Friday, January 16, 2009

Why we Need Appropriate Care Committees: A Case Study

Linda Jones was an 87 year old woman who had been in a nursing home for the past four years. She was admitted to the nursing home by her two daughters because of mental deterioration to the point of being unable to care for her self. Since entering the nursing home she had been transferred to the hospital six times. The first, three years ago, was for pneumonia and while in the hospital her daughters agreed to the placement of a feeding tube. However, her daughters were concerned about her over all well being as she did not recognize them and could not communicate in any meaningful way. She appeared to be unaware of her surroundings and did not respond to her name. Her third child, a son, lived thousands of miles away and was not in contact with his mother or sisters. Linda was returned to the nursing home which was now reimbursed at the much higher Medicare rather than the Medicaid rate. During the past three years Linda was readmitted to the hospital five times, twice for pneumonia and twice for urinary tract infection, each time bumping up the nursing home collections from Medicaid to Medicare. Her last admission to the hospital was for sepsis (bacteria in the blood) possibly from her lungs, urinary tract or the small skin breakdown over her sacrum that the nursing home tried diligently to prevent. In the hospital Linda was placed in the intensive care unit (ICU), intubated (breathing tube) and given other medications.

The ICU doctors told her daughters that Linda was terminal. Her daughters agreed with the doctors that she should not under go cardiopulmonary resuscitation (CPR) and should be transferred to hospice, but wanted to wait for their brother who was about to arrive. Linda, like most Americans, had not executed an advance directive nor designated a durable power of attorney. The son arrived and strongly disagreed with the do not resuscitate order and hospice despite meetings with the ethics committee which had agreed with the ICU doctors. The hospital having had unpleasant and expensive legal experiences in such circumstances took no action. Linda remained in the ICU for another three weeks, had a cardiac arrest and died after one hour of attempted CPR. No autopsy was performed.

Linda’s ordeal is reproduced in one form or another hundreds of thousands of times in American hospitals yearly. The results are: 1) Linda suffered a disfiguring intrusive death that was an assault on her human dignity. 2) The family as a whole (all three children) was faced with decisions they were not prepared to make and were mired in conflict. 3) Doctors and hospitals have become accustomed to, and in many cases financially dependent on, providing non-beneficial care. 4) The resources consumed were enormous.

What would have happened if my admitting form and appropriate care committee system were in place? Upon Linda’s first hospital admission the admitting form would have created a contract between Linda, her family, and the physicians which stated that only beneficial care could be delivered and also would have served as an up-to-date advanced directive. Cardiopulmonary resuscitation would not have been ordered and she would have not had suffered that indignity. Because of her severe and profound dementia the advice of the physician staff likely would have been that after her first hospital admission she should be treated for any complications in the nursing home and if unsuccessful placed in hospice. If conflict arose the appropriate care committee would have been consulted and most likely would have agreed with the physician’s plan, as it was reasonable and humane. With committee concurrence the family would have been told that third party payers would not be responsible for other than nursing home and hospice care. Knowing that, the son would have most likely agreed with the plan and family conflict would have been avoided. Our society would have saved significant resources which could then be devoted to universal coverage and other worthwhile goals.

No comments: