Inpatient Hospice Ethical Dilemma?

[CNSnurse]

Hi everyone, I am a floor nurse at a hospital and where I work we take inpatient hospice patients. I recently had a situation where I was really unsure if we were stepping into a gray ethical area. The patient's family had decided that hospice was the best choice for their family member. Earlier in the day, the neurologist had requested a referral to our inpatient hospice program. When the primary doctor came in later that day, he immediately canceled the referral for our inpatient hospice program and convinced the family that "X" hospice company through "Y" nursing home was the best choice. The family was in a crisis time, sitting in the room crying, and tending to their loved one, so of course the family does not protest and agrees with the physician's plan of care. The physician admits to me and the family that he is the medical director at "X" hospice company and his wife is an administrator at "Y" nursing home that he just convinced the family to use. This immediately sent off alarms in my head, especially after how he went on a long rant about how horrible our inpatient hospice program is (all the times I have worked with our program is has been amazing, the staff are always responsive, and really tend to the patient/family). Now my worry is that this is somehow illegal? He basically pushed his own hospice company on the family and to use the nursing facility his wife is an administrator at! Wouldn't he would be getting money from the hospice portion AND his wife's income from using the facility? Later in the evening, the family requested to use their own choice of hospice and felt really weird about it since the doctor was raving about how he was the medical director and his wife was the administrator at the nursing home he wanted to use. They felt like he had financial motives, not the patient's best interests are heart. Any thoughts?

[BacktotheBeach, ADN, BSN, RN]

Does your hospital have an anonymous ethics reporting line? This is definitely not ok. Google the Stark law. Physicians cannot make referrals to a facility in which they, or an immediate family member, have a financial interest.

[CNSnurse]

I will definitely follow up and see if i can report it. thank you!

[Stcroix, ASN, PhD, RN]

Ya, report his a**. That is waaaaay off base.

[aloevera]

Yes !! Report !!! Just wrong

and unethical

[tyvin, BSN, RN]

I see it, but I don't. It's the family doctor; what better way than to have them under his wing. That's what I see. I don't see any board getting on him for this...it's called care. The family will feel better around more familiar faces. The neurologist should have called the main doc to discuss this whole thing in the first place, instead of rushing to judgement of the fist place available and panicking the family as if they had no other choice. Unless the family is closer to the neurologist, I would say the doc made the right call.

[mkk99]

I see it, but I don't. It's the family doctor; what better way than to have them under his wing. That's what I see. I don't see any board getting on him for this...it's called care. The family will feel better around more familiar faces. The neurologist should have called the main doc to discuss this whole thing in the first place, instead of rushing to judgement of the fist place available and panicking the family as if they had no other choice. Unless the family is closer to the neurologist, I would say the doc made the right call.

If it was about patient care, why wouldn't the doctor be upfront about it? And why does he need to bad mouth their other options? If it was actually about patient care I would think he could say something like "Our services here are great, but I also direct a hospice and it's nice when I know the patient and we have this relationship, I'm not sure if you were aware of it." And if it was good motives, why would the family feel so uncomfortable about it? The patient's family can clearly see the motivation here is financial, not about the quality of care.

[Pbrown1414]

Well I don't know how they came to their decision, but it was the right one to make. The doctor should be reported to the AMA, and possibly you should talk to the nursing board about your responsibility as an advocate for the patient and family. At the outset, when a physician gives an order for hospice eval and treat, it should be made clear to the pt and family that they have a choice of hospices and the case manager/social worker, should be consulted to assist them in evaluating several hospices, as I am sure there are multiple hospices available to them. They should consider a lot of things, including what area the hospice services and how long it will take for a nurse to get there in times of emergency/extreme stress etc, how often the nurses come, aides come, and do they have a chaplain. What medicines will they cover, and what procedures that I need, want etc. Do they have the ability to do continuous care when I need it? Will they admit to the hospital for symptom control when they don't have continuous care? Lots of things to talk about. They would also want to tour any facility they might be thinking about. Also, not the least, they should be made aware of the possibility of taking care of their loved one at home, and what the actual need would be. Ok, I am probably speaking to the choir, but I am a pt advocate at heart, and sometimes these things aren't clearly explained to the patient, and our partners, the clinical hospital based nurses, should be taught about these things and then they would be better able to advocate for their patients upon discharge. I don't think enough is done in this area.

[Pbrown1414]

Actually, in some states at least, it is legal as long as the physician discloses his interest prior to referral.

[MunoRN, RN]

Unless the doctor extensively made the family aware of his financial ties to the nursing home and documented the family's awareness of this very well, including a witness to the disclosure, then this is a pretty severe violation of his license. These violations are rarely taken lightly by regulatory and licensing agencies.

[toomuchbaloney]

It is not ethical or professional for the MD to recommend a specific hospice to the family...ESPECIALLY if the MD is set to gain financially from that recommendation and has not disclosed that fact.

I would report him faster than a musher chased by a wolf.

[CapeCodMermaid, RN]

We have a house doc in our SNF who is also the medical director for a local hospice. He was forever writing orders for "Review and admit to XYZ hospice'. I had to tell him at least once a month that he could only write for a hospice eval. The choice of hospice providers was up to the patient and family. I've had DPH surveyors ask me to prove to them that we gave the family a choice of providers. I developed a form with the names of all our contracted providers and a spot for the family to sign saying they had been given a choice and had decided on the hospice provider they checked off.