Discharge a patient because they go to er?

nhelkhound · Feb 7, 2011

As far as I know, this would not be grounds to discharge. A patient has the right to seek medical care. In this instance the patient will be held financially responsible for charges incurred d/t the ER visits IF he did not inform hospice of the visit prior to or during its occurrance. To address the Roxanol issue, you could prefill syringes so he could self administer in the future.

tencat · Feb 7, 2011

Our company would discharge if he got admitted to the hospital from the ER. Otherwise, I don't think we'd discharge.

SoCalRN1970 · Feb 7, 2011

Depends on if this is a cardiac hospice patient. If the pateint was admitted to the hospital or requested to have agressive tests.. a discharge if admitted would happen and if it was his decision to pursue more treatement a revocation would happen.

I had one pateint with CHF go to the hospital with cp. He wanted everything done. They would NOT let me discharge him... I documented this as part of the his chart. He was admitted, had a few things going on one of which was an MI. He was sent home in a few days.. and died hours later.. all while on hospice. I AM NOT WITH THIS COMPANY ANYMORE.

vapn · Feb 8, 2011

We wouldn't discharge for going to the ER, and we would even cover the visit if it was related to the hospice diagnosis. We have rarely discharged patient for "seeking curative measures", like going on a vent or having surgery, but we can pick them right back up when they are done with what they are doing.

tewdles, RN · Feb 9, 2011

Visiting the ED for a medical need that cannot or should not be addressed in the home by the hospice professionals is not an auto reason to DC...it depends what the hospice dx is, what the philosophy and mission of the hospice agency is, and what the medical culture of your service area is.

We often have patients on service who visit the ED...sometimes they even get admitted. If the patient is visiting the ED for a non hospice dx related issue then no need to consider revocation or DC. In my neck of the woods it comes down to the POC...was the ED visit approved by the hospice IDT? Was there another plan in place to treat his symptoms outside of the ED? Did the hospice staff go to the home to address the symptoms? Did the patient even call the hospice in advance of the ED trip?

A person with chest pain unrelieved by nitro deserves some relief...even when on hospice. If your agency was not able to meet this gentleman's needs in the home, it would make sense that he should be seeking care either in your inpatient unit or in some other urgent care facility. Discharging him for taking care of his medical needs is sort of "bad acting" especially if no one even provided a prn visit during the crisis.

Just my thoughts...

leslie :-D · Feb 9, 2011

hmmm....not sure.

his admitting dx was for "end stage heart", so going to the er for unresolved chest pain, could definitely be construed as related to the hospice dx.

did he want the pain to stop, or did he want to dilate his vessels (which would stop the pain), only to serve as prolonging his life?

there's a difference, to me.

leslie

netglow, ASN, RN · Feb 11, 2011

In this case IMHO, the hospice was unable to control his pain (your bad due to no rox, we'll assume rox would have controlled the pain here). Ethically he must have access to a means to attempt pain control or screw hospice. The hospice should pay for the ER to deliver/control pain and then discharge. You guys have to re-evaluate your services to him ASAP.

Now, you would have had to call ahead/get yourself to ER with the paperwork to be sure end of life is honored DNR or No DNR?! You have to hold the ER to his wishes - big part of your job. But, say he has an MI and now has decided he wants the whole deal/admit with an eye on restorative interventions to some extent, you then discharge/revoke and eval for re-admit upon discharge from hospital.

You still have the pain issue to address, what are you going to do for him next time?

AtlantaRN, RN · Feb 12, 2011

pt is a full code, and wishes to remain so. going to renal doc on monday to have an av graft placed, and going to cardiologist on wednesday for a followup visit. he has been a cardiac pt since 2002. he had roxanol in his home, but wished to do 911 (he is blind, frankly, i think he needs individually drawn up tb syringes with 20mg/1ml in each syringe because he can't see well enough to put his meds in his pill dispenser-case mgr does this). He came back on service on friday.

I don't think he should have been discharged, because he just wanted the pain to stop, but he does want to live. It's a catch 22.....

thanks for the input.

tewdles, RN · Feb 12, 2011

In my mind the av graft is not palliative and would therefore be outside of the hospice goals of care. This would require him to revoke, at least in my opinion.

You are quite correct that prefilled syringes are the way to go. Is he eligible for any personal care services in the area? Hopefully your MSW can work to get him hooked up with something.

No question that your agency should be readmitting him after his procedure. Now you know what things you have to plan for with this guy!

netglow, ASN, RN · Feb 12, 2011

My post partly comes from knowing how hospice gets paid/denied.

Unfortunately you have to sit there and scenario-think it out all the time, which gets exhausting. Can I get a hell yeah?!

jeannepaul, BSN · Feb 16, 2011

if the pt is a cardiac pt. and he goes to hosp. for cardiac, we do not discharge, but they have to revoke or they will get a bill. Medicare will only pay for either hospital or hospice but not both. The problem at my agency is if pt is admitted with anything, we have them revoke, I dont understand this, and I think its a big waste of time and resources to turn around and readmit.