Evaluation question

[Rnmomajmj]

I have a question experienced hospice nurses. I did an eval on 6-7-07, the patient did not seem appropriate at that time and the LTC staff disagree with me. This patient has a dx of Dementia but is not incontinent (she still wears her own undies, not a brief), uses a walker to ambulate, and when I spoke to her, she answered most of my questions correctly. I couldn't get her down far enough on the FAST scale to make her qualify for ES dementia. She has lost 21 pounds since April 07 but her BMI is still 34 so she wouldn't qualify for AFTT either. I told the DON at the facility that I didn't think she would be appropriate for hospice services but that I would have a few of the other nurses double check and I would let them know. The DON at that time appeared to understand and accepted my decision.

Now one week later the DON, ADON and the MDS coordinator attacked me at the nurses station stating they knew she was appropriate for hospice. I assured I had spoke to quite a few people that agreed with me that she wasn't appropriate at this time but we would continue to watch for further decline. They left and went into the DON's office and continued to talk about me (I could hear them). The PA who takes care of the nursing home patients at this facility showed up so I informed him that I did an eval on this patient and didn't find her appropriate and the staff believes I'm wrong. He stated to me that he tried to talk to her and in his opinion she is over sedated right now so he dc'd her vicodin and that I should try to talk to her Monday again due to staff reporting to him changes in her this week.

One of the other MDS coordinators pulled me aside and apologized for the others talking to me like they did, and she agrees with me that this patient is not appropriate at this time. She stated that the DON and others are trying to cover their butts due to her loosing so much weight in a few months.

I guess my question is, does anyone ever second guess themselves? And, what is your definition of someone being incontinent? This patient knows when she needs to use the bathroom and normally gets up and walks to the bathroom with her walker, the night nurse did tell me that the other night she did request a bedpan because she felt too tired to walk.

I've been beating myself up all weekend, going over and over this! Can anyone make me feel better????

Sorry this is so long!

[Allow Mystery]

Dear rnmomajmj,

Doesn't appear anybody has made you feel better:o, but I'll

give it a try;)

From the information you provided, the weight loss of 21 lbs is the only

possible hospice criteria issue. Is the 21 lb weight loss > 10% of her total weight? How and why has the appetite changed?

What are the comorbidities?

My experience with ES Dementia/Alzheimer's is that the appetite may

come and go depending on the brain signals. Take another look, it has

been a few weeks, if she is still losing weight, and total weight loss over the last six months has been >10%, you could admit as ES

Dementia, monitor weight along with other symptoms.

Take care and keep up the good work!

[wonderbee, BSN, RN]

That is a significant weight loss. Is she still feeding herself? Comoribidities? Based solely on the info you posted, I wouldn't have evaluated her for ES dementia either. Have you brought up her case at team? That's what I would do.

[doodlemom]

A 21 pound weight loss is very significant and is a telltale sign that something is going on. She definitely doesn't meet criteria for end stage dementia but I would admit her for general decline/debility unspecified.

[a21chdchic]

I have to agree with the last writer. 21 pounds is alot of weight to be losing in 5 months. This is a significant decline even if it is not 10% of her body weight. I also agree with her that you could admit for Debility, Unspecified. Good call.

But, don't beat yourself up. Nobody's perfect, and making mistakes is how we learn. If you have a question about a certain situation, ask one of your 'Hospice' Colleagues that is more knowledgeable and experienced and if nobody is available, ask a supervisor or your Medical Director, even if he/she is not approachable.

Ana