I Told him she shouldn't be discharged....

Here.I.Stand, BSN, RN · Jun 7, 2016

(((((Hugs)))))

Libby1987 · Jun 7, 2016

People get stuck between denial, Medicare admission criteria and their aversion to SNFs. It's so hard to witness them trying to maneuver around it all. At our end in home health we call it having to let them fail.

whichone'spink, BSN, RN · Jun 7, 2016

As long as it is documented you had this conversation with the patient's family, all you can do is wash your hands clean of this. And if this patient comes back to your floor, don't take her back.

NursingInChaos · Jun 8, 2016

Thanks everyone - feeling better today, just have to move on and try not to treat the doctor differently when I have to deal with him on the next patient - that will be hard lol - thankfully I am moving to a larger- more professional hospital in a few weeks so changes are coming my way I hope! [emoji15]

amoLucia · Jun 8, 2016

Playing devil's advocate - I'll try to see some reasons for the Doc's continued discharge order. PP Libby1987 explained it very succinctly. MD prob just couldn't justify keeping pt in hosp anymore. And if the family declined NH placement (for whatever reason), there wasn't much MD could do.

Had the SW/discharge planner been involved in the case? I'm guessing so. There may be more to the situation than you may know or be privy to. Some families feel entitled to special accommodations when they really have to step up to the plate and make decisions re a family member, decisions that may not be what they EXPECT or WANT. You prob have no idea what all transpired and the fam may only be giving you their side of the story.

I can think of several other alternatives that the family could have pursued. But a lot is unknown

For the future, please, be careful how you intervene on behalf of the pts. Yes, you are the pt's advocate here but ... The MD might have grounds for charging that you were 'interfering his plan of care' and trying to cause family division (and even plain old harassing him). I've disagreed with physicians also, but there are limits to how to do so.

The fact that MD was a schmuck and needs better telephone skills is another issue. Up to you to be the better professional.

jadelpn, LPN, EMT-B · Jun 8, 2016

If this patient was unable to make decisions for herself, the family (or the HCP/POA) has the absolute right to take her home (getting her social security check in the process I would bet the farm). And the nursing home would get her check if in fact she were to go to a facility.

If the patient was no longer acute, then there really isn't anything else an acute care facility could do for her, and if there is no "reason" for her to stay, the hospital doesn't get paid. Confusion can be a part of a progressive, yet chronic disease process, and doesn't always equal an acute situation. Or something that is paid under Medicare....

And if they keep Gram on a vent until the cows come home....they still get her social security check.

I am old and jaded and doing this a long time. In my experience, the main reason the family is not hearing the tremendous responsibility and increased needs of their family member is that there's a dynamic involving money, the house, the social security check....all wrapped up in a tidy little bow of "we couldn't LIVE with OURSELVES putting Ma in the home!!" More like couldn't LIVE without the funds Ma brings to their household. (and a fair number move right into Ma's house....to "care" for her of course!!)

Make sure you always ask for an order for follow up with VNA services going home. (And the family WILL ask if it is "covered" under the insurance). This way, if there's something going on with the care of the relative in the home, akin to neglect, they will see that in the house and be able to report accordingly.

Sometimes you can see it coming from a mile away....but one can't assume unless they see what kind of care Ma is getting in their home.

amoLucia · Jun 9, 2016

jade - you said it all!!!! :up: Like you, whenever I've seen the discharge/placement issue, usually, money is at the root.

Families are reluctant to reveal any details about the pt's financials. A liquidation of assets and/or 'spend-down' will deplete any potential inheritance that families expect. And families have no real idea of the difficulties that they will face in trying to provide adequate care for their relative, or they just don't care. All they see is the MONEY slipping away.

OP's family might have been experiencing denial or ignorance re discharge care options. Or they were trying to 'protect' the assets.

I wish there were a MANDATORY course in all nsg schools (right before graduation time) that would start to explain the "Intricacies of Financing Healthcare for Pts 101". Something that would only begin to start to explain application, eligibility & services, etc for the layman consumer. I believe it would open a lot of eyes and generate a better sense of fiscal responsibility for all.

I really think there may have been more to OP's post that was unknown re the pt's disch. Sad for the pt.

