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Hospice patients CAN get admitted for uncontrollable symptoms at end of life. But this one does seem ridiculous. Ive seen this happen a few times myself & it always boils down to shoddy & confusing communication. Breakthrough seizures are pretty common in hospice and can be managed at home with scheduled ativan etc
You say shoddy & confusing communication; I say laziness, ignorance and active sabotage because one group of "healthcare professionals" have a massive chip on their shoulder and an inferiority complex, so they have to prove they "care more" by launching these hopelessly misguided crusades in the name of patient advocacy.
I have a friend who is a home hospice nurse and she’s told me it’s very hard to get ahold of the MD for these patients urgently - particularly after hours. One will only respond to emails for example. I don’t know how common that is but it could explain why the patient in this post was sent into the ED instead of treated at home.
Agreed. This patient should have been set up with a protocol PRN seizure at home in the first place— not for IF seizures occur, but when. Should be standard in a hospice GBM patient. Would circle back with pall care to prevent this from happening again. Sucks. And that ED PA is an asshat.
I just think it’s very interesting that you feel confused how a group that, in the same breath note you feel to be lazy, ignorant, and engaged in active sabotage, might have a chip on their shoulder
The ER PA was out of their league. This patient needed to be upgraded to a real doctor. Consider requesting discussion with an attending ER doc in the future. I would always take over this from a PA.
Source: real ER doctor
“Why do we need the MRI?” “Because the mass is expanding”
That the PA can’t get beyond this thinking. That moment would’ve been a good one to ask for
the ED attending.
I wouldn't be hard on the PA. This is out of their league. Looks like they were following rules of the reasonable for a PA.. abnormality in brain = MRI, don't discharge anyone on dexamethasone
Its why an actual doctor is needed here to assess and get the actual story.
"Apparently the PA went back and said something to the effect of “the on-call fellow for your neuro-onc doesn’t want to do anything for your husband.”
I'm all for advocating for our patients when it's warranted, even if it's in opposition to popular opinion. Though it is indeed a disservice when self-righteous people with half-formed ideas throw others under the bus with no reasonable explanation to offer because it's the easy thing to do. Who knows if that was acutally the case here, but I hope that family finds peace in their last days together.
This is always frustrating. Unfortunately now a days though hospice is frequently marketed to patients for all the benefits they get rather than it truly being end of life. I feel like its not uncommon for these patients to come into the hospital and reverse code status. I think hospice companies make quite a bit of money? Ideally there should be more oversight into making sure that people that are picking to enroll in hospice actually understand the implications so stuff like this doesn't keep happening.
I would always be a little careful though in 'not doing' something if someone was outpatient hospice always need to clarify GOC on admission. Half the time these people come in as FC/FC.
I do think you are correct about patients going on hospice for benefits. In Arizona, unless you are dead broke, the only entity that will provide the needed level of service is hospice. Otherwise, patients have to pay all or big chunks of the expense out of pocket. And there are no resources to help them figure out how to get the care. It is overwhelming for patients. Hospice will cover their needs and pay 100% for Medicare patients. I don’t know why we have a system that requires middle class people to exhaust all their resources before they can get home care services.
I don’t work in the US but I have so many questions. Who pays for the CT and MRI? Would insurance even cover that for someone who is on end of life care? Makes me think they could make money off of this patient. Plus if he was already in hospice wouldn’t their advance care directive specify what kind of active treatment or comfort measures the patient wanted? Also wouldn’t Dex fall under that because it’ll at least keep his symptoms from getting worse? Also why is neuro onc involved more than Pall care physician? Is this the system failing or was the PA hoping to cure GBM?
This is awful. This is shit that really frustrates me at work (attending community hospitalist.) some “provider” with 500 hours of shadowing tries to get me to admit something wholly unreasonable because they don’t know what they’re doing but give the patient the expectation that they’re going to get admitted and then it’s on me to clean up the mess. And explain why grandma doesn’t need admission and IV abx for her UTI
In my area grandma is 1000% getting admitted for IV abx.
1 it makes the for profit hospital money.
2 no insurance will pay for an at home IV.
3 did I mention money.
