Scenario

[TigerxLiLy]

What would you do in the following:

Resident got CT scan with metastic CA to colon,pancreas,adrenal glands-- actively bleeding for over a week. MD spoke with resident- stated " i dont wanna know if im dying, i do not wanna worry- please tell my husband- he will tell if i need to know" husband does not want his wife to know. Wants life to continue as before (nursing home life- she was on PT/OT and doing activities as she wanted)

Currently has refused/withdrawn i2 days of therapy due bleeding and fatigue.

Asked the resident if she wanted to continue therapy- she said she wanted to do therapy to get stronger, however did not want to do "physical" exercises and wished it not so frequent- just little hand exercises (such as puzzles,writing,etc) OT has maxed out on the fine motor/cognition/arom skills- she has met her goal.

Explained to her unfortunately therapy would atleast have to do 5xwk with just OT (since with no physical activity- PT is out)

I hate just taking her off--- but husband doesn't want her doing physical activities and she doesn't either. OT is maxed- so i suggest activities provide her with activities that she wants and she can do them when she wants.

MD is writing order for 6 months or less to live to skill for end of life. However, because husband does not want her to know- and she says she does not-- hospice is out of the question.

[Talino]

There are probably several modalities a therapist can tailor to suit the resident's stamina. A 30-minute rx can be spread throughout the day. Therapy provided 3X/week totalling 45 mins plus 2 daily Rehab. nsg programs would also satisfy the skilled requirement. The therapy can also be deferred until (or if) she regains some tolerance (conditons met).

We can explore other skilled services except there is no allowance for a resident's right to refuse.

[silverbat]

One thing is to consider that she has to show continued improvement or Medicare will not pay.. I am not sure looking at your post if she is med a or med b, but either way she has to show improvement. If she is at her PLOF, or if she has plateaued and continues receiveing therapy, it becomes a payment issue and you will likely be audited.

Since Dr has already said she is at end of life, Medicare/medicaid do not pay for therapy for end of life care, you may have no other option but to take her off skilled services. I truly agree with giving her things to do and to keep her as active as possible but it may not be finacially responsible. DO you have an RNA program? Perhaps RNA can do things with her, or activities. Will her family pay for PT or OT?

Please don't smack me for the financial references. I do care and care very much for my residents, and want only the very best. However, my job, and yours, if you are MDS, is to consider the financial aspects of all the care. ANd to continue with care that may cause financial hardships/non-payment is unfair to you and the patient. THe staff should be paid for their level of care and the facility mau not be paid for the higher level of care if CMS can't justify that cost.

[TigerxLiLy]

Wont medicare A pay for end of life?

And ur right- as PPS coordinators we have to think money too sadly :/

[imkaren2]

Medicare will cover her for rehab 3x/wk and 2 restoratives, I'd look into pain and if we are how often do we need to change her meds to manage her pain, how about the bleeding and what is being done with that and how often in a weeks time?

All are skilled under medicare if we are doing them. If not, she may become custodial once rehab pulls out.