Full Code Hospice Pt Acute Change in Condition...What to Do?

[bluegeegoo2]

Last night I had a hospice resident who also happens to be a full code. This individual presented with an acute and significant change in condition. Primary Dx mets cancer. He presented with sudden decreased LOC, unable to follow simple commands, one sided facial drooping and could not grasp at all with that same side. Also unable to swallow. Acutally, seemed unaware that there was anything to swallow when a cup was placed on his lips. He was staring off into space and would occasionally offer one-syllable responses when prompted after several attempts. VS's were stable in otherwise no acute distress. I sent him out after speaking with his hospice nurse citing the code status. I was unable to reach family for their input. He looked mighty CVA-ish to me. However, with the mets and not being a MD with all the fancy equipment I can not rule out a brain mets that caused the acute change. Either way, I did not feel comfortable with the situation at all and erred on the side of caution and obtained the order to send out. What would you have done or have done under similar circumstances?

[chrisrn24]

DNR doesn't mean do not treat. You did the right thing.

[bluegeegoo2, LPN]

Thank you all for your responses. This gentleman readmitted to my facility last night. His family had signed the DNR in the hospital so that issue has been addressed. When they were bringing him back in I noticed he had Cheyne-Stokes respirations going. He was not my res last night so did not assess him. I can only hope that he went (or will go if he is still with us) peacefully and painlessly.

[enchantmentdis, BSN, RN]

I did not know that a Hospice Patient can be full code. I would do the same you did.

The patient can be a full code because hospices do not turn down the money that comes with signing on a patient who still wants to be a full code.

[SuesquatchRN, BSN, RN]

The patient can be a full code because hospices do not turn down the money that comes with signing on a patient who still wants to be a full code.

That is offensive. We do not turn down those patients because that choice is not ours to make, and everyone is entitled to dignity and symptom control at EOL.

[Ruas61, BSN, RN]

There are some situations where a patient is seen by Hospice for the purpose of symptom management where the patient does not have an imminently terminal condition and being full code might be appropriate. But in the situation you describe being a full code would be inappropriate, if this patient were sent to my hospital they would not be offered the option of being a full code; BLS and ACLS have no established potential for any beneficial effect in patients who suffer cardiopulmonary arrest in the setting of metastasized cancer. While not an optimal situation, sending him out was still your best option.

We call that palliative care in my neck of the woods.

[MunoRN, RN]

They would not be offered the option of being a full code???? Let me know where you work so I NEVER go there. People are entitled to make their own decisions even if they are what you think are the wrong ones.

All medical treatments that the patient choses from are those that are offered by their Doctor. If your doctor doesn't offer you open heart surgery (because it offers you no potential benefit), then you can't simply demand open heart surgery and expect to receive it.

Ethically, we shouldn't offer treatments, and BLS/ACLS is a treatment, that only have the potential to cause harm and have absolutely no potential to be of any benefit. In certain patient populations, BLS and ACLS have been well established to have absolutely no benefit. Performing a non-beneficial procedure on a patient, even if they want it, is unethical.

We actually started claiming "medical futility" because we were one of the few in our region that were still allowing patients to demand BLS/ACLS despite known medical futility. Surprisingly, we've have very little resistance to it, including patients.

[SuesquatchRN, BSN, RN]

Ethically, we shouldn't offer treatments, and BLS/ACLS is a treatment, that only have the potential to cause harm and have absolutely no potential to be of any benefit. In certain patient populations, BLS and ACLS have been well established to have absolutely no benefit. Performing a non-beneficial procedure on a patient, even if they want it, is unethical.

In the absence of an OOHDNR (out of hospital DNR) it is, in my state, illegal to withhold resuscitative measures, no matter how frail the patient and how futile the effort.

[MunoRN, RN]

In the absence of an OOHDNR (out of hospital DNR) it is, in my state, illegal to withhold resuscitative measures, no matter how frail the patient and how futile the effort.

I think you're talking about something different, but no, it is not illegal in any state for a Physician to declare a patient a medically futile DNR.

[CapeCodMermaid, RN]

I've been a nurse for 31 years and have NEVER heard a physician "declare a patient a medically futile DNR". I've heard them telling families that DNR is brutal and doesn't have a very good success rate in an extremely frail elder, but it is still the decision of the family and the patient. If I want to be a full code and my doctor/nurses didn't try to rescusitate me, my family would be called Attorney Sokolof who loves to sue doctors and nurses, and he'd win the case.

I thought the point of THIS thread was being on hospice while still being a full code.

[MunoRN, RN]

I've been a nurse for 31 years and have NEVER heard a physician "declare a patient a medically futile DNR". I've heard them telling families that DNR is brutal and doesn't have a very good success rate in an extremely frail elder, but it is still the decision of the family and the patient. If I want to be a full code and my doctor/nurses didn't try to rescusitate me, my family would be called Attorney Sokolof who loves to sue doctors and nurses, and he'd win the case.

I thought the point of THIS thread was being on hospice while still being a full code.

Considering how prevalent it is, it's surprising you've never heard of it and unfortunate since it helps us avoid unethical treatment of patients. If a patient demanded that open heart surgery be performed to treat their sprained ankle, would you agree that the Physician must provide it? Would the patient win if they sued?

All states specifically allow Physicians to refuse futile care, and not provide the orders that provide that care, in situations where they deem the treatment to be medically futile. This leaves a little room for interpretation, and that interpretation does occur in courts, which is why 10 states have specifically stated in law that Physicians can declare a patient a DNR for medical futility which helps keeps these cases out of the courts. Even in states without these laws, case law has been fairly well established and overwhelming supports the Physician's right to make these determinations.

Yes, we're a little off topic, my point originally was that the OP was in pickle since the patient was a full code yet it's possible they wouldn't be a full code once admitted to the hospital.

Out of curiosity, why do you think patients for whom CPR/ACLS has been well established to have a 0% chance of benefit should still receive a distressing, yet pointless treatment?

[SuesquatchRN, BSN, RN]

Out of curiosity, why do you think patients for whom CPR/ACLS has been well established to have a 0% chance of benefit should still receive a distressing, yet pointless treatment?

That is not what she said. And as I said earlier, and you ignored, here in TX the physician does not get to choose not to perform CPR. You imply that to refuse futile care is simple, and not fraught with litigation. Further, your attitude reeks of hubris.

[SuesquatchRN, BSN, RN]

I think you're talking about something different, but no, it is not illegal in any state for a Physician to declare a patient a medically futile DNR.

I need sources for this sweeping statement.