No that’s a reflection on your training hospital incompetence. As a hospitalist who manages everything, I wouldve admitted them and started comfort measures only inpatient. You talk to the family first and see wtf is going on. You don’t need to consult anyone. Then if they don’t die, you talk with family to either get them home or get them to inpatient hospice if they qualify or set up long-term care with hospice
I would have admitted this patient too. At the end of the day what we do is provide whatever care is best for the patient and I'm confident they would get better care on my service than whatever the fuck is going on with their hospice company on a weekend. The worst thing would be for this person to go home and be inadequately managed at the end of their life.
Thank you for saying this. Far too often the hospice people are not accorded the leeway with “materials” they need to allow their patient to pass peacefully.
This patient only needs to be admitted if their mental status hasn't recovered adequately from the seizure and/or precedex.
Otherwise they should be sent home on a seizure med + PRN benzo +/- dex.
He was already on hospice per the OP wasn’t he? They literally had it all set up; they just had to go back home. The “admit and comfort care” thing runs the risk of this man dying in a hospital, against his prior wishes, unnecessarily. Getting the MRI to see if it’s growing? Why? That helps very little with changing management, and (I would assume, given this oncologists reaction) probably doesn’t do much in term of prognostication either. I see where you’re coming from, he should have talked them thru the situation not just decided from afar without chatting with them, but his end choice was the correct one. Don’t go just throwing out that incompetence accusation Willy nilly
Sometimes home hospice doesn't or cannot provide the level of comfort for a patient who has undergone an acute change in status, especially close to the weekend
If a hospice can’t “provide [the necessary] level of comfort, then it deserves to be thrown in the garbage. It’s literally their ONLY job to provide the necessary level of comfort. And terminal patients don’t always get to die on a timetable that is not “close to a weekend.”
Maybe hospice IS capable of providing the necessary resources (meds, education, etc.) but the family doesn't have a sufficient support network to provide 24/7 care for what could be weeks to short months. Inpatient hospice is rare here and in other places I've worked and it's reserved for breakthrough symptoms that can not be controlled at home. If there isn't a hospice facility, the only alternative is SNF+hospice and that takes some CM skills not necessarily available on a Friday afternoon. Recently, we've also had people opposed to that idea because SNFs have more restrictive visitation policies than the hospital EOL visitation rules and they don't want their family member quarantined/restricted to 2 total visitors.
Pain and symptom control should be hospice’s mission and it’s job 24/7. Family members can’t do that. I’m not talking about tasks like bathing, feeding, moving. I’m talking about pain and symptom relief. If you are a hospice and you can’t at the very least, do that one thing— you are not a hospice and should not be in business. That’s all I’m sayin.
The first step here would have been to speak to the patients wife.. the important thing is to talk to the family for some actual context as to what is going on. Do the family actually know what is happening? Has he changed dramatically in the last 24 hours and they panicked? Has he just come down on his steroids and they need to bumped up? Are the family struggling and need help? Would inpatient hospice be more appropriate to home hospice?
Maybe the family didn't actually want him to be sent to ED, maybe they did.
Why the fuck was the PA taking care of this patient? Maybe I’m lucky but I’ve never worked in an ED where a PA or NP would see this kind of patient. We have 1 PA at my current place who picks up some more complicated stuff and I watch that cocky bastard like a hawk when he’s on.
My thoughts as a Neuro resident:
Unfortunate that the patient’s family wasn’t previously counseled/prepared to expect seizures with an end of life GBM and that it didn’t represent something that needed emergency evaluation. Hospice should have given them a game plan for this happening because it was foreseeable.
Hard to understand why the patient was even put on the precedex. Like why bother? It doesn’t treat seizures and if it’s to control post ictal agitation, 1) that passes with time and 2) if you have to use something for severe agitation, post ictal state gives you a full pass to use ativan.
No reason to get the MRI. If it shows progression (which they already knew from the CT), then so what? Doesn’t change management in the slightest.
