House Dr. doesn't allow hospice in facility

[KY RN]

I'm new to geriatrics so I need some help. I have a patient who is end-stage COPD and end stage pancreatic cancer. She is in horrible pain all the time and our house Dr. is not managing her well with her meds. He states that he doesn't want to give more pain meds because it will rush her death. Ok, what the h*ll!!! She is in crying out all the time. I suggested maybe a hospice consult. He got very angry with me and said,"If I call in hospice on all my dying pts., I wouldn't have any patients left. It's better to keep them around so I can get reimbursed. Hospice is NEVER allowed in this facility and with my patients." I don't know what to do. I want to be a patient advocate but I also don't know if this is a normal attitude in a SNF. What would you do for your patient, who is not having an easy death?

[pennyaline]

I'm new to geriatrics so I need some help. I have a patient who is end-stage COPD and end stage pancreatic cancer. She is in horrible pain all the time and our house Dr. is not managing her well with her meds. He states that he doesn't want to give more pain meds because it will rush her death. Ok, what the h*ll!!! She is in crying out all the time. I suggested maybe a hospice consult. He got very angry with me and said,"If I call in hospice on all my dying pts., I wouldn't have any patients left. It's better to keep them around so I can get reimbursed. Hospice is NEVER allowed in this facility and with my patients." I don't know what to do. I want to be a patient advocate but I also don't know if this is a normal attitude in a SNF. What would you do for your patient, who is not having an easy death?

It is always appropriate to bring up Hospice with family members anytime there is end stage disease. You may contact the patient's responsible party and, without laying accusations, explain to them the increasing difficulty of managing their family member's pain and ask them if they have considered end of life care. Refer them to your facility's Social Worker, or let them know that they may call around to local Hospice providers themselves if they choose.

Then I would speak with my DON and my administrator, and explain the situation to them. It's up to your facility's administrative people to interact with the physician and determine why he's doing things as he is. It's up to the facility, which approves his continued practice there, to lay down the law.

Remember, it is NEVER appropriate to mention to the family that you don't think the present doc is doing the right thing for the patient or any other observation of that kind. The facts they need to deal with are 1) the increasing pain control problem and 2) the possibility of Hospice services.