Discussion w15 650
Instructions for Discussion Replies to 6 DQS
DO NOT JUST REPEAT SAME INFORMATION, DO NOT JUST SAY I AGREE OR THINGS LIKE THAT. YOU NEED TO ADD NEW INFORMATION TO DISCUSSION.
1- Each reply should be at least 200 words.
2- Minimum One Peer reviewed/scholarly reference ( NO MAYO CLINIC/ AHA)
3- APA 7th edition style needs to be followed.
4- Each response should have reference at the end of each reply
5- Reference should be within last 4 years
Q-1
I would recommend a short term acute rehab for the patient due to the patient’s difficulty walking. This difficulty in mobility is one admission criteria, but we can expand this to include problems in the activity of daily living, and transfers (Bielecki & Tadi, 2020). The other side is that there are special pieces of equipment that can help the patient advance quickly that are unable to be obtained at the home such as a Hoyer lift (Bielecki & Tadi, 2020). However, there are requirements that the patient has to be able to perform or agree to. Such requirements include being able to participate in at least three therapies a day, three hours of therapy for five days a week, and is agreeable to participate (Bielecki & Tadi, 2020).
If the patient can meet the criteria, most insurances will issue precertification or speak with the case manager to apply the patient’s benefits to a rehab facility, and most of the time the insurance will elect to pay for a rehab stay (Smith, Kulhari, Wolfram, & Furlan, 2017).
I have found acute rehabilitation facilities to be highly beneficial for many reasons. These facilities are able to provide intense training programs that are patient-specific and designed to bring the patient back to their prior level of functioning as quickly as they can. I would not want to see a patient who has been deconditioned to the point of motility issues return to the hospital because of a fall, or a subsequent injury from a fall.
Also, there is the timing aspect. For example, home health has a limited amount of availability per week, so this patient may only receive three one-hour sessions per week, increasing the time it takes for the patient to return to their prior level of functioning. This increase in return time also increases the risk of an injury due to decreased mobility. While rehab facilities can perform multiple rehab sessions per day for these patients to quickly return their lost strength.
I would evaluate each patient individually, but in my opinion, I would still elect to send this patient to an acute rehab facility in order to gain his strength back as quickly as possible. There are some things we can weigh against the decision such as evaluation of the patient’s home status. For example, if the patient had the ability to even have the specialized equipment in the home, or family members who were physical therapists. I think this would be the only exception to where I would change my mind and write for home health.
References:
Bielecki, J.E., Tadi, P. (2020) Therapeutic Exercise. StatPearls Treasure Island StatPearls Publishing. Retrieved from:
https://www.ncbi.nlm.nih.gov/books/NBK555914/
Smith, A. L., Kulhari, A., Wolfram, J. A., & Furlan, A. (2017). Impact of Insurance Precertification on Discharge of Stroke Patients to Acute Rehabilitation or Skilled Nursing Facility. Journal of Stroke and Cerebrovascular Diseases, 26(4), 711–716.
https://doi-org.lopes.idm.oclc.org/10.1016/j.jstrokecerebrovasdis.2015.12.037
Q-2
A safe discharge would depend on the patient, the home situation, and the patient needs. If a patient is recovering slowly it could be beneficial for them to go to a rehab facility for help and supervision. The patient isn’t ambulating well and if he lives alone that wouldn’t be a safe discharge as this could increase risk of falls, decreased mobility, and deconditioning. PT/OT would be beneficial to the patient to improve mobility and safety. Requirements include the need of therapy for 3 hours of therapy for 5-7 consecutive days for physical therapy, occupational therapy, and speech/language therapy, they need nursing assistance with specialized training, a case manager, and the expectation that the patient will benefit from therapy (Forrest, et al., 2019). I would begin with getting a PT/OT consult in the hospital and assess for general patient safety. I would use their recommendations to guide my decision and recommend the appropriate services. I would then ask about home life and what type of house he has, what help he has at home, and if he had a plan with getting help if he lived alone (such as having a friend/family stay with him). I would then assess patient’s cognitive function and the ability to safely decide on what he wants. If he was deemed safe to go home with home health services, then I would be ok with sending him home with that. He would get the help he needs, and someone would be able to check on him. There is a benefit of less chance of complications with being at home versus in a facility. The rehabilitation at home and in a facility of knee replacements was evaluated and shown there was no significant difference besides the reduced post-discharge complications (Buhagiar, et al.,2017). If the patient isn’t safe to go home and requires intensive rehabilitation and continuous supervision then the rehabilitation facility would be the safest discharge for the patient.
Buhagiar MA, Naylor JM, Harris IA, et al. Effect of Inpatient Rehabilitation vs a Monitored Home-Based Program on Mobility in Patients With Total Knee Arthroplasty: The HIHO Randomized Clinical Trial. JAMA. 2017;317(10):1037–1046. doi:10.1001/jama.2017.1224
Forrest, G., Reppel, A., Kodsi, M., & Smith, J. (2019). Inpatient rehabilitation facilities: The 3-hour rule. Medicine, 98(37), e17096. https://doi.org/10.1097/MD.0000000000017096
Q-3
A 72-year-old male with a past medical history for hypertension, congestive heart failure, chronic back pain, and diabetes is admitted to the hospital for hypotension suspected from a possible accidental overdose. What are the criteria for discharge? Explain the importance of utilizing hospital recommendations and teachings. List some meaningful community resources in the response.
