Ethics case study
When it comes to nursing home dumps, should you just go along or speak up?
- Previously published ethics case studies are available online.
- For additional ethics resources, visit the College's Center for Ethics and Professionalism
Editor's note: This is the 22nd in a series of case studies with commentaries by the ACPASIM Ethics and Human Rights Committee and the Center for Ethics and Professionalism. The series uses hypothetical cases to elaborate on controversial or subtle aspects of issues not addressed in detail in the College's "Ethics Manual" or other position statements.
Mrs. Smith was back in the emergency room. The 88-year-old nursing home resident had been brought into the hospital every few weeks for the past several months with fevers and other complications. She was hearing-impaired and suffered from dementia, all of which made her delirious in the unfamiliar surroundings of the hospital. As a result, she was yelling and generally disruptive.
The nurses started the work up and the admissions process. Although the housestaff team was not pleased to see another "nursing home dump" admission, they started an intravenous line for fluids and antibiotics, checked a chest X-ray and gave Mrs. Smith a thorough examination. After a three-day stay in the hospital, the patient returned to the nursing home with a diagnosis of urinary tract infection and a prescription for oral antibiotics.
Physicians cannot overlook the mandate to participate in activities that will improve a flawed system.
A few days later, a medical student who had helped care for Mrs. Smith encountered her at the nursing home at the beginning of a medicine rotation. The student was surprised to see her former patient smiling and cheerful, looking at pictures that a group of elementary school children visiting the home had drawn for her. It was hard to believe that this was the same person who had been in such obvious distress in the emergency room just a few days earlier.
After spending some time in the nursing home, the medical student came to realize that it was a valuable community for the severely ill and disabled, not an inferior version of a hospital. For patients like Mrs. Smith, the environment was clearly much more appropriate.
During her visit, the student encountered Dr. Welby, one of the physicians who had treated Mrs. Smith at the teaching hospital. During her conversation with him, she asked, "When Mrs. Smith gets a fever, are you sure it does her good to send her to the hospital?"
"No, I don't think it does," Dr. Welby answered.
The student persisted: "Then why do it?"
"There are lots of reasons, but I don't like any of them," Dr. Welby replied. "She would probably do better if I could keep her here. She wouldn't get skin breakdowns or tears, she would never be restrained and she would be among people who know and care about her. But we just can't afford it. The nursing home gets paid the same per day to treat a patient with antibiotics and one without, and Mrs. Smith usually needs more than $100 a day in antibiotics alone. The nursing home gets no additional income for a day when she needs repeated monitoring and assessments.
"When she is in the hospital," he continued, "I get paid, the nursing home doesn't run up costs, and everyone does well—except perhaps Mrs. Smith. She has no family to advocate for her or even to accept less aggressive medical treatment in order to keep her more comfortable. So we just keep doing this, and it's not just Mrs. Smith. We hospitalize dozens of people from here every month, and with most of them we're caught in the same bind. I don't like it, but it's the best I can do. I know we could do better if we kept her here, but we can't afford that."
The student was upset at what was happening to Mrs. Smith. She realized that her colleagues were not interested in addressing "nursing home dumps," and although she knew that something was wrong, she was not sure that she could fault Dr. Welby.
Increasingly, physicians are complaining that the systems in which they work do not best serve patients' interests. Particularly when it comes to caring for patients in nursing homes, many say, the incentives seem to run counter to good medical care.
As physicians, we sometimes see the shortcomings all too clearly. We can make an occasional accommodation to keep a system functioning, but can we accept recurring inadequacy? If we are unhappy with the situation, what can we do about it?
Although the doctor in this case study is functioning in a deficient system whose failures are self-perpetuating, a good physician must do something to try to improve such a situation. It may be difficult to decide exactly what to do, but that should not obscure the physician's obligation to speak up and try to improve a flawed system.
