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Hard Cases Dr. Abigail Zuger on the everyday ethical issues doctors face.

Everyone on the ward fell hard for the patient in the room at the end of the hall. Her roommate was loud, demanding and a complete nuisance — nobody spent more time in that part of the room than was absolutely necessary. But the gently smiling, impeccably mannered little 90-year-old, admitted to the window bed with a touch of pneumonia, was a big favorite.

The doctors joked with her, the nurses stroked her head and brought antibiotics and nebulizers right on time, and her private-duty attendant organized her pillows and fed her little snacks. She looked like a million dollars when they sent her home.

Two days later she was back in the emergency room, wheezing and choking all over again, her readmission an embarrassment to the professional staff — and, for the hospital, a big fat fine from Medicare in a new effort to discourage these repeat performances.

Cases like hers torture health policy makers, partly because nobody can quite figure out who is to blame. The system’s culpable habits are legion: discharging patients who are still sick, providing them with incomprehensible instructions, forgetting they’re too weak to get to the pharmacy, overlooking the booby traps at home, providing no coherent follow-up. Sometimes the outpatient doctor doesn’t even know the patient has been admitted.

But patients are not always innocent either: They routinely ignore some or all of their discharge instructions, or merrily resume the bad habits that got them into trouble in the first place. And divine providence, of course, supplies us with an array of remitting and relapsing disorders whose behavior no one without a crystal ball could predict.

Studies thus disagree on how many readmissions within 30 days of discharge are actually preventable. Some say almost none, some say almost all. In 2009, Medicare and Medicaid tried to shame hospitals into doing better by posting readmission rates; that didn’t do much, and now fines are imposed.

Hospitals’ efforts to eliminate some of their worst habits have indeed led to modest improvements. (For comic relief, it should be noted that a few of these strategies backfired and raised readmission rates, possibly because they helped outpatient providers see clearly just how sick their discharged patients were.)

But all the various patterns of overt malfeasance were irrelevant to the 90-year-old patient, for whom everyone from head nurse to housekeeping wished only the best: her discharge went by the book. We must blame instead a global failure to understand that in medicine, as in theater, staging can be all.

Imagine a theater director leading a tiny, white-haired amateur actress onto the proscenium for her first big starring role. For Act I, he tucks her into a wonderful electric bed with her head elevated to just the right degree. He hires a dozen veteran actors to bustle about her, feeding her or adjusting the oxygen tubes in her nose. She cracks a few weak jokes and the pros all laugh. Someone helps her with her lipstick. She is warm, safe, admired, mentally stimulated, coughing discreetly into a fist. Offstage — this is an important detail — the voice of her roommate moans in an endless loop of complaint.

Then we come to Act II. Black-clad stagehands make quick work of the set change: Gone is the bed, the oxygen, the bedside tray full of food and ice water. Gone are the professionals, except for a visiting nurse in the wings, and she won’t show up until the Monday after the Friday afternoon discharge. Gone is the voice of the roommate; in the silence, that cough is suddenly much, much louder.

Our star slumps off a teetering stack of old pillows, and from the cutest little thing on a ward full of disasters she becomes a sick old lady lying the wrong way on a bed too far from a bathroom, lipstick smeared, terrifying relatives who don’t know how to lift her properly. Small wonder that on Sunday morning she is rushed right back to a safer place for that embarrassing — and expensive — Act III.

Policy analysts might read this script and highlight the Friday discharge in accusatory yellow, although there is no consensus on whether the 24-hour health care cycle errs when it spits patients out into a world that still has weekends.

The rest of us should try to remember that what we see in the hospital can sometimes be a masterful illusion, staged by experts.

Only by squinting directly at the star of the show until her surroundings blur is there a chance of accurately predicting whether that fabulous performance can be sustained on an empty stage.