I have a question...I work in the ER, and occasionally we get pt from home/nursing homes, whatever that are on hospice. I recently had a pt that was hospice, but was a full code. Is this becoming more common? Thanks.

Yes. Patient may understand that they have a life limiting illness, but aren't comfortable with being a DNR. Some companies are changing that to "AND" Allow Natural Death--that seems to be more palatable to some...

I have several patients that are still full codes.

linda

We cannot exclude patients due to full code status. It doesn't make much sense to be a full code when terminally ill.... but still... some can't bring themselves to sign a DNR. Sometimes it means no one has really educated the family on what running a code really looks like at time of death. It looks so easy on tv... one little jolt with the paddles and the next minute they are sitting up in bed joking with their loved ones again. Usually the family doesn't actually want the code done when it comes down to the last minute, but some do.

I thought that in order for a patient to have their hospice care covered by Medicare, they had to be a DNR patient???

Nope. Nothing in the Medicare guidelines about DNR status.

EMT/ambulance/ED visit won't be covered under medicare hospice benefit, and sometimes it can be a signal for a need to further discuss goals of care and understanding of prognosis, but it's not a limitation.

Actually anything that is related to comfort is covered under the hospice benefit so if the patient ends up being treated for their symptoms the hospice is require to cover it. It is discouraged because of this. We have a few patients that go to the hospital and are admitted and we follow them as a acute inpatient stay (we have contracts with all of the local hospitals.)

A hospice patient does not have to have a DNR.

Whether a patient in hospice has to have a DNR or not depends on the hospice.

I work in hospice and I see this a lot. I know people have a right to their decisions but my feelings on this are that if you are on hospice then you are not seeking aggressive treatment. Which means, to me, that DNR should be the option w/hospice. Maybe, I'm wrong but we had to do CPR on a pt and call 911. When 911 got there they thought we were crazy.

I also think a lot of the time the family truly doesn't understand the complete picture of the disease process. That's where teaching comes in on our part as the nurse.

Just my opinion.

Linda in McDonough

The hospice I worked with required that all patients be DNR.

I work in hospice and I see this a lot. I know people have a right to their decisions but my feelings on this are that if you are on hospice then you are not seeking aggressive treatment. Which means, to me, that DNR should be the option w/hospice. Maybe, I'm wrong but we had to do CPR on a pt and call 911. When 911 got there they thought we were crazy.

I also think a lot of the time the family truly doesn't understand the complete picture of the disease process. That's where teaching comes in on our part as the nurse.

Just my opinion.

Linda in McDonough

I've known Pts who were full code because they had a goal of being alive for a family birthday. That's a very legitimate reason, and this particular individual signed the DNR right after the birthday.

Still, I suspect most people/families who don't sign DNRs are simply not yet reconciled to the overwhelming probability that the disease course is irreversible and imminent.

People usually don't have any idea of what a code looks like, and I think families underestimate by a mile the amount of distress they would sustain watching their loved one be intubated, poked probably several times to get IV access, etc. Nor do they understand that the majority of codes fail. That's also an area for education.

I have worked in Hospice for 9 years ( where has the time gone?) and we do not require a patient to be a DNR. Usually the family will get on the page by the time the patient is near death but not all of the time. If a patient goes 911 to the hospital for life support then we would have to have the family sign off Hospice so Medicare will pay. We would then refer them to the inpatient Palliative Care team, and they will help the family with goals of care. This has not happened very often as I said, but we cannot force people to be a DNR. The more we educate them and support them in decision making, the better the decision.:redpinkhe