Thoughts on Hospice Care w/ non-terminally ill patients

leslie :-D · Dec 1, 2011

based only on the info you have given, my knee-jerk reaction is that you don't want to know my thoughts. :mad:

perhaps there are comorbids we're not aware of, that'd make him more hospice appropriate...

but from what i read here, this is total crap.

but it happens...far too often.

leslie

Nascar nurse, ASN, RN · Dec 1, 2011

I work in LTC and am a huge fan of hospice. Maybe I am lucky because the ladies that come into our facility are truly our team mates. Both sides routinely consult with the other to determine the best needs for the resident. It is also my experience that hospice nurses are always willing to educate us on why they do or do not do certain things. Can you try just asking them in a non-confrontational manner...."Can you help me understand why you are doing XYZ when we are only seeing ABC"? If after that conversation you still have reservations you should probably go to your DON and let him/her sort it out.

evolvingrn, BSN, RN · Dec 1, 2011

hmm....a person just has to have a life expectancy of 6 months or less to be on hospice but that sounds suspicious. There is too much fraud in hospice ...and that is exactly the type of pt places want because they cost little money and they rake in the per diem for the long haul.....not okay.

mindlor · Dec 1, 2011

the only way hospice gets paid by medicare is if a doc has signned off that the patient has 6 mos to live, or sometimes they will cover palliative care up to two years.

trust me, hospice likes to get paid.

So obviously there is a doc out there that signed an order yes?

simplyme06 · Dec 1, 2011

I work in LTC and am a huge fan of hospice. Maybe I am lucky because the ladies that come into our facility are truly our team mates. Both sides routinely consult with the other to determine the best needs for the resident. It is also my experience that hospice nurses are always willing to educate us on why they do or do not do certain things. Can you try just asking them in a non-confrontational manner...."Can you help me understand why you are doing XYZ when we are only seeing ABC"? If after that conversation you still have reservations you should probably go to your DON and let him/her sort it out.

Thanks for your input. I have confronted them very nicely about it and the main nurse seems to get very defensive about it. She explained to me that he may be having pain, but may not be exhibiting any symptoms secondary to his dementia. Doubtful. I've dealt with this nurse with other hospice pt's and she's always been great! I think I might just go to my DON about it.

simplyme06 · Dec 1, 2011

the only way hospice gets paid by medicare is if a doc has signned off that the patient has 6 mos to live, or sometimes they will cover palliative care up to two years.
trust me, hospice likes to get paid.
So obviously there is a doc out there that signed an order yes?

Yes, of course an MD signed an order for hospice.

thebeanRn · Dec 1, 2011

My Grandmother is 100 and is "fine" except for dementia, I am her DPOA and I will not give her antibiotics. PNA is "the old man's friend", that being said, if we gave her antibiotics, she would end up getting sick again, with another run of antibiotics, only to catch another bug, and eventually will end up dying of cdiff. Sorry, I would much rather see my Grandmother pass away from PNA then a multiple drug resistant organism. In the case you described above. Morphine can actually help oxygenation to tissues, which is why it is part of standing orders in patient's with chest pain.

kwyattmd · Dec 1, 2011

I am sad to say that you are right to be suspicious. During my years as a hospice physician (I'm now retired) I saw a change occurring in the industry. When our own hospice was taken over by a for-profit company whose CEO was an MBA who knew nothing about medicine or hospice we suddenly started seeing a push to accept more non-terminal patients. After visiting several of the patients and concluding that they were not appropriate for hospice I refused to sign their certification papers. The CEO then decided that face-to-face visits with the physician were not necessary and urged me to sign papers based solely on the recommendations of the new nurse he had hired. Needless to say I did not remain employed by that company! The Medicare per diem is just too tempting for some business-minded CEO's to resist and there are not enough regulators to keep up with all the fraudulent cases. Even some non-profit hospices are now moving in this direction in order to stay competitive. However, that being said, there are still many reputable hospices out there. Watch for the good ones who value patient care over profit and recommend their services to your patients and families.

