Do Not Hospitalize Orders

[maidao2001]

Kentucky

This isn't a medical malpractice question.

I am the legal guardian and POA of my sister who is in Nursing Care in Warren County, Kentucky. I asked her physician to put a do not hospitalize order in her file, but apparently there isn't one there, just a do not resucitate order. I got a call from the Nursing staff that she isn't eating or drinking (she has advanced A/D) l and needs hydration at the hospital. I went ahead and consented to this for now since there is no order in her file.

I live in California and am wondering how to make sure the do not hospitalize order is in her file and is legal. Kentucky Legal Aid is closed today, and I can't afford to pay a lawyer.

Any advice on the matter is appreciated, and please, no lectures about the moral aspects of this.

EDIT: Moderators - Sorry, I just realized this probably belongs in the category of POA - feel free to move it.

 

[LdiJ]

Kentucky

This isn't a medical malpractice question.

I am the legal guardian and POA of my sister who is in Nursing Care in Warren County, Kentucky. I asked her physician to put a do not hospitalize order in her file, but apparently there isn't one there, just a do not resucitate order. I got a call from the Nursing staff that she isn't eating or drinking (she has advanced A/D) l and needs hydration at the hospital. I went ahead and consented to this for now since there is no order in her file.

I live in California and am wondering how to make sure the do not hospitalize order is in her file and is legal. Kentucky Legal Aid is closed today, and I can't afford to pay a lawyer.

Any advice on the matter is appreciated, and please, no lectures about the moral aspects of this.

EDIT: Moderators - Sorry, I just realized this probably belongs in the category of POA - feel free to move it.

Are you sure that a do not hospitalize order is even possible?..is even permissible under the law in KY? So, if she breaks an arm or a leg she is not to be hospitalized? Again, I am not sure that is possible.

 

[tranquility]

Any advice on the matter is appreciated, and please, no lectures about the moral aspects of this.

The law will not help you do this immoral thing.

 

[Adam G]

The law will not help you do this immoral thing.

Maybe, maybe not (as to the morality). I ran across this article when I was struggling with being the guardian for a terminally ill immediate family member. I found it worthwhile.

by Ken Murray

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.
It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.

How has it come to this—that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.

To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.

The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax&#8221, walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.

But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.

Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.

It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.

Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.
But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.

 

[Adam G]

(article continued)

Several years ago, my older cousin Torch (born at home by the light of a flashlight—or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.

We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.

Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.

Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC.

 

[ecmst12]

It's not immoral. What you need to do is enroll your mother with a hospice. The social worker at the nursing home will be able to get you in touch with one.

 

[justalayman]

do you have anything from sister, when she was competent, that her wishes are to have a DNH or DNR?

 

[tranquility]

Hospice is not do not hospitalize orders. Here, the OP as a POA and guardian has determined mom should not be hospitalized for anything. That, according to society, is immoral. The law will not allow it. We do not even allow a person in full charge of her faculties without another with possible conflicts of interest (medicaid reimbursement and all that) or required judicial review to make such orders. It's been tried before. Even in this forum we have had people wonder how THEY can set up such an order. (Perhaps by medic alert or something.) They can't. Society will not batter a person, but once they go unconscious, we throw them in the ambulance and take them in. Even if they didn't want it. Sometimes, when the person tried to harm themselves, especially because they didn't want it.

 

[ecmst12]

It's not exactly a "do not hospitalize" order, but if a patient is on hospice, they are not going to call 911 and throw her in an ambulance. Now it's possible that hospice is not appropriate for this patient, but with advanced alzheimers and refusal to eat, that's usually a sign that they are getting ready to shut down. A patient on hospice who falls unconscious will be given palliative care at home (or in the facility). A hospice may be able to care for her in her current facility or she may need to be transferred to an inpatient hospice, that's something they will evaluate after you call them.

If the patient is NOT, in fact, at the end of their life, then you are right that there is not a way to refuse hospital care for any/all reasons and the nursing home can't just agree not to send her to the hospital if the standard of care dictates that they send her. OP's description sounded to me like hospice would be appropriate but of course I don't have all the details and many alzheimers patients are physically healthy enough to live just fine for years and years after their faculties are totally gone.