Pangea Reunited, ASN, RN · Jun 9, 2016

In some cases, I've seen families take home an elderly relative for unselfish reasons. One man, in particular, was very active but unsteady, confused, and had an impaired swallow. The family could have opted to put him in a nursing home, physically or chemically restrain him, place a G-tube and deny him the PO food and water he asked for. Instead, they took him home to live out what was left of his natural life.

It's the kind of ending I would want for myself ...not sure about your family and the ventilator, though.

MunoRN, RN · Jun 9, 2016

I think you may be making some false assumptions about what would have been more beneficial for the patient. By far the best treatment for hospital acquired delirium to get the patient out of the hospital, preferably to a familiar environment such as home. When an 88 year old just keeps getting more confused and delirious with every additional day in the hospital, the worst thing you can do is keep them in the hospital because of the delirium. And while that's nice of you to offer the family to send them to a nursing home, I sort of doubt you were also offering to pay the $250 per day that would cost, and yet for all that money it wouldn't have reduced the patient's fall risk over being at home with family support, and certainly wouldn't have helped their delirium to resolve.

I get the frustration in seeing bad things coming and then knowing those bad things actually happened, but sometimes all of the options carry a lot of risk.

Susie2310 · Jun 9, 2016

jade - you said it all!!!! Like you, whenever I've seen the discharge/placement issue, usually, money is at the root.
Families are reluctant to reveal any details about the pt's financials. A liquidation of assets and/or 'spend-down' will deplete any potential inheritance that families expect. And families have no real idea of the difficulties that they will face in trying to provide adequate care for their relative, or they just don't care. All they see is the MONEY slipping away.
OP's family might have been experiencing denial or ignorance re discharge care options. Or they were trying to 'protect' the assets.
I wish there were a MANDATORY course in all nsg schools (right before graduation time) that would start to explain the "Intricacies of Financing Healthcare for Pts 101". Something that would only begin to start to explain application, eligibility & services, etc for the layman consumer. I believe it would open a lot of eyes and generate a better sense of fiscal responsibility for all.
I really think there may have been more to OP's post that was unknown re the pt's disch. Sad for the pt.

Or there may have been nothing sinister going on at all. Why are you so sure a nursing home would have been the best option for the patient? You almost sound as though you have a vested interest. Decent people do exist who actually want to take care of their family member/s in their own homes, especially when they know that their family member would want to remain in their own home. Health care professionals frequently let their prejudices blind them to the patient's family member/s often genuinely caring motivations, and this is very harmful for the patient/family. Of course nursing home fees have to be grappled with, unless one is wealthy. How would you like to be perceived as being abusive to a relative by someone who knows nothing about you or your family? Not everyone is trying to take advantage of their family member. The OP didn't provide enough information for us to determine that there is any kind of patient abuse happening; however you are very quick to assume the worst. I wish there was a mandatory course in nursing school 101 Dealing With Family Members: "Keep An Open Mind About Family Members Motivations Unless You Have Substantial Reasons To Believe They Are Acting Contrary To A Patient's Best Interest."

Susie2310 · Jun 9, 2016

jade - you said it all!!!! Like you, whenever I've seen the discharge/placement issue, usually, money is at the root.
Families are reluctant to reveal any details about the pt's financials. A liquidation of assets and/or 'spend-down' will deplete any potential inheritance that families expect. And families have no real idea of the difficulties that they will face in trying to provide adequate care for their relative, or they just don't care. All they see is the MONEY slipping away.
OP's family might have been experiencing denial or ignorance re discharge care options. Or they were trying to 'protect' the assets.
I really think there may have been more to OP's post that was unknown re the pt's disch. Sad for the pt.

Unless you are privy to the details of a patient/family's financial situation that likely only the person who does their taxes is, you are making a lot of assumptions. Trying to conserve financial assets is the action of a fiscally prudent, sensible person: I am sure you try to conserve your family's financial assets. Would you volunteer: "Here is a statement of all my family's assets; I am willing to liquidate the large assets because you have recommended nursing home placement and I will not even consider either alternative financial arrangements or the option of looking after my family member at home even if that would be in their best interest and/or is their preference because you are the expert and I should defer to your recommendation?" I'm sure you would want to reflect on the whole situation and determine how best to take care of your family member and their finances. In addition, if you are ever in the position of having the power of attorney for someone's finances, you will understand that managing a person's finances responsibly and prudently is an actual legal duty.