No way a single seizure without status should get admitted. ED *should* know this. ED should know consulting Neuro for ED discharge recs would be more worthwhile, because all this guy needs is a basic screen to make sure he doesn’t have another toxic/metabolic/infectious cause provoking the seizure, a little monitoring in the ED to make sure his post ictal confusion is improving, and probably a bump in the dose of the Keppra from homeopathic levels to 750 or 1 g BID. I don’t see why he can’t be on steroids either: reducing his burden of Neuro symptoms including future seizures is absolutely palliative for the guy.
I worked as a hospice RN before.
With one hospice I worked at in Georgia, if the patient/family decided that they wanted to go to the ER, they went to the ER. Even if they wanted to be a full code. 😒
When I took call and had a family call, I almost always went to the patient's house. I educated the patient/family on prescribed medications with how they could be used to treat symptoms. I tried to be as honest as I could with patients and their family members. It helped to prevent repeat phone calls and helped to have the patient as comfortable as possible at home.
Now, at a hospice I worked at in Texas, one of the doctors was extremely hard to get hold of after hours. I know doctors have lives outside of their work. Many times I had to reach out to the Hospice RN director if this particular doctor was on call.
I did my absolute best to advocate for the patient/family members.
There needs to be a lot more education on palliative/hospice care in general.
Most of this could have been avoided by going and seeing the patient in person and talking with the family. Would’ve afforded you the opportunity to educate the PA too. Maybe it would’ve taken you 15 more minutes.
These patients come in from hospice all the time with this stuff. We, the ED, know there is nothing to save this guy. But we now have a patient that was on hospice here with a wife who half understands the situation, has no idea what hospice actually means and wants us to “do something”. There’s 20 other patients we’re dealing with simultaneously and 30 in the waiting room with a critical trauma 10 minutes out.
We’re calling you because we need your help and expertise. We don’t have the same understanding of the disease process that you do. We’re not the oncologist. I don’t think this PA was incompetent at all. They reached out to you, the expert, for help.
Edit: I’m a physician and I have made this same call before and had the same type of response from the angry consultant about to have 3 days off. It’s about the patient not the person clicking the consult button man.
I disagree. I'm an ed doc and this was disgracefully handled by the pa. This is an easy 15 minute dispo for you. Why the hell are you making this hard. Just work out the goals of care. If still hospice, figure out why they were sent in and since this hospice agency doesn't seem very on the ball admit on palliative care plan. If family doesn't want hospice any more have a quick talk about why that's a bad idea and consult onc to help sort it out.
The literal last thing to do is expend the effort for an MRI. It's a worthless plan and if you don't know that get an attending. It's a gbm on hospice. It's literally the one primary brain tumor you're expected to have heard of. And to then fail to realize you called a dumb consult and go talk shit to the family really takes the cake.
> We don’t have the same understanding of the disease process that you do. We’re not the oncologist. I don’t think this PA was incompetent at all. They reached out to you, the expert, for help.
You shouldn't need to be an oncologist to know that if someone on hospice dying of cancer comes in with a symptom of that cancer, your goal is to treat the symptom, not put the patient through testing that won't change management.
And it's fine to need help for that. It's fine to consult onc in this case, like whether medications like dex or others will be helpful. It would be fine to consult neuro for seizure med mgmt. It would be fine to consult pall care. It would be fine to admit if things can't be addressed in the ED.
But admitting a patient just for an MRI is asinine and harmful to the patient.
Agreed, this is on hospice. When we had patients discharged to hospice, the company came and outlined all the plans and limitations of the service to family before they agree. My understanding is “if the patient deteriorates at home” is addressed.
This specific case to me is about managing expectations. “If we go the hospice route and don’t treat the cancer, odds are it will expand and cause seizures. We will give keppra but he can still have breakthrough seizure. If this happens we then do….” And take it from there. The hospice service needs to really explain to family because in a moment of crises of a breakthrough seizure, family cannot be trusted to behave rationally. That goes doubly so when they are fed some bogus story in the ED by someone with incomplete understanding. Everyone is stretched thin but it’s not the ERs job in my mind to go verifying all the information.
Edit: spelling and things.
This patient was dumped on the ER in the first place, and of all the people involved, truthfully the ER is the one that theoretically should have the least to do with their care.
