Case Presentation: A 70 year old female with metastatic cholangiocarcinoma, heart failure with reduced ejection fraction, stage 4 chronic kidney disease and pulmonary embolism on anticoagulation presented to a NYC safety net hospital with bilateral lower extremity edema, dyspnea at rest and a recent unwitnessed fall. Her malignancy was diagnosed 7 months prior and her last dose of chemotherapy was administered two weeks prior to admission. Patient’s course was complicated by delirium, oliguric renal failure and cardiogenic shock requiring a bumetanide drip, sepsis from a urinary source, acute blood loss anemia and supraventricular tachycardia requiring amiodarone therapy. During a family meeting where the team disclosed her poor prognosis, the patient’s son and daughter in law requested that she be discharged so they could arrange for her to repatriate to her home country of Gambia. Initially there was concern that the patient would not survive transport to the airport, much less an 11 hour transatlantic flight. After consultation and discussions between the intensive care team, palliative care, risk management and the family, the patient boarded a flight four days later and arrived safely in her home country of Gambia, where she passed several days later surrounded by friends and family. We note several similar cases of successful repatriation at the end of life to various countries all over the world.
Discussion: In addition to providing excellent inpatient care, hospitalists are tasked with planning a safe discharge after hospitalization. For many immigrant patients, especially those at the end of life, returning home to their birth country is of the utmost importance. In addition, given the limited availability of specialty hospice & palliative care providers, hospitalists are increasingly asked to provide primary palliative care for their seriously and terminally ill patients. Repatriation of dying patients may pose a unique challenge to hospitalist teams who care for immigrant patients, some of whom may be undocumented. This clinical vignette aims to address this unique patient safety matter by sharing repatriation best practices, including the optimal time of repatriation, coordination with various government agencies and embassies, legal responsibilities and ramifications, and other little known flight-related strategies to ensure a safe trip home.
Conclusions: They say “home” is where we make it. And yet, for our immigrant patients, “home” may mean a place thousands of miles away from the hospital. For dying patients who wish to spend their final days in their country of birth, repatriation should be a unique discharge consideration. Hospitalists can play an integral role in coordinating this care while providing goal concordant, culturally sensitive care for some of the hospital’s most disadvantaged patients.