Time for hospice referral?

[casias12]

Case: 84-year-old male who presented to hospital with weakness and fatigue. He had ground-level fall in his home one day prior.

He was found in atrial fibrillation with RVR, Hgb 6.1, Hct 18.3, plt 82, NA 129, K 3.9, GFR 27. Cardiac enzymes negative. CXR small left pleural effusion unchanged from previous 2 months earlier, EKG atrial fibrillation, tachycardia HR 130, ST abnormality consider ischemia, poor R wave progression.

PMH: Atrial fibrillation, CVA 5 years ago without residual deficit, COPD, osteoarthritis, BPH.

Medication changed recently changed from warfarin to apixaban due to patient difficulty getting INR tested.

Patient was hospitalized and transfused. GI consult was ordered. Colonoscopy diagnosed lower GI bleed, treated with H2A. Patient was transferred to rehab on ASA 162 mg daily, apixaban discontinued, no other changes to medications.

One week later, patient returns to hospital with similar complaints. Hgb 7.6, Hct 22.8. Recommendation by palliative care physician was hospice. This was not discussed with patient yet.

Thoughts?

[Libby1987]

What was his function and quality of life prior to the GI bleed? Is there an underlying cause for the GI bleed other than over anticoagulation? What would be the underlying cause for life expectancy under 6 mos? You don't mention anything end stage related to his COPD so I'm not sure what you're considering as the untreatable underlying disease process.

[Jules A, MSN]

So the caveat is that I'm ready to have my and my family members above the age of 60's plug pulled anytime going forward with little more than pain medications. I think all patients and their families should have the end of life expectations talk probably starting around 60. If this is done every so often during yearly physicals the documentation, their wishes and plans can be made before the stress of a crisis is present. Why are health care professionals so reluctant to address this much needed aspect of our job?

Its like waiting until your daughter actually gets her period to discuss menses, right?

[RunNP]

I would want to know his living situation home vs assisted living and his overall support system. His cognitive level and his overall quality of life. maybe investigate the GIB a little more and perhaps additional referrals could be made to GI. Is he depressed? The clinical data is only one piece of the puzzle - we are taught to look at the big picture to include the desires of the patient and family.

[Jules A, MSN]

include the desires of the patient and family.

This is really all we should be concerned with unless there are APS issues. Again I wonder why at 84 this person doesn't already have an advanced directive in place.

[casias12]

I'm glad a couple of people asked about his cognitive and functional abilities. He is an otherwise healthy man with an average degree of function for his age. Lives with his wife, does his own ADL's, as well as many chores around the house. He does have advanced directives, and living will, and has no other family.

The second admission I ordered a CT chest and abdomen to rule out malignancy, and asked GI and cardiology for opinions. We all believed this was related to anticoagulation.

So, given this new information, would a hospice referral still be appropriate?

[traumaRUs, MSN, APRN]

What does his wife say?

[Libby1987]

I'm glad a couple of people asked about his cognitive and functional abilities. He is an otherwise healthy man with an average degree of function for his age. Lives with his wife, does his own ADL's, as well as many chores around the house. He does have advanced directives, and living will, and has no other family.

The second admission I ordered a CT chest and abdomen to rule out malignancy, and asked GI and cardiology for opinions. We all believed this was related to anticoagulation.

So, given this new information, would a hospice referral still be appropriate?

No, not based on the info given. Over anticoagulation is treatable. He needs to be in an end stage irreversible disease or indisputably failing with criteria that support death in less than 6 months. This guy is other wise high functioning for his age with so far a treatable/manageable problem and you want to take treatment options off the table?

Medicare won't pay for it anyway so it's a mute question.

That doesn't mean this guy needs to have aggressive treatment. He can sign a POLST for limited intervention only. And better managed as an out patient, before his Hgb hits 6.

[Susie2310]

Why do you or the palliative care provider believe hospice is indicated? It sounds like the gentleman is enjoying his life with his wife and is not terminally ill with a life expectancy of only a few months. There's nothing wrong with being 84 years old. There's no reason elderly people shouldn't receive curative care, or want to prolong their lives, although some providers appear to believe differently.

Articles have been written about a tendency towards admitting patients to hospice too soon, primarily for financial reasons. Some of my older family members who have significant medical histories and co-morbidities, but are active and enjoying their lives and are certainly not terminally ill, have experienced physicians both in primary care and in the ED try to discourage them from receiving curative care. Fortunately I was with them, and was able to circumvent these efforts. My family member did their best to speak up for themself, and told the primary care physician that they still want to receive curative care, but the physician was quite aggressive in trying to discourage them from doing this. It was quite shocking to watch. In the ED my family member was in no condition to even understand the physician's questions, which were carefully worded.

[Jules A, MSN]

There's no reason elderly people shouldn't receive curative care, or want to prolong their lives, although some providers appear to believe differently.

If this is what the patient wants but there is also no reason why providers should push for treatment if the patient isn't interested in prolonging their life.

[Susie2310]

If this is what the patient wants but there is also no reason why providers should push for treatment if the patient isn't interested in prolonging their life.

As long as this doesn't happen by default or assumption, without first clarifying this with the patient/their family/significant others who the patient wishes to be involved in their care by asking them if this is what they actually want. It would also be necessary to clearly define with the patient/their family what "treatment" means, and to clarify if the patient/family would like interventions for the purpose of comfort only. Patients may not be interested in prolonging their lives (for example, through measures such as surgery) but still wish to receive interventions that will help them to continue living, so it is very important to be very clear about what exactly is being discussed and what will be done/will not be done for the patient.

[casias12]

Why do you or the palliative care provider believe hospice is indicated? It sounds like the gentleman is enjoying his life with his wife and is not terminally ill with a life expectancy of only a few months. There's nothing wrong with being 84 years old. There's no reason elderly people shouldn't receive curative care, or want to prolong their lives, although some providers appear to believe differently.

That was the question I had, and why I brought this case to this forum.

When I first walked in, there was a Palliative Consult” taped to the front of the chart. I didn't ask for a palliative consult for this relatively healthy man with a minor GI bleed. She cited the CVA, pancytopenia, and renal insufficiency as reasons why this man had a life expectancy of less than 6 months. In my professional opinion, I just didn't see this as accurate.

It turns out, this palliative physician is hired by the insurance company, doesn't have privileges at the hospital, and seems to have a huge incentive to refer people away from curative treatment.

As it has gone on, she has done this several times. Because they are members of the insurance she works for, we can't stop her, but we don't ask for her to see our patients either.

A couple of months ago, I had an elderly, but otherwise healthy patient admitted after falling and fracturing 4 ribs. He suffered a moderate-sized hemo-pneumo and ended up going to the OR for endoscopic thoroscopy and better chest tube placement. Given his age, anesthesia elected to leave him intubated. A couple of days later, she showed up. Told the family this was an end-of-life” event, and encouraged them to terminally wean the guy. The family was beside themselves. A couple of days after that, man was extubated and eating breakfast when I walked in.

Not sure if anyone else has seen this, but this palliative” service seems to have a vested interest in pushing people to less aggressive care.