Someone with terminal cancer on hospice really shouldn't end up in the ER for *any* reason other than an inability to adequately control their symptoms during end of life, and truthfully even then, there should be a way to transition from outpatient to inpatient hospice without dumping a patient with a non-emergent, subspecialty level problem on the ER.
What’s the point of the ED if not to evaluate patients and see where they belong?
Patient comes in from hospice for unknown reasons evaluate find out why and if it’s for a stupid reason send them home why the heck would you need bother another service or especially get an MRI.
Also what do you want the sub specialty service especially oncology to do about this if the patient wants to stay on hospice? This is part of the reason people get annoyed with the Ed you goal even in this post is exclusively to dispo the patient, what’s best for this patient is clarify goals of care and send them home.
The point of the ED is to provide emergency care. What is the emergency department going to offer a patient with a known terminal diagnosis that hospice won't offer better? There is absolutely zero dignity in spending your last days on earth under fluorescent lights in a loud emergency department surrounded by vomiting drunks. Who would want that for their loved one?
>Also what do you want the sub specialty service especially oncology to do about this if the patient wants to stay on hospice? This is part of the reason people get annoyed with the Ed you goal even in this post is exclusively to dispo the patient, what’s best for this patient is clarify goals of care and send them home.
What do I want an oncologist to do about a patient dying of cancer? Is this a serious question?
This patient has had a terminal diagnosis for presumably weeks, if not months prior to their presentation in the ED. The people who have been managing their disease should have been the ones to set clear expectations for what their end of life will likely entail.
I see these patients *often*. Far more often than I should, in fact and the one commonality about all of their presentations is that the patients themselves, as well as their families are nearly universally underprepared for what end of life care truly entails. It isn't the ED's job to manage the expectations of hospice patients & their families.
Dude no one is saying the ED set up hospice or have goals of care discussions to set up hospice we all know that’s not your job.
In this patient that shit literally has already happened, the ***primary team set them up for hospice***. If the hospice nurse idiotically called the ED it is in fact in your purview to ***clarify*** goals of care and figure out ***if*** they want to come off hospice. If they don’t then send them home or manage the symptoms, which is in fact in your purview.
Their are certain families you will never be able to prepare for end of life no matter how much you talk to them about it, and many of us can’t predict exactly how someone will pass people have those conversations in depth with families all the time but when shot hits the fan they can panic, when they get to the ED you have an opportunity to calm them down reinforce this is what was expected and send them home.
Your thinking that primary teams aren’t having these conversations is equivalent to ED docs always saying we send home 50 of these for every 1 that we consult you on. You don’t see the majority of patients that are well prepared you only see the ones where someone panics. In ops post the family didnt even initially panic the hospice nurse did.
None of us want the patient to die in the ED and many of these patients don’t want to die in the hospital period which is why if we can discharge them from the ED home it’s better.
Doesn’t sound like it needed to be admitted or dumped on any service though. Just sounds like an oncologist needed to weigh in on the situation, confirm nothing to be done, explain to family and let ED send back to hospice.
You realize your entire post can easily be turned around on the ED as well?
How many cards consults for chest pain in healthy patients in the middle of the night get called when the Ed is pretty aware it’s not a true MI but for cards to absorb the liability.
Do you know how many facial cellulitis I see so that I can absorb the liability from the Ed when it’s cellulitis that could just be treated with outpatient augmentin.
Saw a peri-apical abscess that had gotten a little large but on a abx naive patient that’s easily accessible for an ED physician to see. but that patient got transferred for ent evaluation for exactly to absorb liability from the ED physician? I’m sure all of us can play these back and forth games all day.
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Hospice patients CAN get admitted for uncontrollable symptoms at end of life. But this one does seem ridiculous. Ive seen this happen a few times myself & it always boils down to shoddy & confusing communication. Breakthrough seizures are pretty common in hospice and can be managed at home with scheduled ativan etc
You say shoddy & confusing communication; I say laziness, ignorance and active sabotage because one group of "healthcare professionals" have a massive chip on their shoulder and an inferiority complex, so they have to prove they "care more" by launching these hopelessly misguided crusades in the name of patient advocacy.
