In Georgia, you can be in hospice and a full code. In fact, from what I have been told, it would be a breach of law (bias in health care issue) to not permit a fullcode to be in hospice care, despite it being presumed that hospice care is end of life care.
It seemed odd to me so I asked - such is the answer that I got.
I learned this just last night. I do agency and for the first time was sent to inpatient hospice unit...I have always assumed that hospice patients would be DNR but I was told legally, the Hospice can not refuse a patient because of their code status...I also think it's strange. I mean, If you were hospice and got (like someone above said) urosepsis or UTI, wouldn't you still be treated for those issues?? I mean, we always put our DNR people on ABT when warranted.... I guess I don't understand the rationale for full code.
I learned this just last night. I do agency and for the first time was sent to inpatient hospice unit...I have always assumed that hospice patients would be DNR but I was told legally, the Hospice can not refuse a patient because of their code status...I also think it's strange. I mean, If you were hospice and got (like someone above said) urosepsis or UTI, wouldn't you still be treated for those issues?? I mean, we always put our DNR people on ABT when warranted.... I guess I don't understand the rationale for full code.
let's say a pt has end-stage, esophageal ca and has lost his ability to eat/swallow.
he might opt for a fdg tube but doesn't mean it's going to prolong the prognosis.
he's still going to die but would rather die later than sooner.
if a fdg tube can buy him 2-3 mos, then that is what he aims for.
w/o a fdg tube, it would only be a matter of 1-2 wks.
This is a tad off the original topic, but since we're talking about what can get someone's hospice care revoked, how about this one: pt just doesn't seem to die?!
I have a relative who was placed on hospice care in her late nineties. She got some wonderful services, including music therapy, which she enjoyed. Then the six months passed, and she was still just....old.
Ok, so no hospice. Another year goes by, she's placed on it again because, well, she's REALLY old. And once again, she's kicked off because gosh darn it, she just won't 'kick off' herself!
She's been on it, I believe, three times, she's actually well over a hundred years old now, and you got it: hospice won't take her on because (I think) they don't believe she's actually going to die someday.
I worked on an acute care floor in NY for the past 5 years. When someone was being accessed by hospice before they took over care there had to be a signed DNR.
used to think,hospice = dnr,comfort care only, till i learned of poa who would not allow atb tx per uti of geri. pt.crude! where is the comfort in that? see obituary.... "gramma died of uti" that's nuts!!! i believe if your going to go of say, cancer, you'd rather go fast(no cpr) most likely. but if u can still navigate, smile at visitors feed yourself etc..why should u "go"? ,when your unable to take life anymore,re pain, wasting etc, that is adios time! i've seen pt's in hospice,you'd never guess were"terminal, & i don't think it should take over a year.
Specializes in critical care; community health; psych.
Although it makes no sense to accept hospice care and be of full code status, it's not a requirement. At least not in PA.
I had a patient who was an end stage respiratory patient. She was full code. It was a conundrum. She was the focal point of a hornet's nest of trouble between the facility, the family and the agency. Not only was she full code, she refused palliation by meds for her suffering. This was a very frustrating situation. Feelings ran hot at the care conference. I couldn't understand why she had been admitted in the first place. The day before we were going to revoke her, she took a turn south and changed her code status to DNR. She died the very next day peacefully surrounded by her family and accepted palliation for her symptoms. All of our arguing and worrying, in the end, were for naught. It worked itself out.
Specializes in icu, er, transplant, case management, ps.
Here is an interesting letter in reguards to CPR on a hospice patient, I found this letter several years ago and kept it in my files.
October 31, 2001
Mr. Thomas Scully
Administrator
Centers for Medicare and Medicaid Services
7500 Security Blvd.
Mail stop C5-11-24
Baltimore, Maryland 21244
Dear Mr. Scully:
I write this letter with all due respect as chairperson of the National Hospice and
Palliative Care Organization's (NHPCO) Ethics Committee to lodge the members'
strongest objections to the April 20, 2000 HCFA (now CMS) Memorandum regarding
Clarification of Advance Directive and Do Not Resuscitate (DNR) in Hospice which
mandates that, based upon an interpretation of the Patient Self-Determination Act
(PSDA), hospice providers must provide cardiopulmonary resuscitation (CPR) to
terminally ill patients who choose to elect the Medicare Hospice Benefit and who have
and advance directive for CPR.
Assuredly, the hospice community greatly values the spirit and intent of the PSDA.
However, this peculiar mandate places hospice physicians and other hospice clinicians in
the untenable position of being compelled to provide unsound and sub-standard medical
care to these patients. All available medical evidence supports the conclusion that CPR is
not an indicated procedure for terminally ill patients, on the basis of its complete
ineffectiveness at producing positive outcomes. It is at best futile, and has the more likely
potential to do great harm, adding to morbidity, suffering, and additional costs of care. As
a point of reference and perspective from my background as a board certified
anesthesiologist, I assure you that CPR was never intended to be applied to terminally ill
patients, due to its lack of efficacy, any more than cataract surgery would be applicable to
patients with cortical blindness. Having drafted the first "Do Not Resuscitate" guidelines
for the American Society of Anesthesiologists, in order to more fully support patient self
determination and autonomy, I am intimately familiar with all sides of this issue, most
importantly, those which have been concerned with protecting patients from undergoing
useless and harmful interventions.
