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?
We phrase it more therapeutically. "Jack, you must calm down. Now. We are here to help you control yourself until you can do it yourself." Once in a great while, "Hey! Enough! Stop that immediately!"
Yeah, I was talking about all the family. This facility, too.
Had a drunk woman in the ER who was getting a Foley put in. She decided since the nurse was already "there" she just jumped in a started "pleasuring herself". The nurse slapped her hand, enough to make a smacking sound and said, "Quit that, get your hands out of there, that's nasty!"
We never send someone out to get rid of him. Doesn't work. Nor do we send out someone for being dangerous. That's 911. Or every staff member approaching him and recommending that they calm the blank down. Works.
This is my experience also. There were many times we would have loved to send residents out "just to get rid of them". But unfortunately, those really annoying ones never seemed to go anywhere.
If someone was deteriorating for a legit reason, we had to follow a certain protocol. And the physician on call was the one who gave the final go ahead, on whether or not to send the resident out. And 9 times out of 10, they were back within days.
I also work in longterm care, and I can't tell you how many family members would rather send their mother/father out to a hospital out of some fear of death, or feeling like they are doing them wrong if they don't. And we are forced to abide by their wishes.
Or I also know many nurses who are so terrified of dealing with any type of situation in longterm care that they will send a resident out at the drop of a hat in order to pass the buck to who they feel are more qualified, even when its obviously not needed.
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?
sometimes, when i send pt to the er, the er nurse would call the primary nurse which was me and asked for a report. and i would tell her why i sent pt and what interventions i did before sending the patient. sometimes the doctor would call me as well with the same questions. i don't mind giving them all the necessary info for the continuity of care.
can't staff at your er call the ltc nurses for questions needing clarification? i don't understand what er can do with the diagnosis of "failure to thrive". also, in my facility, a pt needs to have a dnh order for us not to send them to the hospital. even if they have that order though, we still call the md and inform him/her of pt conditions and we also make the family aware of changes in pt conditions.
Don't forget what Leslie said about the 3 days and returning as skilled. The bottom line is always the money. Sad but true and probably one of the reasons I was terminated (don't you hate that word?)
Specializes in Hospice & Palliative Care, Oncology, M/S.
I'm not a nurse, however I worked as a supervisor in an Alzheimer's care LTC and we sent out a few patients in the time I was there. If the resident became very ill or had a bad fall while the nurse was on duty, it was up to her to make the decision on whether to send out the resident.
However, there were a few times where there was no nurse or med-tech on duty, and I had to make that call. One of my residents spiked a very high fever and was bordering on non-responsive. Her breathing was extremely off and I could barely feel a pulse. I actually had to fight with the nurse (my orders were to call her if a resident was ill) to have this woman sent out. I was actively involved with the residents day in and day out and knew that this woman was nowhere near "normal".
Luckily, the woman was sent to the hospital and she was treated for severe pneumonia. Her family, which I had called, was thankful that we had sent her to the hospital.
We (supervisors) ALWAYS wrote incident reports as well as kept a running journal of what happened in that facility. It's hard to believe that nobody on that staff knew what was happening. Unfortunately, we would sometimes have to grill our caregivers to find out what really happened, as they were afraid that it would somehow be their fault.
I also work in longterm care, and I can't tell you how many family members would rather send their mother/father out to a hospital out of some fear of death, or feeling like they are doing them wrong if they don't. And we are forced to abide by their wishes.
Yes, I've seen this. I can also add to this family members who believe that the nursing assessment is wrong, so they'd rather have their loved one sent out, despite what the assessment or MD says. Moreover, if the family starts mentioning lawsuits or calls to the state, that could be a motivating factor for sending someone out.
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?
Great thread! In my town of what seems like 5 billion+ LTC facilities, I struggle with this same thing (on the receiving end). I have always assumed the nurse just wanted a break or didn't want to deal with it. It is nice to have some insight from the other side. I did have one to really surprise me the other night. Similar to the original post, only a terminal DNR cancer pt ultimately admitted to oncology, and I was way too busy call and update his primary nurse at the LTC facility. A common thing to for me to forget and they rarely (if ever) call to follow up. About an hour after he was admitted, I received a call from his very concerned primary nurse. Totally changed my perspective in this case...
The patient had a POLST, which I did have a copy of. It stated "Comfort Measures Only" and "Patient prefers no transfer to hospital for life sustaining treatment".
The family was not involved in the decision to send to the ED.
In the ED, the patient had blood drawn and a cath UA.
The patient was admitted to the hospital, placed on a morphine drip, and passed.
At my facility- if they are a DNR and it is not something that can be treated and actually improve their condition we do not send them out. We prefer for them to pass " at home" with people that know and love them. That being said- at times it is out of our hands. We recently had a 96 y.o. tube fed hospice patient start declining. Family insisted on having her sent out. We learned later she coded, was placed on vent, later trached and on a vent. Not sure what her status is at present. Sad situation.
virgo, i have little experience in ltc (sue is the pro)...
Actually, there are many of us here who have spent years working in LTC and know the many answers to this single question. It is never as cut and dried as it looks.
And for those of you who state that its because LTC workers don't want to deal with a failing DNR/DNI LTC patient because they don't want to be bothered: YOU are primary contributors to the bad rap that long term care and long term care nurses get.
Pat_Pat RN
472 Posts
Had a drunk woman in the ER who was getting a Foley put in. She decided since the nurse was already "there" she just jumped in a started "pleasuring herself". The nurse slapped her hand, enough to make a smacking sound and said, "Quit that, get your hands out of there, that's nasty!"