End stage Alzheimer's

  1. 0 I recently visited a patient with end stage Alzheimer's diagnosis. However, I have problem understanding why she should be in hospice considering her status. The pt is a 93 years old female that walks with walker, most of the time she sits at her sofa and constantly picking the sofa apart ( she is not agitated, it's her habit), awake, very confused. She would talk and lead you to her own world. Bladder and bowel incontinent, vital signs WNL, o2 sat 98% room air, she can feed herself when the meal is ready in front of her. have heart murmur, tricuspid valve disease, lung sounds clear, bowel movement every 2-3 days with daily doses of lactulose. She does need to be reminded of taking food and fluid.

    Would anyone please explain why this pt should be on hospice?

    The family also asks about having her lab works done (after the family talked to the Physician assistant, family said P.A. in agreement of having lab done). I explain to them that unless there is sign/symptoms that warrant the need for lab such as UTI or pneumonia; otherwise, we dont do lab work on routine basic since the patient is on hospice and not seeking curative treatment. Do you think my answer is appropriate? Is there a better way to address this question?

    Thank you so much for you input.
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  3. Visit  tnguy31 profile page

    About tnguy31

    Joined Dec '12; Posts: 26; Likes: 4.

    13 Comments so far...

  4. Visit  brithoover profile page
    0
    If they want active tx and lab tests out the wazoo hospice is not the place to be. I think if you have a prognosis of less than 6 mths you can go to hospice.
  5. Visit  Whispera profile page
    1
    If the lab tests are warranted for a condition unrelated to the reason she's in hospice, then they're acceptable in hospice. Treatments other than the hospice diagnosis are treated, in many cases. What's the reason the family wanted lab tests? How would they relate to Alzheimer's?

    It doesn't sound like she's in end-stage Alzheimer's to me. Maybe she's getting to it, but end-stage patients are generally much more disabled physically. As she is, she could go on for quite a long time...
    tewdles likes this.
  6. Visit  morte profile page
    0
    Yes, she isn't end stage at all. If she were, she might well qualify, but not now.
    Quote from Whispera
    If the lab tests are warranted for a condition unrelated to the reason she's in hospice, then they're acceptable in hospice. Treatments other than the hospice diagnosis are treated, in many cases. What's the reason the family wanted lab tests? How would they relate to Alzheimer's?

    It doesn't sound like she's in end-stage Alzheimer's to me. Maybe she's getting to it, but end-stage patients are generally much more disabled physically. As she is, she could go on for quite a long time...
  7. Visit  NRSKarenRN profile page
    2
    tewdles and leslie :-D like this.
  8. Visit  tnguy31 profile page
    0
    Yes I think so too. Although she is end stage, I don't see her with a prognosis less than 6months. I don't know what the lab for, just CBC and CMP. But I'm checking with the P.A who talks to family. So far, she hasn't respond yet. I have other ES Alzheimer in bad shape physically, but this particular pt is different.
  9. Visit  NC29mom profile page
    1
    A true ES Alzheimer's pt should not be able to walk, talk, maintain an independent sitting posture, or smile. Speech should be limited to a few words. Should have comorbities, and a secondary condition like recurring UTI's, aspiration pneumonia, Stage III - IV pressure ulcers, or serious weight loss over a short time.

    Sadly, this patient does not seem to meet the criteria.

    As far as "routine lab work"....NO its NOT COVERED under the hospice benefit. Now, if they were talking about a PT/INR r/t Coumadin use, then that particular test would be covered under her traditional Medicare. But, to just do routine labs for the sake of checking them (blood count, electrolytes)...absolutely not along with the hospice philosophy of care. So what if the labs are not WNL? As a hospice pt, we expect exactly that. There would be no intervention to correct the abnormal labs....right?

    However, if the pt goes to her primary doctors office, and they do routine labs, her traditional Medicare will likely pay. We, at our office, do not draw them in the field, or pay for transport to primary drs office.

    You should consult your team at IDG, and voice your concerns. Im sure you are not the only one wondering if this pt should remain under care.

    Just curious....is the pt a DNR? If not, have you discussed code status with her family? What kind of response did you get?
    tewdles likes this.
  10. Visit  tnguy31 profile page
    0
    Thank you NC29Mom for your input. The pt is a DNR. The family just dont understand the purpose of hospice, and there is miscommunication betweeen the P.A and the family. I already talked to case manager, still waiting on the response
  11. Visit  leslie :-D profile page
    1
    i've cared for sev'l end-stage alzheimer's pts, many of them still ambulatory.
    the telling sign that warranted hospice, is when pt could no longer eat, i.e., forgets how to swallow, eating non-food items.
    or, family is considering a g-tube.
    it is at those times that hospice could be indicated.

    your pt, while likely not appropriate now...i feel will be in the near future.
    and i agree, no labs.

    leslie
    tewdles likes this.
  12. Visit  NursieDP profile page
    0
    My old company had a lot of pts like this, and sad as it may seem, it seems to be taking advantage of Medicare.
  13. Visit  tewdles profile page
    2
    Rather than taking advantage of medicare, I think medicare should re-examine the criteria for dementia patients.
    There is no question that hospice care for advanced dementia patients is the most effective and cost efficient level of care...
    Many are advocating for a change in the guidelines related to this disease constellation.
    MissIt and tnguy31 like this.
  14. Visit  NC29mom profile page
    0
    Personally, I would not admit an ES Alzheimer's patient if the family was considering a g-tube. I would consider it "aggressive trmt".

    I have seen Alzheimer's pts who "stopped eating" or "eating non-food items" last more than medicares "six month or less" prognosis.

    Several hospice companies take this diagnosis and run with it. As hospice nurses, its our duty to assess, and NOT ADMIT if the pt doesn't meet Medicares criteria. Ultimately, WE are the ones who will be held responsible.

    I only admit an Alzheimer's pt if they have had weight loss (considerable. ...not referring to 300 pound pt whos lost 50 pounds bc they still.have quite a bit of adipose/muscle tissue), AND have been treated/ hospitalized for recurrent UTI'S or aspiration pneumonia. PPS should be 40% or less, and they should be 7c on Alzheimer's functional scale....

    Alzheimer's is a very slow progressing dz. If they are still walking, and not having any major health issues (recurrent infections/major weight loss), how can you justify their prognosis is <6 months?
  15. Visit  leslie :-D profile page
    0
    Quote from NC29mom
    I have seen Alzheimer's pts who "stopped eating" or "eating non-food items" last more than medicares "six month or less" prognosis.
    how does anyone live 6+ months without eating and without a feeding tube?

    leslie


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