Hospice providers should admit terminally ill patients who state that they desire CPR.
Discrimination on this basis should never occur. The hospice admission affords the
opportunity to provide important and realistic information in a gentle, humanistic
manner. Education is necessary to help the patient and family understand that CPR in this
context is a medically futile and torturous intervention that, if actualized, will obviate
major goals of hospice care: safe and comfortable dying. In these cases, the role of
hospice is to inform patients and families at the time of admission that CPR is not a
provided or covered service by hospice, no different from any other non-palliative
("curative") therapy. Should they continue to desire it, they may exercise this "right"
through two different remedies:
NHPCO Ethics Committee
Page 2
1) revoke the Medicare Hospice Benefit (this is anyone's right if a
different plan of care is wanted other than the palliative plan of care
recommended by the hospice interdisciplinary team) and revert to
traditional Medicare Part A coverage;
2) take full financial responsibility for the consequences of accessing the
local Emergency Medical System (EMS), which is readily available in
virtually every community in the United States. Should this intervention
lead to hospitalization where the hospice cannot meet its fiduciary
responsibilities under the provisions of the Medicare Hospice Benefit,
then revocation would be in order.
These options should make moot the policy requirements mandated in the April 20, 2000
HCFA (CMS) Memorandum that hospice staff be trained in CPR, and that hospice
providers be compelled to contradict both good medical and ethical care by providing a
futile and injurious procedure.
In summary, this policy in the name of patient self-determination serves only to
countermand the intent of the PSDA. Mandating hospice providers to perform CPR on
terminally ill patients is tantamount to creating a requirement for surgeons to operate on a
patient without anesthesia because the patient insists on it, due to either excessive fear of
anesthesia or that (s)he has been sorely misinformed about the consequences of that
"choice." Absurd as this analogy may sound, it is, in fact, frighteningly similar. The only
difference is that, heretofore, little accountability has been attached to the malconsequences
of CPR performed on imminently dying patients. It would be irrational,
and no less inhumane, for a hospice plan of care to ever include attempts at CPR when
cardiopulmonary arrest inevitably occurs. Nevertheless, at the time of death, should a
patient on a hospice program who had expressed a desire to undergo this morbid and
futile procedure, triggering the EMS system and providing such services outside the
hospice plan of care and the Medicare Hospice Benefit, would seem the most logical
course of action.
Please reconsider the basis of this policy interpretation. My colleagues and I would be
most grateful to work with you and your office to modify this policy to reflect the
principles of sound and ethical medical practice, as we are sure is intended.
Thank you for you attention to this matter.
Sincerely,
Perry G. Fine, M.D.
Chair, Committee on Ethics
Dr. Fine is correct. I am licensed in NYS and I live in SW Florida. The hospice organization that runs hospice in my county, requires that patients be made aware that the type of care they are receiving is 'end of life' care. And that they are not expected to live for more then six months when they enter their service. The patients and their families are well aware of the end of life requirements. Most, if not all, request that they be allowed to die in peace and dignity. It is a guilty son or daughter, from out of town, out of state, that attempts to gum up everything. Fortunately they generally fail.
It has been a few years now but when I worked Hospice coding the patient was "contrary to Hospice philosophy." That is not to say that families who were ill prepared for death did not call 911 and have the pt coded.
It was viewed that the pt had to have come to terms with the terminal nature of the disease and that remaining a full code demonstrated that they had not.
Specializes in ICU,HOME HEALTH, HOSPICE, HEALTH ED.
I work for Kaiser Hospice--HMO Hospice definitely differs from my original training and employment by a non HMO hospital owned Hospice. My original Hospice employer required a DNR as evidence that the patient understood where progression of disease had brought him and that he was ready to accept end of life comfort care support. This 'beginning' often times resulted in a much easier ending, in that the Hospice work could begin immediately and openly with embrace of the work at hand and sufficient planning by all for that comfortable and respectful death. The work was awesome. We also had the advantage of having lots of inservicing which supported our work. Even yearly trainings from the original founders --English nurses and doctors. I do believe that Kaiser has the right idea to not require patients to accept DNR status as an entry to the program. All MDs to not know how nor have the time to really take their patients 'to the hospice page'. We do a lot of that work at the hospice I currently work with. It definitely is a more emotional journey for hospice staff when they do the work- supporting patients and families toward an understanding of and trust in the DNR decision. But, after all we are the ones chosing to do this work.
PS.-I believe that more MSW and chaplain presence and support is a must for the full code hospice patient and families. This is not always a significant part of some Hospice agency's budgets...
Alibaba
215 Posts
I learned this just last night. I do agency and for the first time was sent to inpatient hospice unit...I have always assumed that hospice patients would be DNR but I was told legally, the Hospice can not refuse a patient because of their code status...I also think it's strange. I mean, If you were hospice and got (like someone above said) urosepsis or UTI, wouldn't you still be treated for those issues?? I mean, we always put our DNR people on ABT when warranted.... I guess I don't understand the rationale for full code.