How would you deal with a Hospice Patient?

[EMS2712]

I agree with what you are saying, and actually having some members of my family under hospice care, I do agree with the choice to die at home comfortably with their family in their home. I have no doubt that this wasn't done on a whim, and a lot of thought went into the decision as this has the potential to be a very emotional time. I still be believe the patient should still have some control in their care. If the patient (or family in this case) makes the decision, and it appears to be a prudent and reasonable decision, does that mean that should forfeit all rights to hospice because you disagree with the hospice decision? As I said, I wasn't on this run, and to get a full view of what was going on, I only have the report to review, and further conversations with the crew on scene. I am putting this up for discussion, and I think we have a lot of valid points on both sides.

[VentMedic]

I agree with what you are saying, and actually having some members of my family under hospice care, I do agree with the choice to die at home comfortably with their family in their home. I have no doubt that this wasn't done on a whim, and a lot of thought went into the decision as this has the potential to be a very emotional time. I still be believe the patient should still have some control in their care. If the patient (or family in this case) makes the decision, and it appears to be a prudent and reasonable decision, does that mean that should forfeit all rights to hospice because you disagree with the hospice decision? As I said, I wasn't on this run, and to get a full view of what was going on, I only have the report to review, and further conversations with the crew on scene. I am putting this up for discussion, and I think we have a lot of valid points on both sides.

There are specific situations that can be outlined in any hospice contract. If the patient decides he wants to live, there is no longer a need for hospice care. If the patient is running a fever or breaks an arm, hospice can and will allow treatment for these things since they cause discomfort. The key is what causes the patient discomfort and hospice cannot alleviate. Thus, the patient calls hospice for advice. A hospice patient may also be transported to the hospital for PICC lines for better access to the comfort meds. Again, hospice will advise and provide the necessary care without being a dictator of care. However, they are also there to protect the patient's rights if he can no longer speak for himself. The family are also part of that decision.

There are also various hospice organizations that specialize in AIDS patients. These patients still come and go from the hospital and may actually not even be a full DNR. They can get dialysis regularly and have infections treated. But, they also have access to a predetermined plan of care which ensures them comfort when it is needed. This is why it is wise to be aware of the many possible legal choices a patient can make.

Edited March 11, 2009 by VentMedic

[crotchitymedic1986]

This is actually quite common, and the family is correct (although I imagine it can vary by region, country, or state). Once you enter hospice care, the family is supposed to call "hospice first" not 911. The on-call hospice nurse will determine if the patient requires an ER visit or an in-home visit from hospice nurse. Each patient is unique, and their's or their family's wishes (which were determined at time of admission to program) are followed.

Those who say DNR does not mean do not treat are correct, but you have to ask yourself what do you really think you can fix for this patient ? You can not fix his cardiac output, nor can you restore the lung function of a terminal lung cancer patient who has dyspnea.

If his G-tube or foley had come out, or if he had a suturable laceration as a result of the fall, the hospice nurse may determine an ER visit as beneficial. But it sounds like (with what little that I read) there is little that an ER or an ambulance crew could fix for this patient. Healthy people dont go to hospice care; death is expected in the immediate future, thus at some stage they will become unstable.

When in doubt in any situation like this, it is best to contact your medical control and/or your supervisor for guidance. There is no "catch all" solution, other than that, as each patient, each DNR order, and each living will may be different.

[FireMedic65]

Before insulting someone, you should also understand the many variations there are and how YOU will be challenged legally if you do not.

Ignorance is not a good defense to claim in a court of law.

You're right. My apologies for going overboard.

[crotchitymedic1986]

and a side note: about giving up your rights when you enter hospice. You would have had to have been around in the 80s, before hospice was around in any legitimate form, to understand how it progressed to this. In those days, grandma got cancer, she reached the point where hospitilization could not improve her condition, and then the family doc would write a script for a hospital bed at home, and discharge the patient.

Everytime grandma coughed, or was hard to wake-up, or did anything unusual, the family would call 911 and we would transport to the ER. Or when the patient was actually in the process of dieing, the family would get scared and call 911 because they didnt want her to die in the house, or they changed their mind.

Since hospice has progressed, you youngsters dont have to deal with this as much as many of these patients go to a hospice facility (instead of home) and hospice does not call you when they code.

[VentMedic]

You're right. My apologies for going overboard.

No problem.

It is a confusing process.

It is best when the patient can make the decisions. We have had patients who had been set on being a DNR/DNI until they couldn't breathe. They will then rescend their DNI to be intubated to get through a period of PNA or CHF. But, they may remain a DNR. Confusing? Yes. Luckily BIPAP(tradename) can be done instead for many situations but will only be done if it is agreed that the disease process is reversible. If the patient deteriorates when removed from BIPAP for basic care, the patient may have to go back on BIPAP and a family or ethics committee decision may have to be made to discontinue life support just as if it was a ventilator(which it is but not invasive). If it was not specified, in my area, about intubation (DNI), that may be the next step.

[VentMedic]

and a side note: about giving up your rights when you enter hospice. You would have had to have been around in the 80s, before hospice was around in any legitimate form, to understand how it progressed to this. In those days, grandma got cancer, she reached the point where hospitilization could not improve her condition, and then the family doc would write a script for a hospital bed at home, and discharge the patient.

_____________

Since hospice has progressed, you youngsters dont have to deal with this as much as many of these patients go to a hospice facility (instead of home) and hospice does not call you when they code.

