Do Not Send to Hospital From Nursing Home

[toughjob,nurse]

Is a do not send to hospital order valid? Is it valid in all situations? I had a DNRCC patient have a heart attack and was in a great deal of pain. He had a PRN order for nitro and it was given as directed with no relief. Followed directions that stated call dr. for further instructions with no relief from pain. Called dr. and advised as to situation, including DNRCC directive. He asked if the patient had orders for morphine, which the patient had no orders and was not a hospice patient. I also advised dr. that he could order the morphine, however in our rural setting the morphine would be difficult to obtain in a short period of time. It would take hours to get the needed pain medication. The doctor ordered the patient to go to the hospital to eval and treat for pain.

This is the 3rd shift and I am the only nurse. When the DON arrived in the morning, I was given the "what for" for sending this completely lucid patient to the hospital for pain management. The lucid patient was asking me for help and asking for something to make him feel better. I could not comply with anything other than Tylenol. The DON stated this patient has a do not send to the hospital order. I asked to see that order. It was nowhere to be found in the chart.

By the way, this patient came back from the hospital on round the clock morphine and ativan and on hospice. I am thinking this is exactly what I wanted to accomplish in the first place. How could I have handled this differently? What would you have done? My impression is that DNR CC specifically states that he is to get comfort care that I could not provide. Now I can provide this. Answers and advice please?!?!?!?!?! I will also be asking my DON for answers and advise. My impression was that I was to wait hours for the morphine, but I will assume nothing for the future.

[TheCommuter, BSN, RN]

First of all, you absolutely did the right thing in advocating for your resident.

I strongly suspect that your DON was upset about the financial aspects surrounding the transport to the hospital. In the area where I live, the local contracted EMS service charges anywhere from $900 to $2,500 for transports to the emergency departments of hospitals in the area. If no emergent reason is clearly documented for the transport, the LTC facility is often stuck with the hefty bill.

[prettymica, ASN, BSN, MSN, LPN, RN, APRN, NP]

When in doubt, send them out! I used to work 3rd shift and you don't have many resources so what else can you do

[LadyinScrubs, ASN, RN]

Let me understand: the DON is questioning a physician's order?

[SuesquatchRN, BSN, RN]

I have sent DNH folks to the hospital in the wake of an accident or sudden onset pain. With an order. You did good.

[montecarlo64, ASN, BSN, LPN]

You did the right thing...Even if this patient had an order not to send to hospital, the patient has the right to participate in his care and make health care decisions, including the decision to seek attention for pain management...It sounds like he wanted to go and you were absolutely right in helping him make this happen...DNRCC means "no code" not "no care"...Your DON either does not have the medical knowledge to realize what is best for the patient or she just doesn't care...You did a great job:)

[CT Pixie, BSN, RN]

Patient was on comfort care? But a Do not hospitalize. Ok, you did the right thing in my opinion. The order was for comfort care..patient was not being kept comfortable with the ordered meds..something needed to be done. You did the right thing. And the patient wasn't kept over (admitted) correct?

My facility's do not hospitalize usually is in terms of due to chronic illness things or new onset of things like UTI, PNA etc. Falls, ? of broken bones, accidents etc are usually sent to the hosp for eval even with the do not hospitalize.

I work for an insurance company that supplements medicares payments and I use to volunteer for our local ambulance. Chest pain is a valid reason to transport and the patients insurance (be it medicare, medicaid, combo of both or medicare w/supp policy) will consider that an emergent transport. I'd be willing to be it will be paid.

[dream'n, BSN, RN]

Yes you did the right thing. To leave a patient suffering in pain for hours would be horribly wrong and inhumane Since I don't know all the facts, I'll withhold judgement on your DON...but I wonder how she would defend herself to the BON or even look herself in the mirror if she had done nothing but wait. Sounds like the DON lacks common sense.

[TheCommuter, BSN, RN]

I strongly suspect that your DON was upset about the financial aspects surrounding the transport to the hospital.

I would like to add to this. . .

Midnight census is important in LTC facilities due to the monetary aspects. If the resident is not physically present in the LTC facility at midnight due to taking up a bed at a local ER, the LTC facility cannot charge the resident for that day even though their nursing home bed is being held in anticipation of a return (a.k.a. bed hold).

Your DON possibly has money on her mind, which is probably why she is upset over the transport to the hospital. However, I'll reiterate that you did the right thing for your resident.

[NurseCard, ADN]

I think you did the right thing. Assuming that there was no way that you could have gotten the resident anything

stronger for pain to get him/her through the night. But, morphine and ativan needed to be ordered, Hospice needed to intervene... those things may not have happened, or happened quick enough, without a hospital visit. I say good job. :)

[NICU Kristen]

You did the right thing. You advocated for your patient and got him the medication/care that he needed and deserved. Great job!

[toughjob,nurse]

Thank you for your thoughts. I have a lot of respect for my DON and believe that she is a caring person. Maybe I just don't understand where she is coming from (still trying to give benefit of the doubt). I had no idea that money would be such a huge factor in this equation. I wasn't at all thinking about money issues, but our facility is very small and money has been an issue.

I did not feel that the DON was questioning the dr., I felt she was questioning my judgment. I am relatively new at the facility. It is not my intention to complain about my DON. This does not solve anything for the patients. For me the next step is how to approach this moving forward and not backward.

Seems that there may be some policy and procedure issues that need to be addressed, if there is such a huge problem with what I did. What can I suggest to solve the problem? I want to be part of the solution for all and not a whining and complaining employee. Just had to get past the "what did I do wrong feelings"?

Sounds like I didn't break any laws here, but I sure felt like I did. So, how to keep from breaking any unwritten practices is the thing I guess. Need to discuss this with DON, but I want to approach her with solid facts and ideas. If sitting around and waiting is our policy, my opinion is it needs to change and change quick! How can we make this a smooth process for the patients and get what they need quickly? Better and quicker pharmacy communication with pharmacy folks to prevent sending patients to hospital? I don't know the answers, but it would be great to suggest something!>! Confused by the whole situation, but your comments help. I also need to keep a good attitude. I think another problem is that when hospice is called in, we must share the income with them. Can this whole thing be solved with a good attitude, or shall I just start looking for a new job now?

By the way, the patient left after midnight and arrived back at the facility in the evening before midnight. Was in the ER for a few hours, then spent 11 hours in ICU to stabilize/get him comfortable. No testing done.