The phone rings at two in the morning. "Your mother has a temperature of 101 and she's confused. Do you want us to send her out?"
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 an ER 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 — and there is a specific form for exactly this.
1. What a transfer actually does to a very old person
This is not ideological. Hospitals save lives, and for some things there is no alternative. But the costs deserve saying out loud, because nobody says them:
- Delirium. An older person with dementia taken to an ER at night — lights, noise, strangers, nothing by mouth, none of her landmarks — very often becomes acutely confused. That is not a detail: 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 the hospital is the answer, no argument
- suspected fracture, especially a hip: it needs fixing, even at a great age, because the alternative is pain and immobility;
- 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 facility is not equipped to treat.
3. When it can often be avoided — if the facility is set up for it
A large share of transfers from nursing homes are for conditions a well-staffed facility handles better on site:
- urinary or respiratory infection responding to treatment;
- dehydration, including subcutaneous or IV fluids where available;
- 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 facility can actually do — including whether a physician or nurse practitioner can be reached at night, and whether labs and x-ray come to the building. Establish that in advance, not at 2 a.m.
4. Three questions to ask on the phone
- "What have you already done, and what can you do there tonight?" IV or subcutaneous fluids, oxygen, labs, portable x-ray, antibiotics, a provider on call.
- "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 a provider assessed her, or is this a nurse's phone judgment?" Not a criticism — information about how solid the assessment is.
And a fourth: "Call me back in an hour." A great many situations resolve within the hour.
5. The form that prevents all of this
POLST — Physician Orders for Life-Sustaining Treatment, called MOLST, POST or COLST depending on your state — is the tool most families have never heard of, and it is the one that matters here.
Unlike an advance directive, a POLST is a medical order, signed by a clinician, written for someone who is already seriously ill or frail. It is usually a brightly colored one-page form that stays at the front of the chart and travels with her. It says, in terms a paramedic can act on at 3 a.m.:
- CPR or no CPR;
- full treatment, selective treatment, or comfort-focused treatment — this middle option is the one families never know exists: treat infections, give antibiotics and fluids, but do not transfer to intensive care;
- whether to transfer to hospital at all, and under what circumstances;
- artificially administered nutrition.
Alongside it
- An advance directive / living will states her wishes for the future. It is not an order and a paramedic cannot act on it directly.
- A healthcare proxy or durable power of attorney for healthcare names the person who speaks for her. This is different from a financial power of attorney, and the financial one gives no authority over treatment.
- A DNR order covers cardiac arrest only. It does not mean "no treatment", and this is misunderstood constantly.
The sentence to say to the facility: "I'd like to complete a POLST for my mother with her physician. Can we schedule that?"
Under federal rules you can also request a care plan meeting rather than waiting for the scheduled one — that is the right setting for this conversation.
6. If she can no longer say
With no POLST and no proxy, the facility turns to the surrogate decision-maker your state law designates — usually a spouse, then adult children — and decisions are made on what she would have wanted.
Note the framing: family members act as her voice, not as their own. Which is exactly why telling the physician 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 the ER if you possibly can. A confused older person alone on a gurney for six hours is the worst version of this.
- Bring the medication list, the facility's contact and the POLST if one exists.
- Tell the receiving staff immediately that she has dementia.
- Ask that restraints be avoided and that someone can stay with her.
- Push for discharge as soon as it is safe — and understand the bed-hold policy: the facility must give you written notice of its bed-hold and readmission policy, and Medicaid bed-hold rules vary by state. Ask before she leaves the building.
For the paperwork and for the search
If the 2 a.m. call happens because the facility cannot treat anything on site, then the problem is not that one night. It is the facility. Staffing data, including whether there is a nurse in the building overnight, is public on Medicare Care Compare.
Curalune Care Help ($89) puts together, usually within 24 business hours, a shortlist of 3 to 5 facilities matched to her area and care needs — with contacts and the questions to ask about night coverage and on-site capability.
*General information, not medical or legal advice. In an emergency call 911. Every clinical decision belongs to the clinician who has assessed the person.*