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 restrain only those who don't remember that they can't get up, with geri-chairs with trays or lap buddies. Very rarely.
We can't not accept back. This is a very rural, under-served area and we'd be ditching someone we knows granmma.
Most facilities are prohibited by regulations from not accepting back. If the patient you sent to ED is now stable, ready for discharge and still qualifies for your level of care, you must take him or her back.
Specializes in ICU, PICC Nurse, Nursing Supervisor.
without reading the other replies i am going to answer this question.....first dnr does not mean do not treat... did he have a specific order that he is to have comfort measures...if so where was his hospice ....dnr does not mean comfort measures..it also does not mean do not treat...!!!!
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?
without reading the other replies i am going to answer this question.....first dnr does not mean do not treat... did he have a specific order that he is to have comfort measures...if so where was his hospice ....dnr does not mean comfort measures..it also does not mean do not treat...!!!!
yes, i know dnr does not mean "do not treat". this person had a polst which designated him as comfort measures only, not to be transported to the hospital for any life sustaining measures, no antibiotics, etc. he was clearly dying, and beyond any reasonable expectation of cure. this was not somebody with a touch of pneumonia or a uti or dehydration that could be tuned up with a little supportive care and sent back to the facility. that is basically the root of my frustration. this person was at end of life.
virgo, i have little experience in ltc (sue is the pro)...
Leslie, I included you because you seem to know a lot about end of life care.
EOL care has a special place in my heart. I feel very strongly about it. I've considered hospice some day, but for now I'm happy where I am.
What frustrates me about it is that in the ED, I am very ill equipped to provide appropriate EOL care. I can give narcs and anxiolytics, I can darken the room and close the curtain and put on some soothing music, but I cannot provide the dying person with the kind of care they deserve.
The gurneys are hard. They're uncomfortable. They only adjust position so much. The rooms are cold, we do not have individual thermostats in the rooms. The blanket warmers empty so quickly that "warm" blankets are usually just warm on the outside and still cold when you unfold them. We do not have an abundance of extra pillows. There are drunks, traumas, screaming babies, psychotics, and all kinds of things going on that make the ED a chaotic, NON therapeutic environment for a person who needs a calm, restful atmosphere.
Just the process of being transported from their home on a gurney in the back of an ambulance is disruptive, uncomfortable, and anxiety provoking.
Even if they get admitted for inpatient palliative care, it will be hours before that happens, and in the meantime, they are sitting on a gurney in the ED. The best I can do for them is snow them IF I have a cooperative physician (in this instance, the physician ordered pointless, uncomfortable labs and diagnostics).
I am just thankful that the admitting physician demanded that everything be stopped and put him on an MS gtt.
I too am thankful the attending stepped in and stopped everything. No idea why he was sent to you based on the updated info. Sad for him. I'm not ER or LTC so I was wondering if someone from the ER would follow up with LTC and find out given the circumstances why he was sent to you. Just curious.
pennyaline
348 Posts
Most facilities are prohibited by regulations from not accepting back. If the patient you sent to ED is now stable, ready for discharge and still qualifies for your level of care, you must take him or her back.