To define what the physician should do to effect change, it's helpful to consider what a good system of care would look like. For one, it would be able to care for many acutely ill nursing home residents on-site, and it would encourage residents to make hospitalization and resuscitation plans in advance. In addition, hospital care for this population would cause fewer iatrogenic complications, and the payment system would not punish nursing homes for providing acute care for their patients.
With that in mind, there are several steps the physician can take when faced with this kind of situation:
- One possible approach would be to go to nursing home administrators and explore the idea of caring for a few of the frailest patients at the nursing home, without transfer. Physicians could use such an opportunity to see if it is possible to provide adequate care in these instances in the nursing home without running up too much of a bill.
- Another avenue is to explore having a local hospice provide on-site care. Though changes in Medicare regulations may soon alter the situation, Medicare hospice can usually be made available to nursing home residents. The hospice gets paid almost the same daily rate as for patients at home, though for patients who are also relying upon Medicaid, that payment is routed through the hospice program, which then pays the nursing facility. The hospice benefit is only available when the two programs have a written agreement that meets certain requirements, so coordination and advance planning are essential.
- Talking to the emergency room medical staff and hospital administration may also yield fruitful suggestions on how to improve the care of nursing home patients. For example, the emergency room staff might welcome clarifications to routine advance directives so they can more easily understand and trust the written forms that the patient brings. The hospital might also be willing to move a nursing home resident to a regular hospital bed more quickly to limit the hazards of falls and skin breakdown that so often occur in the emergency room. Perhaps hospital physicians could also take the lead in talking to a patient's family about re-hospitalization for long-term chronic problems.
- Physicians could also collect data on the frequency and outcomes of situations where nursing home residents are transferred to hospital emergency rooms. It might turn out, for example, that the problem transfers are mostly confined to one nursing home, or involve patients with a particular set of conditions, and responses could be tailored to those situations. Measuring the frequency of transfers may help galvanize nursing home leadership into taking these situations seriously.
- Playing an active role in advance care planning in the nursing home for hospitalization and resuscitation could also help to ameliorate the problem. Many patients this frail—or their families—are willing to take their chances with the treatments they can get in their nursing facility, and they should have the opportunity to make that desire known. Even those who want more aggressive treatment often have limits that they can articulate: a time-limited trial on a respirator, for example. Knowing about such considerations in advance would be helpful and would allow physicians to tailor care to the patient and family in an efficient and sensitive way.
- An even more direct tactic would be to approach the local Medicaid carrier to find out what accommodations it might be able to provide. For example, the carrier might be willing to subsidize advance care planning or care management. Physicians could also ask the local quality review organization to study the practices and possible opportunities for improvement.
Ultimately, working to help mobilize political forces to change Medicare and Medicaid reimbursements is a key to achieving better care. Physicians can start by writing letters to their representatives and professional societies.
Obviously, physicians can't spend all of their time on this issue; it is likely to be just one of many problems that demand their attention. Moreover, not every nursing home can take on the level of care that such improvements might require. Change of any sort may be troubling or threatening to colleagues, and even strong efforts by physicians may prove ineffective.
Physicians, however, are often in a unique position to identify problems and they have real power to effect change. A physician's ethical obligation as a patient advocate extends beyond individual patients.1 Physicians also have a responsibility to help improve health care delivery systems that disadvantage or devalue patient care.1, 2, 3, 4 Only then can physicians serve their patients and communities well. If they are not part of the continuing improvement of our systems of care, the problems are likely to continue.
Acknowledgements: The Ethics and Human Rights Committee would like to thank Joanne Lynn, FACP, author of the case history and commentary.
1. American College of Physicians Ethics Manual, 4th ed. Ann Intern Med. 1998;128:576-594.
2. Pellegrino ED. Ethics. JAMA. 1994; 271:1668-70.
3. Povar G, Moreno J. Hippocrates and the health maintenance organization: A discussion of ethical issues. Ann Intern Med. 1988;109:419-24.
4. Sulmasy DP. Physicians, cost control, and ethics. Ann Intern Med. 1992;116:920-6.
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