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Thread: Dubious hospitilizations for Dementia patients

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    Super Moderator cougarnurse's Avatar
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    Dubious hospitilizations for Dementia patients

    http://www.denverpost.com/nationworld/ci_18999626?source=rss


    One-fifth of Medicare nursing-home patients with advanced Alzheimer's or other dementias were sent to hospitals or other nursing homes for questionable reasons in their final months, often enduring tube feeding and intensive care that prolonged their demise, a new study found.

    Nursing homes may feel hospital care is warranted when a frail, elderly patient develops swallowing problems, pneumonia or a serious infection, but researchers suspect a different motive for many transfers: money. After a patient is hospitalized for at least three days, Medicare pays about three times the normal daily rate for nursing homes to take patients back — three times the rate paid by Medicaid, which funds such long-term care for many.

    "I think that's unfortunately a factor in what's happening here," said Dr. Joan Teno, a palliative-care physician and health policy professor at Brown University​. "A lot of this care just feels like in and out, in and out. You really have to question, is the health care system doing a good job or not."

    Teno is a co-author of the study, published in today's New England Journal of Medicine and done with researchers from Harvard University and Dartmouth Medical School.

    Among the nearly 475,000 patients studied, 19 percent were moved for questionable reasons. The study provided no evidence that money motivated such transfers or that there was wrongdoing involved. However, the large variation that researchers saw from state to state suggests money may be playing a role.

    Rates of such transfers varied from 2 percent in Alaska to more than 37 percent in Louisiana. In McAllen, Texas, 26 percent of study participants had multiple hospitalizations for urinary infections, pneumonia or dehydration — conditions that usually can be treated in a nursing home. That compares with just 1 percent of patients in Grand Junction.

    The researchers used Medicare records from 2000 through 2007 to identify "burdensome" transitions of care: moving patients in the last three days of life, moving them multiple times in the last three months of life, or moving them so they landed in a new nursing home afterward.

    Medicaid pays on average $175 per day, depending on the state, for long-term care, but Medicare will pay three times that for skilled nursing care after a patient returns from three days or more in a hospital.

    "If you have a nursing home that is operating on a margin, it adds up. It can be a tremendous incentive to hospitalize these people," Teno said.

    Researchers found that patients who had a dubious transfer were more likely to have a feeding tube inserted, to spend time in intensive care in the last month of life, to have a severe bedsore or to be enrolled in hospice late (three days or less before they died).

    Dubious transfers were more common with black patients, Hispanics and those without advance directives, legal documents spelling out care wishes.

    The National Institute on Aging sponsored the study. One author consults for a nursing- home system and owns stock in a long-term-care information services company.

    Beth Kallmyer, who runs programs for caregivers for the Alzheimer's Association, said the most important thing is to have a plan in place, with legal documents like "do not hospitalize" directives, before a nursing home has to make a decision about whether to hospitalize someone or instead focus on comfort care and not try to prolong life.

    Caregiver tips

    • Involve patients in planning their care while they're still able to do so, and make sure wishes like "do not resuscitate" or "do not call 911" are spelled out in legal documents.

    • Develop good relationships with nursing home staff and attending physicians so they understand the family's goals of care.

    • Consider hospice care when seniors with advanced dementia are admitted.

    • Revisit and review the plan whenever there is a change in a loved one's status. Someone may not be end-stage when they enter a nursing home, but that can change.

    • Seek advice. The Alzheimer's Association has a 24-hour toll-free number, 800-272-3900, with counselors to help families.
    The Associated Press



