adult patients admitted to a pediatric hospital - page 2

by rnsusan

6,844 Unique Views | 30 Comments

How do pediatric nurses feel when they have to take care of an adult patient? We do not get that many, but we do get a few when there is no one to transition them to. Many of my co workers get upset and think they need to go up... Read More


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    As others have alluded to, there are 2 main reasons this happens:

    1) Adult patients with peds conditions are generally covered by Medicaid. Adult doctors dont like Medicaid and a lot of them refuse to see those patients.

    2) Adult patients with peds conditions generally make adult doctors uncomfortable. Adult cardiologists for example are essentially coronary artery plumbing experts, but they get nervous with complex congenital heart disease becaues its a completely different animal to them.

    These 2 explanations account for why we have 25 year olds who cant be transitioned over to an adult service. Its particularly bad for pulmonology, cardiology, and heme/onc patients (sickle cell particularly bad).
    DeLanaHarvickWannabe likes this.
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    Quote from platon20
    As others have alluded to, there are 2 main reasons this happens:

    1) Adult patients with peds conditions are generally covered by Medicaid. Adult doctors dont like Medicaid and a lot of them refuse to see those patients.

    2) Adult patients with peds conditions generally make adult doctors uncomfortable. Adult cardiologists for example are essentially coronary artery plumbing experts, but they get nervous with complex congenital heart disease becaues its a completely different animal to them.

    These 2 explanations account for why we have 25 year olds who cant be transitioned over to an adult service. Its particularly bad for pulmonology, cardiology, and heme/onc patients (sickle cell particularly bad).
    As an addendum to #2, it's also that people with many of these conditions didn't use to LIVE to adulthood so adult doctors are sometimes not the best to treat these patients. Cystic fibrosis, for example... CF patients used to routinely die in their teens. Now it's not uncommon to see CF patients in their 40s/50s. Adult pulmonologists don't know how to care for these patients because they've never had to.

    That said, I do still think it's a disservice to some of these patients to keep them in a pediatric hospital for EVERYTHING. For example, if a 40 year old with a history of CF has a stroke, they should be seen by an adult neurologist. Same for if they had a heart attack- they should go to the adult hospital. PALS and ACLS are not the same thing and I don't even want to think about what would happen in the event of an acute MI at my former hospital.
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    Quote from KelRN215

    That said, I do still think it's a disservice to some of these patients to keep them in a pediatric hospital for EVERYTHING.
    Not all adult patients feel that way though. There is a 40ish frequent flyer at my hospital and he'll tell anyone who asks that he'd rather be at the children's hospital than the adult hospital across the street. He feels he gets better care, the "amenities" are nicer and that being an old TOF pt people know what they're doing with him & his heart.
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    I work with a 19 year old girl w SMA, and now that she's off to college in a major city, her nurses/aides and even her closest friends are on strict orders to be sure that if she needs to go to a hospital, it's the local children's hospital. They would be well-versed on SMA since it's a pediatric disease. The family is convinced that an adult hospital would be dangerous for her.
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    The hospital I work at has an AYA (adolescent/young adult) oncology/bone marrow transplant program and we often take care of adults up to their mid 20's with "pediatric" oncology diagnoses. Studies have proven that if these patients are treated on pediatric protocols in pediatric hospitals, their outcomes tend to be much greater and long-term morbidity/mortality lower. I personally love the diversity of being able to take care of a 2 year old, a school-age child and a young adult all in one assignment. The creativity and critical thinking it takes to be a pediatric nurse, working with many different ages of patients and their families makes us better nurses... taking care of young adults just broadens that experience.
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    Quote from pedshemoncRN:)
    The hospital I work at has an AYA (adolescent/young adult) oncology/bone marrow transplant program and we often take care of adults up to their mid 20's with "pediatric" oncology diagnoses. Studies have proven that if these patients are treated on pediatric protocols in pediatric hospitals, their outcomes tend to be much greater and long-term morbidity/mortality lower. I personally love the diversity of being able to take care of a 2 year old, a school-age child and a young adult all in one assignment. The creativity and critical thinking it takes to be a pediatric nurse, working with many different ages of patients and their families makes us better nurses... taking care of young adults just broadens that experience.
    I have heard before that young adults (up to 24ish) with cancer treated at pediatric institutions tend to do better. Your screen name, however, reminded me of a patient I encountered before I left my job at the hospital.

    This patient was 21 years old- alert and oriented, developmentally appropriate and her own legal guardian. She had some kind of end stage rhabdoid tumor and her prognosis was less than a few months. Her team, however, had been discussing all of this- prognosis, end of life issues, etc- with her parents only and because her parents didn't want her to know she was dying, no one on the medical team discussed this with the patient. I think what happens often is that providers at a pediatric institution are so of the mindset that they talk to the parents about the patient, that they don't even realize what they're doing when they talk to the parents of an adult patient without the patient's specific consent. My colleagues and I were all extremely distraught over this when she came to my floor (she was primarily a patient on heme/onc but was admitted to my floor after spinal surgery) because it is both unethical and illegal to discuss these issues with family only and not involve the adult patient in the conversation. I realize that at some point in her treatment, the patient probably did agree that her parents could be involved in her care but that does not mean that her parents can make decisions for her or withhold information from her. Not to mention, she can revoke her consent for them to receive information at any time yet she was never given the option to do that since the providers were talking exclusively with the parents.

    I can't even count how many times I've had to have a resident re-do a surgical consent form because they- out of habit- had a 19 year old's parent sign consent for surgery. And then they'd get confused when I'd bring it back to them and say, "this is not a valid consent." Just like my mother cannot consent to surgery for me, this 19 year old's mother cannot consent to surgery for her. I'd also come across nurses who would think that it was ok for a 20 year old's mother to sign their discharge paper work or who wouldn't understand what I was talking about when I mentioned that the mother's signature meant nothing for their 19 year old daughter's elective surgery. For what it's worth, we did have a fair amount of adult patients whose parents were their legal guardians but I just found that inappropriate lines were often crossed when we had developmentally appropriate adults admitted to that hospital.
    DeLanaHarvickWannabe likes this.
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    KelRN215, I've seen similar situations in the past, even though our facility manages many adults with chronic health issues as adults. One sticks with me. The patient was an adult with congenital heart disease. Didn't want any more surgery, didn't want a transplant, didn't want anything invasive done at all. Content with the life the patient had been given but not eager to extend it at all/any cost. On admission to the adult cardiac ICU, these wishes were made plain to anybody who would listen. When the inevitable arrived and the patient required intubation, the parents took over. Intubation was followed by VAD (ventricular assist device) placement. The nurses on the adult unit were angry and upset that their patient's wishes had been ignored and made their views well-known. Next thing we know, the patient was now a peds patient. The handful of days of "life" gained were agony for all concerned. The peds nurses were told to do their jobs and keep their opinions to themselves.

    Another situation involved an adult patient who had a degenerative disorder, in need of a VAD and under a lot of pressure from family, who had been turned away by every other program in the country. Not ours. Several weeks of complication after complication ensued with the patient finally saying that had all the drawbacks been explained up front, the VAD would have stayed in the box. And the inevitable happened, and the family was filled with regret for having gone forward. Terribly sad.
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    Horribly frustrating! Similar thing had happened with my 26 year old BMT patient, one day the patient said he didn't want to do this anymore, next thing you know moms getting papers signed to be his POA and making him "incompetent" to make decisions

    I also had a similarly frustrating situation happen to myself, not as severe obviously and not at a children's hospital, but I was awaiting a call from a doctors office to make an appointment after a biopsy confirmed I may need radiation/chemo and when the woman couldn't get a hold of me (sorry I showered) she immediately called my dad. She only told him she was calling from "such and such CANCER center" but couldn't tell him why else she was calling, only that I needed to call back and make an appointment. Ok I though the "in case of emergency" contact was for a medical EMERGENCY, not making a doctors appointment. In any case I didn't need treatment at the time but I think my dad lost ten years off his life. HIPPA violation anyone?
    KelRN215 likes this.
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    Wow... Just wow. Very unprofessional. Did you call her on it?
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    Quote from umcRN
    Horribly frustrating! Similar thing had happened with my 26 year old BMT patient, one day the patient said he didn't want to do this anymore, next thing you know moms getting papers signed to be his POA and making him "incompetent" to make decisions

    I also had a similarly frustrating situation happen to myself, not as severe obviously and not at a children's hospital, but I was awaiting a call from a doctors office to make an appointment after a biopsy confirmed I may need radiation/chemo and when the woman couldn't get a hold of me (sorry I showered) she immediately called my dad. She only told him she was calling from "such and such CANCER center" but couldn't tell him why else she was calling, only that I needed to call back and make an appointment. Ok I though the "in case of emergency" contact was for a medical EMERGENCY, not making a doctors appointment. In any case I didn't need treatment at the time but I think my dad lost ten years off his life. HIPPA violation anyone?
    I had almost forgotten that something like that happened to me before too! When I was in nursing school, I had a syncopal episode at the pediatric hospital in which I was doing clinical and was sent to their ER (much to my dismay). I have been in control of my medical problems since I was 19 and I don't discuss things with my mother unless absolutely necessary. I didn't tell her this because there was no need to. Next time I see her, she tells me that someone from the hospital called her house and left a message on her answering machine that said something like, "We're calling to check on Kel, because she was seen in the ER due to fainting on Wednesday." Um, hello? They didn't even try to call me on my cell phone or at college- went right to calling my mother's house. I was 23 years old at the time. If I hadn't been trying to get a job there at the time, I would have called and pitched quite the fit.


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