My mistake?

[makes needs known]

Recently a pt of mine started to severely desat (40's-50's) on 4L o2, and I notified my SV, she assessed the pt, who happened to be on hospice. She contacted the MD for orders and got an order to send to the hospital for eval. She discussed the fact that the patient was on hospice. Pt did not want to go initially (anxious and confused) but did agree when we reassured her they would be able to determine what would make her feel better. She was admitted with pneumonia. She was started on antibiotics and began to feel better. The SV did not inform the family that she had been sent to the hospital, they were mad and pt was sent back to us the next day with orders not to continue antibiotics. SV was new and did not call the family. She did the paperwork and on it there is a section asking which family member was contacted. I feel like a fool. I'm in trouble, for sending a hospice pt to the hospital and not letting the family know.

[Anna Flaxis, BSN, RN]

Comfort care DOES NOT EQUAL no acute care.

Actually, in my facility, it does. It means no more vital signs, no more lab draws, no more diagnostic imaging, no more medications other than medications specifically ordered by the Palliative Care physician, such as a morphine drip, scopalomine patches, etc. In my facility, Comfort Care would definitely mean no chest x ray and no antibiotics. This is all spelled out in black and white in the Palliative Care Order Set.

So, the question in this particular instance becomes, what is the care plan for this particular patient? Again, the hospice should have been the ones called, if it is unclear to the bedside nurse and the supervisor.

[klone, MSN, RN]

I know that once in a while it IS appropriate for a hospice patient to go to the ED. If the issue is not hospice related. For example, if a COPD patient falls and breaks a hip, it might be appropriate to get transferred to the ED for acute care. They would be temporarily taken off hospice care, and then put back onto hospice care after being back-transported. It's a whole big medicare thing (my husband is a hospice director, so I know more than I ought about hospice, even though I'm an perinatal nurse).

[DeLana_RN, BSN, RN]

Hmm... is there any need to be so harsh toward the OP, who came here for advice and is well aware that the situation could have been handled better?

I guess it never ends - nurses just have to eat their young (and their own).

P.S. As a hospice nurse myself, I agree that acute care can definitely be appropriate for hospice pts. Yes, the hospice nurse should have been called, family should have been called... but perhaps it was the responsibility of the SV. It's not like LTC nurses don't have enough to do already.

[netglow, ASN, RN]

Former hospice nurse too. Just call hospice as soon as you think you need to call a doc. The hospice nurse will know (should know) what dynamics are involved with all parties. Makes your job easier. True that the patient might decide they want to go to the er, that's OK. But, hospice will arrange for all. Call hospice, then talk to your supervisor because your supervisor is not in charge of clinical decision-making for your patient, hospice is, you see? Sometimes that hospice nurse is going to need every available minute to make things go best for the patient/family. It's a lot of wrangling. Once on hospice MDs don't want calls from regular nurses as well as hospice. It's hospice only. You can see the provider confusion in "status" and careplans that happens.

Sorry you are in a tough spot. Slip on that extra skin now for a while, families can get very upset.

[netglow, ASN, RN]

I agree with DeLana. OP, I tell ya that nurses (who are not hospice) often think they know what to do and yet they don't and they are quick to chide other nurses who are really just as confused as they are. Heavily rely on your hospice nurse. Seek her out and ask if she could explain things to you some time soon. Ask for her phone number and call her after your shift. So much better to know what's what.

[nurseprnRN, BSN, RN]

you are entirely welcome. :thankya:

[Esme12, ASN, BSN, RN]

Actually, in my facility, it does. It means no more vital signs, no more lab draws, no more diagnostic imaging, no more medications other than medications specifically ordered by the Palliative Care physician, such as a morphine drip, scopolamine patches, etc. In my facility, Comfort Care would definitely mean no chest x ray and no antibiotics. This is all spelled out in black and white in the Palliative Care Order Set.

So, the question in this particular instance becomes, what is the care plan for this particular patient? Again, the hospice should have been the ones called, if it is unclear to the bedside nurse and the supervisor.

This patient was hospice and not all hospice patients are comfort care. The family needed to be notified reguardless. I think the OP gets it now.

[makes needs known]

Thank you again for your help, I honestly thought my superviser called the family. We have paperwork that is sent to the hospital and I never saw it. The chart was taken and the transfer papers prepared somewhere else. I stayed with the patient until she was shipped.

[Anna Flaxis, BSN, RN]

This patient was hospice and not all hospice patients are comfort care. The family needed to be notified reguardless. I think the OP gets it now.

I think you are misunderstanding my post. I was simply replying to someone else who said that comfort care does not mean no acute care. In my facility, "Comfort Care" means exactly that. No acute care. Nowhere did I state that all hospice patients are on comfort care. Also, nowhere did I state that the family didn't need to be notified, nor did I state that the OP doesn't understand that.

[Anna Flaxis, BSN, RN]

Sorry, don't mind me. I had my cranky pants on when I wrote the above.

[CoffeeRTC, BSN, RN]

So...what have you taken from this experience?

Sounds like you are LTC? What should happen with a hospice pt in LTC....#1 call the hospice nurse first! They are really good with getting back to you asap. Call the family next. Sometimes I will call them first. Think about what could have been going on with this resident...why the desat? What did the lungs sound like? Other issues...was this an asp pneumonia? Might not be appropriate for po intake at this point? What could have been done in the facility..breathing treatments, O2, chest xray?

Another thing to learn..what are your duties vs the supervisor (SV?) when they come to help with situations? If I am called to help another nurse I will tell them that I will take care of XYZ. I've had the nurses ask me "hey, did you call so and so? did you fill out that paperwork?" Not being mean, but just CYA incase it wasn't done and making sure things weren't missed.

One more thing to mention again....call the hospice nurse with changes first. We have big notes in and on the charts to remind staff for this.