Why is admitting a patient so hard?

[Rendar5]

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This might make me a bad person, but that's a patient I'd rather either send them to a non-tele floor bed or home. If the patient's (and family's) goal is to die peacefully, I say let em. I wouldn't ever call for an ICU bed on a DNR patient where everyone, including family, was on the same page.

DNR does not mean no aggressive care and DNR patients can and should go to the ICU if warranted. The ICU after all is capable of a lot more than just CPR (which the patient is refusing). Now a patient who does not want aggressive interventions on the other hand, i agree that floor or maybe even AMA home is appropriate.

 

[deleted547339]

DNR does not mean no aggressive care and DNR patients can and should go to the ICU if warranted. The ICU after all is capable of a lot more than just CPR (which the patient is refusing). Now a patient who does not want aggressive interventions on the other hand, i agree that floor or maybe even AMA home is appropriate.

Would you even get an AMA form on a patient like this? I had a patient recently that was a train wreck. She had metastatic cancer with a tumor burden that was crazy. She was told by her PCP that she "probably had cancer" - she had a recent CT and got a liver biopsy two weeks days prior. She said that no one really told her anything (and I believed her, her family was with her the whole time). She had an appointment scheduled with an oncologist in 2 weeks "for staging."

I had a long talk with this lady. She had no desire for aggressive therapy. She just wanted to spend time with her family and not be in pain.

I discharged her with a lot of pain meds. We couldn't find a reason for her to have belly pain except her massive, diffuse, necrotic metastases in her liver. Her pain responded well in the dept to PO pain meds. DIdn't have her go AMA, just regular d/c. My attending was happy with how it went. I clearly documented that she was sick and at risk of dying in the near future. I wrote about the fact that we talked about her goals of being comfortable and spending time with family.

Would anyone else would have done this differently?

 

[Birdstrike]

Would you even get an AMA form on a patient like this? I had a patient recently that was a train wreck. She had metastatic cancer with a tumor burden that was crazy. She was told by her PCP that she "probably had cancer" - she had a recent CT and got a liver biopsy two weeks days prior. She said that no one really told her anything (and I believed her, her family was with her the whole time). She had an appointment scheduled with an oncologist in 2 weeks "for staging."

I had a long talk with this lady. She had no desire for aggressive therapy. She just wanted to spend time with her family and not be in pain.

I discharged her with a lot of pain meds. We couldn't find a reason for her to have belly pain except her massive, diffuse, necrotic metastases in her liver. Her pain responded well in the dept to PO pain meds. DIdn't have her go AMA, just regular d/c. My attending was happy with how it went. I clearly documented that she was sick and at risk of dying in the near future. I wrote about the fact that we talked about her goals of being comfortable and spending time with family.

Would anyone else would have done this differently?

Context is everything. If it was right for the patient, then it was right for the patient.

 

[Groove]

Would you even get an AMA form on a patient like this? I had a patient recently that was a train wreck. She had metastatic cancer with a tumor burden that was crazy. She was told by her PCP that she "probably had cancer" - she had a recent CT and got a liver biopsy two weeks days prior. She said that no one really told her anything (and I believed her, her family was with her the whole time). She had an appointment scheduled with an oncologist in 2 weeks "for staging."

I had a long talk with this lady. She had no desire for aggressive therapy. She just wanted to spend time with her family and not be in pain.

I discharged her with a lot of pain meds. We couldn't find a reason for her to have belly pain except her massive, diffuse, necrotic metastases in her liver. Her pain responded well in the dept to PO pain meds. DIdn't have her go AMA, just regular d/c. My attending was happy with how it went. I clearly documented that she was sick and at risk of dying in the near future. I wrote about the fact that we talked about her goals of being comfortable and spending time with family.

Would anyone else would have done this differently?

I don't think there's a right or wrong answer, but I typically don't send them out in that context unless they are requesting to leave after pain control, understand the gravity of the situation, and only after they've been offered admission. Especially when I don't have a specific Ca dx, haven't talked to the PCP/oncologist and have no idea what anybody has planned for this lady.