Discharge planning is characterized as a development of an individualized discharge plan of the patient before leaving the hospital to ensure that the patients are discharged at the right time and that adequate resources are given after discharge (Alper et. al, 2020). Patient cognitive status, activity level, and functional status, nature of the patient’s current home and suitability for patient’s conditions, family support, transportation from the hospital to home and follow- up visits, and the availability of services in the community to assist the patient with ongoing care are some of the factors that providers consider when deciding where to send the patient after hospitalization. One of the hospital standards when discharging patients in the hospital is a discharge summary. A discharge summary is an important tool that is written by the discharging physician that is usually reliable and standardized to ensure that there will be clear communication about the hospital course(Sponsler,2017, p. 94). The recommended components of the discharge summary are the primary and secondary diagnoses, pertinent test results, pending results, patient’s condition at discharge, recommended additional workup or treatment plan, a complete list of the reconciled medications, follow-up arrangements, resuscitation status, documentation of patient education and identification and contact information for the sending and receiving providers (Sponsler,2017, p. 94). In this case, providers need to ensure that the medication is reconciled properly and the instructions are clear to prevent any errors or adverse effects such as hypotension to the patient. Patients need to be educated and instructed on how to prevent falls while at home and to make sure that the patient is capable of safely preparing and taking their medications on time. Also, providers need to identify any pending results and follow-up appointments after discharge. It is also important that patients who have the chronic condition is well-informed about their disease, the disease process and what can they do to prevent further exacerbation or hospitalization. Some of the community resources such as adult day health, pharmacies that offer blister packs, medication therapy management, and those pharmacies that deliver medications at home are available in elderly or disable patients.
References:
Alper, E., O’Malley, T.A. & Greenwald, J (2020).
Hospital discharge and readmission. Retrieved from https://www.uptodate.com/contents/hospital-discharge-and-readmission#H8
Sponsler, K.C. (2017). Care transitions at hospital discharge. S.C. McKean, J.J., Ross, D.D. Dressler, D.B. Scheurer (Eds). The
Principles and Practice of Hospital Medicine 2nd edition (pp. 90-96). Mcgrawhill education.
Q-1
A provider’s obligation is to do no harm. Healing the patient from whatever ails them is a holistic healing process. Advanced directives are a large part of the healthcare process as well, and should be discussed earlier and more often than they actually are (House & Ogilvie, 2020); (White, 2019). Advanced directives are essentially the wishes of the patient when they were made when the patient was in a fully coherent mental state and was able to make their own decisions
(House & Ogilvie, 2020); (White, 2019). These are the direct wishes of the patient to be followed when the patient themselves are either incapacitated or incoherent (House & Ogilvie, 2020); (White, 2019).
State and federal legislation affect advanced directives in the way that family members can override them when the patient is incapacitated as they are the next of kin or the emergency contact (House & Ogilvie, 2020). Each state has some variations to this loophole, but they mostly stay the same amongst the states (House & Ogilvie, 2020). Some believe that this loophole has arisen due to the massive increase in litigation especially in healthcare (House & Ogilvie, 2020).
There are many ethical dilemmas that occur when allowing for such a loophole and having advanced directives at the same time. A perfect example is from my work in an MSICU yesterday (2/17). I had a patient who coded last Sunday and was extubated Tuesday. The patient is no longer neurologically intact, now on dialysis, and we suspect an anoxic brain injury that has left the patient lethargic, drowsy, unable to follow commands, and opens his eyes to his name but does not track. The family originally brought in a Living will and Advanced Directive when the patient arrived that clearly stated DNR status and refusal of lifelong treatments. However, once the patient began to code, the wife rescinded everything. As healthcare professionals we are now stuck, as there is appropriate documentation to validate the DNR, but as the patient is now incapacitated the next of kin now has medical decisional making capacity. So at this point, she wanted everything done. Fast forward a few days to 2/17, I am explaining to the wife and sister that his prognosis is poor, dialysis isn’t helping, his quality of life is how he is presenting now, and I even relayed the fact that the patient clearly said he did not want any of this. The wife acknowledged his advanced directive, but stated: “We need to do everything anyway”.
The ethical dilemma has presented as such: we are going against the patient’s wishes, especially with futile and end-of-life care, while the wife has the power and authority to change any medical decision that was made previously. We, as healthcare professionals, are now forced to prolong this patient’s suffering out of fear of retaliation and litigation.
In my practice, I have always reasonably accommodated the patient’s spiritual practices regardless of what they were. We have had sermons in the ICU patient’s rooms, as well as celebrations of life, or spiritual rituals.
In my opinion, if that’s what the patient wanted, then so be it, we have to respect their wishes, even if we don’t agree with them.
