DNR/transfer to hospital

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Specializes in RN/Hematology/Oncology/Long-termcare/SNF.

Hi nurse community

I need some nursing knowledge from seasoned nurses.

Crack down on transfers to hospital.

Scenario

72 year old IDDM, Copd, CHF, Afib HTN squamous cell lung cancer to name a few CKD

this patient was not on a single diuretic. I understand he most likely wasn’t on Lasix due to his kidney disease. However, he wasn’t on torsemide either.

First time I met this gentleman. During morning care he seem to be having some respiratory discomfort. That time I didn’t check his O2 sats and continue to monitor. During morning care he seem to be short of breath. At that time is O2 sats were 93% on RA. Went along with my med pass. I got to his room to administer his medications checked his blood pressure and his O2 sats. Blood pressure was 90/58, heart rate fluctuating between 70 and 120. Both extremities with +2 to 3 pitting Adema. No air exchange entire right lobe. Diminished in the left lobe. Alert and oriented times three. I reviewed his medications and noticed he wasn’t on Lasix. I looked at his history and noticed he had renal disease. I talked with the unit manager about why he wasn’t on a diuretic, question torsemide Long story short he continued to decline quickly. O2 sats dropped to 74%. I put on O2 at 2 L up to 76%. Went in search for a non-re breather there wasn’t one. I asked the staff member to please get a nonrebreather. Call the doctor. The doctor came in 15 minutes later(must have been close). He placed his stethoscope on his chest for about 15 seconds and then walked out of the room. I gave him all my assessments. He went out and looked over the chart and talked with the unit manager. Meanwhile the patient was on 15 L and his Satz were 60% Blood pressure 102/50 heart rate from 70 to 130. No nausea, skin pale. The doctor says to transfer to the hospital. The patient is a DNR.

I’m walking out the door at 4 o’clock and incomes my patient in no distress. I guess you could say I was surprised to say the least. Skilled nursing facilities frown on transfers to the hospital. I tried all nursing interventions before I really felt he needed to go as well as the doctor.

I’m thinking that they must’ve given him diuretics which stabilized his respiratory and cardiac status.

Any thoughts? Sorry for any typos

cissy

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He was transferred to a hospital for acute care higher level of care/intervention that was likely beyond what would be reasonably accepted at your long term care facility.

You're right they probably did try lasix or bipap for a bit until he got better. I don't know how reasonable that would be to expect to be able to do high turnaround lab work - ABGs, CXRs, continuous sp02/ekg monitoring in an LTACH but I assume it's probably limited. DNR does not mean do not treat. You do everything up until cardiopulmonary resuscitation. At a facility I worked in Texas, DNR did not even mean DNI (do not intubate), though I think the law on that has recently changed.

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Specializes in Psychiatry, Community, Nurse Manager, hospice.

The DNR is irrelevant to whether or not pt needed hospitalization.

Should this patient be on hospice?

If the pt is in end of life hospice will prevent unnecessary hospitalizations.

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1 hour ago, FolksBtrippin said:

The DNR is irrelevant to whether or not pt needed hospitalization.

Should this patient be on hospice?

If the pt is in end of life hospice will prevent unnecessary hospitalizations.

^ this.

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.

DNR doesn't mean "do not treat."

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Specializes in LTC, home health, critical care, pulmonary nursing.
19 hours ago, CyclicalEvents said:

He was transferred to a hospital for acute care higher level of care/intervention that was likely beyond what would be reasonably accepted at your long term care facility.

You're right they probably did try lasix or bipap for a bit until he got better. I don't know how reasonable that would be to expect to be able to do high turnaround lab work - ABGs, CXRs, continuous sp02/ekg monitoring in an LTACH but I assume it's probably limited. DNR does not mean do not treat. You do everything up until cardiopulmonary resuscitation. At a facility I worked in Texas, DNR did not even mean DNI (do not intubate), though I think the law on that has recently changed.

Just wondering where an LTACH comes into play in this situation?

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Specializes in RN/Hematology/Oncology/Long-termcare/SNF.
16 hours ago, lovingtheunloved said:

Just wondering where an LTACH comes into play in this situation?

Yes I realize Dee and I are just doesn’t mean do not treat . His most said transferred to hospital. Skilled nursing facilities frown on transferring patients out. However, this patient needed to be diuresis therefore he needed to go out. I was simply hoping that he would at least be admitted overnight so that my transferring him seem legit. Does this make sense.?His most said transferred to hospital. Skilled nursing facilities frown on transferring patients out. However, this patient needed to be diuresis therefore he needed to go out. I was simply hoping that he would at least be admitted overnight so that my transferring him seem legit. Does this make sense.?

