To Treat or Not to Treat Unrelated Dx Hospice Pt.

vintagemother, BSN, CNA, LVN, RN · Jun 19, 2014

I'm a new grad so I don't understand the ins and outs yet, but I observed similar situations over and over again when I worked in an LTC ALF. The family gets to decide on any medications the doctor orders. I suppose it's because the family is the POA. They can say "No". I've seen families say they didn't want their loved one who was actively dying to receive pain meds prescribed. It was sad to me. A little education may have gone a long way to help them understand, but in my role, as an LVN I didn't get to do this. My supervisors agreed with not giving pain meds. I've seen families also refuse to allow us to administer anxiolytics that were prescribed by the patients MD. Of course, the families weren't there to witness their loved ones behaviors that warranted some sort of intervention.

LadyFree28, BSN, LPN, RN · Jun 19, 2014

In the case of sepsis, we treat our pts; the family is informed, but usually the primary doctor is making the decision, not the family. :no:

toomuchbaloney · Jun 19, 2014

The hospice plan of care (POC) is developed collaboratively with the patient or DMPOA and the hospice team, including the physician. If the hospice patient is not competent to make decisions then the DPOA has that responsibility.

In my experience the hospice team would recommend a treatment course for the UTI and notify the DPOA of the recommendations. If the DPOA does not want that treatment the team would discuss this with the DPOA to insure that they understand the ramifications of that choice. If the team believes that the patient should be treated they will advocate for that treatment. Ultimately the hospice team does not dictate the care.

People have the right to self determine. That includes deciding to not treat what are considered treatable ailments, particularly at end of life. The choices for the health professional are to honor their wishes or to pursue a court order forcing treatment.

In this instance you indicate that the patient is comfortable and not suffering secondary to the UTI. This would be my primary concern, that the untreated UTI would diminish comfort and quality of life. In the absence of such an effect we have to allow patients and their spokes people to self determine, IMHO. Even when that is philosophically uncomfortable for us as individuals.

misstrinad · Jun 19, 2014

It really depends, if treating the infection will still leave them alive with a poor quality of life then many times we don't treat and let the infection take them, while keeping them on hospice/comfort care. At this point it sounds like she is never going to get better, never going to have a decent quality of life so prolonging her life may not be the best option

misstrinad · Jun 20, 2014

It really depends, if treating the infection will still leave them alive with a poor quality of life then many times we don't treat and let the infection take them, while keeping them on hospice/comfort care. At this point it sounds possible she is never going to get better, never going to have a decent quality of life so prolonging her life may not be the best option I've had a few times I really thought the pt should have been treated. Another example is Is I have a 93 yo female w severe dementia. All she does is sleep, pick at her food, pace the halls, mutter/chant, and barely allow staff to complete cares which she is beyond completing any for herself. She became lethargic and had a fever. Labs were done which indicated an infection of some sort. Dr ordered a ua/uc Cath stat, chest x Ray, abd x Ray and several rounds of im rocephrin. Each of these things took 3 staff to hold her down to complete and drained what little energy she had. Infection appears to be clearing she is now on oral antibiotics. However now she is too weak to ambulate and just sits in a wc. What is her quality of life after putting her through that trama to treat the infection? It has been determined she will not return to her pre infection baseline. Either way it's sad.

misstrinad · Jun 20, 2014

I apologize, I dont know why half of that posted twice.

LadyFree28, BSN, LPN, RN · Jun 20, 2014

It really depends, if treating the infection will still leave them alive with a poor quality of life then many times we don't treat and let the infection take them, while keeping them on hospice/comfort care. At this point it sounds possible she is never going to get better, never going to have a decent quality of life so prolonging her life may not be the best option I've had a few times I really thought the pt should have been treated. Another example is Is I have a 93 yo female w severe dementia. All she does is sleep, pick at her food, pace the halls, mutter/chant, and barely allow staff to complete cares which she is beyond completing any for herself. She became lethargic and had a fever. Labs were done which indicated an infection of some sort. Dr ordered a ua/uc Cath stat, chest x Ray, abd x Ray and several rounds of im rocephrin. Each of these things took 3 staff to hold her down to complete and drained what little energy she had. Infection appears to be clearing she is now on oral antibiotics. However now she is too weak to ambulate and just sits in a wc. What is her quality of life after putting her through that trama to treat the infection? It has been determined she will not return to her pre infection baseline. Either way it's sad.

The "quality of life" is depending on having the pt "suffer" through sepsis; her hospice diagnosis is not related to the acute diagnosis; hospice is to ensure "comfort"; we have had conversations with family members to stop PP meds and the physician stating that stopping the meds is a sure fire way for an acute death to occur, not a "peaceful" death; although we do suspect the family trying to hasten the death; not every POA wish is granted, at least in my area; it's truly based on acute versus related to illness; to not treat an acute infection is not grounds to not treat, again, at least in my area and experience.