POLST

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Specializes in ICU, Step-down, CCU.

Today I have a Patient on CMO... although, the patient is on IV fluids, has daily labs drawn, on IV antibiotics. Someone placed a new IV before my shift. My interpretation is that this patient is NOT CMO. 

HX.. non verbal although alert, responds to painful stimuli, tracks with their eyes, otherwise no other meaningful responses. In for aspiration PNA, WBC normal, lungs clear, on 2L NC. 

Now the rub. I pull the POLST and it clearly says no hydration, it does say antibiotics with comfort as a goal. 

The MD/PA is radio silence at the moment and I am picking this patient up after they have been on the floor for the last two days. The AOD is too busy to address my concerns. 

Any "legal" ramifications for what appears to be a clear disregard for the POLST?

 

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Specializes in Critical Care.

A POLST includes active physicians orders including when a patient becomes hospitalized.  How those orders get implemented, particularly when there are conflicting orders, is up to individual organizations and facilities to define, but the overriding consideration should be that the patient has made their wishes known, and in an actionable way to those caring for the patient, so going against those wishes is potentially criminal, although we typically fail to see it that way.  

It certainly becomes a bit more of a gray area when we can't be sure if the patient's POLST directives were written with their current situation considered as a possibility, in which case it may be necessary to involve the patient's legal surrogate decision maker to help clarify the patient's wishes (keep in mind they can only clarify the POLST, they can't fundamentally change it).  

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Specializes in ICU, Step-down, CCU.

Thanks, this pt was basically a nursing home dump on our ED door. Family is mostly absent, so there is little clarification. As I mentioned, my local management is also absent.

I was just looking to make sure I am covered as I do not have much direction on leaving the fluids up or not per the POLST

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Specializes in retired LTC.
1 hour ago, MunoRN said:

A POLST includes active physicians orders including when a patient becomes hospitalized.  How those orders get implemented, particularly when there are conflicting orders, is up to individual organizations and facilities to define, but the overriding consideration should be that the patient has made their wishes known, and in an actionable way to those caring for the patient, so going against those wishes is potentially criminal, although we typically fail to see it that way.  

  

 

5 hours ago, dondk said:

 

 

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Now the rub. I pull the POLST and it clearly says no hydration, it does say antibiotics with comfort as a goal. 

Combining the 2 bolded lines (my bolding) into my thinking, I ask ... how is  the IV/ABT being administered??? If it's being done via a line for the SOLE purpose of antibiotic tx, , I see no problem for the IV. Now if extra fluids are given, that I see THAT as an issue.

How to measure "with comfort as a goal' is the grey area. But personally, I see no problem with the POLST. But then the family may see otherwise. But if they've failed to commit, the BAD is on them!

I'm not the legal person here. Maybe this should be referred to your facility's Ethics Committee for input.

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Specializes in retired LTC.

dondk - This is different entry. As a long-time LTC/NURSING HOME RN PROFESSIONAL, I was upset, offended, hurt, even angered that you refer to us NHs as 'dumpers'. I think my 25+ LTC years out-trumps your 10 yrs of exp which prob does not include any real practical knowledge of how LTC has to proceed.

Without family input, the Nursing Home has NO, NADA, NOTHING, NONE, etc options except to send the pt out for better assessment & in this case,  interventions.

My guess, the change in status necessitated stat CXR & labs, incl sputs, at the least. Aggressive pulmn care incl. With such significant changes, most facilities are marginally equipped to deal with critical pts quickly.  IV access could have been a problem - most often THE MAJOR one at many places. Not all nsg homes have all their staff IV certified. Dang - I read about hosp nurses bemoaning the lack of IV practice as they work in their facilities!

Most facilities are loathe to transfer out pts if NOT absol nec. To NOT care for this pt in a fairly reasonable & quick process would be deficient.

So unless there was some other EGREGIOUS issue re this pt's transfer, you really made a very disparaging comment re LTC/NH nurses. Talk about nurses BASHING nurses!. That is what was so sad to me about your second post and I find so disturbing! If we can't be professional among ourselves, how else can we expect others!

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Specializes in ICU, Step-down, CCU.

I am sorry, poor choice of words. My frustration from this issue and it was uncalled for.

When I researched this patient, they came from LTC on hospice, was "allegedly" on a pureed diet, although ED reports suctioning out "chunks" of food. The EMS report that the LTC facility reported the reason for transfer was choking.

While I will NEVER know the real story behind this patient, it does make one wonder how a non verbal, completely contracted patient ends up with chunks of food. Someone had to feed it to them and with absent family, it is safe to say it was not family or the patient that created this sad situation.

Please accept my apology for the disparaging remarks

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Specializes in retired LTC.

TY for the comeback. Apologies accepted.

But I have to tell you - it is NOT unheard of for some lump of food to be mushed into pureed food. It could have just been poorly pureed and buried in the mush as it was being spooned. Have you ever had a piece of shell in a bag of 'shelled' nuts (like one just got missed in the factory manufacturing)? Or a prune pit in a bag of pitted prunes? I just got one the other day. Even if you buy a bag of dry beans, the bag tells you to pick & search for twigs, stones, etc.

And not to speak poorly of the dietary staff, but sometimes the puree person just hurried the process along. After all, it looked pureed in the processor!! Have you ever seen rye bread crust in pureed bread? I have. So it's not beyond possibility that some lumps were in the food and just not seen in the mush when the pt was fed.

Maybe the NH tried suctioning  - with a narrow #14 catheter. I would have tried using a Yankuer tube, but not all facilities readily have them.

Would you ever consider using a foley cath as a regular substitute for a GT Flexi-flo tube? I have worked at several places that were too cheap to buy the right ones, until I made a stink! I saw many stomal tears, mechanical gastroenteritis from tube migration with horrible skin excoriations. Poor weight control, also.

GT formulas? Oh, we don't use that flavor/brand here.

How about make-do ostomy supplies that are slapped on? Like facilities expected one-size-to-fit-all. So there's leaks & excoriations again.

Also, be VERY understanding re hospice in NHs. Usually it's not a big service. Like for maybe 2 hrs, maybe a CNA comes in to do a bath while an RN CM writes a care plan and visits once a week. I will admit I have met EXCELLENT hospice providers that provided exceptional assistance in getting nec DME and pain med mgt controlled. There are good ones with excellent CNAs. But I guess my point is not to be so 'expectant' of the kind of service provided by in-hosp hospice service.

Another thing jumps out to me. It is often difficult to well-position a contracted pt. And if the pt were to have up-chucked AFTER the meal, say while being turned with a full stomach?

I could go on & on. Like trying to get consults. Don't get me started on that one.

You're right. We weren't there to know the full episode re your pt And yes, it was poss for a WRONG tray to have been served. I have seen BIG mistakes. Oh, to have been that proverbial fly on the wall.

 

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