On Call: Vsit or Not?

[NTS]

I am an on-call Hospice nurse who works 7 on, 7 off. I get all after hours and weekend calls, triage, after hours admits, visits, deaths, emergencies and anything else that comes up. I do have a backup Nurse who case manages during the day.

I got a message At 4:45 am from the answering service that pt was having difficulty speaking. When I returned the call the pt was speaking clearly, no slurred words or word finding noted. Pt stated just couldn’t get words to come out right. Pt was alert and oriented and answered my questions appropriately. Pt denied pain, dizziness, weakness, shortness of breath or stroke symptoms. Pt stated couldn’t get medicine until the next day.
This pt was known to drink alcohol and use illicit drugs, frequently intoxicated or high during nurse visits. Also insistent on getting pain pills on time.
The call was about difficulty speaking which was clearly not a problem at that time. The pt was advised I would speak to the case manager and see about the medications. The pt agreed and hung up.

later in the morning the pt was found dead.
based on the info at the time I didn’t feel a visit was warranted. Now I’m questioned why a visit wasn’t made when called. I called nursing judgement. I admitted the pt and knew the background. And knew how things were going. My manager says he agrees with me.

what would you have done?

[Daisy4RN]

My answer would depend on a few more facts such as: who called the service originally (pt, family, neighbor etc), was anyone else with the pt (either when called was made or when you called back), did the pt have a history of calling the nurse for insignificant reasons, were you planning to give report for the day nurse to do a visit, pt diagnosis/prognoses/recent changes, what medication the pt was taking including the one you mentioned that pt couldn't get until the next day..

[NTS]

The pt called and is who I spoke to on return call. Lives alone and independent. Does call regularly to make sure to get narcotic meds refilled. Did give report to IDG on morning call and agreed pt usually calls to inform of problems with meds. Slow decline, no major recent changes. Cm was planning visit as first pt for her that day.

trying to be generic in details and not give too many details.

[Katillac, RN]

Wow, this part of allnurses has gotten quiet.

There is no part of this scenario as presented that would have triggered an automatic visit from me. The patient called about a symptom. When you called back the symptom was resolved. In our agency, On Call is for urgent needs. There was no urgent need when you talked with the patient. On Call’s role would not be to investigate what might have caused symptoms in the past, that would be a part of ongoing case management, a process you triggered. BUT my hospice also wants On Call to document that they offered a visit, and whether or not that offer was accepted or declined.

If this had been me I would be second guessing myself wondering if the fact the patient was an addict caused me to dismiss the concern. But in this case I would have looked at it, clarified mentally my role on call, and realized that even had this been a non-addict I would have responded in the same way. Not saying this should have been your process, but possibly you are being questioned by someone who thinks you may have discriminated against this patient because of bias. But I don’t see any.

[vampiregirl, BSN, RN]

On call hospice can be tricky at times. All we can do is make recommendations/ assessments based upon the information we have available at the time of any call interaction. From the information provided, I don't see any red flags that would prompt me to identify this patient as a visit need at the time of the call either.

As for knowledge that a patient has recent history of substance use/ misuse for me that doesn't trigger a "bias" per se but it does warrant some considerations for care planning. Safety (patient and hospice staff), potential medication interactions and knowing that symptom management may be more complicated are all things to be aware of. Also, in order to be eligible for hospice an individual has to have a terminal diagnosis. Where I'm going with all this is that your patient has elevated risk for death.

Reviewing cases such as this can be beneficial for everyone if done appropriately. It's a good time to review processes (including on call) and gather input. But I hope you (the OP) is being supported by your agency. Sometimes even when we make sound decisions based upon available information things don't play out like we'd like them to. But that also doesn't always mean someone is at fault.