Time for hospice referral?

Specialties Advanced

Published

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?

Can we back up a bit please. Palliative Care consults and Hospice care consults are two different things entirely. This man would meet criteria for palliative care because of the Afib with multiple readmissions within the past 6 months. Palliative Care is about managing chronic conditions - he has anemia, Afib with RVR hx, chronic pleural effusions - to try to keep people out of the hospital as much as possible while promoting life! Hospice is about people who have less than 6 months to live, are no longer seeking curative treatment, and need support to fulfill their dying process needs. Please please please do your research on the difference between palliative care and hospice!

As an hematology oncology RN, I would recommend an MD consider this patient for a palliative care consult so he can learn to manage these chronic conditions, seek treatment from his doctors, and f/u with possible outpatient blood transfusions while attempting to AVOID inpatient stays.

Can we back up a bit please. Palliative Care consults and Hospice care consults are two different things entirely. This man would meet criteria for palliative care because of the Afib with multiple readmissions within the past 6 months. Palliative Care is about managing chronic conditions - he has anemia, Afib with RVR hx, chronic pleural effusions - to try to keep people out of the hospital as much as possible while promoting life! Hospice is about people who have less than 6 months to live, are no longer seeking curative treatment, and need support to fulfill their dying process needs. Please please please do your research on the difference between palliative care and hospice!

As an hematology oncology RN, I would recommend an MD consider this patient for a palliative care consult so he can learn to manage these chronic conditions, seek treatment from his doctors, and f/u with possible outpatient blood transfusions while attempting to AVOID inpatient stays.

casius12 said that the recommendation from the palliative care physician was hospice.

He/she said in his/her post above of the physician: "she cited the CVA, pancytopenia, and renal insufficiency as reasons this man had a life expectancy of less than six months" and had referred the patient for a palliative care consult. From the information the OP has provided, I can see why a palliative care consult could be appropriate, but not why the patient has a life expectancy of less than six months, or why the patient should not receive treatment to correct their medical problems to the extent possible. Just from the information about the patient that the OP has provided I'm not understanding why hospice would be indicated. The way I read casius12's posts, he/she is trying to understand why the palliative care physician had recommended hospice.

Specializes in Cardiology nurse practitioner.
Can we back up a bit please. Palliative Care consults and Hospice care consults are two different things entirely. This man would meet criteria for palliative care because of the Afib with multiple readmissions within the past 6 months. Palliative Care is about managing chronic conditions - he has anemia, Afib with RVR hx, chronic pleural effusions - to try to keep people out of the hospital as much as possible while promoting life! Hospice is about people who have less than 6 months to live, are no longer seeking curative treatment, and need support to fulfill their dying process needs. Please please please do your research on the difference between palliative care and hospice!

As an hematology oncology RN, I would recommend an MD consider this patient for a palliative care consult so he can learn to manage these chronic conditions, seek treatment from his doctors, and f/u with possible outpatient blood transfusions while attempting to AVOID inpatient stays.

Thank you for your insight, but maybe you need to go back and read the original post.

First off, I am the provider. Why do nurses come to this forum and recommend that an MD order” this or that? Maybe you need to understand what section of the forum you are in first.

This was an exercise for nurse practitioners who see hospitalized patients. The Palliative Consult”, recommended hospice for a patient with acute medical issues, but no specific terminally ill condition.

It's not uncommon for us to follow the advice of consults in the hospital, assuming they are the specialist”. But in this case, the palliative” physician was uninvited, and gave a recommendation that seemed to be in the interest of her employer (the insurance company), without regard for the patient's actual condition.

Palliative consult? Maybe. But I would prefer to order the consult, and choose a palliative provider who understands the difference between acute medical issues and chronic disease burden.

So. Now that you are in the section for nurse practitioners, what would be your plan of care for this patient?

Edit: So you know my background, and why I came here to post this. I worked in palliative and hospice care for several years, as a nurse practitioner. If I saw this patient as a consult, I wouldn't have admitted him to hospice because he doesn't meet our criteria. I would have followed him for palliative care, if he desired.

Casias 12 - first of all, please accept my apologies if you thought I was contradicting your thoughts. I was agreeing that palliative care MIGHT be an option, but definitely NOT hospice. I've met so many people who don't understand the difference between palliative care and hospice, I am actually a big proponent of getting people into both early on in the discovery of a chronic condition processes to assist with keeping people OUT of the hospital.

As for the whole forum thing, I admit, I did not see this was written in the ANP forum. However, please understand that your question came up on the main page for me, not in the ANP forum AND people post in the wrong place all the time, but again, I apologize.

As for "why do nurses always come here and write the MD should write this and that", well, because where I work, only the MD/DO can write a palliative care/hospice consult; our hospital does not allow PAs OR NPs to make that recommendation.

I've met so many people who don't understand the difference between palliative care and hospice, I am actually a big proponent of getting people into both early on in the discovery of a chronic condition processes to assist with keeping people OUT of the hospital.

You sound as though you are in the grip of some ideology. You are in favor of getting people with early stage chronic diseases into hospice early on, and taking away curative treatment options, in order to keep people OUT of the hospital? Are you serious? How about what the patient wants? You don't think that people with chronic diseases may want to receive curative medical care that helps them to continue living because they want to continue to live, instead of giving up options for curative care? And you are in favor of enrolling people in palliative care too, with early stage chronic diseases. Wow. I can see some situations where early palliative care consults could be helpful, but not across the board. Being enrolled in a palliative care program means more medical/nursing appointments and more patient monitoring, - why try to impose this on a patient before they really need it? Oh, yes, we're doing all this so we can keep patients OUT of the hospital so they don't run up more Medicare hospital bills or other insurance hospital bills, or even just hospital bills.

Specializes in Internal and Family Medicine.