 

[maidao2001]

do you have anything from sister, when she was competent, that her wishes are to have a DNH or DNR?

Unfortunately no - her Alzheimers came on suddenly. I am certain of her wishes though, since she was a nurse and we both suffered the death of our parents who did not have Health Care Directives in place. We discussed it at length.

I've read the phamplet from this site http://www.hardchoices.com/ (I recommend it) through, cover to cover, in addition to a number of books on the subject, so I'm not going into this uninformed.

The thing is, last time I spoke to her physician he said he would put the order to do not hospitalize in there - I assumed he would know whether that's legal or not.

Are you sure that a do not hospitalize order is even possible?..is even permissible under the law in KY? So, if she breaks an arm or a leg she is not to be hospitalized? Again, I am not sure that is possible.

You make an excellent point that I didn't consider regarding breaking a leg, that sort of thing. I certainly would want that treated. Thank you. I think instead I probably need to put in specific orders regarding artificial feeding and hydration.

Regarding the question of Hospice...the facility has hospice care in the facility so I'm guessing that I need some sort of order to change her regular care to hospice care.

It's not exactly a "do not hospitalize" order, but if a patient is on hospice, they are not going to call 911 and throw her in an ambulance. Now it's possible that hospice is not appropriate for this patient, but with advanced alzheimers and refusal to eat, that's usually a sign that they are getting ready to shut down. A patient on hospice who falls unconscious will be given palliative care at home (or in the facility). A hospice may be able to care for her in her current facility or she may need to be transferred to an inpatient hospice, that's something they will evaluate after you call them.

If the patient is NOT, in fact, at the end of their life, then you are right that there is not a way to refuse hospital care for any/all reasons and the nursing home can't just agree not to send her to the hospital if the standard of care dictates that they send her. OP's description sounded to me like hospice would be appropriate but of course I don't have all the details and many alzheimers patients are physically healthy enough to live just fine for years and years after their faculties are totally gone.

This is the crux...I'm pretty sure they are hospitalizing her because she's not eating and is getting dehydrated, they said that this is happening, but the reason they gave me for hospitalizing her was that they needed to get some blood tests and they were unable to draw blood.

The fact that I'm out here in California doesn't make it easier...I would have put her in care here except her son lives where she's at now and I wanted him to have easy access to her. Though he never visits her, it doesn't make sense to move her now.

To everyone I haven't replied to directly and to those who I have, I thank you all for your replies and thoughts, keep 'em coming if you have more.

 

[justalayman]

Kentucky does allow the withholding of artificial hydration and feeding of a patient as well as any treatment to prolong the life of the patient. That is within their statutes. I have also seen support of a do not hospitalize directive being allowed as well but have not found anything absolute. Of course each is available by an advance directive. It there is no advance directive, the following law applies.

regarding the ability of a person other than the patient making such decisions

311.631 Responsible parties authorized to make health care decisions.

(1) If an adult patient whose physician has determined that he or she does not have
decisional capacity has not executed an advance directive, or to the extent the
advance directive does not address a decision that must be made, any one (1) of the
following responsible parties, in the following order of priority if no individual in a
prior class is reasonably available, willing, and competent to act, shall be authorized
to make health care decisions on behalf of the patient:

(a) The judicially-appointed guardian of the patient, if the guardian has been
appointed and if medical decisions are within the scope of the guardianship;

(b) The attorney-in-fact named in a durable power of attorney, if the durable
power of attorney specifically includes authority for health care decisions;

(c) The spouse of the patient;

(d) An adult child of the patient, or if the patient has more than one (1) child, the
majority of the adult children who are reasonably available for consultation;

(e) The parents of the patient;

(f) The nearest living relative of the patient, or if more than one (1) relative of the
same relation is reasonably available for consultation, a majority of the nearest
living relatives.

(2) In any case in which a health care decision is made under this section, the decision
shall be noted in writing in the patient's medical records.