I get really pissed off with these types of situations when pt's come in (not exactly in this specific context) and the PCP/oncologist hasn't had any code status discussions (still full code), they obviously need hospice yet nobody has brought it up because they've been tip toeing around the subject of death, etc.. Then I get stuck feeling like a glorified SW.

Better yet, they get sent out, still full code and show back up within 72h in full arrest, no family, get them back and once the family shows up they vehemently agree that the pt never wanted to be on life support and nobody ever explained it to them. I had one recently like that... always frustrating.

 

[Groove]

Just to add some humor to this thread... Recently found this on YT and I laughed until I cried.

[YOUTUBE]http://www.youtube.com/watch?v=3TNs3YddRj8&feature=share&list=PLqBLoScSYEGcLtGGOMEvE1QhFfmpHfd7l[/YOUTUBE]

 

[Rendar5]

Just to add some humor to this thread... Recently found this on YT and I laughed until I cried.

[YOUTUBE]http://www.youtube.com/watch?v=3TNs3YddRj8&feature=share&list=PLqBLoScSYEGcLtGGOMEvE1QhFfmpHfd7l[/YOUTUBE]

I show that to all my interns 🙂

 

[Rendar5]

Would you even get an AMA form on a patient like this? I had a patient recently that was a train wreck. She had metastatic cancer with a tumor burden that was crazy. She was told by her PCP that she "probably had cancer" - she had a recent CT and got a liver biopsy two weeks days prior. She said that no one really told her anything (and I believed her, her family was with her the whole time). She had an appointment scheduled with an oncologist in 2 weeks "for staging."

I had a long talk with this lady. She had no desire for aggressive therapy. She just wanted to spend time with her family and not be in pain.

I discharged her with a lot of pain meds. We couldn't find a reason for her to have belly pain except her massive, diffuse, necrotic metastases in her liver. Her pain responded well in the dept to PO pain meds. DIdn't have her go AMA, just regular d/c. My attending was happy with how it went. I clearly documented that she was sick and at risk of dying in the near future. I wrote about the fact that we talked about her goals of being comfortable and spending time with family.

Would anyone else would have done this differently?

Sure I'd have them sign an AMA form. "I knowyou understand that you will probably die if you go hom. Because of that, as a doctor, I can't take that risk for you, but I can understand your decision. If you want to go home understanding this, would you mind signing a form saying that you're taking the risk yourself?" or something to that effect. No reason to have an AMA be confrontational. I just want a form on file so that her long-last cousin who hasn't seen her in 20 years doesn't get pissed off that we sent her home to die and try to convince her kids to sue =p

 

[FutureInternist]

In my IM residency, the ER docs did not have admitting privileges, and each admission to the team had to be approved by the senior resident on that team
Consequently if you refused an admission, then you had to talk to your attending, who did not have to come see the patient if they trusted your evaluation & since they are not seeing the patient & hence cannot bill, the "consult" note was 5-10 lines of type rather than the insanely long H&Ps that we in IM tend to do
Our system had a cap like all do, but we made exceptions for our own clinic patients to where they were admitted to the next day's call team (max of 3) so the attendings in the ER would not even do any workup. "Oh this guy is seen in IM clinic = call IM"
The stupidest case was when as an almost graduated third year (May'ish) I got 3 admits in a row that capped mine & the next day's team. While receiving face-to-face sign out from one of the attendings, another attending handed me a chart & said "Clinic patient. Has chest pain"
When I told her that I just capped & that she should call the private hospitalist, she just shrugged & said "Well I guess I'll send him home"
That bothered me quite a but so in front of the full ER with all the other docs, NPs, PAs, scribes etc I asked her why she thought he needed an admission a minute ago & now all of sudden she's sending him home. She got a little pissed first but she really blew a gasket when I told her that just because it's a clinic patient doesn't mean she shouldn't do her job
Heard from my attending about that one the next day but f--- it , I was graduating in a month anyway

To really know the hell that is "ER admits pts" just ask anyone IM resident that does a rotation at the VA.

 

[FutureInternist]

DNR does not mean no aggressive care and DNR patients can and should go to the ICU if warranted. The ICU after all is capable of a lot more than just CPR (which the patient is refusing). Now a patient who does not want aggressive interventions on the other hand, i agree that floor or maybe even AMA home is appropriate.

As much as we like to tell patients that this is the way it is, in reality there is a perceptible drop in care once a patient becomes DNR. This is a huge issue for people, I think, specially in intern & 2nd year.
Once you have accepted the fact that the patient is OK with dying, you are less likely to spend the time needed to keep them alive
I was seeing an ID patient in MICU & picked up the wrong chart. Saw the Na was > 160 & had been for 2-3 days. Once I found the right chart I went to the intern & asked about it & they said "Oh. She's DNR"
Granted the senior or the attending should have picked up on it but this is the theme that seems to run anytime someone is made DNR.

 

[deleted109597]

Consequently if you refused an admission, then you had to talk to your attending, who did not have to come see the patient if they trusted your evaluation & since they are not seeing the patient & hence cannot bill, the "consult" note was 5-10 lines of type rather than the insanely long H&Ps that we in IM tend to do

Then what happens to the patient? Are they sent home? Does someone else admit them?

 

[Rendar5]

As much as we like to tell patients that this is the way it is, in reality there is a perceptible drop in care once a patient becomes DNR. This is a huge issue for people, I think, specially in intern & 2nd year.
Once you have accepted the fact that the patient is OK with dying, you are less likely to spend the time needed to keep them alive
I was seeing an ID patient in MICU & picked up the wrong chart. Saw the Na was > 160 & had been for 2-3 days. Once I found the right chart I went to the intern & asked about it & they said "Oh. She's DNR"
Granted the senior or the attending should have picked up on it but this is the theme that seems to run anytime someone is made DNR.

I agree that some ppl stop taking as much care of pt's once DNR is there, but doesn't mean we should let the resident's butt off the case=p Until it says comfort measures only, they get everything from me. and that should still include IV fluids =p.

 

[Old_Mil]

Would you even get an AMA form on a patient like this? I had a patient recently that was a train wreck. She had metastatic cancer with a tumor burden that was crazy. She was told by her PCP that she "probably had cancer" - she had a recent CT and got a liver biopsy two weeks days prior. She said that no one really told her anything (and I believed her, her family was with her the whole time). She had an appointment scheduled with an oncologist in 2 weeks "for staging."

I had a long talk with this lady. She had no desire for aggressive therapy. She just wanted to spend time with her family and not be in pain.

I discharged her with a lot of pain meds. We couldn't find a reason for her to have belly pain except her massive, diffuse, necrotic metastases in her liver. Her pain responded well in the dept to PO pain meds. DIdn't have her go AMA, just regular d/c. My attending was happy with how it went. I clearly documented that she was sick and at risk of dying in the near future. I wrote about the fact that we talked about her goals of being comfortable and spending time with family.

Would anyone else would have done this differently?

There are different kinds of patients. In an ideal world we could have discussions like this with all our patients and partner with them to teach them about their illnesses and do what is right. In the real world every patient is a potential legal adversary and no testing or admission decision is made without that in the back of your mind.

There are different kinds of hospitalists. Some fight you on everything. I had one tell me to admit the patient to his PCP although he wasnt on call. Others are great. I try not to turf stuff out...but sometimes a 90 something patient is going to get admitted for obs because the dept is packed, this is his third visit in two weeks and his 30 day risk of death is not insignificant.

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[WilcoWorld]

While receiving face-to-face sign out from one of the attendings, another attending handed me a chart & said "Clinic patient. Has chest pain"
When I told her that I just capped & that she should call the private hospitalist, she just shrugged & said "Well I guess I'll send him home"

Wow, that sounds like a lousy ED.

I was seeing an ID patient in MICU & picked up the wrong chart. Saw the Na was > 160 & had been for 2-3 days. Once I found the right chart I went to the intern & asked about it & they said "Oh. She's DNR".

But not nearly as bad as your MICU...

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.
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Troll bait, I know, but I just couldn't resist.

 

[e30ftw]

As much as we like to tell patients that this is the way it is, in reality there is a perceptible drop in care once a patient becomes DNR..

per laws of medicine there should be an appropriate decrease in mortality associated with the drop in care.

