Discharged at the point of death.

Specialties Geriatric

Published

Are you getting lots of residents admitted from hospitals that are breathing their last breath or still sick as a dog. Hospital sent me a lady, that went back in 16 hours and died, one on 10 lts of 02 (hello, how high do your concentrators go?), he went back before getting off the stretcher, one who lasted like 5 hours before complaining of chest pain (she was in the hospital for an MI) who we sent back and she died.

I thought the new medicare stuff was supposed to stop some of this.

maelstrom, you make some very valid points. We've out-sourced death. When I was a kid CPR was still very new and old folks with big problems just - died. If not the first MI then the second, or the stroke, or whatever. Now we can keep people going for decades with multiple morbidities that just a generation ago would have been fatal much earlier.

I will say that the biggest obstacle towards accepting mortality can be physicians. We live in a culture of heroics (see Ann Chapel Stanton, No Place for Dying) and hospitals are the center of it. As new nurses we all had visions of whisking folks away from the grasp of the angel of death. I certainly didn't envision becoming her. And doctors do. not. discuss it. In LTC I would see a physician's note saying, "someone should discuss comfort care with the family." Um, that would be me. But until the doctor verified what I said it didn't matter - I got to soften 'em up. Now, my poor folks get hospitalized and sometimes literally within hours of their deaths are they referred to us. Why? Why has the inevitable end of living become a dirty word? We don't even say die but instead employ the euphemism "pass."

I don't think emergency nurse was referring to us, but to those unrealistic expectations that people have regarding precisely what we can do. I always liked, "What HAPPENED?" Um, what part of SHE'S 90-FREAKING 8! is beyond your ken?

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Specializes in Trauma Surgical ICU.

Where do these pts go then?? I know from the ICU perspective, we can't save them all and while they or the family may not be ready for the death, we can't stop it. Once we reach a point in their care when nothing is working, all treatment options have been exhausted; what do we do then??

This goes much deeper than hospital vs LTC.

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Specializes in Geriatrics, Home Health.

I can see this from the family's point of view. Last month, my mother was admitted to a SNF with metastatic cancer and multi-organ failure. We all knew she wasn't going to leave alive, but home hospice turned her down because of hoarding, and room and board at the local inpatient hospice was $300/day. I made sure she was DNR and CMO, but they really, really pushed for Do Not Hospitalize. I settled for Call Before Sending Out (they knew I was an RN). Part of it was a very bad experience working at SNF, part of it was wanting to be able to do something if she fell or had an MI. She was never sent out, and died 6 days later.

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I'm so sorry, not-a-hat-person.

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Specializes in PCU.
I can see this from the family's point of view. Last month, my mother was admitted to a SNF with metastatic cancer and multi-organ failure. We all knew she wasn't going to leave alive, but home hospice turned her down because of hoarding, and room and board at the local inpatient hospice was $300/day. I made sure she was DNR and CMO, but they really, really pushed for Do Not Hospitalize. I settled for Call Before Sending Out (they knew I was an RN). Part of it was a very bad experience working at SNF, part of it was wanting to be able to do something if she fell or had an MI. She was never sent out, and died 6 days later.

So sorry for your loss :(

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Specializes in ICU, Telemetry.

What breaks my heart is when we get people in the unit who are able to tell us, "I just want to go home" -- home being their house, their SNF, whatever -- and the family won't let us do the right thing. Yes, certainly, if a person who's a DNR and not imminently dying has a UTI, treat it. However, if they're guppy breathing, blue, HR of 38, BP by palp only, it's just cruel to send them to me for me to code them. But I also understand you've got families and MDs who absolutely won't let the kind thing be done.

We've got a doc who think death=failure, and doesn't want to sedate anyone -- a wide awake person on a vent is just horrible. We've broken the arms just to get to the space to do compressions/put on defib pads on a person who was over 100, severely contracted, decubes you could put your open hand into, PEG, trach, and he's telling the family they're doing better as we're looking at an idioventricular rhythm. And he's dumb as dirt and thinks he's God's gift to medicine.

I really, REALLY hate stupid....

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Specializes in ICU, Telemetry.
I can see this from the family's point of view. Last month, my mother was admitted to a SNF with metastatic cancer and multi-organ failure. We all knew she wasn't going to leave alive, but home hospice turned her down because of hoarding, and room and board at the local inpatient hospice was $300/day. I made sure she was DNR and CMO, but they really, really pushed for Do Not Hospitalize. I settled for Call Before Sending Out (they knew I was an RN). Part of it was a very bad experience working at SNF, part of it was wanting to be able to do something if she fell or had an MI. She was never sent out, and died 6 days later.

I'm so sorry. It's horrible when the daughter or son in you is trying to think, "maybe they're getting better, maybe we'll have more time," and the nurse in you knows what's going to happen. I remember looking at my dad's CT and realizing he had lung CA and trying to convince myself that the mass was anything else. I'm not going to tell you a bunch of sappy stuff, but I will tell you, there are a lot of us out there with you on some stage of the journey with our parents, and we care. You're not alone. :hug:

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Specializes in LTC, Hospice, Case Management.
I really, REALLY hate stupid....

Had an 80 yr old with lung cancer, mets everywhere. She had a DNR and an understanding/supportive family by her side as she passed away peacefully. We called the oncologist to inform of the death and she was shocked.."Really, what happened to her. She was just fine a week ago". (Um, really??)

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Specializes in Hospice / Psych / RNAC.
In our facility of 103 only 37 are DNR or do not transport. This means we have no choice but to send them out. Most families don't get it.

This is one of the main concerns. Family members who have POA need to be educated and ready when the inevitable happens and think first of the person passing on and not of their own needs. If they are full codes then they got to go out .... horrible shame for the most part. When there is a change in status family members must be prepared to do what's right for their loved ones.

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Specializes in ED/ICU/TELEMETRY/LTC.
Hey! Guess what? People die.

What about death with dignity? A hospital isn't

necessarily a place to go to die.

Give some palliative care and let them just sail on out.

Quit sending people to the ER to make their last

moments on earth a living hell. Yes we'll code them

until they glow in the dark but should you keep doing

that to people? ...think about it.

Gramma & Grandpa might not want you to do that to them.

EmergencyNrse, are you speaking to the family??

Because the patient lived at home with family before she went to the hospital.

So the patient is sick, and the family does not know what to do. They send them to the hospital.

I have years and years of hospital experience, most of it in the ER. I know where you are coming from.

But what did the hospital do to educate the family that the 79 lb. patient with multiple comorbidities might not go home or anywhere else.

There is something to be said for a nurse who sits quietly with a family and explains quality vs. quality of life and that can be done at the hospital, in the ER, or any other department. Do you do it?

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Specializes in ICU.

We had long termers in the ICU that we had for 3+ months, about as stable as they come, but as soon as we'd send them to LTAC, they'd either bounce right back or die shortly after. Something about the moving, either physical or psychological.

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And exactly how is it anymore dignified to be admitted into a strange nursing home hours before death?

The idea is that a nursing home is traditionally thought to be more comfortable and better equipped to give a dignified death. Hospitals are cold and clinical, nursing homes are supposed to be warm and inviting...homes.

At least a nursing home should be...

Besides, this is an admissions problem not a hospital problem. If you don't want dying patients then assess them before they arrive at the facility.

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