End-of-Life Choice, Palliative Care and Counseling

A Revolving Door to Avoidby Sonja

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by Judith Graham
The New York Times
October 25, 2012

Two weeks ago, Dr. Arif Nazir got a call from a colleague about a 79-year-old woman at an Indianapolis hospital. The cardiologist on the phone explained there was nothing more that could be done for this patient, who had advanced heart failure, chronic lung disease and diabetes.

After a brief conversation, Dr. Nazir agreed to admit her to a nursing home and try to keep her out of the hospital, respecting her recently signed “do not resuscitate” order, or D.N.R.

It was a promise that was broken within several hours, much to Dr. Nazir’s dismay. The reasons highlight troublesome problems with long-term care that frequently frustrate caregivers and that are receiving fresh attention from medical providers and Medicare.

At the nursing home, staff members noticed several hours after her transfer that the patient’s oxygen levels were very low. This was to be expected given her condition, Dr. Nazir said, but no one picked up the phone to ask his advice.

Instead, a doctor on call who wasn’t familiar with the patient or her recent medical history gave the order to send her back to the hospital — just where the patient, her son and her physician didn’t want her to go.

This might not have happened if the woman’s D.N.R. order had traveled with her when she was discharged from the hospital. But that didn’t happen, and staff members in the nursing home had no way of knowing what this patient’s wishes were (she was groggy and unable to say at that time) or whom they should contact to find out.

This is a distressingly common problem. D.N.R.’s signed in hospitals aren’t regularly transferred to skilled nursing facilities. So when crises arise (and this occurs often in frail, sick older patients) no one knows what to do, and shipping the patient off to the hospital becomes the default option.

That may seem like a sensible choice — after all, hospitals are where really sick people go to get better — but for nursing home patients it can have deleterious consequences.

Dr. Nazir, a geriatrician at Indiana University and a staff physician at several Indianapolis nursing homes, explained why, using the example of another patient in her late 80s with advanced Alzheimer’s disease who becomes excessively agitated and combative at night.

“When she goes to the hospital, she will be seen by a physician who doesn’t know her, usually for only a few minutes,” he said. “Most likely, he’ll end up doing a lot of tests because histories are not readily available for these nursing home patients.”

Because the patient is old, with several other medical conditions, “every test this physician does is going to come out with some kind of abnormality, and she’ll be admitted for further evaluation and observation.”

In the hospital environment, this older woman with cognitive impairment will feel disoriented and most likely afraid. “There will be lots of strangers, lots of noise, perhaps little sleep, and she will be at very high risk of becoming even more agitated,” Dr. Nazir said. “At that point, she’s going to get aggressive medications.”

In short order, this patient may become sedated, delirious and confined to bed. Upon discharge, an older person like this “will come back to us very debilitated, really having lost a lot of quality of life” and often unable to regain it, Dr. Nazir said.

Few caregivers realize this is a likely chain of events. Rarely do nursing home doctors or nurses sit down and explain the risks of hospitalizing a frail older person who is profoundly physically and mentally compromised.

This is the set of problems that a new pilot program of the Centers for Medicare and Medicaid Services hopes to address. The program is to be introduced in Alabama, Indiana, Missouri, Nebraska, Nevada, New York and Pennsylvania later this year, and I’ll describe how it works in a future post.

What about you? Have you had experiences along the lines of those described by Dr. Nazir? Have you witnessed this all-too-frequent revolving door between nursing home and hospital and seen its adverse effects?