Readmission of patient whose family calls 911

[AtlantaRN, RN]

It is my understanding that a patient with CVA has had more than 2 readmissions after family called 911 for UTI for kleibsella x2. We had treated the patient with Bactrim several times during this last admission, but apparently didn't work. I guess the big problem is the wife doesn't notify the hospice, in fact, this last hospital admission occured on a friday and we didn't find out until the CNA went out on Monday.

So, i'm sent out yesterday to readmit patient. Now, it is my understanding that going to the hospital has happened X2. I readmit the patient. I get back to the office and i'm told, "if they are going to continue to go to the hospital, then you shouldn't have readmitted them." So, NOW, i'm supposed to discharge this patient in 30 days.

Doesn't the family always have the right to seek treatment for things that don't pertain directly to their admitting terminal diagnosis? Is it wrong to discharge this patient in 30 days? WHY was I sent out to readmit this patient if they have already shown that calling 911 is a first priority and not calling the hospice.... inquiring minds want to know.

Thank you for your input.

linda

[andre]

What we have done in these scenarios is explain to the pt and family that if they call 911 or go to ER without calling us first, they are revoking their hospice benefit as that is outside our plan of care. There are occasions where we will ok hospitalization if the diagnosis is treatable and clearly outside of their hospice diagnosis (such as a recent patient with new onset seizures.....hospice diagnosis is cardiac).

I think rather than making a blanket decision to discharge the patient in 30 days, now is the time to once again educate the pt and family about hospice philosophy, reevaluate patient goals, and establish a plan of care where it is clearly documented that all are understanding that 911 calls/ER visits without first discussing with hospice team means you are choosing to revoke the hospice benefit.

Hope that helps,

Andrea

[aimeee, BSN, RN]

These are gray and much debated areas. You cannot discharge a patient for going outside the plan of care. There are only three reasons you can discharge a patient:

1) They are no longer appearing to meet the criteria for terminality....in other words, it appears that their prognosis is greater than 6 months.

2) They move out of your service area

3) You cannot provide care to the patient without endangering your staff (but you must document your attempts to work through finding ways to make it safe)

The patient/family can revoke their hospice benefit for any reason, or no reason at all other than whim and they don't have to tell you why. There is no such thing as an automatic revocation because they choose to go to the hospital. What you can do is have discussions regarding what makes sense as palliative measures to treat their symptoms. If you feel they will choose to go outside those measures you can provide them with an ABN, a notice that you will not be paying for those measures outside the plan of care and what the costs would be. They can then make an informed choice.

Now is a good time for the team to have a goals of care discussion with the family see if you can all agree on how things will be handled. Perhaps they could have the UTI treated as part of a GIP admission instead of revoking their benefit and going off on their own. In this way, their continuity of care could be maintained.

Discharging automatically after 30 days is going to be a red flag and I would wonder what the justification would be for it if I were a surveyer or reviewer.