# What would you do. Not really medical.



## Sasha (Dec 17, 2011)

Your patient is a 55yo female whose only available history is the fact she had a heart attack two months ago and she is on hospice for ES Cardiac disease but was discharged from the inpatient unit a week ago due the stability of her condition. She lives alone with parents and adult children in the area. 

You are called to the ER to transport her home. She was evaluated at the ER for chest pain. Blood work and EKG came up negative. 

The ER nurse tells you she was anxious and doesn't want to die alone. The hospice nurse arrives and says she has arranged for someone to meet you at the home and the pt is to get 24hr care so she does not become anxious and afraid. 

Patient's vitals are all within normal range and she ambulates to the stretcher with no assistance. 

You arrive at her home to find the hospice nurse is not there. The house is dirty with clothes and various other objects strewn about the floor creating potential fall hazards. 

You contact the hospice provider who tells you they will not have a nurse out there until 7pm. Patient is alert and oriented and refuses to go back to the hospital. Patient becomes anxious and hysterical stating she has less than 24 hours to live and doesn't want to die alone. 

How do you handle it? What would you do? 

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## medic417 (Dec 17, 2011)

What time is it?  If just a few minutes I'll delay on my own.


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## fast65 (Dec 17, 2011)

That depends on the current time. I would probably try to get in contact with one of her family members and see if they can come over and keep her company. If that doesn't work out, I would check with her neighbors. 

As much as I hate to do it, if nobody is available to come keep her company, then I would probably have to leave her home alone. Unfortunately there's no medical reason for me to stay there.


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## Sasha (Dec 17, 2011)

Whoops sorry. You arrive at 4pm. Nurse isn't available til 7pm.  

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## Sasha (Dec 17, 2011)

fast65 said:


> That depends on the current time. I would probably try to get in contact with one of her family members and see if they can come over and keep her company. If that doesn't work out, I would check with her neighbors.
> 
> As much as I hate to do it, if nobody is available to come keep her company, then I would probably have to leave her home alone. Unfortunately there's no medical reason for me to stay there.
> 
> ...



Do you not consider anxiety a medical problem? Not being cranky just asking. 

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## saskvolunteer (Dec 17, 2011)

Probably not hanging around for 3 hours.


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## fast65 (Dec 17, 2011)

Sasha said:


> Do you not consider anxiety a medical problem? Not being cranky just asking.
> 
> Sent from LuLu using Tapatalk



I suppose it is, however, I don't know if it's enough for me to justify hanging around for 3 hours. Don't get me wrong, I don't want to really leave her alone, but I don't want to get my *** chewed for spending 3 hours there either.


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## medic417 (Dec 17, 2011)

Spending 3 hours is a no go.  Spend a few minutes to attempt getting family or neighbor to stay with her.  If none available her only option is to request return to hospital or to be alone.  If you are working for a private service maybe she can arrange with the company to pay for you to remain.  

Sorry can not take a 911 ambulance out of service for this and for profit services have to make money.  As a compassionate human I would like to help but you have to take care of the greater number of people or make the most dollars depending.  Now if there is not a pending call waiting perhaps your service would let you stage there, but patient would have to understand you may be leaving at any time.


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## Sasha (Dec 17, 2011)

We really didn't either. But we were also worried about the possible legal implications of leaving her without a medical provider. We were told she required round the clock care for anxiety/fear BUT at the same time we did not have a lot of information available to us about the patient. She was not simply being discharged home, she was being discharged home with 24hr home health care. 

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## MMiz (Dec 17, 2011)

I once spent over three hours on a call on-scene working with NR staff, family, MD, and finally police on an involuntary psych. commit.  Not one of the highlights of my career, but my supervisor and dispatcher understood.

I'm not saying that it's the best solution, but I'm not sure I had any other choice.


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## mycrofft (Dec 17, 2011)

*Three tracks.*

Call your company and tell them you are notifying them officially that you will be leaving the pt to further injury or death with the home in it's present condition. Explain the hospice worker was to meet you there and didn't, and suggest they could bill that company or agency for any loiter time you have to spend. I'd text or email it to preserve a copy with a time and date stamp.

