My mom is 66, has been underweight for many years due to undiagnosed anxiety/depression/other mental health conditions. She was paranoid of doctors/dentists so rarely went to them, she was also a reclusive person without friends generally and while we have a friendly relationship, I've grieved over her so much already over the years. She smoked in her home, became widowed last year, and now had a stroke resulting in left side paralysis, incontinence, etc. She's too weak to even hold her self up in the bed and has cervical dystonia. I'm honestly shocked she's still alive, as I was the one who called the police for a wellness check and she likely laid in that bed several days after the stroke.
She was in the regular hospital for two weeks, now one week into acute rehab (IRF) stay and they'd like to transfer her in ten days. She's 5'3 and weighs 81 lbs. She doesn't want a feeding tube, which I understand, but has to be spoon fed/encouraged to eat and drink ensure. She's getting her meds via crushed pills and shots at this point and doing some therapy at the rehab. She unfortunately has a Humana Medicare Advantage plan, so we're not sure yet if they are going to cover anything for skilled nursing (but we've started the referral process with case mgr). My husband and I are her only family support and she has limited financial means, which is a whole other thing but we're working to figure out that portion. The hospital doctor definitely mentioned hospice to me, but not in a lot of detail, and I haven't yet talked to either rehab doctor about her condition. I'm just visiting her daily to encourage her/see how things seem to be, but she didn't have much will to live before this stroke, so it's hard to know what to do next. I'm sorting through her medical record from the hospital discharge but know the main things they are treating is HBP and depression. She's taking a variety of vitamins, tylenol for pain and lidocaine patches. She's responsive, can talk and write her name, and is cognitively in the middle somewhere I guess.
I don't really have a specific question, but I'm 41 and a SAHM of a 5 & 7 year old, so none of my friends have been in this kind of situation before. I've been through some of this process with my grandmother (mom's mom, who I'm also POA for) who is 88 and moved to AL last year, but was willing and just needed the extra attention in case of falls (and being appropriately old). It's a complicated life, thanks for listening. :)
So the weight has been ongoing, she is adjusted to it, and it is what it is.
As to current issues, she has had a stroke. She is unlike to need skilled nursing but does need long term care placement, likely in a nursing home. You should, yes, be getting together any legal records for POA, documentation, will, advanced directives and etc. This will involve talking to her and now is the time, with or without the help of Social workers. Ask her wishes. Be direct. Cover all things from tube feedings, to dialysis, to IVs and etc. Ask her what care she will want, what heroic measures. This should be done by you, or the person willing to be her POA or MPOA in your family.
Your mother is not currently in a place to refuse LTC it would seem. She may delay it with rehab facility for some weeks, but cannot, I think, avoid it. She would be unsafe on discharge. See to it you do not accept her in your home unless you do want perhaps 3 decades of caregiving. Once in you will have painted yourself in a corner you will not easily escape. Make it clear this isn't an option.
I am so sorry. The time to talk to social workers at her facility is YESTERDAY so get on this with discharge planners as soon as you can. I am so sorry you are facing this.
I wish you luck in this difficult time.
Does she have her paperwork in order? Living will? You're already POA so that's good - is it activated?
Best of luck.
Have you talked to your mom about Hospice option?
If so what was her response?
And I suppose I should ask, is she competent to make a decision like that? If so then she should be given the information.
I suppose her participation in rehab or the lack of participation might be your guideline for what she wants.
The Social Worker can help with Medicaid application or you can do that.