Munchausen's Is NOT a Hospice Diagnosis

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Hi all. Just need to vent about for-profit hospice and its ridiculous quest for patients, regardless of appropriateness. Just because a physician is willing to sign an order stating a patient has six months or less to live doesn't mean it's so....sigh. Had a physician refer a man to us who has been 'sick' for years with vague neurological and 'autoimmune' diseases. This man claims he's got uncontrolled shakiness and cannot talk at times......however when you get him talking about himself, suddenly all the symptoms go away.....until he realizes that they're gone, and they suddenly come back......He claims caretakers have tried to kill him by putting bleach in a drink he was drinking which sent him to the hospital with severe chemical burns (he did end up in the hospital with severe chemical burns from bleach, but doubtful that a CARETAKER put it in the ice tea....) Vital signs are all perfectly normal. Patient claims he's so weak he can barely walk, but is able to sit up straight on the edge of a chair for an hour without sitting back to rest. Patient claims he's been to several 'specialists' who have found nothing wrong with him and he has 'excruciating' pain that would 'kill a normal person', but is 'allergic' to all pain medications except Morphine.

The physician keeps referring the guy every three months or so, and we nurses keep telling everyone that he is NOT dying from organic disease....if he dies it will be because he overdosed on some med or chemical. Physician wants desperately to get rid of this psycho....and management keeps thinking we should take him. He does NOT qualify for hospice for any diagnosis, and won't get a psych eval (flat out REFUSES).

Lucky for us the medical director is on board with the nurses. But this is getting really old really fast. It's a waste of our time to have to go out and spend an hour or two 'evaluating' this guy. At this point, even if he WERE dying of organic disease, I wouldn't take care of him because he did state in the interview that he feels homicidal at times toward people who have 'hurt' him. How on earth can we get management to say "sorry, we're NOT taking this guy" instead of continually sending us out on pointless evaluations? This has been going on for over a year. UGH!

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Specializes in Hospice, LTC, Rehab, Home Health.

OMG! :eek: I am with you on this! I am sooo tired of doctors referring every whacko patient and family they no longer want to deal with but dragging their heels referring the appropriate patients and families that we could really help!

:up: to your Medical Director for not caving in to his "peer" and admitting him! Management will probably never flat out refuse to evaluate him for fear of losing other appropriate referrals and for those other patients' sakes I guess I understand that reasoning.

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OMG! :eek: I am with you on this! I am sooo tired of doctors referring every whacko patient and family they no longer want to deal with but dragging their heels referring the appropriate patients and families that we could really help!

AMEN!!!!

Ok, I guess I get that we might 'turn off' the doc we refuse and lose patients who really are appropriate. Sigh. It's so frustrating.

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Specializes in Hospice.

Actually, there doesn't have to be an physical disease to qualify, usually under adult failure to thrive or nonspecific terminal illness. The person could be terminal due to the physical consequences of the psychiatric illness.

I took care of a woman whose hospice admission was perfectly legitimate, although her physical issues were clearly of a psych origin ... she basically starved to death. We took her on after she was "fired" from another hospice. In the six weeks or so before her death, she had three inpatient admissions - all in the space of a week. She tried for a fourth, but the doc refused to admit her to our IPU (thank heaven!).

Given the info in the OP, I'd be willing to bet that this would be a very high cost patient, even if given enough morphine to keep him high and happy. With the need for attention, he's likely to be in the ER or looking for inpatient hospice (GIP) admission or Continuous Home Care constantly. At the very least, your on-call and field nurses will be spending significant amounts of time dealing with his repeated crises. Maybe pointing this out to mgt might make them take a second look. They are highly likely to lose substantial sums of money ... worth it when someone is truly terminal and needs the support but another story entirely when it's all in honor of meeting the needs of an untreated psych patient who's likely to live for quite a while.

I hope your medical director sticks to his/her guns. If the patient ever actually qualifies, I hope you have good psych resources available.

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Specializes in LTC, Psych, Hospice.
OMG! :eek: I am with you on this! I am sooo tired of doctors referring every whacko patient and family they no longer want to deal with but dragging their heels referring the appropriate patients and families that we could really help! quote]

..and that, my friend, is the $64K question!:coollook:

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Specializes in M/S, ICU, ICP.
amen!!!!

ok, i guess i get that we might 'turn off' the doc we refuse and lose patients who really are appropriate. sigh. it's so frustrating.

if the doctor is the same one each time doing the referral, can you refuse to do the evaluation unless there has been a change in diagnosis or medical condition? if the patient is stable where he/she is then their condition would not require hospice.

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Specializes in Med/Surg, DSU, Ortho, Onc, Psych.

In Australia an intern could section this guy (get him put in a locked psych ward), and he would have to stay until he is evaluated by a psychiatrist within either 24 or 48 hours. He has major psych and drug addiction issues.

I had a patient similar to him years ago. This woman was dizzy all the time only when she stood up; was fine sitting etc. She had every test done, scans etc and nothing showed up. I reckon she was just stressed from work and taking care of her family.

I urge you to refuse to see this guy if he has homicidal tendencies. You can refuse to see him without an escort in Australia (don't know re US laws), but I have heard from 3rd parties of nurses being killed/nearly killed by psych patients whom management didn't take seriously. I would not be going anywhere near him.

He also needs a qualified drug & alcohol addiction nurse/specialist to evaluate him and refuse the morphine. Get the Dr to write up less addictive med's, if he in fact does need them. He definitely has psychotic/hallucinatory and paranoid and/or schizophrenic tendencies by the sounds of it and needs to have a psych assessment done (which I realise you know).

You could call the mental health regulatory unit in your state and report this, as it is a breach of not only his rights to get assessed, but also if he states he has homicidal tendencies, the police can become involved and a court order can force him to be sectioned. It is also a threat to other patients/staff and yourself personally. Threats like this should never, ever be taken lightly.

Here in Aust we can make anonymous phone calls if we so wish re any patients or threats to nurses/health staff to a neutral number.

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Specializes in Management, Emergency, Psych, Med Surg.

Your medical director needs to have a 1:1 with the doctor that keeps referring this patient and tell him that he is not going to accept the patient on the hospice service any longer until there is a definitive diagnosis that will lead to death. I have a friend who is the medical director for a hospice and he would never accept a patient like this on the service.

This is not a man that you can require a mandatory 72 hour hold for a psych eval because for the most part he does not meet criteria. Unless he is actively suicidal, homicidal or gravely disabled they won't put him on a hold. But this varies state to state.

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