Call the hospice nurse's employer (your pt ought to have their number) and tell them you are officially notifying them of an unsafe situation, that their worker hasn't arrived, that you are contacting your company to have them charge them for any loiter time you have to spend until you meet the worker as you were told you would on report. If your boss is going to call them, when you call just ask if they have an ETA for their worker to arrive.

Call the adult children. One might be able to pop over and either fix things or relieve you.

If all else fails, call LE , report an elder abuse situation, and wait for them to arrive.

In any event, the hospice company really ought to be told ASAP because either something is wrong with their worker, or the worker flaked, as sometimes happens in home health care.

Probably, if your state is like CA, leaving the patient there would be reportable, certainly ethically and civilly willful negligence.

(See if the pt would like to drop by the office and do some filing, eat some cold pizza, watch some training videos...)


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## firetender (Dec 18, 2011)

*People can will themselves to death*

so this case does have potential for disaster. Mycroft's ideas are good, but time-consuming and likely not to be responded well to since the job is about availability not necessarily the most appropriate actions in cases like this.

An odd thought I had was to borrow a neighbor's cat or dog for companionship and comfort. Really, just getting a volunteer warm body in there for a few hours would do the trick. 

Much would depend on how busy it is out there, and how long you can stall and get away with it until you get something to plug the hole of continuity of care, which is what this is all about.


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## 18G (Dec 18, 2011)

Firstly, I would not leave this patient home alone. 

There is no way this patient can be left unattended. The crew has knowledge of the patient's condition and that she requires 24hr care and the patient is obviously distressed. Arrangements were made prior to departing the hospital for a hospice nurse to meet at the residence. I would be calling hospice and become very assertive in saying that they need to have someone out there within a reasonable amount of time. I would also be attempting to call the parents and children in the area to have one of them come out. 

If nobody can be at the residence within a reasonable amount of time, than I would be calling hospice back and telling them that it is completely unreasonable and impossible for an EMS crew to remain at the residence until 7pm, family was attempted to be contacted, and that it is hospice responsibility to be at the residence NOW. If they can't be then I would be advising them that the patient is being transported back to the hospital and they can arrange transport at 7pm when they have someone available. 

You cannot leave a patient like this alone. Bottom line.


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## firecoins (Dec 18, 2011)

Sasha said:


> We really didn't either. But we were also worried about the possible legal implications of leaving her without a medical provider. We were told she required round the clock care for anxiety/fear BUT at the same time we did not have a lot of information available to us about the patient. She was not simply being discharged home, she was being discharged home with 24hr home health care.
> 
> Sent from LuLu using Tapatalk



Right so she can't bel left alone.  Got to wait or its abandonment. You can get a supervisor to sit with her.


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## bigbaldguy (Dec 18, 2011)

If all other avenues were exhausted I guess contact LE and report a possible case of abuse. If nothing else it will probably take LE 3 hours to show up and you can spend the time picking up her living room. Sounds like her level of anxiety was bad. Could you have argued that her statement "I won't live 24 hours" might have been a veiled suicide reference?


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## 18G (Dec 18, 2011)

bigbaldguy said:


> If all other avenues were exhausted I guess contact LE and report a possible case of abuse. If nothing else it will probably take LE 3 hours to show up and you can spend the time picking up her living room. Sounds like her level of anxiety was bad. Could you have argued that her statement "I won't live 24 hours" might have been a veiled suicide reference?



Law enforcement isn't going to be able to do anything. It's not a criminal matter and there are healthcare providers (EMS) currently with the patient. Law enforcement won't be able to do anything more than the EMS crew. 

A scheduling issue isn't abuse. It's just a bad situation created by hospice not having someone at the home when they were supposed to.


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## Sasha (Dec 18, 2011)

We did get kind of mouthy with Hospice. We were on the phone for them for a long time, one time we held for 10 mintues. 

While we were trying to work this out, our patient was ambulating around her residence, doing dishes she had left behind, spraying airfreshner, fussing with her purse.

She did NOT appear to require medical care, she didn't even appear to be a hospice patient. 

