Impaction question

[feelix]

Scenario: Patient is total care with no s/s of actively dying. NPO with tube feed. No BM for 7 days. Stops tolerating tube feed. Hospice nurse instructs family to stop feeding. Constipation/impaction not addressed. Rationale: Patient is in hospice.

Your input please?

[nutella, MSN, RN]

Update: I wrote the original post on April 28. Today is June 11.

The patient is alive and well today. We had to hatch an elaborate plot to extricate her from the 'care home' she was dumped into by her family and left by hospice to die.

She had cared for her 4 kids and hubby till she herself became disabled. The moment she became disabled herself, everybody dumped her.

Suffices to say, when she arrived at the hospital they said her kidneys were shutting down. After two days of hydration kidneys started producing urine, she is tolerating tube feeds after a bowel program was initiated. She was transferred to an LTACH, from where she would be sent to a nursing home.

What you write concerns me on several levels.

If a patient signs on to hospice, it means that they want to focus on maximizing comfort and forego treatments. That of course does not mean to let the person get impacted and not do anything. But a lot of hospice plans do not include tube feed because it would prolong the dying process and cause other problems at the end of life like congestion.

When we look at a terminal illness itself, hospice care is usually understood as "letting things go the natural way", meaning for example, if somebody has endstage dementia and hospice appropriate, artificial nutrition and hydration is not recommended. Of course that will lead to dehydration, weakness and so on and forth but in that case it is only allowing the illness to take it's normal course with a natural death.

Of course we do not know details about your case and such, so this is just a general thought.

Ask yourself : Is what happened in the hospital something that this patient wanted, given that her plan was hospice ? Sometimes people change their mind but actually what I see more often that somebody is on hospice, has to come to the hospital for whatever reason, and suddenly the person gets worked up, interventions and treated, when in fact that is not what the person wants - but nobody actually had a discussion with the patient or /and family.

So while you might feel "successful" - look at the bigger picture. The care we provide should really match the goals that the patient or HCP formulates.

[feelix, RN]

The patient had become unable to communicate due to a catastrophic event. She had become deeply depressed because family abandoned her and since she was visiting from out of state, she had no coverage. She was left at a 'personal care home' to be taken care of by a family. It was church volunteers who took the initiative, applied for medicare/medicaid, asked hubby to authorize taking her to the hospital, stayed at the hospital with her 24/7.

[ktwlpn, LPN]

:

The patient had become unable to communicate due to a catastrophic event. She had become deeply depressed because family abandoned her and since she was visiting from out of state, she had no coverage. She was left at a 'personal care home' to be taken care of by a family. It was church volunteers who took the initiative, applied for medicare/medicaid, asked hubby to authorize taking her to the hospital, stayed at the hospital with her 24/7.

Oh,so church "do Gooders" got involved,saving the world one heathen at a time.Maybe she was depressed because of the incapacitating catastrophic event.I wonder if anyone considered her wishes.

[TammyG]

I have never known a hospice to refuse a patient that is on tube feeding. We have an obligation to allow pts and families to direct their own care to the extent that they understand palliative versus curative. In most cases, tube feeding is considered palliative. It certainly is not curative. I have seen hospices discharge a patient who has decided to have one inserted, as that is not a procedure that a hospice would cover, and it is usually disease-related. However, the patient who has a tube feeding inserted and it is their only form of nutrition, has the right to be on hospice if they so choose, and hospice would have the responsibility to cover the feedings and supplies including DME tp provide that comfort. It doesn't matter that we don't personally agree with a pts decision, it matters that we allow them to make it. Just like a DNR. We are restricted from requiring one, and must admit a patient to hospice if they qualify, even though they are a full-code.

I agree with pbrown here that I have never known a hospice to refuse a patient on tube feeding. This is fairly routine at the hospices that I have worked for. However, no patient has a right to care with any particular hospice, and a hospice can refuse admission to a patient who has medical needs that the hospice chooses not to cover, whether that be TPN or vent or tube feeding or palliative chemo. Sadly, there are some smaller or more rural hospices that choose not to accept these patients.

[nutella, MSN, RN]

I agree with pbrown here that I have never known a hospice to refuse a patient on tube feeding. This is fairly routine at the hospices that I have worked for. However, no patient has a right to care with any particular hospice, and a hospice can refuse admission to a patient who has medical needs that the hospice chooses not to cover, whether that be TPN or vent or tube feeding or palliative chemo. Sadly, there are some smaller or more rural hospices that choose not to accept these patients.

This is exactly how hospices regulate what they can carry financially.

While the largest hospice in my area also participates in the medicare trial and will cover tubefeeds, occasional transfusion and hydration all the smaller ones will not take on a patient who requires frequent transfusions and often tubefeed. It is also a difference between the patient already using tubefeeds and the patient not on tubefeeds but later asking for it while on hospice.

Those problems come from the way hospice is reimbursed...

[toomuchbaloney]

Update: I wrote the original post on April 28. Today is June 11.

The patient is alive and well today. We had to hatch an elaborate plot to extricate her from the 'care home' she was dumped into by her family and left by hospice to die.

She had cared for her 4 kids and hubby till she herself became disabled. The moment she became disabled herself, everybody dumped her.

Suffices to say, when she arrived at the hospital they said her kidneys were shutting down. After two days of hydration kidneys started producing urine, she is tolerating tube feeds after a bowel program was initiated. She was transferred to an LTACH, from where she would be sent to a nursing home.

So is this patient alert, oriented, able to make decisions for herself?

Had she elected the hospice benefit and did she then revoke?

Is she actually at end of life or was she admitted inappropriately to hospice?

How did the family just dump her if they are engaged in her ongoing care?