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Specializes in LTC, home health, critical care, pulmonary nursing.
15 minutes ago, Cisl4him said:

Yes I realize Dee and I are just doesn’t mean do not treat . His most said transferred to hospital. Skilled nursing facilities frown on transferring patients out. However, this patient needed to be diuresis therefore he needed to go out. I was simply hoping that he would at least be admitted overnight so that my transferring him seem legit. Does this make sense.?His most said transferred to hospital. Skilled nursing facilities frown on transferring patients out. However, this patient needed to be diuresis therefore he needed to go out. I was simply hoping that he would at least be admitted overnight so that my transferring him seem legit. Does this make sense.?

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Specializes in ICU, trauma, neuro.

Many people place themselves (or their family members place them in conjunction with the patient) into a DNR status without fully considering the ramifications. I have probably cared for at least several hundred patients (thousand?) over the years in the ICU who were truly end of life (DNR status) who were receiving virtually every intervention in the book CRRT, intubation, multiple pressers. Why? Maybe the DNR wasn't available when they first came into the hospital (and they were emergently intubated) and then the family decides they "want everything done". Often even patients that are end stage hospice "change their minds" or their families change them for the patient. It is a complicated, soul wrenching situation with no easy answers. In my opinion much of it has to do with our overly materialistic perspective as a society and lack of belief in a "soul" (even many who go to church or call themselves spiritual seem to lack a core conviction of any sort of eternal existence). If you are truly convinced that the material is "everything" then you are much more inclined to hold on to every last second of material existence no matter how miserable, expensive, or futile. Conversely, if you see people as eternal souls then you are more likely to understand that death is a natural part of life and that unnaturally delaying it is simply delaying the progression into the next stage of existence.

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Specializes in Geriatrics, Dialysis.

Being a DNR is irrelevant, that doesn't mean do not treat and there are interventions that can make this gentleman more comfortable that can't be performed in the SNF setting. If he survives this episode and comes back I would think a Hospice consult might be in order if he and his responsible party agree to one.

Skilled Nursing Facilities do not generally frown upon transfer's out to hospital. At least mine doesn't. Hospital's of course have way more resources than a SNF including but not at all limited to immediate access to an MD and lot's of equipment and access to procedures that a SNF just can't perform. Not to mention the cynical side of me believes the SNF would much rather transfer out the resident as it sounds like that gentleman was circling the drain and a transfer out to a higher level of care looks better on census reports than a death, even if that death is not unexpected.

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22 hours ago, Cisl4him said:

Skilled nursing facilities frown on transferring patients out. However, this patient needed to be diuresis therefore he needed to go out. I was simply hoping that he would at least be admitted overnight so that my transferring him seem legit.

He did need to go in (unless that would have been against his wishes), per a nurse and physician evaluation of the situation. He didn't end up needing to be admitted.

The fact that he didn't need to be admitted doesn't have anything to do with the transfer decision being inappropriate, but it seems possible that if you yourself are going to give legitimacy to the idea that it does say something about your assessment and decision-making, you just open the door wide open for mindless critique of your actions. Why do that?

If I saw my patient rolling back in looking much improved I would think I made a great decision and wouldn't entertain any nonsense to the contrary.

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Specializes in Critical Care; Cardiac; Professional Development.
On ‎6‎/‎29‎/‎2019 at 11:55 AM, Cisl4him said:

Yes I realize Dee and I are just doesn’t mean do not treat . His most said transferred to hospital. Skilled nursing facilities frown on transferring patients out. However, this patient needed to be diuresis therefore he needed to go out. I was simply hoping that he would at least be admitted overnight so that my transferring him seem legit. Does this make sense.?His most said transferred to hospital. Skilled nursing facilities frown on transferring patients out. However, this patient needed to be diuresis therefore he needed to go out. I was simply hoping that he would at least be admitted overnight so that my transferring him seem legit. Does this make sense.?

Forgive me but...no. That doesn't make sense. You wanted him admitted in order to validate your assessment? How exactly does that work?

Apparently he was successfully treated in the ER to the point that an admission was not necessary. That has no bearing on your assessment in terms of its validity. You assessed; you advocated; the patient got treated and improved as rapidly as he had declined. There's no issue here.

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