What are the best management options for a homebound patient with severe symptoms who is refusing hospitalization?

Management of Homebound Patients Refusing Hospitalization

For a homebound patient with severe symptoms refusing hospitalization, immediately call emergency medical services (EMS) and stay with the patient until they arrive, as severe prolonged symptoms of acute onset call for immediate action regardless of the underlying cause. 1

Immediate Actions by Phone or In-Person

• Make immediate contact with professional medical advice through emergency services (911/ambulance), as waiting for symptoms to disappear is unreliable for risk assessment 1
• Do not delay transport - severe prolonged chest pain, dyspnea, syncope, or other acute severe symptoms require immediate hospital care for potentially life-threatening conditions including myocardial infarction, pulmonary embolism, pneumothorax, or aortic dissection 1
• Patients with high-risk features including continuing chest pain, severe dyspnea, syncope/presyncope, or palpitations should be referred immediately to the emergency department and transported by EMS when available 1

While Awaiting EMS Arrival

If cardiac symptoms are suspected:

• Administer fast-acting aspirin 250-500 mg (chewable or water-soluble) as soon as possible 1
• Give sublingual nitroglycerin 0.4 mg if available, unless bradycardia or low blood pressure is present 1, 2
• Consider opiates to relieve pain and anxiety 1
• The general practitioner or healthcare provider is obliged to stay with the patient until the ambulance arrives 1

Addressing Refusal of Hospital Care

When called by a patient with suspected serious acute illness, the best action is telephone triage and calling for an ambulance, specifically within the first hour of symptom onset when risk for life-threatening complications is greatest. 1

Key considerations:

• Patients often underestimate the urgency of their condition - 25% of patients that physicians rated as needing immediate attention did not recognize the need for urgent care 3
• 44.4% of patients thought they needed immediate care, but physicians determined 70% actually needed care within 13 hours 3
• The perceived severity or urgency by the patient does not reliably correlate with actual medical urgency 3, 4

When Home Management May Be Appropriate

Home management is only appropriate for specific low-risk conditions with adequate support systems:

For Low-Risk Pulmonary Embolism:

• Home treatment may be offered only if PESI or simplified PESI scores indicate low risk, the patient has adequate home support, can afford medications, has no history of poor adherence, and does not require IV analgesics 1
• This recommendation does not apply to patients with submassive or massive PE, high bleeding risk, or other conditions requiring hospitalization 1

For Uncomplicated Deep Vein Thrombosis:

• Home treatment may be considered only if the patient does not have massive DVT (severe pain, entire limb swelling, phlegmasia cerulea dolens, or limb ischemia), is not at high risk for bleeding, has no major comorbidities, and has adequate home support 1

Social Factors Favoring Hospitalization:

• Limited or no home support 1
• History of medication nonadherence 1
• Limited financial resources or inability to afford medications 1
• Residence in a nursing home increases odds of requiring hospital-level care (OR 1.73) 5

Critical Pitfall to Avoid

Never delay emergency transport based on patient preference when severe symptoms are present. The physical examination contributes almost nothing to diagnosing life-threatening conditions like myocardial infarction, and the differential diagnosis of severe prolonged symptoms includes multiple conditions requiring immediate hospital care 1. Pre-hospital care decisions and early interventions greatly affect outcomes, particularly in the first hour when irreversible pathology can be prevented 6, 7.

Special Considerations for Elderly Patients

For elderly homebound patients with cardiac symptoms and elevated troponin:

• Immediate hospitalization with continuous electrocardiographic monitoring is mandatory, as sudden ventricular fibrillation is the primary preventable cause of death in the early period 2
• Elevated troponin is an independent predictor of adverse outcomes with an odds ratio of 3.44 for death or myocardial infarction at 30 days 2
• Early invasive strategy in patients older than 75 years conferred an absolute reduction of 10.8 percentage points in death or myocardial infarction at 6 months 2