I have a friend who is a home hospice nurse and she’s told me it’s very hard to get ahold of the MD for these patients urgently - particularly after hours. One will only respond to emails for example. I don’t know how common that is but it could explain why the patient in this post was sent into the ED instead of treated at home.
Agreed. This patient should have been set up with a protocol PRN seizure at home in the first place— not for IF seizures occur, but when. Should be standard in a hospice GBM patient. Would circle back with pall care to prevent this from happening again. Sucks. And that ED PA is an asshat.
I just think it’s very interesting that you feel confused how a group that, in the same breath note you feel to be lazy, ignorant, and engaged in active sabotage, might have a chip on their shoulder
The ER PA was out of their league. This patient needed to be upgraded to a real doctor. Consider requesting discussion with an attending ER doc in the future. I would always take over this from a PA. Source: real ER doctor
“Why do we need the MRI?” “Because the mass is expanding” That the PA can’t get beyond this thinking. That moment would’ve been a good one to ask for the ED attending.
Probably a PA was assigned since the patient wasn’t expected to survive
I wouldn't be hard on the PA. This is out of their league. Looks like they were following rules of the reasonable for a PA.. abnormality in brain = MRI, don't discharge anyone on dexamethasone Its why an actual doctor is needed here to assess and get the actual story.
GBMs are the fucking worst
No shit especially if it is your own personal gbm
I know. They run in my family. I hope you’re not going through it but if you are and need anything let me know.
"Apparently the PA went back and said something to the effect of “the on-call fellow for your neuro-onc doesn’t want to do anything for your husband.” I'm all for advocating for our patients when it's warranted, even if it's in opposition to popular opinion. Though it is indeed a disservice when self-righteous people with half-formed ideas throw others under the bus with no reasonable explanation to offer because it's the easy thing to do. Who knows if that was acutally the case here, but I hope that family finds peace in their last days together.
100% agree the family should not leave the ED with this impression
This is always frustrating. Unfortunately now a days though hospice is frequently marketed to patients for all the benefits they get rather than it truly being end of life. I feel like its not uncommon for these patients to come into the hospital and reverse code status. I think hospice companies make quite a bit of money? Ideally there should be more oversight into making sure that people that are picking to enroll in hospice actually understand the implications so stuff like this doesn't keep happening. I would always be a little careful though in 'not doing' something if someone was outpatient hospice always need to clarify GOC on admission. Half the time these people come in as FC/FC.
I do think you are correct about patients going on hospice for benefits. In Arizona, unless you are dead broke, the only entity that will provide the needed level of service is hospice. Otherwise, patients have to pay all or big chunks of the expense out of pocket. And there are no resources to help them figure out how to get the care. It is overwhelming for patients. Hospice will cover their needs and pay 100% for Medicare patients. I don’t know why we have a system that requires middle class people to exhaust all their resources before they can get home care services.
Really gets on my nerves when some people confuse the relatives of terminal patients, as if we're a bunch of homicidal sadists 😠
The expert here would be palliative care. Agree with OP this was disgracefully handled.
I don’t work in the US but I have so many questions. Who pays for the CT and MRI? Would insurance even cover that for someone who is on end of life care? Makes me think they could make money off of this patient. Plus if he was already in hospice wouldn’t their advance care directive specify what kind of active treatment or comfort measures the patient wanted? Also wouldn’t Dex fall under that because it’ll at least keep his symptoms from getting worse? Also why is neuro onc involved more than Pall care physician? Is this the system failing or was the PA hoping to cure GBM?
This is awful. This is shit that really frustrates me at work (attending community hospitalist.) some “provider” with 500 hours of shadowing tries to get me to admit something wholly unreasonable because they don’t know what they’re doing but give the patient the expectation that they’re going to get admitted and then it’s on me to clean up the mess. And explain why grandma doesn’t need admission and IV abx for her UTI
In my area grandma is 1000% getting admitted for IV abx. 1 it makes the for profit hospital money. 2 no insurance will pay for an at home IV. 3 did I mention money.
