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 The Case Against Heroic Measures

​Research has shown that if a patient gets readmitted to the hospital within 15 to 30 days of discharge, “the advance directive did not meet the prognosis of the patient. What this essentially says is these patients continue to go back to the hospital because the family wants them to do everything possible” to help the patient stay alive, says Crystal Brown, DNS, director of nursing with Bayberry Commons, a skilled nursing center in Pascoag, R.I.

As many health care observers contend, this is not always the best course of care for the patient.
Hospitals for the most part do a good job of treating acute illnesses leading to the hospitalization, but the person’s overall health often deteriorates, says David Gifford, MD, senior vice president for quality and regulatory affairs with the American Health Care Association. Upon returning, they often have a Foley catheter inserted. They could have delirium or difficulty walking or be on an antipsychotic medication once they return to the long term care center. They might have also acquired a drug-resistant infection from their stay in the hospital.

Some never get back to their prehospital state, which for many patients isn’t the way they wanted to live, Gifford says.

May Cause Harm

The “heroic measures” families often push for don’t always result in improved outcomes and in some instances can result in unnecessary or potentially harmful treatments. In a news article recently, Provider highlighted the work of Magnolia Cardona-Morrell, MPH, PhD, of the University of New South Wales’ Simpson Centre for Health Services Research.

In an analysis of 38 studies, she and her colleagues found that excessive treatments on elderly patients nearing end of life were not markedly improving outcomes. The analysis, published in the International Journal for Quality in Health Care, spanned 20 years, based on data from 1.2 million patients, bereaved relatives, and clinicians in 10 countries.

The study cited cases where patients received unnecessary imaging, blood work or invasive procedures, nonbeneficial chemotherapy, and other measures that were preventing them from dying in comfort.
Some observers contend that a center isn’t doing its job if patients are bouncing back and forth to the hospital and getting excessive treatments. “If you know if someone is in the last stages of life, going back to the hospital is the worst thing for the individual,” says James Gonzalez, MPH, FACHE, LNHA, president and chief executive officer of Broadway House for Continuing Care, in Newark, N.J. It gives the impression that the center couldn’t manage the person appropriately, he says.

But the situation is often more complex than that, says Janet Feldkamp, RN, BSN, LNHA, CHC, JD, a nurse attorney based in Columbus, Ohio.

Feldkamp is a partner at Benesch Friedlander Coplan & Aronoff and represents long term care facilities. Some families are quicker than others to request transfers to the hospital, she says. Even if the doctors or nursing staff at a skilled nursing center believe the patient shouldn’t be transferred, the family may decide that a trip to the hospital reflects the patient’s needs and desires.

Family Leverage

Susan Cornell, administrator of Bayberry Commons, a skilled nursing center in Pascoag, R.I., is familiar with this scenario. A family’s insistence is “one of the No. 1 reasons that residents get readmitted to the hospital.”

Depending on where the resident lives, the type of advance directive he or she has, and the legal authority that directive possesses, it may be possible for the family to override what it says. A living will outlines the terminal patient’s care plan, whereas a do-not-resuscitate (DNR) focuses solely on resuscitation measures.
In some states, an advance directive may allow a person to say: “I don’t want to go to the hospital,” according to Feldkamp. In others, the document might just specify whether someone wants a DNR or not, which gives the family leverage to send a patient to the hospital. “There’s a distinction there,” Feldkamp says.

One way to prevent this “bounce back” is to educate family members on alternative options to hospital care. One of the main benefits of Bayberry’s palliative program is that staff form a trusting relationship with the families regarding end-of-life care, Cornell says. “Getting the family involved from day one and being open and honest about their loved one’s prognosis is crucial.”
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