I was seeing an ID patient in MICU & picked up the wrong chart. Saw the Na was > 160 & had been for 2-3 days. Once I found the right chart I went to the intern & asked about it & they said "Oh. She's DNR"

this intern needs an appropriately epic wrath of kahn smackdown.

 

[deleted547339]

per laws of medicine there should be an appropriate decrease in mortality associated with the drop in care.

.

Rule #13: THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH OF NOTHING AS POSSIBLE.

Never question the rules in the house.

 

[FutureInternist]

Then what happens to the patient? Are they sent home? Does someone else admit them?

If the ER docs really feel like an admission is warranted, even after talking to the attending, the they will call the private hospitalists

Wow, that sounds like a lousy ED.
But not nearly as bad as your MICU...
Troll bait, I know, but I just couldn't resist.

In their (intern's) defense, it was early on (Aug-ish) but the resident did hear it from me

 

[ccfccp]

at my urban trauma center job it's more like this:
" hello, Dr. venagali, this is emedpa, I'm one of the em pas here(because they have no idea who anyone is). I have a hypoxic 84 yr old lady with a chf exacerbation on bipap who needs to come into the unit"
Dr. V " why do you think she needs to come in? has she been adequately diuresed? what is her serum porcelain level? did you talk to her pcp? has your attending seen this patient? I'm really busy. call me back in 5 hrs if you want me to see her if you haven't fixed her yet." Click.

This actually made me spit up my oatmeal. Thanks for the laugh...

 

[deleted109597]

If the ER docs really feel like an admission is warranted, even after talking to the attending, the they will call the private hospitalists

So, they just talk on the phone, or they come down and see then decide not to admit?

Because, hospital policy notwithstanding, if the attending refuses to come see a patient that they're consulted on from the ED, then they're violating EMTALA. And if there's a negative outcome, case law has followed that the doc who never saw the patient is typically held to be more at fault if they were consulted.

 

[FutureInternist]

So, they just talk on the phone, or they come down and see then decide not to admit?

Because, hospital policy notwithstanding, if the attending refuses to come see a patient that they're consulted on from the ED, then they're violating EMTALA. And if there's a negative outcome, case law has followed that the doc who never saw the patient is typically held to be more at fault if they were consulted.

I don't know about the ramifications of it but most of the time the attending does not see the patient (if they trust your judgment)
EMTALA, refers to stabilisation of an acute process does it not? Not necessarily guaranteeing an admission?
Any lawyers on here?

 

[deleted109597]

I don't know about the ramifications of it but most of the time the attending does not see the patient (if they trust your judgment)

That's the point. They're the attending on call. The buck stops with them.

EMTALA, refers to stabilisation of an acute process does it not? Not necessarily guaranteeing an admission?

No. If their acute process requires a specialist, be it someone with admitting privileges, someone who can provide operative services, or someone who can evaluate the patient and then discharge them, and that person is on call, they're required to see the patient (or arrange to see them, such as at their clinic directly after discharge/next morning). If you're on call, and refuse to come see the patient and they require your services, you commit an EMTALA violation.

 

[MJB]

Because at our hospital, about 80% of the "admissions" are complete BS. It's not uncommon for us as residents to deny admissions from ED attendings. When average LOS for the vast majority of your patients is less than 24hrs, that should tell you something.

 

[Rendar5]

Because at our hospital, about 80% of the "admissions" are complete BS. It's not uncommon for us as residents to deny admissions from ED attendings. When average LOS for the vast majority of your patients is less than 24hrs, that should tell you something.

Tells me that most likely you're either rushing them out too fast, or you've got a low acuity hospital with a lot of rule out admissions. Or I will admit it means you've got a lot of non-EM trained docs down in the ED.

 

[Daiphon]

Tells me that most likely you're either rushing them out too fast, or you've got a low acuity hospital with a lot of rule out admissions. Or I will admit it means you've got a lot of non-EM trained docs down in the ED.

May also be a high-volume ED without an obs unit & no other alternative method for clearing beds... my community rotation in residency was like that.

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