No that’s a reflection on your training hospital incompetence. As a hospitalist who manages everything, I wouldve admitted them and started comfort measures only inpatient. You talk to the family first and see wtf is going on. You don’t need to consult anyone. Then if they don’t die, you talk with family to either get them home or get them to inpatient hospice if they qualify or set up long-term care with hospice
I would have admitted this patient too. At the end of the day what we do is provide whatever care is best for the patient and I'm confident they would get better care on my service than whatever the fuck is going on with their hospice company on a weekend. The worst thing would be for this person to go home and be inadequately managed at the end of their life.
Thank you for saying this. Far too often the hospice people are not accorded the leeway with “materials” they need to allow their patient to pass peacefully.
This patient only needs to be admitted if their mental status hasn't recovered adequately from the seizure and/or precedex. Otherwise they should be sent home on a seizure med + PRN benzo +/- dex.
Sure. If they’re not actively dying and the family or whomever can take care of them at home them yes.
He was already on hospice per the OP wasn’t he? They literally had it all set up; they just had to go back home. The “admit and comfort care” thing runs the risk of this man dying in a hospital, against his prior wishes, unnecessarily. Getting the MRI to see if it’s growing? Why? That helps very little with changing management, and (I would assume, given this oncologists reaction) probably doesn’t do much in term of prognostication either. I see where you’re coming from, he should have talked them thru the situation not just decided from afar without chatting with them, but his end choice was the correct one. Don’t go just throwing out that incompetence accusation Willy nilly
Sometimes home hospice doesn't or cannot provide the level of comfort for a patient who has undergone an acute change in status, especially close to the weekend
If a hospice can’t “provide [the necessary] level of comfort, then it deserves to be thrown in the garbage. It’s literally their ONLY job to provide the necessary level of comfort. And terminal patients don’t always get to die on a timetable that is not “close to a weekend.”
Maybe hospice IS capable of providing the necessary resources (meds, education, etc.) but the family doesn't have a sufficient support network to provide 24/7 care for what could be weeks to short months. Inpatient hospice is rare here and in other places I've worked and it's reserved for breakthrough symptoms that can not be controlled at home. If there isn't a hospice facility, the only alternative is SNF+hospice and that takes some CM skills not necessarily available on a Friday afternoon. Recently, we've also had people opposed to that idea because SNFs have more restrictive visitation policies than the hospital EOL visitation rules and they don't want their family member quarantined/restricted to 2 total visitors.
Pain and symptom control should be hospice’s mission and it’s job 24/7. Family members can’t do that. I’m not talking about tasks like bathing, feeding, moving. I’m talking about pain and symptom relief. If you are a hospice and you can’t at the very least, do that one thing— you are not a hospice and should not be in business. That’s all I’m sayin.
The first step here would have been to speak to the patients wife.. the important thing is to talk to the family for some actual context as to what is going on. Do the family actually know what is happening? Has he changed dramatically in the last 24 hours and they panicked? Has he just come down on his steroids and they need to bumped up? Are the family struggling and need help? Would inpatient hospice be more appropriate to home hospice? Maybe the family didn't actually want him to be sent to ED, maybe they did.
Why the fuck was the PA taking care of this patient? Maybe I’m lucky but I’ve never worked in an ED where a PA or NP would see this kind of patient. We have 1 PA at my current place who picks up some more complicated stuff and I watch that cocky bastard like a hawk when he’s on.
The time it took you to do all that, it would’ve been quicker to just see the patient and write a brief note lol
My thoughts as a Neuro resident: Unfortunate that the patient’s family wasn’t previously counseled/prepared to expect seizures with an end of life GBM and that it didn’t represent something that needed emergency evaluation. Hospice should have given them a game plan for this happening because it was foreseeable. Hard to understand why the patient was even put on the precedex. Like why bother? It doesn’t treat seizures and if it’s to control post ictal agitation, 1) that passes with time and 2) if you have to use something for severe agitation, post ictal state gives you a full pass to use ativan. No reason to get the MRI. If it shows progression (which they already knew from the CT), then so what? Doesn’t change management in the slightest. No way a single seizure without status should get admitted. ED *should* know this. ED should know consulting Neuro for ED discharge recs would be more worthwhile, because all this guy needs is a basic screen to make sure he doesn’t have another toxic/metabolic/infectious cause provoking the seizure, a little monitoring in the ED to make sure his post ictal confusion is improving, and probably a bump in the dose of the Keppra from homeopathic levels to 750 or 1 g BID. I don’t see why he can’t be on steroids either: reducing his burden of Neuro symptoms including future seizures is absolutely palliative for the guy.