I'm an FNP student, and I saw this post and am interested. I do not see impetus for Hospice. Palliation for the chronic issues that are never going to be completely remediated makes sense, but I am unclear as to what about this client would warrant hospice. Along those lines, do we know what caused the fall? The GI bleed traces back to anticoagulation therapy, but I wonder about the fall. Was that attributed to generalized weakness/dizziness from the medication/blood changes? Based on the case presented, I would look at cognitive function/mental status and musculoskeletal fitness/functional status for ADL's. Anecdotally, I have seen this very issues and a similar list of dx with my own grandmother. In her case, a mix of statins and being sedentary has caused muscle wasting, so without any identifiable pathology, she is in a wheel chair from sheer lack of strength to hold herself erect. She just celebrated her 90th. Back to the case at hand, your client looks like a great candidate for palliative care, rehab/PT for improving functional status, a neuro/cognitive consult and a look into the home situation for added safety, care-taker ability etc. As I mentioned I am an FNP student, and found your post interesting. Thanks for sharing your case.

Specializes in Cardiology nurse practitioner.
Casias 12 - first of all, please accept my apologies if you thought I was contradicting your thoughts. I was agreeing that palliative care MIGHT be an option, but definitely NOT hospice. I've met so many people who don't understand the difference between palliative care and hospice, I am actually a big proponent of getting people into both early on in the discovery of a chronic condition processes to assist with keeping people OUT of the hospital.

As for the whole forum thing, I admit, I did not see this was written in the ANP forum. However, please understand that your question came up on the main page for me, not in the ANP forum AND people post in the wrong place all the time, but again, I apologize.

As for "why do nurses always come here and write the MD should write this and that", well, because where I work, only the MD/DO can write a palliative care/hospice consult; our hospital does not allow PAs OR NPs to make that recommendation.

Hey, no problem. Maybe that's why I see it so often and wonder why nurses are chiming in but don't seem to know the discussion is about ARNP issues.

As for your hospital not allowing NP/PA's to refer patients to hospice/palliative: Ouch. I can tell you there are certain things that require” a physician order”, even in my world. But I'll just say that the order gets taken care of. The physicians in my group are pretty easy to work with.

But, every year we gain a little more. Hoping that trend continues.

As for the general theme of the thread. After working in palliative/hospice for quite some time, I am disturbed by this trend of palliative physicians” being hired by insurance companies to talk patients out of reasonable care and move them towards hospice. In this case, and I really hope it is isolated, this physician will flat out deceive the patient and family about their condition and hopes for recovery. I am on both sides of the fence, so I think every person with chronic, debilitating comorbidities should address their advanced directive/living will and DNRO when it is appropriate. But this discussion shouldn't take place during acute decline, if reasonable treatment may reverse the course.

As for this patient. We discussed the risk of going without anticoagulation for the atrial fibrillation with regards to having another CVA, vs the risks associated with ongoing bleeding and blood transfusions. The GI did change the H2A to PPI, and he was off of anticoagulants for about 3 months. When he resumed the ASA at 81 mg, he has a moderate risk (3% per year) of CVA, but has not had any more bleeding.

Specializes in Family Nurse Practitioner.
You sound as though you are in the grip of some ideology. You are in favor of getting people with early stage chronic diseases into hospice early on, and taking away curative treatment options, in order to keep people OUT of the hospital? Are you serious? How about what the patient wants? You don't think that people with chronic diseases may want to receive curative medical care that helps them to continue living because they want to continue to live, instead of giving up options for curative care?

Please keep in mind there are some people who have absolutely no interest in trialing curative care to "keep on living". It is a personal decision between the patient and their family. To act as if this isn't ever the case will in effect do what you are vehemently opposing which is forcing your ideology on your patients.

Please keep in mind there are some people who have absolutely no interest in trialing curative care to "keep on living". It is a personal decision between the patient and their family. To act as if this isn't ever the case will in effect do what you are vehemently opposing which is forcing your ideology on your patients.

Yes, I understand that and already addressed this in a reply to you in an earlier post on this thread.

Specializes in Cardiology nurse practitioner.
I'm an FNP student, and I saw this post and am interested. I do not see impetus for Hospice. Palliation for the chronic issues that are never going to be completely remediated makes sense, but I am unclear as to what about this client would warrant hospice. Along those lines, do we know what caused the fall? The GI bleed traces back to anticoagulation therapy, but I wonder about the fall. Was that attributed to generalized weakness/dizziness from the medication/blood changes? Based on the case presented, I would look at cognitive function/mental status and musculoskeletal fitness/functional status for ADL's. Anecdotally, I have seen this very issues and a similar list of dx with my own grandmother. In her case, a mix of statins and being sedentary has caused muscle wasting, so without any identifiable pathology, she is in a wheel chair from sheer lack of strength to hold herself erect. She just celebrated her 90th. Back to the case at hand, your client looks like a great candidate for palliative care, rehab/PT for improving functional status, a neuro/cognitive consult and a look into the home situation for added safety, care-taker ability etc. As I mentioned I am an FNP student, and found your post interesting. Thanks for sharing your case.

Yes. His fall was attributed to the anemia. When he was transfused, he did well in rehab, then back home at his usual state of health.

When he wasn't losing blood, he didn't have any other significant symptoms, cognitive impairment or unusual functional decline. I didn't refer him to palliative care, but did clarify his wishes with him and his wife, made sure they had advanced directives, in the event he declined further.

I too, am an NP student. It seems like the problem in this case is the palliative care person who interjects themselves in cases uninvited, recommending hospice care across the board. This seems unethical to me, and I wonder what is being done to address this? If no one wants to tackle this head on then maybe at the very least an anonymous call to the ethics line at your facility might be in order.

+ Add a Comment