(3) An individual authorized to consent for another under this section shall act in good
faith, in accordance with any advance directive executed by the individual who
lacks decisional capacity, and in the best interest of the individual who does not
have decisional capacity.

(4) In any case in which a health care decision is made under this section,
hospitalization for psychiatric treatment at a general hospital shall not exceed
fourteen (14) consecutive days unless a court order is obtained under KRS Chapter
202A or 202B. For the purposes of this section, a general hospital is one that is not
owned or operated by the Commonwealth of Kentucky.

(5) An individual authorized to make a health care decision under this section may
authorize the withdrawal or withholding of artificially-provided nutrition and
hydration only in the circumstances as set forth in KRS 311.629(3).

Effective: July 13, 2004
History: Amended 2004 Ky. Acts ch. 116, sec. 19, effective July 13, 2004. -- Created
1994 Ky. Acts ch. 235, sec. 6, effective July 15, 1994.

 

[maidao2001]

Kentucky does allow the withholding of artificial hydration and feeding of a patient as well as any treatment to prolong the life of the patient. That is within their statutes. I have also seen support of a do not hospitalize directive being allowed as well but have not found anything absolute. Of course each is available by an advance directive. It there is no advance directive, the following law applies.

regarding the ability of a person other than the patient making such decisions

Great information...what I was looking for Justalayman. Thank you!!!

 

[tranquility]

It's not exactly a "do not hospitalize" order, but if a patient is on hospice, they are not going to call 911 and throw her in an ambulance.

I think you've just described a DNR.

Now it's possible that hospice is not appropriate for this patient, but with advanced alzheimers and refusal to eat, that's usually a sign that they are getting ready to shut down. A patient on hospice who falls unconscious will be given palliative care at home (or in the facility). A hospice may be able to care for her in her current facility or she may need to be transferred to an inpatient hospice, that's something they will evaluate after you call them.

Please stop thinking. Any "what if's" are irrelevant if one can make such a do not hospitalize order. The decision was made. Now, who do I call the police on if the patient's bedsores can't be treated properly in the nursing home and the home does not get the person to a facility that can handle it? The nursing home, its workers or the OP?

Info edit:I am uncertain how "do not hospitalize" has morphed into food and hydration. They are not equal. But, on the food and hydration front, what of the limitations?

(3) A health care surrogate may authorize the withdrawal or withholding of artificially-
provided nutrition and hydration in the following circumstances:
(a) When inevitable death is imminent, which for the purposes of this provision
shall mean when death is expected, by reasonable medical judgment, within a
few days; or
(b) When a patient is in a permanently unconscious state if the grantor has
executed an advance directive authorizing the withholding or withdrawal of
artificially-provided nutrition and hydration; or
(c) When the provision of artificial nutrition cannot be physically assimilated by
the person; or
(d) When the burden of the provision of artificial nutrition and hydration itself
shall outweigh its benefit. Even in the exceptions listed in paragraphs (a), (b),
and (c) of this subsection, artificially-provided nutrition and hydration shall
not be withheld or withdrawn if it is needed for comfort or the relief of pain.

Doctors and criteria are involved. Absent mom dying from something else within a few days, I don't see her meeting the criteria.

 

[Gail in Georgia]

"Do Not Hospitalize" orders are not unusual.

A patient with a DNH can still be taken to the ER or Life Support Unit (often another name for the ER). They would typically be treated as needed (in this case, rehydrated for dehydration) in the ER, then released back to their previous living arrangement instead of actually being admitted into the hospital.

In the other example used, a person with a DNH who suffered a broken leg would, again, have this addressed in the ER as opposed to being admitted INTO the hospital to have the broken leg addressed.

Gail

 

[justalayman]

"
A patient with a DNH can still be taken to the ER or Life Support Unit (often another name for the ER). They would typically be treated as needed (in this case, rehydrated for dehydration) in the ER, then released back to their previous living arrangement instead of actually being admitted into the hospital.
l

unless there was an order in place to not provide artificial means of hydration, which is legal in Kentucky.