IEDave, ASN, CNA, LVN · Dec 1, 2011

I work in a LTC facility. I have a pt who is 91 and has dementia, but no real terminal illness. He talks w/ the staff and propels himself in his w/c. Very nice man. Obviously confused, but nonetheless, nice and happy. One day, he started coughing and had some SOB, so we did a CXR and slight infiltrates turned up. MD ordered Avelox. Called daughter (DPOA) to let her know what was going on and she became very angry that he was "STILL BEING GIVEN ANTIBIOTICS". She called a hospice center nearby who came out and admitted him right away to hospice care. D/C'd all his meds (including anti-biotics) and started routine Morphine and Ativan to "keep him comfortable". Pt is never in pain, rarely has SOB. IMO, I see no need for Morphine. So he's been on this set up for about 2 weeks now. Whenever the hospice nurses come in, they seem shocked that he's still eating and functioning well. So shocked it seems, that they increased the time intervals for the ATC Morphine and Ativan.
Now, I'm not trying to belittle hospice by any means. I totally appreciate the care they give to our terminal patients and those that are actively dying. I also understand that hospice doesn't only help the actively dying patients, but also those that are coming close to the end.
In this situation, I just feel as if they are facilitating a faster decline in the patient...and for what reason? I just don't understand. I try to advocate for my pt, but the daughter continues to say that she wants him kept comfortable...yet she's not even here to see that he IS comfortable without all the meds. I guess I'm just confused. Maybe I'm missing something? I've only been a nurse for 2 years, but I can't help but feel like there is something wrong with this. Thoughts?

Well - I'm not a nurse, but I've been on the caregiver side of the equation for several years (and I'm currently a volunteer with a hospice), and I'll throw in my :twocents: on the issue. Can't speak for your locality, but around here if Medicare's footing the bill then it takes MD's to get that to happen. If she's acting unilaterally, yeah, that does seem a bit odd to say the least.

As far as facilitating a faster decline for the patient - by no means am I advocating this, but one thing I can say is that being the DPOA can be a monumentally stressful task in and of itself. Constantly talking with consultants, advisors, attorneys, keeping multiple sets of books, constantly back-checking yourself to make sure you're acting in the patient's best interest, yadda yadda yadda - and in a lot of cases just winging things and hoping no one calls you on it 'cause NOBODY has the answers you need. If the daughter is trying to do a solid job of managing her father's care, it's not out of the question that she may be trying to hurry the process along - not necessarily for financial gain, but just to get out from under all the ever-lovin' stress!

And, yep - had those accusations from the nursing home that my mom was, ahem, "incarcerated" in. And then some. Never over the issue of hard-lining the DNR order, or denying her access to meds (here, you can only do that if MD's approve it), but the nursing home wanted her out - because she was Medi-Medi (Medicare - MediCal) and they didn't make enough money off of her.

Personally, I'd love to sit down with the daughter and just ask her exactly what she's doing, and why - I don't necessarily disagree with your assessment, but there just isn't enough info for me to offer much more than an opinion based on having been in a similar situation myself.

Couple of points before I go put on my Nomex suit:

- One, does the daughter have the DPOA for healthcare only, a full DPOA (managing all aspects of the person/estate/etc.) or just a financial DPOA? In our case, I had the Financial DPOA, my sister was listed as the primary on the Advanced Healthcare Directive (she managed healthcare-related issues only), and we were both listed as alternates on the other's paperwork. Reason I bring this up is that I ran into the situation (every single time) of hospital staff that didn't make the distinction as to where the boundaries were supposed to be between my sister and myself. Whoever they talked to first, that was it - they were on the hot seat for that round in the hospital. In this instance, she may or may no have the authority to act as she has been.

- Two, is there an H&P document signed by the attending MD attesting to the patient's incapacity to act on his own behalf? If not, then she may be acting outside the scope of what she's allowed to legally do. Another thing the nursing home "conveniently" forgot to do in our case - I had to raise a bit o'hell with them over that as well.

Keep in mind that I'm not an attorney, and a lot of this probably varies from state to state - just a guy who's been on the other side of the process. Feel free to ask if there's something I wasn't clear on - I'll do what I can to advise.

Oh, one last point (yeah, I know I'm being chatty) - hospice also provides for family care after the patient passes on as well.

Blessings to all,

---- IEDave

SuesquatchRN, BSN, RN · Dec 1, 2011

Alzheimer's is terminal, although the lack of an AD-specific terminal event leads to this misapprehension. That said, abx are not inconsistent with hospice. We do not attempt to cure the underlying condition. We certainly don't not treat infections. One can be on hospice and be a full code.

Abx can be addressed in the POLST or MOLST if your state uses one. That has nothing to do with hospice. We do not hasten death, we simply do not pretend we can keep it at bay.

caliotter3 · Dec 1, 2011

Recently cared for a similarly situated patient, my first in this category. Felt kind of "off". Just did not seem right for the hospice approach, the way I saw it.