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 “For a patient nearing the end of his or her life, transfer from a
nursing home to the emergency department can be inappropriate, with
potentially negative consequences, but transfer in these
circumstances is, regrettably, all too common,” UK researchers write
in the Emergency Medical Journal.
“People are trained to call emergency services, we learn as children
to call 911,” said Nancy Berlinger of The Hastings Center, a
bioethics research institute in Garrison, New York. But calling
emergency services is often the worst medical option for nursing
home residents, and antithetical to what they actually desire, said
Berlinger, who wasn’t involved in the study.
Yet, “without clear and authoritative instructions indicating an
alternative, that is likely to happen,” she told Reuters Health.
In those cases, first responders get little clarity from staff or
medical records, she added.
For the new report, Georgina Murphy-Jones of the London Ambulance
Service NHS Trust and Stephen Timmons of the University of
Nottingham interviewed six London-based paramedics about challenges
they face in nursing homes.
The paramedics often had trouble understanding nursing home
residents’ wishes, according to Murphy-Jones and Timmons. When a
patient no longer had the capacity for decision-making, paramedics
found it challenging to balance patients’ best interests with
pressure from nursing staff, patients’ relatives and colleagues.
Records of patients’ wishes were “rare” and generally restricted to
resuscitation preferences. One paramedic reported, “The care notes
would tell me what medication she’s on and what type of cancer if
you are lucky.”
The paramedics wanted to act in patients’ perceived best interests,
but others’ interests often come into play. One paramedic who
arranged for a patient to be treated at the nursing home rather than
transported to a hospital felt the “staff were unhappy because it
meant they had to provide one-to-one care and actually look after
someone dying.”
Another recalled a typical scenario when relatives oppose the
patient’s preferences: “So if she’s ill and she says she wants to
stay at home and the family want her in and I think she’s sick
enough to go in, she goes in, even though she said she wants to
stay.”
Kevin Biese, who leads the American Geriatrics Society’s emergency
medicine collaborative, told Reuters Health that the choice to
transport a nursing home resident to the hospital can be a “life and
death” decision. Transfer increases the risk of delirium, functional
decline and death, he said.
“The reason to go the hospital is to get a therapeutic intervention
helpful to the patient and consistent with the patient’s wishes,”
said Biese, of the University of North Carolina at Chapel Hill
School of Medicine.
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But Biese doesn’t blame facility staff. “I am sympathetic to what a
hard position they are put in,” he said. “For cultural reasons, for
liability reasons and for lack of resources, it is really hard for
nurses at nursing homes in the U.S. to keep patients at the
facility.”
Biese and Berlinger both said Americans near the end of life have an
advantage that the UK patients in this study did not. In most
states, patients can have their doctors fill out a “POLST” form, for
Physician Orders for Life Sustaining Treatment.
“For those who are seriously ill, advance directives are not
enough,” said Susan Tolle, director of the Oregon Health and Science
University Center for Ethics in Health Care.
“Patients nearing the end of their lives who wish to set limits on
treatments need to turn preferences into action with orders on a
POLST,” Tolle, who wasn’t involved in the new study, told Reuters
Health. Theresa Sanderson, administrator of the West Hartford Health
and Rehabilitation Center, told Reuters Health that because the
study involved just a few paramedics, it can’t be considered “true
evidence.” At her 160-bed facility, “We do not have situations where
paramedics are the decision-makers,” said Sanderson, who is a member
of the American College of Health Care Administrators.
“We have educated our staff about the very real impact of transfer
trauma,” she said. “We want patients to stay at home and be treated
in place.”
It’s important for all nursing homes to clarify residents’
preferences regarding resuscitation and intubation, Berlinger said.
Even more important: a facilitated discussion of values and goals
that can be transcribed into instructions for every employee. “It is
owed to the patient, the family and to that aide at three o’clock in
the morning,” Berlinger said. “It is owed to the paramedic.”
The authors of the study were unable to respond to a request for
comment by deadline.
SOURCE: http://bit.ly/25RQD6k Emergency Medical Journal, online May
17, 2016.
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