Eventually a friend of hers came to see how she was as she had seen us pull up and unload her. We spoke with her friend who agreed to stay with her until hospice care came. We had her sign our paperwork stating we weren't leaving her alone. We were leaving when the friend came after us and stopped us. 

She looked at us with a very grave face "How long does she have?" We tried to explain that we weren't qualified to answer that but she was in stable condition. She then began to tear up and told her that the patient told her she had less than 24 hours and she had been sent home to die.

This patient was NOT dying any time soon. Her vitals were all perfect, she was strong and in decent health. If we didn't have the hospice packet I would not have believed that she was on hospice care.

This patient was an all out drama queen! 

Soon as we got in the truck her mother and father pulled up, with her son and grandchildren in the car and they came and asked us the same thing stating that she had called them while we were on the phone with hospice stating she was actively dying.

We were still not comfortable with leaving her simply for the fact that we were supposed to be handing off care to a hospice nurse, but we had no choice. We had other calls to do and our supervisor was blowing up our pager.

There was nothing wrong with this lady, absolutely nothing. How she's on hospice care we still haven't figured out.

We actually passed by the house today on our way to drop off another patient and saw her ambulating in her yard, as strong and healthy as the day before.


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## usalsfyre (Dec 18, 2011)

Does she have a physicians order for round the clock care or is it just her word?


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## medic417 (Dec 18, 2011)

usalsfyre said:


> Does she have a physicians order for round the clock care or is it just her word?



I was wondering that as well.  In my area Hospice does not stay with patients 24 hours a day.  They check on the patient frequently depending on what stage patient is in and will come to home when called.


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## 18G (Dec 18, 2011)

It's a tough spot to be in. I always have the fear of once we leave and something happens (ie fire, fall, etc) than I am liable. Personally, I don't take that chance unless I cover all the bases.

Glad your case worked out.


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## Sasha (Dec 18, 2011)

medic417 said:


> I was wondering that as well.  In my area Hospice does not stay with patients 24 hours a day.  They check on the patient frequently depending on what stage patient is in and will come to home when called.



The hospice nurse who met us at the hospital said there would be a hospice nurse at the house. That nurse was just a "runner" who visited hospitals and made arrangements. That nurse stated they had arranged for 24hr care.


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## atropine (Dec 18, 2011)

This is an easy one since we don't take people home, however if one of the local bls companies found thier self in this situation, I would imagine they could contact their supervisor, who could then get the local PD, or FD clergy to come out.


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## firecoins (Dec 18, 2011)

PD will not and should not come out for. They have no business being there. Same with the FD.  

If you feel the patient is compitent to refuse going to the hospital, than she is compitent to stay home alone. If she isn't compitent to stay home alone, she needs to go to the ER until the hospice nurse is at home.


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## bigbaldguy (Dec 18, 2011)

18G said:


> Law enforcement isn't going to be able to do anything. It's not a criminal matter and there are healthcare providers (EMS) currently with the patient. Law enforcement won't be able to do anything more than the EMS crew.
> 
> A scheduling issue isn't abuse. It's just a bad situation created by hospice not having someone at the home when they were supposed to.



I was thinking more as a stall tactic. If it's anything like here calling for LE on a bs thing like this will get you a 2 to 3 hour response time.


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## atropine (Dec 18, 2011)

firecoins said:


> PD will not and should not come out for. They have no business being there. Same with the FD.
> 
> Well why the hell do we have PD, and FD chaplins getting a public retirement, if your not going to use them for the public?


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## bigbaldguy (Dec 18, 2011)

Clergy isn't a bad idea. Maybe ask the woman what church she goes to and try contacting them? Maybe they have a do gooder who can sit with her. After thinking about it ,calling LE as a stall tactic as I suggested is prob a bad idea as it could backfire if you get an officer who is too gung ho. Could ramp the whole situation up further and cause patients anxiety to sky rocket.


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## Handsome Robb (Dec 18, 2011)

firecoins said:


> Right so she can't bel left alone.  Got to wait or its abandonment. You can get a supervisor to sit with her.



