Dialysis 9 yrs, but terminal illness is COPD???

  1. Sometimes I just want to pull my hair out! Account exec has been working on getting a patient discharged for the last 3 weeks, daily notes from md says "husband considering stopping dialysis", then, tonight when she does get home--"of course we are continuing dialysis". Patient had dialysis this evening. Admitting orders state "esrd", but there is a note from the AE saying "admit under copd" when copd is only mentioned as a comorbidity. She is on a buttload of medications related to dialysis-renagel, sodium bicarb, meds for htn, etc.

    IF patient has been on dialysis for 9 years, had a renal transplant 9 yrs ago that failed, how can I in good conscious admit this patient under copd?

    thanks for listening.

    linda
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    About AtlantaRN

    Joined: Oct '98; Posts: 772; Likes: 293
    med/surg/hospice/home health RN
    Specialty: 13 year(s) of experience

    14 Comments

  3. by   heron
    The question is, does the copd meet criteria for hospice admission? That would mean that hospice is on the hook for just meds to treat copd and all the renal-related meds as well as the dialysis itself would be covered by the pt's other insurance. If admitted under esrd, then hospice has to eat the cost of the dialysis, since it's life-extending treatment, so I can see the md wanting to avoid that.

    So, how advanced is the copd?
  4. by   MississippiSweetpea
    I didn't know you could have someone on dialysis in hospice. I was always told that it was not allowed since it is considered aggressive treatment....
  5. by   traumaRUs
    Nope - you can be on hospice and still dialyze. I have two current pts considering hospice for metastic Ca but both are ESRD on hemodialysis. Medicare allows this.
  6. by   gt4everpn
    Seems like some kind of scheme to my by your exec.. the husband wants dialysis stopped but she will still be getting dialysis??? Seems like a plot to keep the patient admitted although she has a terminal illnes (ESRD) they want to keep her for dx of COPD.. more $$$$ for the hospice or less money lost, idk, just my guess.
  7. by   gt4everpn
    you'd be surprised the things some hospice patients recieve.. i work in hospice from time to time (float through the unit) until now i can't understand why hospice patients are:
    [color=#48d1cc]1.hospice with no dnr
    2.life-preserving med (bp meds, iv flds for hydration, etc..)
    [color=#48d1cc]3. tube feedings usually at the request of the families in my experience.
    [color=#48d1cc]does anyone know why?

    Quote from traumarus
    nope - you can be on hospice and still dialyze. i have two current pts considering hospice for metastic ca but both are esrd on hemodialysis. medicare allows this.
  8. by   AtlantaRN
    what really gets me on this one is one of the higher ups in the company chose copd as her terminal diagnosis, not her physician. Physician usually writes "evaluate and treat if appropriate." frankly she has more pointing to chf than copd as I don't have any pft's. I guess it's because she is on more meds for heart failure, and is only on 2 meds for neblulizer? sometimes I just don't get it.

    thank you for listening.
  9. by   BandEmom
    gt4everpn,

    I think that people who are on hospice with DNR are really just not still there emotionally. Comfort care is acceptable to them but accepting the full implications of DNR is just out of their comfort zones. Some people and families worry that it may compromise their care. Many of them end up changing their code status down the line. Of course, all of my hospice patients are living at home. I can see how it would be much more frustrating to see full code hospice patients in an inpatient setting.
    Last edit by BandEmom on May 7, '09 : Reason: misspelled name of original poster
  10. by   gt4everpn
    and i completely understand and respect the decisions the families and/or patient make, but it does pose such a dilemma for staff members, i haven't been in the situation of a full code on a hospice patient with no dnr, but i did have a patient who was dying and the wife didn't sign a dnr (and not to be mean, she was a hard family member to please), i was advised by my nm to call the wife should he expire or code and ask her what to do because she knew he was dying and might have changed her mind, but thankfully my shift ended and he was still breathing.

    Quote from bandemom
    gt4everpn,

    i think that people who are on hospice with dnr are really just not still there emotionally. comfort care is acceptable to them but accepting the full implications of dnr is just out of their comfort zones. some people and families worry that it may compromise their care. many of them end up changing their code status down the line. of course, all of my hospice patients are living at home. i can see how it would be much more frustrating to see full code hospice patients in an inpatient setting.
  11. by   MississippiSweetpea
    Ya'll have just blown my mind.........I am still reeling from this revelation. Medicare will allow dialysis. WOW. I just had a pt revoke Monday because the doctor was referring him for dialysis.
    We had him for COPD.
  12. by   heron
    Quote from MississippiSweetpea
    I didn't know you could have someone on dialysis in hospice. I was always told that it was not allowed since it is considered aggressive treatment....
    It depends on the condition under which the patient is admitted to hospice. If admitted as an end stage renal disease patient, then dialysis is not covered by medicare. It can continue, but the family has to pay for it, or the hospice eats the cost. Thus, we tend to discourage pt signing on for renal disease unless he/she is ready to stop.

    If, however, the hospice diagnosis ... ie the official terminal condition ... is end-stage cardiac disease, or copd, then dialysis is covered by the pt's other insurance ... usually regular medicare.

    Does that make sense?
  13. by   MississippiSweetpea
    Yes, thank you. That answered a few questions. Thanks.
    I worked hospice in 1998 for about a year, then went back to local hospital on night shift. I got tired of resisting God's plan for me, so I came back to hospice about 1 1/2 years ago.
    Several changes in my state during that time. Or maybe, its just a difference in the companies. Before, we had cancer pts only. That's all. And they were all DNR. That was explained on admission. Now, we have full codes, speech therapy, physical therapy, etc.; CHF, COPD, Alzheimers, even had a 96 y/o with Failure to Thrive. She was a sassy little thing, and at 96, I though she had "thriving" figured out.
    But as the old saying goes. "You learn something everyday".
    Thanks again.
  14. by   heron
    Quote from MississippiSweetpea
    Yes, thank you. That answered a few questions. Thanks.
    I worked hospice in 1998 for about a year, then went back to local hospital on night shift. I got tired of resisting God's plan for me, so I came back to hospice about 1 1/2 years ago.
    Several changes in my state during that time. Or maybe, its just a difference in the companies. Before, we had cancer pts only. That's all. And they were all DNR. That was explained on admission. Now, we have full codes, speech therapy, physical therapy, etc.; CHF, COPD, Alzheimers, even had a 96 y/o with Failure to Thrive. She was a sassy little thing, and at 96, I though she had "thriving" figured out.
    But as the old saying goes. "You learn something everyday".
    Thanks again.
    Hospice has been expanding it's scope steadily ever since the medicare hospice benefit kicked in. It makes a certain amount of sense ... people do die of conditions other than cancer and need good palliative care, too.

    It also has to do with the idea of "open access" as my company terms it. They couch it as a compassionate effort to bring hospice care to anyone who needs it. It's really a marketing concept to maximize the census. Since medicare pays a flat fee per patient, the company depends on head count and cost controls to make a profit. As a result, we are seeing patients earlier and earlier in the course of their terminal illness. It can make for some labor intensive nursing, for sure.

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