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Client was end stage cancer and started in hospital, still cognizant and making decisions for themselves. They had a medical POA in place. I was called in to help navigate the medical aspects of care. Communication between myself and client was limited as I live in another state, but there were people to mediate.
After 4 weeks and near the end, they were transferred to a nursing home. The client was on heavy pain meds and going in and out of consciousness. They made their treatment wishes clear to me shortly before the pain got unbearable and, ultimately, lost consciousness. Their wishes had changed since discussing previously with the medical POA, but POA was not privy to that discussion. POA was told of client’s new decision but chose to stick to the original plan made with the client months prior. I appealed to the POA to alter the treatment plan to keep client as comfortable as possible and bring in a hospice team. The POA declined. Final result was that my client had to endure bouts of excruciating pain that could have been prevented.
Question: Do we have any leverage to go above a POA if we have knowledge of a change in the client’s wishes? It seems like third-party interference to me, but I felt I had no legal authority.
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You’re correct, you have no legal authority. The DPOA has that. It’s really unfortunate that the client didn’t talk w/ their DPOA regarding their change in priorities. All you could do was share w/ the DPOA (assuming you had the client’s written permission to do so) the details of your conversation. Then it was up to them. This reinforces the importance of having a release of information in place as well as very quick turnaround w/ communications.
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I am sorry to hear that this patient suffered because their paperwork no longer reflected their wishes. This case is a good reminder that everyone needs to review their advance directive periodically to be sure it reflects their current choices of agent and care. I suggest patient advocates consider adding that task to their client checklist.
Linda Beck
Square One Elder & Health Advocacy
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Hello,
I have a patient in their late 70’s in a SNF short term rehab. He has been in and out of the hospital since March for emergency gall bladder surgery, stent in liver and then diagnosed with end stage renal failure – he has been on dialysis since that time. No prior other major medical other than major deconditioning from back problems. It appears his kidneys are now starting to function again and will know by end of week if dialysis will be discontinued. The patient was making significant progress with rehab, walking up to 50 yards with assist, and the had a set back three weeks ago He started having confusion, some mumbled speech and refusal to cooperate with rehab, etc. It took several requests for urinalysis, staff had difficulty obtaining, and results came back negative. Requested again, another delay for 5 days and results came back positive but NP wouldn’t prescribe antibiotic for another 6 days until sensitivity report. Thus over 3 weeks of symptoms with no antibiotic. Patient just completed antibiotic treatment yesterday but continues with escalating delirium, remains non cooperative with rehab and is somewhat combative – very unlike his personality prior to a month ago. Patient may also be dehydrated as he refuses to drink but DON doesn’t want to give him IV fluids due to dialysis fluid restriction (he is allowed 1500ml day). Pt had severe constipation last week but that is resolved. Per recommendation from the nurse at dialysis, the NP agreed to remove him off five meds last week that may increase confusion (pain pills, anti depressant, muscle relaxer, antihistamine). Vitals remain normal. The NP does not take initiative or have any urgency but I’m thinking the patient should have a repeat urinalysis to check UTI status, blood panel, hydration and be examined by physician. The administrator of the nursing home says “this is normal and it’s the transition before a patient goes from rehab to full time skilled nursing care”. What are your thoughts? -
Can NPs practice independently in your state (i.e., without physician oversight)? If not, a physician should be overseeing your patient’s care, but some physicians “oversee” more carefully than others. I would insist on evaluation by a physician . (Full disclosure: I am a physician). Many NPs do not have sufficient training to understand highly complex cases.
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I am mortified by the administrator’s response that this is “normal”. One of the most important things we can do for our elderly clients is to ensure that the care team is well-informed about their baseline. On so many occasions, aging/elderly patients have acute mental status changes that are chalked up to “normal aging” when a detailed workup would, as you have suggested with the UTI, reveal a source of acute delirium. I agree with Carolyn to insist on a physician evaluation (even if the NP is able to practice independently in your state). You can also request to speak to the Medical Director and/or file a complaint with the state agency that oversees SNFs in your state.
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What is the client saying? My thought is it doesn’t take six days to get a sensitivity back. It takes 72 hours. Not sure what the six day delay was also, he has a liver stint. could it be malfunctioning and causing high ammonia levels ? I would ask for an ammonia level to rule out other possibilities. ? Brain scan? Since this is not baseline, the ruling out should cover all until cause found in my opinion. It seems they are showing delays in care which is an issue. Difficult case. Good luck.I am glad she has you
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