"no further hospitilization" order

BlueRidgeHomeRN · Jun 23, 2008

no, but it sounds like a great idea..anything to stop the revolving doors from ltc to hospital and back in terminal patients who haven't opted for hospice!

joyflnoyz, LPN · Jun 23, 2008

i have seen "do not hospitalize" orders written in keeping with family wishes

CT Pixie, BSN, RN · Jun 23, 2008

I recently ran across that order in quite a few LTC residents charts. It was written as a DNR/DNH. I had NO idea what DNH was so I asked my clinical instructor and she said its a Do Not Resusitate and Do Not Hospitalize order.

Jolie, BSN · Jun 23, 2008

While this certainly has the potential to stop the revolving door between LTC and the hospital, it seems as though there needs to be some type of support established for both the dying patient and staff.

If hospitalization is not appropriate or desired, shouldn't a hospice consult be initiated?

If the patient does not desire hospice, I would question whether s/he is aware of and agrees with the "do not hospitalize order".

wooh, BSN, RN · Jun 23, 2008

If the patient does not desire hospice, I would question whether s/he is aware of and agrees with the "do not hospitalize order".

I think a lot of times there are people that know what they don't want (further treatment, more hospitalization, etc.) but aren't prepared to say that they are ready to die. And for a lot of people, accepting hospice is saying to themselves, "I'm ready to die."

I think it's sort of the same thing as limited codes. "Give me drugs but no compressions to circulate them." To the healthcare worker, it doesn't make sense, but it's the patient slowly working themselves towards acceptance.

Dixielee, BSN, RN · Jun 24, 2008

From an ER perspective, I have seen LTC pts come to the ER with DNR/DNH orders. The family wants ER treatment but not hospitalization. Many times we are between a rock and a hard place. The family wants them treated "instantly" but do not want them in the hospital. Many LTC facilities will not take patients back who may need IV antibiotics or other treatments.

We also fairly regularly get patients from LTC facilities who have a valid DNR, start to have respiratory distress or cardiac issues and EMS brings them to us as they are minutes away from death. Instead of letting them die in peace, they come to us where it is loud, bright and provides little or no privacy for the family. Then we have to deal with the whole issue of organ donation, calling the medical examiner, are they a coroners case or do they go to the morgue, is there a funeral home the family wishes, etc. These are things that could be avoided it they had died at "home".

Sigh...there is no perfect answer for this problem.

Skeetersmom119 · Jun 24, 2008

I have saw orders stating "No hospitalizations, no vitals, no weights, no IV's". Following that order, most of the meds were discontinued, with exception of cardiac meds. I have also saw orders where it stated "No hospitalizations" but it did specify that if the pt needed ABT that it could be given, which is sort of the type of order you are talking about.

CT Pixie, BSN, RN · Jun 24, 2008

I've seen orders for "comfort measures only" (no meds, no vitals, weights, I&O's, not to be hospitalized etc) they did receive pain meds and some had the ok for ABT and wound treatments and O2.

I've seen orders for DNH but they had weights, vitals, I&O's etc done. Their normal course of care was carried out, they just didn't want to be hospitalized for any reason.

joyflnoyz, LPN · Jun 24, 2008

Some of our residents' families choose palliative care without involving an "official" hospice organization. Blessedly, our MD and NP are totally on board with palliative care, and will give us orders for what we need.

My experience is very few of my residents wish to ever go to the hospital, they resist it as much as they can.

Furwillfly · Jun 25, 2008

I think perhaps I'm taking this a different way.

If we have a resident who let say has lung cancer. Of course a DNR, but only hospitalize if in extreme distress.

To me that means if I can't control his pain well enough, or he can't breath and is scared and I can't help him with meds........he is shipped to the hospital. Not to save him, but to let him die comfortably.

I don't run into this much, but it has happened, I gave this resident as much drugs as I could, etc. When you can't reduce the pain, or the anxiety..... Esp. when you have a very conservative MD.

morte, LPN, LVN · Jun 25, 2008

i have seen "treat in facility only", "do not send out, except for fx"...DNH, CMO.......