References:
House, S.A., Ogilvie, W.A. (2020). Advance Directives. StatPearls Treasure IslandStatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK459133/
White, G. (2019). Do not postpone discussing advanced directives. CMAJ : Canadian Medical Association Journal = Journal de l’Association Medicale Canadienne, 191(28), E796. https://doi-org.lopes.idm.oclc.org/10.1503/cmaj.72212
Q-2
The grieving process is altered in patients who have dementia living with a spouse (Hovland, 2018). This is suspected because the outcome of dementia usually ends up being failure to thrive due to cognitive decline (Hovland, 2018). The spouse recognizes the end result, and pre-emptively begins to grieve as they become aware of the end result of the disease (Hovland, 2018). The stages of grief differ in each individual in terms of intensity, duration, speed, and accpetance to move onto the next stage (Hovland, 2018). Some people take it well, while others do not, and my need support from family, friends, or healthcare team members (Hovland, 2018).
The nurse practitioner can offer many options for support for both the patient and the spouse, especially once the information has been obtained of advancing metastatic cancer (Mughal, Azhar, Siddiqui, 2020). Palliative care, respite care, or hospice placement can be offered as the criteria is met for hospice placement with a life threatening illness, futile care, and/or failure to thrive (Mughal, Azhar, Siddiqui, 2020). The etiology of hospice admission could be either dementia, or the advanced metastatic cancer (Mughal, Azhar, Siddiqui, 2020).
In terms of actually offering these options to the spouse, careful conversations would need to be had regarding what hospice is, what they do, and what they can offer (Mughal, Azhar, Siddiqui, 2020). I usually begin this conversation with the idea that the goal now has changed from treating and curing, to making the patient as comfortable as possible. A common question I usually get asked in the MSICU is “well how long will it take?” as in how long will it take for the patient to expire, and I usually answer “Only God knows, and all we can do is what the patient wants us to do”. However, I also explain that if the patient persists for an extended time, hospice lasts up to 6 months in Florida, and can be extended at any time. Also, I am sure to mention that if they need a break, or begin suffering from caregiver fatigue, that hospice offers respite care as well, where the patient can be moved into the hospice home and the fmaily member can take a break. I belive that the patient being comfortable is just as important as the family members involved being able to take care of themselves as well.
Usally these conversations are difficult to begin, but once the explanation process starts, it ususally sets in with teh family members that this si the best course of action tso theeir loved one can die with dignity.
References:
Hovland, C. (2018). Welcoming death: Exploring pre-death grief experiences of caregivers of older adults with dementia. Journal of Social Work in End-of-Life & Palliative Care, 14(4), 274–290.
https://doi-org.lopes.idm.oclc.org/10.1080/15524256.2018.1508538
Mughal, S., Azhar, Y., Siddiqui, W.J. (2020). Grief Reaction. StatPearls Treasure Island StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK507832/
Q-3
Providers must address the advance directives to their patients to determine the future medical care when the patient becomes incapable of making medical decisions. Advance Directives are described as the legal mechanisms that reinforce the fundamental professional and moral responsibilities of health care providers and institutions to promote and to protect patient autonomy, welfare, and dignity (Armstrong & Silverman, 2017, p. 224). There are two types of advance directives namely the living will and the health care proxy. The living will is also known as instructional directives that define the type of decision that should direct the patient’s care. The second type of advance directive is the health care proxy that is often called a durable power of attorney for health care. It is an individual that is selected by the patient to make decisions.
Some states have a state-authorized portable order. State-authorized portable orders are described as a specialized form of an identifier such as a do not attempt to resuscitate bracelets or necklaces that are authorized by state law or a state medical director that translates to the patient’s preference regarding specific life-sustaining treatment decisions into portable medical orders (National Archieves and Records Administration, 2020). Oregon’s Physician Orders for Scope of Treatment (POST) and New York’s Medical Orders for Life-Sustaining Treatment (MOLST) are some of the examples of the state- authorized portable orders that aim to make the patient’s desire more easily available to emergency medical personnel (National Achieves and Records Administration, 2020). Some of the ethical or spiritual dilemmas that patients and families encounter during these discussions are unethical experimentation, life-prolonging treatment, life-sustaining treatment, and medical orders of end-of-life care. For example, providers support that each person has the right to determine what medical treatment they will receive including what life- sustaining treatment should be provided if an individual has a terminal issue. Providers need to ensure that they know the current state laws, living wills and durable power of attorney, they are considerate of the patient’s cultural beliefs and practice and should discuss the issue of life- sustaining measures with each of their patients before medical emergency happens or before institutionalization to prevent ethical dilemma during end-of life care.
References:
Armstrong, K. & Silverman, R.D. (2017). Medical- Legal Concepts: Advance Directives and Surrogate Decision Making. S.C. McKean, J.J., Ross, D.D. Dressler, D.B. Scheurer (Eds). The Principles and Practice of Hospital Medicine 2nd edition (pp. 224-230). Mcgrawhill education.
American Academy of Family Physicians (2020). Ethics and Advance Planning for End-of-Life Care. Retrieved from https://www.aafp.org/about/policies/all/ethics-advance-planning.html
National Archives and Records Administration, (2020). Federal register: Informed consent and advance directives. Retrieved from https://www.federalregister.gov/documents/2020/05/27/2020-10264/informed-consent-and-advance-directives