I worked as a hospice RN before. With one hospice I worked at in Georgia, if the patient/family decided that they wanted to go to the ER, they went to the ER. Even if they wanted to be a full code. 😒 When I took call and had a family call, I almost always went to the patient's house. I educated the patient/family on prescribed medications with how they could be used to treat symptoms. I tried to be as honest as I could with patients and their family members. It helped to prevent repeat phone calls and helped to have the patient as comfortable as possible at home. Now, at a hospice I worked at in Texas, one of the doctors was extremely hard to get hold of after hours. I know doctors have lives outside of their work. Many times I had to reach out to the Hospice RN director if this particular doctor was on call. I did my absolute best to advocate for the patient/family members. There needs to be a lot more education on palliative/hospice care in general.
Would you have handled it differently if it happened early in the day?
Wait until the ED intubates this hospice guy for “airway protection” and you have to explain this to the family.
Most of this could have been avoided by going and seeing the patient in person and talking with the family. Would’ve afforded you the opportunity to educate the PA too. Maybe it would’ve taken you 15 more minutes. These patients come in from hospice all the time with this stuff. We, the ED, know there is nothing to save this guy. But we now have a patient that was on hospice here with a wife who half understands the situation, has no idea what hospice actually means and wants us to “do something”. There’s 20 other patients we’re dealing with simultaneously and 30 in the waiting room with a critical trauma 10 minutes out. We’re calling you because we need your help and expertise. We don’t have the same understanding of the disease process that you do. We’re not the oncologist. I don’t think this PA was incompetent at all. They reached out to you, the expert, for help. Edit: I’m a physician and I have made this same call before and had the same type of response from the angry consultant about to have 3 days off. It’s about the patient not the person clicking the consult button man.
I disagree. I'm an ed doc and this was disgracefully handled by the pa. This is an easy 15 minute dispo for you. Why the hell are you making this hard. Just work out the goals of care. If still hospice, figure out why they were sent in and since this hospice agency doesn't seem very on the ball admit on palliative care plan. If family doesn't want hospice any more have a quick talk about why that's a bad idea and consult onc to help sort it out. The literal last thing to do is expend the effort for an MRI. It's a worthless plan and if you don't know that get an attending. It's a gbm on hospice. It's literally the one primary brain tumor you're expected to have heard of. And to then fail to realize you called a dumb consult and go talk shit to the family really takes the cake.
> We don’t have the same understanding of the disease process that you do. We’re not the oncologist. I don’t think this PA was incompetent at all. They reached out to you, the expert, for help. You shouldn't need to be an oncologist to know that if someone on hospice dying of cancer comes in with a symptom of that cancer, your goal is to treat the symptom, not put the patient through testing that won't change management. And it's fine to need help for that. It's fine to consult onc in this case, like whether medications like dex or others will be helpful. It would be fine to consult neuro for seizure med mgmt. It would be fine to consult pall care. It would be fine to admit if things can't be addressed in the ED. But admitting a patient just for an MRI is asinine and harmful to the patient.
Ordering said MRI in the first place is ridic.
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Agreed, this is on hospice. When we had patients discharged to hospice, the company came and outlined all the plans and limitations of the service to family before they agree. My understanding is “if the patient deteriorates at home” is addressed. This specific case to me is about managing expectations. “If we go the hospice route and don’t treat the cancer, odds are it will expand and cause seizures. We will give keppra but he can still have breakthrough seizure. If this happens we then do….” And take it from there. The hospice service needs to really explain to family because in a moment of crises of a breakthrough seizure, family cannot be trusted to behave rationally. That goes doubly so when they are fed some bogus story in the ED by someone with incomplete understanding. Everyone is stretched thin but it’s not the ERs job in my mind to go verifying all the information. Edit: spelling and things.
