In as recent post, I made a case for engaging hospice services. Here is an example of the reason that unfortunately I encountered several times.

Katherine’s situation illustrates how sloppy end of life decision making can be harmful, both from a humanitarian and fiscal point of view.  She was 92, and a long time denizen of a nursing home.  She had suffered many strokes, was non-communicative, and needed facility personnel to perform all personal care for her.  Her out-of-state daughter provided somewhat less than compulsive oversight of her care.  One evening, the patient was found on the floor next to her mattress (no bed–an intervention designed to minimize injury from a fall).  This happens frequently in nursing homes and usually does not result in significant injury.  “Going to ground” is a more appropriate conceptualization of the event. However, this unwitnessed “fall” caused the nursing home, by policy, to call 911.  Most nursing homes, spooked by the fear of legal liability, would have done the same.  The ambulance arrived, even as the nursing home tried to unsuccessfully notify the daughter.  This unaware woman was trundled off to the hospital where thousands of dollars worth of x-rays, blood tests, and cardiac tests were performed.  Nothing concrete showed up, and she was admitted to the hospital for observation.  

Isolated in her unfamiliar environment, she became agitated and psychotic, a common occurrence when the elderly are subjected to a change in scenery—even when they appear to be oblivious to external stimuli. As physical restraints are illegal in Illinois, Katherine was chemically “restrained.”  That is, she was given a combination of sedatives and anti-psychotics that calmed her—for awhile.  As the medications wore off, she continued to be combative, so the hospital doctor poured on more medications.  By morning, she was in a coma.  This of course prompted a head CT scan, which was negative for any acute pathology.  Her unresponsive state was clearly due to an overdose of drugs, which, as is often the case in the elderly, built up to dangerous levels due to the slower metabolism that attends aging.  In three days, she was finally arousable and was sent back to her nursing home.  No one had been able to contact her daughter.  The patient did not carry a DNR status, so, if she had suffered a cardio-pulmonary arrest, the hospital and the facility would have been legally obligated to attempt cardio-pulmonary resuscitation.  

Had the patient been on hospice, an entirely different scenario would have unfolded.  When the patient was found on the floor, the nursing home would have called the hospice caring for her, and a nurse would have been dispatched to evaluate the situation at any time day or night.  The nurse would have looked for signs of injury (bruises, an out-of-line limb, etc.) and any indication of pain.  The on-call hospice doctor would have been contacted for consultation if necessary and would have prescribed any necessary medications.  In the absence of any obvious fractures, no x-rays would have been performed.  Hospice would have contacted the patient’s health care power of attorney, and any decision regarding more aggressive care would have been discussed.  For instance, if it appeared that the patient had fractured her hip (an injury that can be detected fairly easily by clinical exam), hospitalization, with surgery, would have been contemplated, if that course seemed be best for the long term comfort of the patient.  Alternatively, simple treatment of any associated pain might be the best prescription.  

After her hospitalization, Katherine never recovered what little cognitive function she had, and she quit eating.  Her daughter was finally contacted and the patient was admitted to the care of my hospice.  Detailed discussions resulted in a DNR order, which inoculated the patient against inappropriately aggressive care.  The daughter directed hospice to admit her mother to a hospital under no circumstances, and stated that we should render comfort care only—no matter what malady might occur.  The patient died in a couple of weeks, and the patient’s dying process could have been much less expensive if she had been on hospice before her “fall.”  But far more importantly, had a primary care doctor been proactive in helping to make end of life decisions years before Katherine’s acute events, her death would have been much less painful, and far more dignified.


  1. Mary Walsh says:

    Good article. My husband and I shared it with our children. These matters should be discussed in advance. Thank you.

  2. Anonymous says:

    What would have been her admitting diagnosis to Hospice if she had had the good fortune to join prior to her “going to ground?”

  3. Anonymous says:

    Oops, just read your previous Medical Beat.

  4. Anonymous says:

    Terrifying story. You say it would have been different if the patient had been “on hospice” before all of this happened. How does one proactively get on hospice?

  5. jpwmd says:

    The patient would have qualified for hospice with the diagnosis of dementia–she could do nothing for herself and she was unable to speak. There are specific criteria for demented patients to be eligible for hospice, and Katherine would have been more than qualified. Her primary care doctor would have been the one to make the referral to hospice. If there is no primary doctor, nursing home physician could make the referral. Simply ask them (and refer them to this blog if there is any resistance); then the hospice doctor
    has to agree on the need for hospice, which in Katherine’s case would have been virtually automatic.

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