transition from hospital to LTC

I had a patient in LTC before that was a DNR but needed some IV Lasix for CHF and I had to beg my RN supervisor to give. He finally gave it after much encouragement and the resident was not having to fighting for air, so I would say it was a comfort measure in her case.

"No code" and "comfort measures" aren't the same thing. In my facility a "no code" means that we do not start CPR or other heroic measures if they suddenly die. Many residents have a DNR status, but are still treated aggressively in the course of any illness - the DNR implies sudden, unexpected death. Where as a "comfort measure" means we (Dr, family, resident and nsg team) all recognize the resident is dying and all have agreed to manage pain and do whatever is needed to keep the resident comfortable only. No aggressive treatment. In your example of a resident going bad during the night with a DNR - definately call the Dr and the family to inform of the change in condition ( I would do this even with comfort measures) - I believe that is a federal regulation that you MUST do this regardless of code status. It will really be up to the Dr. and the family as to what treatment is done or not done. Some families will say up front - I don't want mom sent to the ER but oxygen, antibiotics, even IV med in house is ok. Then I let Dr know what family says and 99% of the time they will go w/ whatever family wants. The worst is when families get wishy-washy about what they want. You educate em on the dying process and what to expect and they are all in agreement, but then mom/dad starts going real bad and just when it's almost to late they demand immediate transfer to ER. I suppose I understand this, luckily has never been my mom/dad I am dealing with, but I think it's real sad for the resident.

First thing I would do is call the doc and let him know about the change in condition then call the family and inform them. The POA can agree to send them out ,agree to medicine or do nothing. If they were hospice I would be calling them as well. Also a DNR and comfort meaures are two very different things. You can be a DNR and have aggressive treatment but comfort measures are keeping the patient absolutly comfortable with usually no aggressive treatment (unless it will increase the patients comfort). And when I say this I mean for example Lasix to help with SOB D/T fluid overload or something like a laxative to keep the patient from becoming constipated. You will see this type of thing frequently because of the population you are working with. Working in LTC is so much different than hospital nursing ... Good luck to you.....

I have sent hospice patients to the ER, but it was because they were suffering terribly and not responding to the amount of meds we could give them here (the doc apparently slept through his pages). I was told the next day that I absolutely did the right thing.

Now, if a resident is DNR and I notice a significant decline, I will call the hospice nurse if they are on hospice (which many are.) They are wonderful, and will help you a LOT. If they are not hospice, I will call the family and let them know. Usually they will ask "Is Mom hurting?" and if I can reassure them that she is not, often they will tell me not to send her out. The most crucial thing is to document who you have spoken with, the information you have relayed to them, their response, and your actions. If the family can't be there, and I know the end is coming, I stay past my shift, sit with them and hold their hand. I pray that when it is my time, someone will care enough to be holding mine.

I will assume that as you are working in a LTC facility, if the patient needs to be seen by a doctor you will need to get orders to send him/her in and then arrange transport. With that in mind I would
advise as quoted except I would change one thing, and add another:

You need to know if the patient is responsible for self or if there is an active POA for healthcare. If there is an active POA that person must be contacted first to notify them of any change in condition and find out how they would like to proceed. Find out if they want the patient transferred if needed or kept comfortable and treated in house. If the patient is responsible for self and able to respond appropriately, then do whatever they wish. If the patient can't make any decisions due to change of condition, then call the next of kin for advice.
Now that you have a good idea what you need for orders you should call the doctor. I know from experience that finding out what you would like the doctor to do before you call will save you a lot of aggravation later. Especially working the night shift when it is likely that you are waking the doctor up. They don't appreciate being called for orders, only to be called back 30 minutes later and told "sorry, the family wants..."

Just a last word of advice. When the time comes that a patient passes away be prepared to handle the paperwork. If your facility has a "cheat book" with instructions use it. If not, try to familiarize yourself with the policies/procedures; know the orders required from the doctor to pronounce death, any specific wording required in a nurses note, what forms need to be completed for the mortuary and if they provide them. You need to know if the death is reportable to the ME by the standards of your state because that will be on a form either in your facility or from the funeral home. Its also a good idea to know your facilities license number as that is required [at least in WI], usually the funeral home will have that information but every now and then I've run across one that doesn't.
Keep in mind while you are dealing with this you might be consoling a grieving family, supervising the building, doing a med pass and caring for a lot of other people at the same time!
I know it sounds overwhelming, but if you know the procedures it doesn't really take that long to complete the paperwork.

Good luck to you and welcome to long term care!! I really hope you come to enjoy it as much as I do.

In Massachusetts, you have to have a Health Care Proxy which is different from a POA AND it must be invoked by the doctor before your health care proxy can make any decisions for you. We encourage all our residents both short and long term to sign a health care proxy if they don't already have one. Mine is on the refridgerator door ready to go just in case I need it.