What would you do. Not really medical.

[Sasha]

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]

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

 

[fast65]

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]

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

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[Sasha]

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

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[saskvolunteer]

Probably not hanging around for 3 hours.

 

[fast65]

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

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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]

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.

 

[Sasha]

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]

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.

 

[mycrofft]

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...)

 

[firetender]

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.

 

[18G]

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.

 

[firecoins]

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

 

[bigbaldguy]

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?

 

[18G]

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.

 

[Sasha]

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.

 

[usalsfyre]

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

 

[medic417]

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.

 

[18G]

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.