How to stop the cycle of ER visits?

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E

ellantz Asked October 2012

How to stop the cycle of ER visits?

My 93 year old mother has been in a skilled nursing facility for almost 3 years, and is seen by an internist there periodically. She has heart problems, congestive heart failure, high blood pressure, atrial fibrillation, kidney issues, dementia, and squamous cell carcinoma, just to name a few, and is on approximately 18-20 daily meds. She is mobile in her wheelchair, but cannot use her walker without assistance.
The facility has sent her to the ER a number of times, where she is always given an extensive number of tests, and typically remains in the hospital for a week to 10 days. Then she comes back to the nursing home and undergoes Medicare-paid rehab for 4-6 weeks, and is then released back to private pay status, and the cycle begins again.

As a family, we do NOT want to expedite her passing, but we do not want to prolong the inevitable, and to keep putting her through all of this, not to mention the extreme costs to a bloated Medicare system.
We have the appropriate "do not resuscitate" legal documents on file, but I've come to learn that that means if her heart stops beating, then they do not resuscitate. Until that happens, they will just continue on with this process.
My father and I talked to the facility social worker about hospice for Mom, and she explained the process, and was going to "get right on it" with Mom's doctor, and get back to me. When I didn't hear from her for 2 weeks, I called and left a message, asking her to call me back. She never did, so I did not pursue it, because I did not want to appear inappropriately anxious, and I took her unresponsive-ness to me to indicate that hospice was not an option. To my knowledge, Mom does not have a terminal diagnosis.
I would appreciate any comments, thoughts, advice, etc. from the great pool of wisdom here.

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score 1 · Answer 1

I just wanted to give you kind and supportive folks an update:
I discussed my concerns with the head nurse at the SNF, and she gave me a form to complete, sign, and get witnessed. The form allowed the Medical POA to specify the levels of comfort care, as well as transportation to the hospital. I discussed with my family and we all were in strong agreement, so this is now on file at the SNF.
Thanks again for your very helpful and compassionate responses!

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score 1 · Answer 2

You can call hospice yourself without a referral. They will evaluate your mom's situation and then contact her doctors to get her admitted to hospice. Hospice doesn't mean stopping everything, instead it means continuing treatment until it makes no sense to continue, then provide meds for comfort. My dad also had CHF and had at least monthly trips to the hospital. When I realized that to keep him out of heart failure with meds meant putting his kidney function at risk, I asked that he be admitted to hospice. Heart failure is a disease that can be found acceptable for hospice even though there may be no true understanding that they will live 6 months or less. But once they get to the point that they have multiple hospital visits, they are probably at the end stages and so qualify for a life limiting disease. The advantage for my dad was that he could stay at home. The hospice nurse and I still adjusted his meds as she felt was needed until he had reached a point where no adjustments would have changed the end result. At that point, the main focus was comfort - morphine to ease his shortness of breath, something to dry up secretions if fluid overload happens. For my dad, he wasn't in an acute stage of congestive heart failure as I had seen so many multiple times in past, rather his heart muscle was failing so we were able to keep him comfortable yet able to speak to us, know we were with him until the last breath, in his own home where he was most comfortable. Good luck, Kuli

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score 0 · Answer 3

Oh, thank you so much, MonicaFaye - that is such good info. We are in Dallas.

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score 2 · Answer 4

Your situation sounds similar to mine. We live in Texas as well, and my dad was in a nursing home with a contained Alzheimer's unit. Every time we turned around they were transporting him to the ER for one thing or another. He was also on 15 different drugs, many of which were causing significant side effects. We told the NH that we wanted the hospitalizations stopped as they were causing my dad a lot of unnecessary stress and were of no real benefit to him. We contacted his doctor and requested a hospice evaluation which was done within a 7 day period. Hospice was approved and soon removed him from all unnecessary drugs and tests. His last months of life were made more comfortable because of hospice. It was the best decision for my dad and our family.

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score 0 · Answer 5

Thank you, Geewiz, for those suggestions, and for your good wishes. We are in Texas, and I will inquire about the "do not hospitalize or transport" option, as well as trying to contact the dr directly.
Yes, 2much2cover, your unfortunate observations have come up in our family discussions. My mother would definitely be considered a "problem" due to her very obnoxious and demanding personality, but her family is not a problem as we have backed the facility 100%. I have seen a seasoned nurse almost break down after dealing with her. Thank you for your comments - it is great to hear about the experiences of others.

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score 2 · Answer 6

I think this is a common practice in nursing homes and rehabs and I fear it might be financially motivated or motivated to get rid of a problem resident (or resident's family members). In one rehab facility, a nurse even commented to me that the medical director (who is also the attending physician) was too quick to send residents to the hospital who could be treated in the facility. Perhaps he didn't trust his own staff to take proper care of the patients???? Also, I have had EMT transport techs say the same thing about the same facility and they said the same thing geewiz said. The patient (or whoever is responsible) has a right to refuse transport to the hospital. There are some facilities that dump demenia or Alz patients into Baker Act situations b/c they don't want to do their job at their facility that are being paid to do. This revolving door situation is very traumatic to the patients, especially those mentally ill who have no family to watch over them.

Now all that being said, I would still want a facility to notify me when a situation exists where they would have ordered transport to the hospital but there is a do not transport order on record.

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score 2 · Answer 7

Rules vary by state, but here are 2 options to consider. NJ has a "do not hospitalize or transport' option for those living in SNF. If the person with medical decision making signs that form, the patient is kept at the SNF.

Second option is to pursue the hospice evaluation. This does not mean you are hastening your Mom's passing -- rather it is an acknowledgement that due to the multiple health issues and age, your primary concern is that your Mom be kept comfortable. After a face to face and follow up call to the social worker, I'd skip right to the MD. It's the physician that needs to write a script for the hospice evaluation. After that is written, everything else just moves along. Your Mom will continue to receive her meds as well as other items that may make her more comfortable. Best wishes to you and your family.

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How to stop the cycle of ER visits?

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