rehabilitation improves exercise tolerance, quality of life, and reduces hospitalizations in severe COPD 1
• However, this patient's cognitive impairment and inability to manage ADLs may preclude participation 1
• Rehabilitation programs also provide opportunity for advance care planning education 1
• Consider only after stabilization in structured care environment 1

5. Address Palliative Care Needs

Symptom Management:

• Assess and treat dyspnea, which may require opioids for refractory breathlessness 1, 3
• Evaluate for depression and anxiety (common in advanced COPD) and treat appropriately 1
• Address nutritional status and weight loss 1

Palliative Care Consultation:

• Appropriate for patients with advanced COPD regardless of prognosis 1
• Focuses on symptom relief and quality of life 1
• Can be provided concurrently with disease-modifying treatments 1

Common Pitfalls to Avoid

• Do not send patient home without structured support—this creates immediate safety risk and virtually guarantees readmission 1
• Do not delay advance care planning—discussions should occur during stable periods, not during acute crises 1
• Do not assume patient can manage simplified medication regimen—cognitive impairment and visual deficits preclude safe self-administration 1
• Do not overlook insulin management—erratic dosing poses immediate life-threatening risk 1
• Do not continue current oxygen delivery system—repeated episodes of "running out" indicate system failure 1

Documentation Requirements

• Document assessment of decision-making capacity 1
• Record advance care planning discussion and patient preferences 1
• Obtain social work consultation for placement options 1
• Coordinate with case management for insurance authorization 1
• Arrange follow-up within 4 weeks of any care transition 1

The evidence is clear that patients with frequent exacerbations requiring hospitalization carry very high mortality risk and require intensive, coordinated care that this patient cannot provide for herself. 1