Hospice?

[Luella]

Do you ever refer patients to hospice? What if someone has CHF and the fam calls 911 once a week. When is it appropriate to suggest palliative care?

Looking at NHPCO's guidelines (6 mo prognosis, palliative care need), it seems like a lot of ER admits would be better hospice candidates. Not to mention how much better that would be for resource allocation...

And, what if a hospice patient is admitted? Do you honor the DNR or is there no time to check?

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[docB]

In general it is not appropriate for EPs to place patients into hospice. That should be done by primary docs who have continuity with the patient. That continuity gives them the in depth knowledge of the patient's condition, course, attitude and a relationship with the patient and family that is required to appropriately address hospice issues.

Having put forth that firm sounding generalization special circumstances do arise (it's EM dammit) so I have occasionally put people in hospice. It is appropriate to discuss palliative care in the ED when the patient and family bring it up. I frequently will stabilize a patient, admit them with selective DNR orders and tell the primary that they will want to talk about hospice with them.

I'll honor anyone's DNR. If a hospice patient comes to the ER it's important to find out if they are taking themselves off hospice and want to be full code again. In general hospice patients shouldn't be in the ER.

 

[DropkickMurphy]

What if someone has CHF and the fam calls 911 once a week. When is it appropriate to suggest palliative care?

When they start interrupting the local paramedics' sleep patterns.

"Look lady, your mom is starting to piss everyone off because you calling 911 for her all the time- it's cutting into the time we all rely upon for sleep, watching TV, and drinking coffee.....time to pull the plug!"



NOTE: TOTAL SARCASM ABOVE

 

[SoCuteMD]

Just FYI: My grandmother's hospice (awful, awful organization - not hospice in general, but this specific one) required us to sign somethign that said we wouldn't call 911, essentially because if she was admitted to the hospital they wouldn't get paid. If we called 911 we would be responsible for all the unpaid hospice charges.

 

[leviathan]

NOTE: TOTAL SARCASM ABOVE

Ahh yes, the ever important disclaimer as a consequence of the multitude of sanctimonious people who cannot detect sarcasm and humour.

 

[DropkickMurphy]

Yeah, the last thing I want to deal with tonight is one of those people who bitched us out about talking bad about our patients.....

 

[colforbinMD]

Ahh yes, the ever important disclaimer as a consequence of the multitude of sanctimonious people who cannot detect sarcasm and humour.

Sarcasm CHECK Humor ?????
As for my disclaimer: As far from sanctimonious as you can get but require funny for my humor.

 

[southerndoc]

In general it is not appropriate for EPs to place patients into hospice.

I have placed patients in hospice from the ED. In fact, just today I tried to arrange hospice for a patient who was DNR, DNI (do not intubate), who was sent by an extended care facility for acute oxygen desaturation. The patient was alert and oriented. He was clear with his wishes: he wanted only comfort care. He realized the consequences of his actions.

Unfortunately I wasn't able to place him in hospice because the nearby places were full. Outpatient hospice is more difficult to arrange.

So he was made "comfort care" and admitted to the hospital. I had discussed this with his primary care physician and his family, and all were in agreement.

I disagree that ED physicians shouldn't place patients in hospice. We need to do what's best for the patient. I agree, however, that you cannot do this without consulting the primary care physician. This doesn't mean that the primary care physician must arrange the hospice. The ED physician is perfectly capable of this.

 

[bartleby]

If a patient who is hospice or "CMO" (Comfort Measures Only) comes my way, I touch base with the people who take care of them and make decisions for them to verify their paperwork is correct and updated, then hopefully do nothing.

A nurse from a local nursing home panicked the other night when the obese 50 y/o patient with newly diagnosed HIV in the setting of end-stage liver disease due to Hep C who did not qualify for transplant began decompensating. He was clearly documented to be CMO and "Do Not Hospitalize". She called 911 anyone "because he looked really sick". I explained to her that with his liver (INR of 9.7, no anticoagulation) there wasn't any hospital in the world that was going to fix him and that she'd better get used to the idea. "But I'm not trained to do nothing" was her reply.

We spend years in school learning how to do stuff. Knowing when not to do anything and sticking to it are two of the hardest things to learn in medicine.

 

[docB]

I have placed patients in hospice from the ED. In fact, just today I tried to arrange hospice for a patient who was DNR, DNI (do not intubate), who was sent by an extended care facility for acute oxygen desaturation. The patient was alert and oriented. He was clear with his wishes: he wanted only comfort care. He realized the consequences of his actions.

Unfortunately I wasn't able to place him in hospice because the nearby places were full. Outpatient hospice is more difficult to arrange.

So he was made "comfort care" and admitted to the hospital. I had discussed this with his primary care physician and his family, and all were in agreement.

I disagree that ED physicians shouldn't place patients in hospice. We need to do what's best for the patient. I agree, however, that you cannot do this without consulting the primary care physician. This doesn't mean that the primary care physician must arrange the hospice. The ED physician is perfectly capable of this.

I stand by my assertion. To place someone in hospice a thorough understanding of their medical history and current situation is necessary. That understanding should really be more complete than an ED H&P. Thorough discussions with the pt and often the family are advisable. The hospice programs that I work with also require an atestation that the patient has a terminal condition and is likely to expire in less than 6 months. In my area comfort care does not equal hospice because people can desire longer term comfort care. I also need to have a primary doc who can handle the longer term orders at the hospice or arrange home hospice. If I admit the guy to hospice they'll be calling me for Tyleol, etc. forever.

That said I have placed people in hospice for various reasons and I agree with your placement in your case. I think that in general we shouldn't be doing it.

 

[Luella]

Agreed.

The hospice I work with offers a "bridge program," a pre-hospice of sorts. The pt and family can form a relationship with the RN and social worker who can stay with them when they are ready for hospice. Referring to this is a good way to emphasize comfort care without deciding to w/draw life-sustaining treatment.

In any case, the ED seems to be the least conducive place to the holistic and passive approach of hospice-type care.