Dialysis 9 yrs, but terminal illness is COPD???

[AtlantaRN]

Sometimes I just want to pull my hair out! Account exec has been working on getting a patient discharged for the last 3 weeks, daily notes from md says "husband considering stopping dialysis", then, tonight when she does get home--"of course we are continuing dialysis". Patient had dialysis this evening. Admitting orders state "esrd", but there is a note from the AE saying "admit under copd" when copd is only mentioned as a comorbidity. She is on a buttload of medications related to dialysis-renagel, sodium bicarb, meds for htn, etc.

IF patient has been on dialysis for 9 years, had a renal transplant 9 yrs ago that failed, how can I in good conscious admit this patient under copd?

thanks for listening.

linda

[heron, ASN, RN]

Yes, thank you. That answered a few questions. Thanks.

I worked hospice in 1998 for about a year, then went back to local hospital on night shift. I got tired of resisting God's plan for me, so I came back to hospice about 1 1/2 years ago.

Several changes in my state during that time. Or maybe, its just a difference in the companies. Before, we had cancer pts only. That's all. And they were all DNR. That was explained on admission. Now, we have full codes, speech therapy, physical therapy, etc.; CHF, COPD, Alzheimers, even had a 96 y/o with Failure to Thrive. She was a sassy little thing, and at 96, I though she had "thriving" figured out.

But as the old saying goes. "You learn something everyday".

Thanks again.

Hospice has been expanding it's scope steadily ever since the medicare hospice benefit kicked in. It makes a certain amount of sense ... people do die of conditions other than cancer and need good palliative care, too.

It also has to do with the idea of "open access" as my company terms it. They couch it as a compassionate effort to bring hospice care to anyone who needs it. It's really a marketing concept to maximize the census. Since medicare pays a flat fee per patient, the company depends on head count and cost controls to make a profit. As a result, we are seeing patients earlier and earlier in the course of their terminal illness. It can make for some labor intensive nursing, for sure.

[Ginapixi, BSN, RN]

IMHO it is all a game! We have hospice patients on Dialysis, on tube feeds, on TPN and we have full codes! my last admission was a DNI but yes to CPR - until I explained and they changed their mind right then and there and made the pt a DNR- does not always happen! The full codes are the least of our problem, most of our patients are at home and if/when family does call 911 and the paramedics hear this is a hospice pt they do not intubate; the TPN patients frustrate me most. We had an inservice not too long ago, and the explanation was that other hospices (we are one of 7 or 8 here) offer palliative care not just hospice, for the people who are not in the hospice frame of mind and hope to live longer if they still get treatment. So hospice will eat the cost of TPN and other treatments (yes, even chemo if it is sen as palliative). Most of the chemo receiving patients have only one more treatment, then are physically not able to do it any more. It is a numbers game in my mind. If one more chemo, one more radiation makes the families some times the patients feel better about starting hospice so be it. This society fights dying at all cost (financial as well as physical), though it claims to believe in a life after this. My thought: it is hard to let go! However, we all are destined to go, the only difference is how.

[hospicevolunteers]

We have had patients without the DNR orders and the careplan is adjusted to reflect the need for intensive social services to manage awareness and coping with decision making. It doesn't always work, but sometimes the family is in need of hand holding to get through the major decisions.