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    I see this all the time and it's nightmarish. Our society doesn't want to accept death, period. Perhaps some of our favorite hospital dramas aught to feature elderly and demented patients in the acute care setting. Zoom the camera in on them and listen to their terrorized screams. Watch as the family who so desparately wishes their loved one to be made better by the miracles of modern medicine hound the staff to do something. Fix it! Or worse, watch as they leave, after all the consents are signed, because they can't bear to see it any longer. Now let's move grandpa into the ICU and put his frail, wasted body on vasopressors to fix his septic blood bressure but first, we need to insert a central line. Watch as he freaks out and thrashes at the sterile drapes that is if he has the strength to do it. Mostly he'll moan and squirm. We can't sedate him yet because his blood pressure is too low, so he has to suffer while the nursing team restrains him. If he's lucky, he hasn't gotten a pneumothorax because of all the movement. Now the line is in so, we can put him on levophed, vasopressin and probably phenylephrine. No Aline because his extremities are too clamped off. Watch as his pale extremities continue to get mottled and cold as the drugs work their magic. Now we can sedate him because he has a blood pressure but only a little, because we don't want to supress his breathing. Oh look, he's having ectopy now. He's in Vtach, get the code cart! Does he have a pulse? A BP? Yeah but it's nosediving. Shock him and watch him lurch. VFib now. Shock him again but turn up the Joules. Still VF. Start CPR. Damn, I just broke his fragile sternum with my compressions but, I have to keep going. First round of code drugs are in and we check for a pulse. It's there but very weak. Grandpa isn't breathing anymore so it's time to intubate him and put him on a ventilator. His PH is now too low for another round of code drugs to be effective should he arrest again, so we give bicarb. He's still having a lot of ectopy so it's likely he'll code again shortly. Where's the family? Oh, they went out for dinner and said they will be back later. Grandpa is alone. What would House do now? There is no exotic diagnosis to be made and treated here. This is called the debility of advanced age and it is terminal. The alarm sounds. Grandpa is in VF again- magically 5 minutes after the first round of code meds have been given. No pulse. No pressure. Shock him again- max setting. VF still. Start compressions again, break more ribs. Push more drugs. Stop compressions. Look, there's some sort of ventricular rhythm. No pulse. PEA. Continue CPR. Look at his neck veins! Quick! Get the sonosite and see what's going on in his chest. Grandpa is on warfarin and now with compressions and all the fractures, I'm thinking he has pericardial tampenade. There it is. Hurry! Get a spinal needle and 60 cc syringe and stick it into grandpa's chest at the apex of his heart and aspirate out all that blood. Okay, done. Is there a pulse? Actually, there is. He pulled through again. Is the family back yet? No. Grandpa is alive but very critical. Amiodrone bolus is running. Let's examine our patient now. Get a flashlight and check his pupils. Fixed. No surprise. A short while later, he codes again while the family is in the room. They're shocked by how sick he is. What do you mean he's gone? He was sitting on the porch yesterday at the nursing home. WHAT? He isn't responding anymore? DO SOMETHING! The code is called after 10 minutes, because grandpa's neck veins were distended again. Probably a ruptured ventricle. The family is asking why that happened. Somebody HAD to be too rough. No grandpa didn't have the ability to come back a third time. Stunned, they sit. You gather the information. The family cries in the room for awhile, then leaves. You take off all the wires, remove all the tubes and do post-mortum care on that poor ravaged body. It takes a while for all the bleeding to stop. Finally you send him to the morgue and call the funeral home. There is still 4 hours left of your shift but you are tired.

    I wonder if Grandpa likely would've preferred to die with dignity in his own familiar bed with family holding his hand. We will never know because nobody asked him.
    Last edited by Ricu; 10-02-2011 at 03:45 PM.

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    Super Moderator cougarnurse's Avatar
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    Ricu, I recently had a conversation with a friend of mine about some of your points.

    What ever happened to dying at home, peacefully?

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    Member Extraordinaire hppygr8ful's Avatar
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    Here here

    My Mother-in-law passed away 9 years ago from brain cancer -she made it very clear when she was diagnosed that she wanted no extraordinary measures taken to prolong her life - though she died in a hospice she went the way she wanted to go surrounded by family and friends painless and at peace.

    My father passed 4 years ago in his own bed with my mom/his wife beside him. He was in extreme pain at the end but refused to be taken to the hospital.

    Both the above cases have in common that the patient made their end of life wishes clear and they had families who respected those wishes.

    Just something to think about

    Peace

    Hppy

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    Quote Originally Posted by cougarnurse View Post
    Ricu, I recently had a conversation with a friend of mine about some of your points.

    What ever happened to dying at home, peacefully?
    What a luxury it is to die at home. We discuss this often and the palliative care team has shed some interesting light. Our society has sterilized itself from agedness and death.

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    Quote Originally Posted by hppygr8ful View Post
    My Mother-in-law passed away 9 years ago from brain cancer -she made it very clear when she was diagnosed that she wanted no extraordinary measures taken to prolong her life - though she died in a hospice she went the way she wanted to go surrounded by family and friends painless and at peace.

    My father passed 4 years ago in his own bed with my mom/his wife beside him. He was in extreme pain at the end but refused to be taken to the hospital.

    Both the above cases have in common that the patient made their end of life wishes clear and they had families who respected those wishes.

    Just something to think about

    Peace

    Hppy
    It's a good thing that your loved ones had family who remained clear thinking about those wishes in the setting of terminal state. Imagine this scenario; An individual with DNR/I status finds himself in the ED experiencing acute changes that deteriorate into a critical state and the physician, believing that the rapidly progressing pneumonia or UTI is not terminal, states therefore, that mechanical ventilation and vasopressors are theraputic, not life support. "This buys us time for the antibiotics to work." Now the family is made to feel guilty if they don't give grandma the chance so they reverse her code status. Grandma may pull through but will not bake cookies ever again. She will be in such a weakened state that she will live out her days trached and pegged and will likely never get out of bed again- maybe to a chair and that's it.

    Physicians are trained to believe that death and debility are to be faught like enemies. They do not understand that advanced age is a phase in life and death is the last page in someone's life book. It's a natural process and we're interfering with it.

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