This was my thought as well. I'd be a pain in the hospice company's butt as well along with attempting to contact the patient's family along with friends or neighbors if the patient is comfortable and close with the neighbors. I would also contact the sending facility and explain what I was told, who told me it and request that they get involved. They made a 'commitment' so to speak, although after the patient leaves their facility their responsibility in the problem is questionable unless it was put in writing along with signatures but I doubt it would be. 

With that said I still think a situation like this implies intervention from a supervisor. I'm all for patient care, but in the system I work in I can't be tied up on a scene in this situation, we are too busy. 

My thoughts are that if we did make the decision to leave the patient alone we are setting ourselves up for another 911 activation if things go downhill (hopefully). This isn't a bad thing but looking at the best interests of the patient it is questionable patient care. With the patient being AAO and ambulatory she meets our criteria for ability to sign an AMA. 

This is a shiesty situation at best. Was this something you experienced Sasha?

Edit: seeing the posts about clergy this would be a viable option IMO. *IF* the patient was religious. I would be more comfortable if it would be someone that knew the patient rather than just a random pastor.


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## Sasha (Dec 18, 2011)

NVRob said:


> This was my thought as well. I'd be a pain in the hospice company's butt as well along with attempting to contact the patient's family along with friends or neighbors if the patient is comfortable and close with the neighbors. I would also contact the sending facility and explain what I was told, who told me it and request that they get involved. They made a 'commitment' so to speak, although after the patient leaves their facility their responsibility in the problem is questionable unless it was put in writing along with signatures but I doubt it would be.
> 
> With that said I still think a situation like this implies intervention from a supervisor. I'm all for patient care, but in the system I work in I can't be tied up on a scene in this situation, we are too busy.
> 
> ...



Yeah it was a call we had on Saturday. My report on that one started out short, but ended up being super long because I documented the heck out of it, lots of quotes and names. 

The hospice company told us they weren't even notified that she was being discharged and would require the care until 3:30. The EARLIEST they could get someone out there was 7. We got to her house at four. I don't know how that works when they have REAL actively dying patient requiring crisis care.

We were not comfortable with this at all. I didn't think anything would happen, but knew if it did it could be our butts on the line.


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## Handsome Robb (Dec 18, 2011)

Sasha said:


> Yeah it was a call we had on Saturday. My report on that one started out short, but ended up being super long because I documented the heck out of it, lots of quotes and names.
> 
> The hospice company told us they weren't even notified that she was being discharged and would require the care until 3:30. The EARLIEST they could get someone out there was 7. We got to her house at four. I don't know how that works when they have REAL actively dying patient requiring crisis care.
> 
> We were not comfortable with this at all. I didn't think anything would happen, but knew if it did it could be our butts on the line.



That's a terrible situation I'm sorry. What ended up happening if you don't mind me asking?


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## Sasha (Dec 18, 2011)

Read up a few posts


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## Handsome Robb (Dec 18, 2011)

Sasha said:


> Read up a few posts



/lazziness 

Well that's just backasswards 6 ways to Sunday... Idk what to say about that.


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## coolidge (Dec 24, 2011)

