Why Does this Happen?

Why does this happen?

•  Medicare will only reimburse the hospital for care that a patient receives that is medically necessary and billable
  • Hospitals often eat the costs when a patient is just waiting for placement

There can be mounting pressure to treat ‘something’ as long as it deems the patient’s stay inpatient and billable. The top two offenses against the patient’s autonomy and dignity during times like this are:

1. The creation of a medical necessity to treat presumed pain or anxiety and not with oral medication, because that can be done at home

• • This would be done using intravenous medications (IV)
    • IV Morphine, IV Ativan, etc…

This type of treatment plan can translate to the family as their loved one is now medically complex and not able to transfer out of the hospital at all.

Suddenly, there is a complete loss of control of the patient’s wishes

and the environment surrounding the patient is frazzled and

leaves family members questioning if they are doing the right thing or not. 

 

2. Provide minor to major life support measures

• • Minor life support: these are non-emergency therapies used to maintain bodily functions.
    • IV hydration, high flow oxygen support, enteral feeding tubes, heart monitoring, antibiotics, etc…
  • Questions to ask as you discern if it is a moral obligation to provide such therapies?
    • Does the therapy offer reasonable hope of benefit?
    • Is the treatment burdensome to the patient?
    • Does it support the dignity of the patient?
    • Is there treatment considered basic normal care and not an intervention?
  • Treatments and therapies that are extraordinary and should prompt you to pause and ask deeper questions:
    • Mechanical ventilation; long-term or in actively dying patients
    • CPR in advanced illness
    • Feeding tubes; when they no longer provide benefit– this is nuanced
    • Chemotherapy in the final stages of disease
    • ICU-level interventions with no realistic recovery
  • All of these things are dependent on the specific person. The same intervention can be ordinary for one patient and extraordinary for another.Example: Antibiotics
    • Ordinary– simple infection, patient will recover
    • Extraordinary– used with an actively dying person, causing more burden than benefit.

When these treatments are proposed or are being actively received, it can translate to the family as their loved one is receiving the support measures to cure or maintain their life. There are times when this is appropriate,

but once it is clear that their disease is progressing and their prognosis is short,

all attention should turn to supportive comfort care for end of life.

Unfortunately, what ends up happening, is the family and patient are left in limbo.

On the one hand, there seems to be a glimmer of hope that they will improve

and return to their former baseline, and on the other hand,

the reality is staring them in the face and they know that their loved one’s time is limited,

but they do not have any other resources to provide the comfort care they need.