Wednesday, February 3, 2010

Case Study #8

This is, as requested, another case study: two, in fact. They are from a fabulous blog, written by a Toronto Emergency Room Nurse. She tells her story from the other side of the gurney.

I have heard, through my contacts, about the reluctance of Emergency Rooms to accept residents from long-term care (LTC- formely called 'nursing homes'). In theory, a LTC has a nurse, and a doctor on call all the time. In theory, a LTC accepts folks who do not need (or want) resuccitation, who want to die peacefully. Most LTC homes are for-profit (500/650 in Ontario) and rely on OHIP and tax dollars to care for failing seniors too healthy for hospital, too ill for a retirement home.

These real-life stories demonstrate the dance between emergency rooms, long-term care residents/family members and the disconnect between standing orders, and advance directives that permit a resident to die peacefully, in dignity and palliative care. (Reprinted by permission.)

Do Old People Have Rights?

I don’t mean in the theoretical, warm-fuzzy, it-says-so-in-the-policy-manual-so-it-must-be-true, everyone-has-rights sort of way. I mean in hard practice: do the elderly really have autonomy to determine their own treatment? Illustrated in two recent cases I had, the short answer is No.

Case 8a). Female patient, 94, previously competent, but in nursing home for other medical problems, arrives via EMS as an apparent CVA. A CT confirms a massive cerebral bleed and the patient later dies on an emergency stretcher in the Resus Room. Her advance directives, signed by the patient herself, clearly state “No transfer to hospital” and “Palliative measures only”.  The nursing home, when questioned why this patient was transferred to hospital against her wishes — which in fact is the whole point of having an advance directive — can only say she was “unwell” and the nursing home physician “ordered her to be sent to hospital.”*

Case 8b). 84 year-old female, who again has well-documented advance directives forbidding transfer to hospital previously written by the patient herself, but now has Alzheimer’s dementia, presents as a possible urosepsis. The nursing home says the patient was sent to the Emergency at the “request of the family.”

These aren’t hypothetical cases, and ones similar happen with dismal regularity. Physical frailty means, in the minds of some, means mental incompetence. Advance directives are frequently subject to the capriciousness of nursing home staff or family members. In point of fact, the ability of anyone practically to direct their own care if incapacitated is limited. Even strictly delineated advance directives can and will be overridden by families and by health care professionals.

The nursing role in all of this is threefold: to educate patients and families on advance directives, to facilitate provision of services, including providers like home care, pain management and palliative care, and finally, to advocate for the patient. Whether we actually do it, of course is another question. Working in the Emerg, you frequently get the impression that expediency or convenience (or even laziness) trumps good patient care.

torontoemerg said...
Welcome to my world. My (latest) favourite was the nsg home which sent in a UTI on po antibiotics for "uncontrolled fever" --- then when questioned why (like NurseMe) they didn't give Tylenol, the RN told me (very haughty-like, as if I just fell off the nursing turnip truck)there was a "high risk of aspiration." Ahem, I said. Pt is already getting po meds, and there is such a thing as per rectum. "Oh," she said. "I'd have to get an order to change the route.." You just gotta shake your head and move on. . .
If you think this is isolated? See also: another emerg room nurse post:  The nursing home dump.
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*The game, according to a colleague used to manage a nursing home, goes like this: The nurse in charge simply calls the nursing home physician, advises of  patient’s condition, but “forgets” to tell the doc of the advance directive. The physician of course then orders the transfer.

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