Here is the history of hospice.

http://www.nhpco.org/i4a/pages/index.cfm?pageid=3285

Hospice was around in the 80s.

Hospice is still done in the home frequently especially if that is the patient's wish. However, some patients may not have the living situation that allows this. Some may prefer a facility which Medicare will pay to some extent but the better facilities will be out of pocket. We supplemented an additional $40K for one of my family members to be in a very nice facility with 24/7 nursing care for just a few days. From what others have told me that is a bargain. Hospice is covered by most insurances but they may not pay for all the luxuries of a resort style hospice.

Extensive initial and continuing family education is why families don't call 911. But, occasionally emotions will cause a family member to crumble when death is near.

[Jeepluv77]

So, let me get this right. Someone pays thousands a year for health insurance. Then, they become terminally ill. Hospice care is covered at just enough to keep them at the minimal level of comfort. If the family doesn't have the ability to care for them, they either have to send themselves horribly into debt or send their family member to a nursing home that that they don't like because that's what hospice says, thus making their last days that much more stressful? And then if the family calls 911 and has the pt transported(say their pain is beyond what their current meds can handle) the person is no longer eligible to receive comfort care because the family forgot to call the hospice first? Someone please tell me it isn't like this and that I'm just reading too much into. I know that if I was in the position this family was in, calling someone that has no idea what's going on with my loved one at that moment for their opinion on what I should do would be the last thing on my mind. Also, would hospice care still be cut if the family transported? Maybe the crew could help load the pt into the family's vehicle and some one else could help get them out at the hospital? Or would still ruffle the feathers of some anonymous hospice overseer?

[itku2er]

Being a nurse in a LTC facality we have several patients in our facality that on Hospice care. We deal with them on a day to day basis. Here When we think a resident is bad enough to send to the ER they come assess the patient and then we send them to the ER. The Hospice care is revoked but just because its revoked at this time does not mean that it can not be picked back up when the patient is well enough to go home. We have several residents that have been under Hospice care that have been admitted to the hospital for things like sespis, dehydaration, and pneumonia. The list does go one but that is just a few examples. Since Hospice has revised their protcols for people to be on hospice care the rules have changed for the admitting process. But when the patient comes home they may be picked back up on hospice care.

I am with Vent and Spenac on the DNR I have seen many DNR they are all yellow and have no room for anything to be added or taken out.

A Living Will is what allows you to make the choices specifically spelled out for what you want and do not want in your health care in the event that you are no longer capable of making those choices.

As far as the senerio goes, If the patient is his own RP and no one has medical power of attorney over him then I would transport on the basis of implied concent if he was lathargic and not responding that gives you the consent to treat.

[VentMedic]

So, let me get this right. Someone pays thousands a year for health insurance. Then, they become terminally ill. Hospice care is covered at just enough to keep them at the minimal level of comfort.

Minimal level of comfort? No, hospice provides comfort to the fullest extent legally possible.

If the family doesn't have the ability to care for them, they either have to send themselves horribly into debt or send their family member to a nursing home that that they don't like because that's what hospice says, thus making their last days that much more stressful?

This is about the patient. The family needs to respect their loved one's decision if they want hospice. As I have already stated, insurances do cover hospice. But, if your loved one wants an ocean view for their last days, that can be arranged at an extra charge. Comfort care measures can be done in a nursing home or sub-acute. Hospice nurses just have more expertise. Either way, the patient has to decide whether they want end of life comfort and the family must respect that.

And then if the family calls 911 and has the pt transported(say their pain is beyond what their current meds can handle) the person is no longer eligible to receive comfort care because the family forgot to call the hospice first?

EMS will not be able to give the patient anywhere near the meds that hospice can. If the patient's code status is reversed, the patient arrives at the ED unconscious, the first thing the ED will do is give narcan to reverse every comfort med the patient has gotten. They will then minimally sedate if at all while re-establishing BP. That is what happens when a hospice patient is taken to the ED. Calling hospice first will prevent that from happening even if the patient is transported to the hospital. There are a few conditions that transport is allowed.

Someone please tell me it isn't like this and that I'm just reading too much into. I know that if I was in the position this family was in, calling someone that has no idea what's going on with my loved one at that moment for their opinion on what I should do would be the last thing on my mind.

Exactly. There is not reason to call EMS except in this situation was a public assist to get the person off the floor. The family was then probably wanting an assessment to see how much longer...not "are they okay" but more "is death coming soon?"

Also, would hospice care still be cut if the family transported? Maybe the crew could help load the pt into the family's vehicle and some one else could help get them out at the hospital? Or would still ruffle the feathers of some anonymous hospice overseer?

The family should still call hospice even if they are going POV. Hospice may allow for some things to be treated like a fever or broken arm. But, if it is for resuscitation, no...why should hospice pay since that is not what they are about? Maybe Medicare or their other insurances will pick up that cost as they had been for Hospice. However, it will be very difficult to get accepted into a hospice program and no regular home health nurse is going to be responsible for that level of comfort.

There is no need to bash hospice here. Hospice is a choice.

I believe Hospice is an excellent way to provide comfort for your loved ones. But, again, it is not about you or even the families when it comes down to it. It is a personal decision for the patient and they should be able to exercise their right to decide how they will live their remaining days and die. Hospice is the patient's best advocate to see their wishes are carried out.