What happens...

[DoubleblessedRN, ADN, RN, EMT-B, EMT-P]

...when a patient is brought to the ER (either by ambulace or family via personal vehicle) is elderly and unable to care for themselves anymore? I'm sure most of you vetran ER nurses have dealt with this one time or another.

Here's the situation: I worked in the ambulance last night. We were called to a residence because the family seemingly wanted their elderly mother who could no longer care for herself out of their house so that they wouldn't have to take on a new responsibility. She had been hospitalized about a month prior for an unspecified type of infection. She was discharged in care of her family. She wanted to return to her own home, but there was nobody to care for her there. (It is also not in the best of neighborhoods.) It seemed as if the family just wanted her out of their house, yet she was refusing to leave and per family she had been refusing their help, and they didn't have the guts to literally boot her out. She was AOx3 (family stated she is occasionally confused) and her own legal guardian. They said that if she didn't go to the hospital they would petition to have her put on the psychiatric floor. (But she didn't meet any of that criteria - she wasn't a threat to herself or others.)

Fortunately, with much help from the police, we were able to convince the patient to go to the hospital. What is the usual disposition of these type of patients?

[classicdame, MSN, EdD]

social workers will probably intervene to see if she can be placed in a nursing home or similar facility, depending on medical needs.

[DoubleblessedRN, ADN, RN, EMT-B, EMT-P]

I figured that social work would probably be called. However, the pt is her own legal guardian. The daughter was beating around the bush, asking me in more complicated terms "How do I get her into a nursing home against her will?" I said that if somebody obtained power of attorney or legal guardianship over her. I simply told her to contact the county's probate court for more info, that she would need supporting evidence that she is no longer able to care for herself in order for a judge to grant the request, and that if granted, the legal guardian is also financially responsible, and the daughter bristled.

[Dorito, ASN, RN]

More than likely the patient will be returned to her own home if she refuses nursing home and is A&O. If she falls or is unable to care for herself at home then most likely the courts would be involved and she may be placed elsewhere. It's a tough situation and unfortunately occurs more than we would like to see. Maybe short term placement would get her strong enough to stay alone if her family refused.

[Penelope_Pitstop, BSN, RN]

A & O does not equal competent all of the time. Just because she is "with it" does not mean that she is competent to make those types of decisions. In my experience, psychiatrists determine competency, but a consult order was necessary. However, nurses could do their own social work/case management referrals. The way I've seen it happen...social work is consulted by provider, sees patient and hopefully physician takes social work's expertise to determine if a competency evaluation is necessary. If patient is alert, oriented AND competent and refuses anything, that is his or her right.

[NURSEOK5]

It sounds like the family just wants respice care for the pt. to relieve them of duties. Social Services can assist with placement if the pt. qualifies for a LTC or Assisted Living. When I worked in a geri-psych unit we would see this all the time. Family members just are'nt educated to assist with health care needs and it puts everything in turmoil. Sounds like you handle the situation great, that is all you can do.

[DoubleblessedRN, ADN, RN, EMT-B, EMT-P]

Good answers, Dorito and Nurseok5, I really appreciate all of your input. It was a good thing we all were able to get her to go to the hospital, otherwise we would have REALLY been between a rock and a hard place. (ER staff seemed angry that we even brought her in.) The reason the police were there in the first place was because she shoved a male family member away when he was trying to help her and reason with her. The police could have arrested her for assault, but then what good would jail have done for an elderly woman? Not a good environment for somebody like that. And the officer would have taken much grief from his sergeant. I do not know the outcome yet but if I find out I will let you all know. Thanks again.

[loricatus]

Good answers, Dorito and Nurseok5, I really appreciate all of your input. It was a good thing we all were able to get her to go to the hospital, otherwise we would have REALLY been between a rock and a hard place. (ER staff seemed angry that we even brought her in.) The reason the police were there in the first place was because she shoved a male family member away when he was trying to help her and reason with her. The police could have arrested her for assault, but then what good would jail have done for an elderly woman? Not a good environment for somebody like that. And the officer would have taken much grief from his sergeant. I do not know the outcome yet but if I find out I will let you all know. Thanks again.

ER staff was probably frustrated & not angry. This is what we call a "dump" & not what the emergency room is intended for. She wasn't an emergency! It is frustrating because the emergency room resources have to be used for a social service function. Many times, the patient will be cleared of a medical condition and have to be transported right back to where they came from, unless a social worker is available to intercede. Rather than transport this patient to the local ER, a social worker should be contacted to make a home visit-since they will have to visit the home environment anyway.

[DoubleblessedRN, ADN, RN, EMT-B, EMT-P]

ER staff was probably frustrated & not angry. This is what we call a "dump" & not what the emergency room is intended for. She wasn't an emergency! It is frustrating because the emergency room resources have to be used for a social service function. Many times, the patient will be cleared of a medical condition and have to be transported right back to where they came from, unless a social worker is available to intercede. Rather than transport this patient to the local ER, a social worker should be contacted to make a home visit-since they will have to visit the home environment anyway.

I understand and know those are "dumps." I hate running on those types of calls as much as you hate receiving them. Unfortunately, when someone calls for our services, we have a duty to act which includes transporting a pt to the hospital if s/he requests it, even when we are sure there is nothing wrong, just as the ER's cannot refuse a pt treatment. That family COULD have either taken her back to her home and called or visited to check on her or tolerated her in their home until a social worker could intervene, but it was just too convenient for them to have her taken away to the ER. They think PD, fire, EMS and hospitals have all the solutions.

[CanERRN]

"It was a good thing we all were able to get her to go to the hospital, otherwise we would have REALLY been between a rock and a hard place. "

This comment alone is enought to frustrate any ER Nurse, not to mention physician. My question would be what was the ER supposed to do?

Ever try to find a hospitalist or Family Care Practitioner to admit with a diagnosis of "No where else to go"? I'll bet Case Management had a field day with that - not to mention the CFO _ the hospital just provided ANOTHER free stay.

[zamboni]

"It was a good thing we all were able to get her to go to the hospital, otherwise we would have REALLY been between a rock and a hard place. "

This comment alone is enought to frustrate any ER Nurse, not to mention physician. My question would be what was the ER supposed to do?

Ever try to find a hospitalist or Family Care Practitioner to admit with a diagnosis of "No where else to go"? I'll bet Case Management had a field day with that - not to mention the CFO _ the hospital just provided ANOTHER free stay.

Unfortunately, the ER provides a temporary safe environment for the patient until something can be figured out. In the case of the OP, I suspect that they didn't feel like it was safe to leave the patient at the residence. If they had, and the patient fell 20 minutes later, it would have been not only their butts in a sling, but the patient would have been injured (which we all want to avoid, right?). Someone said that a social worker should have been called...I've worked in a lot of EMS systems, and not one of them had a social worker on staff. Adult Protection isn't interested at 3:00AM, and won't respond anyway just because the family doesn't want or can't deal anymore. EMS doesn't have the rescources to do what an ER can in this situation...all they can do is try to get the patient somewhere safe.

I know how frustrating it can be, I'm on the other side of the fence now in the ER. But a high at-risk patient is safer in the ER than being left with family that is done with them.

(Personally, I think it's a breakdown in our society...but that's a rant for another day...)

[ZippyGBR, BSN, RN]

possibly admitted under emergency physician while sorting out place of safety placement in residential care

then competency assessment dfro ma psych poin t of view and bounce the whole shebang to social services as it's primarily a vulnerable adult issue if anything