Medical Ethical Scenarios

[JPINFV]

But there's a duty to care there.

The duty to follow the patient's wishes trumps all. Other wise we would be able to over rule an AMA for no better reason than, 'the patient is really really sick.' So the question now is, does hospice and the patient's family OR the nursing home represent the patient's wishes? Which actually brings up another question. If the hospice provider is an RN, why follow the SNF RN over the hospice RN?

Besides, the SNF RN doesn't care about providing this patient care. The RN just doesn't want the patient to die under his or her care. That's not a valid medical reason to turf the patient.

So I think you have to transport. It's in everyone's interest to try and smooth things out a little, and not get too confrontational.

So you don't mind getting confrontational with the family (who ultimately has to pay the bill for unwarranted and unwanted hospitalization)?

That's the question really. Is whether there's a document in place rendering it illegal to transport the patient.

Actually, I don't see a document as being nearly as important as deciding who get's to ultimately decide medical care. The SNF RN, the hospice RN, or the family. In most, if not all states, there is already a legal order of precedence for who gets to make health care decisions in an unconscious patient who doesn't have a POA. If, say, the patient's spouse was part of the 10 family members present, I'd have a hard time over ruling their request in favor of an RN who's request basically boils down to "I don't want to deal with this patient any more."

 

[mycrofft]

Definition of resuscitation

Quote:
Originally Posted by JPINFV
...and yet no one has answered the question about where the RN gets to make unchallengeable and unilateral treatment choices without consent of the POA or family.

Is this (3)?

Because that does sound a little tricky, and I guess it depends a little on the legal definition of a "DNR" in the given jurisdiction. If a DNR only comes into effect at the point at which the patient's heart stops, then they get acute treatment / transport.


Resuscitation is not just revival after clinical death, it actually begins with any lifesaving treatment to a diagnosed threat (e.g., oxygen to a decompensating asthmatic).

Having sat in a circle with family members and a convalescent center's manager with an apparently dying and somewhat disoriented father who had no living will or DNR established, I will say even if you are convinced of death's inevitability and proper place, it is very hard to decide to let someone die, whether or not they did have such wishes established, and part of that is worrying about how it will affect the others concerned.

(BTW he snapped out of it, but that's another story)

 

[firecoins]

Situation 3 sounds impossible. Why would a SNF accept a hospice patient with a policy that no on dies at the facility?

 

[systemet]

The duty to follow the patient's wishes trumps all.

I agree that it should. I believe strongly in personal autonomy and freedom. The question here is whether the patient has indeed expressed the wish that he doesn't want to be transported to acute care in an appropriate legal manner.

If the DNR is sufficiently detailed, and the laws in effect in the given jurisdiction allow a DNR to cover situations where the patient is incapacitated but not yet pulseless, then we're golden. As I said, I wouldn't take the patient in that situation.

But if the DNR doesn't cover this situation, and the patient hasn't expressed their wishes in a legally acceptable manner, the situation becomes more difficult. In this particular instance you have a sending facility and medical consult in agreement that the patient should be transported. If he is incapacitated and in their care, deoending on the legal framework in place, they may get to make that call.

Other wise we would be able to over rule an AMA for no better reason than, 'the patient is really really sick.' So the question now is, does hospice and the patient's family OR the nursing home represent the patient's wishes?

I agree that that's the primary issue here. Where I've worked previously we use something called a "personal directive" to cover this situation. It requires no physician input, no standardised form, just the signature of the patient and a witness, and allows the patient to describe exactly what procedures they are willing to allow in the event they lose decision-making ability, and gives them the option to nominate someone to make medical decisions in their place. (In contrast, a POA delegates responsibility for financial matters)

A lot of the facilities have more detailed DNR forms that cover transportation, advanced care, analgesia / fluids / feeding etc. But unfortunately at 0-dark-00 I've often been confronted with a random sheet of orders with "DNR" written in omnipotent red marker, with no explanatory notes, or incomplete forms. I'm sure this isn't a unique experience.

Which actually brings up another question. If the hospice provider is an RN, why follow the SNF RN over the hospice RN?

When did a hospice RN become involved in the scenario? The way I see it, is we have a sending facility calling for transport. This may have been initiated by the RN, but has probably been done in consultation with an MD. We have concerns about this, so for some reason we've chosen to contact med consult (presumably an EM Physician?), and they advise transport as well.

So we need a legal reason not to transport. The family not wanting the patient to go is understandable. But the questions remain, are they legally allowed to make decisions for the patient? And does the existing documentation prohibit transport?

Besides, the SNF RN doesn't care about providing this patient care. The RN just doesn't want the patient to die under his or her care. That's not a valid medical reason to turf the patient.

Agreed, the stated reason is not medically valid. However, the situation has been discussed with a physician (med consult), who seems to feel there is a medical necessity to transport the patient. I don't think we get to overrule that.

The whole scenario of a nursing home that doesn't allow deaths on site is contrived and a little unbelievable.

So you don't mind getting confrontational with the family (who ultimately has to pay the bill for unwarranted and unwanted hospitalization)?

I would hate to "get confrontational" with the family. This would be a terrible situation to deal with.

I would try to mediate discussion between the nurse and family. I would contact with a supervisor to diffuse responsibility a little. I don't see the point in talking with medical consult, unless they represent a physician at the receiving facility, in which case it would be worth discussing with them the family's objections, and seeing if they change their mind.

Ultimately though, if there's a legal responsibility to take the patient to the hospital, it has to be done. Hopefully it can be done with the consent of the family, but perhaps it can't.

The billing issue is crazy, by the way. This wouldn't be billable to the family where I've worked, but I've never worked in the US.

Actually, I don't see a document as being nearly as important as deciding who get's to ultimately decide medical care.

Well, I think the document plays a role in that decision, right? I mean, we need to know the legal framework in place in the region where this event is occurring. The documentation probably forms part of that.

For what it's worth, I have taken the personal risk of not beginning resuscitation in an out-of-hospital death where no DNR / personal directive etc. has been in place. I did this with the realisation that if other members of the family who weren't present objected to this decision, it could cost me my licence, job, financial security, and possibly my freedom.

But this decision isn't to be taken lightly. And in this scenario we have multiple actors. We've got med consult (again, not sure why), the sending facility and the family. It would be best if we can somehow build a consensus so that everyone's happy.