No dying in the ER allowed!

[MQ Edna]

Hello, Allnurse peers. I'm probably about to "preach to the choir", although as always I would welcome your advice, support and wisdom. I sit on the ethics board of the hospital where I work, and the topic came up of an elderly end-of-life gentleman with an out-of-hospital DNR who appeared to have had a a respiratory distress at home. The wife, who at the end couldn't cope with the idea of him dying there in pain, in the home with her by herself, called EMS, who naturally took him to the ER, where these trained professionals naturally did what they were trained to do: they intubated and coded him. The wife was distraught, and so was the patient when he woke up and realized that what was done to him was exactly what he didn't want done.

ERs are for emergencies, just like it says. They are places where trained multidisciplinary specialists do everything they can to keep viable people among the living. They aren't places for people to be brought to die, and the professionals attracted to this speciality usually aren't hard-wired to stand to the side, push morphine, hold a hand and LET someone die. Even if they were, in today's litigious climate, who can afford to take the time to say, "What is this patient's code status?" before you jump on his chest, bust his ribs, cram a tube down his throat, etc.

On the other hand, who can feel anything but pity for an elderly woman alone in the middle of the night with a husband who is suffering as he departs this world? Who can blame her for picking up the phone and dialing 911?

If in addition to our ERs, wouldn't it serve a purpose to have a "D.R", a Departure Room where persons who were in distress or dying, but didn't want all of our technological wonders performed on them, could be brought for pain and anxiety relief and spiritual support as they and their loved ones make this final journey? Probably not cost efficient (and how would you code and bill for it?). Ideally there is Hospice, but for a variety of reasons, not all of these people are Hospice candidates.

What are you doing at your progressive insititutions? Thoughts, feelings, feedback, ideas? Thank you, JeannieM:scrying:

[CANRN, MSN, RN]

You pose some valid concerns. A few years ago this dilemna faced healthcare workers in Ohio just like your do in Texas. Ohio revised the DNR laws and they are very specific of what can and cannot be done. Patients are now sent to the ER from LTC facilities with symptoms and can still be treated but if they expire no code will be called. In fact, the law is very specific about not even monitoring the heart, no EKG's etc. People are sent to the ER for more than just heart related problems, Elderly have problems that can be treated effectively without all the monitors.

I worked in the ER before and after these new rules and I can tell you it did help..some, but there are still gray areas. If that woman had called and her husband brought to our ER, NO INTUBATION would have occured. the EMS personnell would NOT have intubation. With the new law, there is no change in code status just because someone goes from LTC to ER, home to ER, or whatever the circumstance. Comfort measures would have been provided to that gentleman, Lasix, Respiratory treatments, everything except intubation. He more than likely would have died, but at least his wishes would have been meet and his wife would have felt she did all she could do to help him. If he would have lived, he would not be angry that he was on a vent, there would have not been one.

One time, a family had their terminally ill 17 year old son in Hospice care and he was actively dying, they just could not handle it, they called 911, he came to our ER, the docs determined there was no sense in resucitation efforts, the boy didn't want it anyway, the mother made sure we all knew that, and we allowed the family to stay in the room with him and he passed there, still with his family around him, without heroics but his family had the support of medical professionals for the comfort measures we could provide to him.

A room as you suggested would be a good idea.

[eldernurse]

And just which nurse would work this room? I work in a busy ED. and the families need as much care, or more, than the patient. I thought this is what HOSPICE

[eldernurse]

(SILLY ME, I TOUCHED THE WRONG KEY, SO CONTINUING) As I was saying, that is what I thought hospice was all about. When we have a patient come into the ED and they are a DNR, the entire ED comes to a grinding halt. If it is horribly busy, the family does not get the attention they need and deserve. I am not for a special room in the ED to die.

[MQ Edna]

Originally posted by eldernurse

[bI am not for a special room in the ED to die. [/b]

Sorry, eldernurse. I didn't mean to say that the "DR" would have to be in the ER proper. I recognize that would be inappropriate. I really meant that there should be some place other than the ER for these people. I agree that Hospice would be great, but not all of these people are Hospice candidates.

I really like the progressive thinking at CANRN's institution. It gives me an idea to take back to my ethics committee. Thanks so much! JeannieM

[eldernurse]

I do agree that this entire country needs to get real about death. I am tired of tubing an 80 year old double amputee who hasn't had a bite of food for years and hasn't been able to meaningfully communicate with the outer world in a long time, who has decubitus ulcers to the bone in many places and who's family thinks it is a big suprise that they are going to die!

Even the ones who accept it as an inevitability need TLC to get through it. I did Oncology for several years. I could write a book about death and dying. I guess I am open for any suggestions that make it a more compassionate end.

[CANRN, MSN, RN]

Eldernurse, the nurse does not have to be one on one with this person, it was not that way when it happened where I worked at the time. I work for a catholic healthorganization and we called the appropriate team members to come and be with the families of these patients. We also had an adorable 80 year old nun, no bigger than a ten year old but the energy of one!) who responded to every code, or dying patient we had in the hospital. So, the care of the family is not just with the nurse, it's a team effort.

[thisnurse]

they come to our ER and are sent to the floor...usually ours...to die.

[Reabock]

they come to our ER and are sent to the floor...usually ours...to die.

Same thing at our hospital, what bugs me is that at a time like this that we still have to do a full admission process. Seems inhumane to me!

[CEN35]

well i am not trying to stir the pot. however, i don't know who the hell decided that er's are for emergencies. the bottom line is one of the wonderful goverment agancies (i.e. joint commison), said to be a hospital that gets medicare/medicaid funding, you must screen all people that request it.

if you refuse, you do not get medicare/medicaid funding. all patients would have to be admitted, to be screened. so the er's initial purpose, was to decide who needed to be admitted and treated, and who could be ttreated and released.

the bottom line is, the system abused on a daily basis. er's have now taken over, the place of the pmd!

with all the laws and governing groups the current health system is doomed. (i.e. osha, joint commision, hicfa, cobra, and starting 2003' hippa) any hospital in the world, could not uphold to all of these different groups requirements, without going bankrupt.

why? because insurance companies, and medical coverage rule the system.

me ............. out

[CANRN, MSN, RN]

CEN you said it! I worked the ER for a little over a year and got pretty fed up with it. Half the people that came through the doors did NOT have to come there, I loved the ones who had 'pain for two weeks and it jsut became unbearable so I came..." at 3am it's now an emergency. They get their drug and out they go.

No family doc, so the ER becomes their doctor's office.

It just got to me, my attitude was going down the tubes. I'm now back on the floor and happier than I have been in a long time. At least the people I care for now NEED to be there!

[mattsmom81]

I agree that patients that are DNR's should be allowed to die comfortably....but I also understand why the ER intubates when the wife does not share the info re DNR...what are they to do?

I also hate going through the lengthy admission process which takes time away from supporting and caring for the family and patient...when we know they have come to die...

I think there would be a stigma to a 'departure room'...these are patients just like everyone else and I believe the answer is to provide sufficient staffing to allow proper support on the general floors for these types of patients...and ALL our patients.

Hospice care is ideal if they 'qualify' as mentioned. So many don't these days so the patient falls through the cracks and ends up just one of 10 patients a nurse has to care for on a busy unit. The nurse has only so much time to give, unfortunately.

I have felt a lot of satisfaction from end of life care...but I wish we were allowed the time to really care, instead of shorting patient A to give more attention to patient B.

Perhaps the best solution is to remove the barriers in hospice to make it available to ALL patients who are dying regardless of insurance, etc.