Why????????

[Virgo_RN, BSN, RN]

Leslie, Suesquatch, anyone else who might know the answer to this:

Background: I receive an elderly patient in the ED coming via EMS from an LTC facility for "failure to thrive". One look at him, and I already know he is in end stage Alzheimer's. Medic gives me report, hx Alzheimer's dementia and a couple of other pretty benign conditions, has a DNR-comfort measures only. Medic cannot tell me exactly why EMS was called, as he could not get straight answers from the staff at the facility. We don't even know if family has been called. I do my assessment and it's clear to me that this person's symptoms are r/t their disease process; impaired swallowing, nonverbal, etc.; even if it is a stroke, exactly what are we going to do about it?

So, I am wondering if there is something I am missing here. Is there a good reason to send a person with a DNR who is in the end stages of Alzheimer's Disease to the ED? Exactly what are we going to do for them that can't be done for them at home in the facility that they know? They will spend at least two hours if not more sitting on one of our notoriously hard and uncomfortable gurneys, under bright, glaring lights, with lots of strangers in and out of the room, and who knows what kinds of sights and sounds right outside their doorway? If this were me, I would be absolutely furious that my wishes were ignored. Fortunately, and I can only hope, it didn't seem that this person understood what was going on at all, as their facial expression was completely vacant.

So, my question is, WHY? Why did someone make the decision that the right thing to do was to call an ambulance and send this person to the ED? What am I missing?

[April, RN, BSN, RN]

Hopefully it wasn't because the patient is difficult to handle and the facility made up an excuse to send them out to get a break.

[locolorenzo22, BSN, RN]

you said yourself, you didn't know if family was called....I work in LTC, and there are numerous times that if a condition is changing on a DNR patient, if family is POA I will call them before I call a doctor to see what they want done. If they want the patient sent out, I will talk to the doc and tell them what the situation is, and if they give me orders but not to send them out, or if they say to go ahead, I'll call the family back, let them know, and send them.

often, the ER isn't going to do anything for them I couldn't have done myself, but such is the world of LTC. It's frustrating, but you get used to it. then you have the flip side, no quality of life patients with full codes and family that just doesn't get it.

[Virgo_RN, BSN, RN]

Usually though, the medics know if family has been called and whether they are en route. The answers they got from staff were so vague, they were as much in the dark as I was. Since it was shift change, I never got to find out the answer to the question of family involvement, but that was one thought I had. Maybe the family wanted them taken to the ED. That's the only thing that makes any sense at all.

[FLArn]

I, too, have called MD's for orders on patients , say maybe neb tx for example. only to have covering MD order pt to go to ER for "eval and treat" This especially is common on weekends and holidays. The covering MD doesn't know the patient and he sure isn't taking my word for anything! so off the poor patient goes to the ER so the MD can CYA.

Super frustrating esp. if transport gives you a hard time about taking them (although I more than understand their point--so PLEASE don't flame me !)

[jadelpn, LPN, EMT-B]

Here's a thought. It is the holidays. Perhaps family has not seen patient since last year this time. WOW. Gramps has really gone downhill--WHATTA YA MEAN he can't swallow? WHY isn't he speaking---You NEED to do something NOW...and off to the ER Gramps goes....Often, families just don't understand the disease process and think that the usual progression of a disease is in fact an acute situation.

[caliotter3]

First response said it. If the person is somehow a problem, or they were assessed as circling the drain, someone sent them out because they didn't want to deal with the resident or the resident's impending demise on their shift. They sent them out, hoping the resident would not return and someone else would have to deal with the situation. Can't think of any other reason to do this.

[leslie :-D]

virgo, i have little experience in ltc (sue is the pro)...

and i have absolutely NO idea why NO ONE at the facility, knew why?

'someone' had to have taken the order to send this pt out.

but it can be a couple of scenarios:

i'm inclined to agree with the poster who talked about family not seeing pt for long time, and when they did, they had no idea as to the level of deterioration.

it could be an agency nurse who knows little about the pt, and shared concerns about dysphagia, aspirating, junky lungs...

and said nurse could have called dr.

then there are totally inept doctors, who don't want to be responsible for the demise of one of their pts.

when you call said dr. to report a concern, dr. orders pt sent out (no matter how benign the concern is!).

heck, it could be a way of the ltc facility trying to get the hospital to do the 'official' diagnostics (swallowing eval, xrays, labs, etc), so the facility knows exactly where they/the resident stands.

another thought is the facility's census of skilled beds may be down.

i've heard of DON's wanting certain (eligible) residents sent out, in hopes they stay at hospital for 3 days.

this way, they will be returned to facility as a skilled pt, which is where the $$ are for these facilities.

i would personally get to the bottom of WHO wrote the order to send this resident out.

or, have any nurse, read the nn's on this resident-obviously it would have been documented why.

let us know?

i'm glad your pt seems to be unaware.

leslie

[SuesquatchRN, BSN, RN]

Virgo, do you have a current copy of the MOLST?

If it is not clear that he is comfort care only, if it is not clear that he is not to be hospitalized, if it is not clear that he is no abx, and if the family can not be notified, he will be sent out.

I have three residents right now who are back and forth from the hospital. They get sent out for fevers and difficulty breathing. Is this the case?

[SuesquatchRN, BSN, RN]

Oh, and a DNR doesn't mean we don't treat, to repeat the cliche. The ONLY thing that means is no CPR.

[Bug Out, BSN]

Many times I have to send people to the ED just because I do not have the ability to accomplish STAT orders. For example, STAT in my facility means that the Lab has 5 hours to draw/do the Xray.

Sometimes I have to send out just because I need the Lab or Xray now...not in 5 hrs lol.

Other times we have had to send them to the ED just because we were kicking the person out of the facility, behaviors or a little too high acuity. Many LTCs do not restrain so if I have someone who will not comply with facility rules and is in danger of harming themselves they go by by.

There are specifc things that a some LTCs will or will not do based upon their staff and rules. For example if one of my pts needed a NG tube we would have to send them out, its no big deal to place one or deal with one for our RNs, its just against our facilities rules.

The ED is the catch all, sorry but :flowersfo my problems are your problems.

[Lovely_RN, MSN]

Don't flame me but I will tell you what goes on at my job

If that person was a resident at my facility it would be because the family is a potential source of trouble.

The way that it works in my facility is that those with DNRs and a family that wanted or accepted the DNR get to die a quiet death in their room.

Everyone else and this means anyone who poses even the tiniest potential of starting a problem gets sent out to avoid trouble.

An example would be a case where maybe the daughter is the POA and signed the DNR but the son is against it and threatens to call state or sue if "we let his momma die" on our watch. In a situation like that even though we have a DNR signed by a POA to avoid trouble everyone from the CNA to the MD will be playing hot potato.

Here's the dirty truth.

Everyone will be charting that the next in command was notfied. Everyone will chart that all measures to prevent the inevitable :icon_roll were carried out.

It's not that we don't know what is happening to the resident and it's not that we don't know that what we are doing is futile and causing distress to the resident.

I've been told time and time again DNR doesn't mean DNH...when in doubt ship them out.

The problem is that we are all scared of the BON or going in front of a judge to explain what we did or didn't do. I'm not going to lie...when I hear a family start screaming lawsuit or I'm calling the state it makes me nervous and I just hand them off to my supervisor and start charting triple time to cover myself because I'm a big chicken about things like being sued or reported to the state.