The phone rings at two in the morning. "Your mother has a fever and she's confused. Do you want us to send her to emergency?"
You have eight seconds, almost no information, and the certainty that whatever you say will be wrong. Say yes and it goes badly, and you sent her to a hallway. Say no and it goes badly, and you denied her treatment.
This page has one purpose: to make sure that call does not find you unprepared. The right decision is not made at 2 a.m. It is prepared beforehand.
1. What a transfer actually does to a very old person
Hospitals save lives, and for some things there is no alternative. But the costs deserve saying out loud:
- Delirium. An older person with dementia taken to emergency at night — lights, noise, strangers, nothing by mouth, none of her landmarks — very often becomes acutely confused. Delirium worsens outcomes and does not always fully resolve.
- Deconditioning. A few days in a hospital bed can undo walking that took a year to maintain.
- The hallway wait, which nobody factors in.
- Hospital-acquired infection and procedure-related risk.
None of that argues against transfer when transfer is needed. It argues for deciding deliberately rather than reflexively.
2. When hospital is the answer, no argument
- suspected fracture, especially a hip: it needs fixing, even at a great age;
- stroke signs — face droop, arm weakness, slurred speech: there is a treatment window and minutes matter;
- significant shortness of breath, chest pain;
- acute abdomen, persistent vomiting;
- head injury, especially on a blood thinner;
- bleeding that will not stop;
- anything the home is not equipped to treat.
3. When it can often be avoided — if the home is set up for it
A large share of transfers from long-term care are for conditions a well-supported home manages better on site:
- urinary or respiratory infection responding to treatment;
- dehydration, including subcutaneous fluids;
- fever in someone in the advanced stage of an illness, where transfer changes the outcome very little and the last weeks a great deal;
- a fall with no sign of fracture, with observation in place;
- a mild flare of something already known and managed.
The deciding factor is rarely severity. It is what the home can do overnight — whether a nurse practitioner or physician can be reached, whether portable x-ray and lab come to the building, and whether the province funds any kind of urgent in-home or in-reach response. Establish that in advance, not at 2 a.m.
4. Three questions to ask on the phone
- "What have you done already, and what can you do there tonight?"
- "What would the hospital change, compared with what you can do?" The decisive question. If the answer is "they'd run the same tests", the answer is usually no.
- "Has the physician or nurse practitioner on call been reached?"
And a fourth: "Call me back in an hour." A great many situations resolve within the hour.
5. The plan that prevents all of this
Every province has some version of an advance care plan and a goals of care conversation, and the vocabulary differs: goals of care designations in Alberta, levels of intervention elsewhere, a personal directive, a representation agreement in British Columbia, a power of attorney for personal care in Ontario.
What matters is not the label. It is that a documented conversation exists which answers the specific question: if she gets an infection, do we treat here or transfer?
Two practical points
- A DNR order covers cardiac arrest only. It does not mean "no treatment", and this is misunderstood constantly.
- The document has to be findable. An advance care plan in a drawer at home is useless at 3 a.m. It belongs in the chart, at the front, and it should travel with her.
The sentence to say to the home: "I'd like a goals of care conversation with the physician or nurse practitioner, documented in her chart. Can we schedule it?" You can request a care conference rather than waiting for the annual review.
6. Who actually gets to decide
This is the part most families do not know: in several provinces, the law sets a ranked list of who consents on behalf of someone who is incapable.
In Ontario, under the Health Care Consent Act, the hierarchy runs roughly: a court-appointed guardian, then an attorney for personal care, then a representative appointed by the Consent and Capacity Board, then the spouse or partner, then a child or parent, then a sibling, then any other relative. The highest-ranked person who is available, capable and willing decides — and must decide according to her known wishes, not their own preference. Other provinces have comparable rules.
Two consequences that surprise people. The eldest child does not automatically outrank the others — same rank means they must agree. And a power of attorney for property gives no authority over treatment; only the personal care document does.
Which is exactly why telling the clinician what she used to say — "she never wanted to be kept going on machines", "she'd want everything tried" — is not sentiment. It is the material the decision is built from.
7. If she does go
- Meet her at emergency if you possibly can.
- Send the medication list, the advance care plan and the home's contact with her.
- Tell the receiving staff immediately that she has dementia.
- Ask that restraint is avoided and that someone can stay.
- Push for discharge as soon as it is safe, and confirm the home is holding her bed.
For the paperwork and for the search
If the 2 a.m. call happens because the home cannot treat anything on site, then the problem is not that one night. It is the home.
Curalune Care Help (CA$99) puts together, usually within 24 business hours, a shortlist of 3 to 5 homes matched to her area and care needs — with contacts and the questions to ask about overnight medical cover.
*General information, not medical or legal advice. In an emergency call 911. Every clinical decision belongs to the clinician who has assessed the person.*