*discharge planning*

Here is language from the CMS survey procecures which hospitals are inspected:
A-0468
(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)
[All records must document the following, as appropriate:]
§482.24(c)(2)(vii) - Discharge summary with outcome of hospitalization, disposition of case, and provisions for follow-up care.
Interpretive Guidelines §482.24(c)(2)(vii)
All patient medical records must contain a discharge summary. A discharge summary discusses the outcome of the hospitalization, the disposition of the patient, and provisions for follow-up care. Follow-up care provisions include any post hospital appointments, how post hospital patient care needs are to be met, and any plans for post-hospital care by providers such as home health, hospice, nursing homes, or assisted living.
The MD/DO or other qualified practitioner with admitting privileges in accordance with State law and hospital policy, who admitted the patient is responsible for the patient during the patient’s stay in the hospital. This responsibility would include developing and entering the discharge summary.
Other MD/DOs who work with the patient’s MD/DO and who are covering for the patient’s MD/DO and who are knowledgeable about the patient’s condition, the patient’s care during the hospitalization, and the patient’s discharge plans may write the discharge summary at the responsible MD/DO’s request.
In accordance with hospital policy, and 42 CFR Part 482.12(c)(1)(i) the MD/DO may delegate writing the discharge summary to other qualified health care personnel such as nurse practitioners and MD/DO assistants to the extent recognized under State law or a State’s regulatory mechanism.
Whether delegated or non-delegated, we would expect the person who writes the discharge summary to authenticate, date, and time their entry and additionally for
delegated discharge summaries we would expect the MD/DO responsible for the patient during his/her hospital stay to co-authenticate and date the discharge summary to verify its content.
The discharge summary requirement would include outpatient records. For example:
• The outcome of the treatment, procedures, or surgery;
• The disposition of the case;
• Provisions for follow-up care for an outpatient surgery patient or an emergency department patient who was not admitted or transferred to another hospital.
Survey Procedures §482.24(c)(2)(vii)
• Verify that a discharge summary is included to assure that proper continuity of care is required.
• For patient stays under 48 hours, the final progress notes may serve as the discharge summary and must contain the outcome of hospitalization, the case disposition, and any provisions for follow-up care.
• Verify that a final diagnosis is included in the discharge summary


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## coolidge (Dec 24, 2011)

*more on discharge planning CMS language*

A-0799
(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)
§482.43 Condition of Participation: Discharge Planning
The hospital must have in effect a discharge planning process that applies to all patients. The hospital’s policies and procedures must be specified in writing.
Interpretive Guidelines §482.43
This CoP applies to all types of hospitals and requires all hospitals to conduct appropriate discharge planning activities for all inpatients. It applies to patients who are admitted to the hospital as inpatients. This CoP does not apply to patients who appear in a hospital emergency department but are not admitted as hospital inpatients.
The written discharge planning process must reveal a thorough, clear, comprehensive process that is understood by the hospital staff.
Adequate discharge planning is essential to the health and safety of all patients. Patients may suffer adverse health consequences upon discharge without benefit of appropriate planning. Such planning is vital to mapping a course of treatment aimed at minimizing the likelihood of having any patient rehospitalized for reasons that could have been prevented.
Survey Procedures §482.43
• Review hospital written policies and procedures to determine the existence of a discharge planning process.
• Review patient care plans for discharge planning interventions.
• Interview a sample of hospital staff that are involved in direct patient care. Ask the following questions:
o How is discharge planning conducted at this hospital?
o How are you kept apprised of the hospital’s policies and procedures for discharge planning?
o How is this communicated and integrated into a plan of care?
______________________________________________________


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## rmabrey (Dec 29, 2011)

Just curious how taking her back to the ER would play out. If we put a hospice patient on our cot, they are immediately off hospice care. Also, could the nurse not being there be considered fraud.......kind of like a PCS saying patient needs O2, but there isn't O2 in the home when you get there?

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## mycrofft (Dec 29, 2011)

*Parse.*

Ambulance crew was told care was arranged to be at the home and they were ordered to deliver the pt. They did but the care was not there. The order did not say "Unless the pt seems fine".

The issues are abandonment and failure to follow orders.

The actions I cited could be initiated by cell phone. 

The hospital can say the pt was discharged on the guarantee the pt was covered by hospice; their hand are clean. 
Hospice can say that their coverage was not set up due to a clerical error or failure of the employee to arrive. Since _*the failure is with hospice*_, and it would be illegal to abandon the pt, and it would be a breach of orders to leave the pt without the hospice hookup, I'd wait there eating her fig newtons and drinking her lemonade ,on the phone to your company and the hospice (or better yet, get your company to call the hospice company) until either someone came out, or a new order was received. (Can you accept phone orders except from your medical control?). The hospice can pay for your time, so there is no lost income.

Your company may have ordered you to leave, and if the pt assessed fine, have her sign an AMA if she would, record the time date and name of the person issuing you that order, leave the hospice and ambulance company numbers with the pt, and drive away; file your contact report with all the pertinent info; maybe submit a "memo for record" to your boss.


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