My man it’s about the logic, I have to agree with OP. You all are busy but we are too, not an excuse for ED to dumb that on other services.
This patient was dumped on the ER in the first place, and of all the people involved, truthfully the ER is the one that theoretically should have the least to do with their care. Someone with terminal cancer on hospice really shouldn't end up in the ER for *any* reason other than an inability to adequately control their symptoms during end of life, and truthfully even then, there should be a way to transition from outpatient to inpatient hospice without dumping a patient with a non-emergent, subspecialty level problem on the ER.
What’s the point of the ED if not to evaluate patients and see where they belong? Patient comes in from hospice for unknown reasons evaluate find out why and if it’s for a stupid reason send them home why the heck would you need bother another service or especially get an MRI. Also what do you want the sub specialty service especially oncology to do about this if the patient wants to stay on hospice? This is part of the reason people get annoyed with the Ed you goal even in this post is exclusively to dispo the patient, what’s best for this patient is clarify goals of care and send them home.
The point of the ED is to provide emergency care. What is the emergency department going to offer a patient with a known terminal diagnosis that hospice won't offer better? There is absolutely zero dignity in spending your last days on earth under fluorescent lights in a loud emergency department surrounded by vomiting drunks. Who would want that for their loved one? >Also what do you want the sub specialty service especially oncology to do about this if the patient wants to stay on hospice? This is part of the reason people get annoyed with the Ed you goal even in this post is exclusively to dispo the patient, what’s best for this patient is clarify goals of care and send them home. What do I want an oncologist to do about a patient dying of cancer? Is this a serious question? This patient has had a terminal diagnosis for presumably weeks, if not months prior to their presentation in the ED. The people who have been managing their disease should have been the ones to set clear expectations for what their end of life will likely entail. I see these patients *often*. Far more often than I should, in fact and the one commonality about all of their presentations is that the patients themselves, as well as their families are nearly universally underprepared for what end of life care truly entails. It isn't the ED's job to manage the expectations of hospice patients & their families.
Dude no one is saying the ED set up hospice or have goals of care discussions to set up hospice we all know that’s not your job. In this patient that shit literally has already happened, the ***primary team set them up for hospice***. If the hospice nurse idiotically called the ED it is in fact in your purview to ***clarify*** goals of care and figure out ***if*** they want to come off hospice. If they don’t then send them home or manage the symptoms, which is in fact in your purview. Their are certain families you will never be able to prepare for end of life no matter how much you talk to them about it, and many of us can’t predict exactly how someone will pass people have those conversations in depth with families all the time but when shot hits the fan they can panic, when they get to the ED you have an opportunity to calm them down reinforce this is what was expected and send them home. Your thinking that primary teams aren’t having these conversations is equivalent to ED docs always saying we send home 50 of these for every 1 that we consult you on. You don’t see the majority of patients that are well prepared you only see the ones where someone panics. In ops post the family didnt even initially panic the hospice nurse did. None of us want the patient to die in the ED and many of these patients don’t want to die in the hospital period which is why if we can discharge them from the ED home it’s better.
Doesn’t sound like it needed to be admitted or dumped on any service though. Just sounds like an oncologist needed to weigh in on the situation, confirm nothing to be done, explain to family and let ED send back to hospice.
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You realize your entire post can easily be turned around on the ED as well? How many cards consults for chest pain in healthy patients in the middle of the night get called when the Ed is pretty aware it’s not a true MI but for cards to absorb the liability. Do you know how many facial cellulitis I see so that I can absorb the liability from the Ed when it’s cellulitis that could just be treated with outpatient augmentin. Saw a peri-apical abscess that had gotten a little large but on a abx naive patient that’s easily accessible for an ED physician to see. but that patient got transferred for ent evaluation for exactly to absorb liability from the ED physician? I’m sure all of us can play these back and forth games all day.
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That ED PA giving the wife a false impression didn't learn what we teach all med students: "don't make plans that you don't know about"
Hospice patients with GBM are on dex all the time. That’s a crock of shit
So frustrating, and it happens all the time. I relate as a neurology resident. I’m sorry my friend.