Unnecessary trips to hospital

[mrsapple]

Mum is in 7th year of VasDem. She has been sent to hospital twice this week as an emergency by the CH, who rang me to go to the hospital after she had left the CH. The first time was because they found a soft tissue lump on her hip - we waited just over five hours for an X-ray and blood tests, to be told her GP should have made an Out Patient appointment for her for an ultrasound scan.

The second time (at 2.30am) the CH sent her in as an emergency because she was "unresponsive". After four hours of tests we were told she had merely been deeply asleep and nothing unusual had been found after chest X-ray and more blood tests - this time it took another four hours to get ambulance transport back to the CH. Altogether distressing and upsetting.

Basically I want to instruct the CH not to send her to hospital again unless she appears to be in pain. I want them to keep her at the CH, and keep her comfortable and pain free with GP's help if necessary. I have EPA, and she has a Living Will with a DNR. I don't want her to have any treatment which might prolong her life, which is fully in accordance with her expressed wishes.

Has anyone given written instructions to their CH about this, and how forceful can I be in pushing for it? Also, could the CH refuse to look after her there?

All advice much appreciated!!

 

[Soobee]

Yes I had asked for the Nursing home not to send mum to hospital. This was because the last time she was left in A&E for over ten hours in a soiled pad. I don't think they knew what to do with her and she would not have made any sense. The home rang me at 11.30pm.

It was the only time I did not go to the hospital with her to ensure she was getting the correct care and it was a decision I deeply regret. I went in the next day and they had just sent her back with the soiled pad and no discharge letter or anything.

After that I said to only send her to hospital if there was something they could treat her for which couldn't be given at the home. They agreed to this and put it into her care plan and didn't call paramedics again. The trouble is paramedics always want to get the person checked over at hospital whether you feel it's necessary or not.

Hopefully you can get the home to agree to something similar.

 

[nitram]

In my wife's case the DNAR, which is typically a red edged A4 sheet https://www.resus.org.uk/pages/DNARfma1.rtf
was always kept at the front of her care plan.

There was also an advanced care plan which said that on any transfer out of the care home the DNAR was to accompany her and the receiving party made aware of its existence.

The advanced care plan also stated that she was to be kept pain free and comfortable and only be transferred to hospital for a fracture, bleed, or any other clinically reversible condition not treatable in the care home.

 

[jaymor]

My husband has recently been very ill which lead to a long conversation instigated by his doctor. DNR was put in place and I asked for no hospital admission unless for broken bones. He was not to be peg fed and if they thought appropriate they could re hydrate using the subcut he was already having. Pain was to be controlled.The Manager and senior Sister assured me they could give my husband all the palliative care he would need.

The Doctor said he now knew what to do should he need to as he planned my husband's care. I can at anytime change my mind and he has to be advised immediately. The staff have never given up on my husband and he is still with us, something a month ago neither I or the staff though he would be.

So for us we know there will be no hospital visits for him regarding dementia and he can be cared for as we wish.

Jay

 

[Witzend]

Funnily enough today I had the annual care plan meeting with my mother's CH, where such things are discussed, among others.

Since she is 96 with advanced AD, we had already told them that we would want hospital ONLY if it were absolutely necessary, e.g. in case of another broken hip. Basically, at this stage, we just want her kept calm and comfortable. She falls fairly often and so does sometimes have to go to A and E, which she finds distressing and agitating, so in her own best interests we want to avoid it as far as poss, certainly as regards actual admission.

The CH has never argued with us, or insisted on sending her. Thing is, I think a lot of care homes will see it as their duty of care to send someone to hospital if there is the slightest concern. They may also worry about relatives accusing them of negligence if they do NOT send someone for everything, so it is up to relatives to make their wishes clear. They may of course not agree and so much will naturally depend on the individual circs.

A while ago I asked the CH to cancel a follow up hosp appt, about 10 days after my mother had fallen yet again. Since she would not keep still for an X ray at the time, and medics thought she might have broken her nose, they arranged this follow up. But since she was obviously OK I could not see the point of putting her through all that hassle and upset. The CH agreed 100%, but if I had not said anything they would have felt obliged to send her anyway, because the medics had suggested it.

 

[mrsapple]

Thank you so much for your replies.

The CH has a copy of the Living Will and DNR, so do the hospital as I supplied them with a copy when mum was admitted to hospital in September last year and the doctor requested a discussion on end of life care with me at that time.

I didn't mean to sound harsh in previous post, but mum finds these protracted hospital visits distressing and she seems to go even more downhill after them.

I will arrange a meeting with the CH Manager and separately with GP and see what plan we can put in place.

 

[nitram]

"...The CH has a copy of the Living Will and DNR, so do the hospital..."

Beware

 

[Pickles53]

If the person did not make any advance directive or living will and there is no H&W POA then am I right that there is nothing that can be put into a care plan along the lines the various posts have suggested? In other words, the care home would have to send the person to hospital regardless of the family's wishes? (All this assuming the person no longer capacity to make these decisions)

 

[cragmaid]

I recently have had a discussion with Mum's GP as we already have a DNR form in place. This was to agree on an Emergency Health Care Plan.....EHCP. This is a separate plan and is designed to set out the plan of action for Emergency care. What we agreed is that Mum may be taken to Hospital in the event of a trauma such as a fall causing skeletal damage or significant blood loss, but in the event of a Chest Infection for example she would be treated trip with oral antibiotics but no hospitalization for IV treatment likewise with her frequent faints which are usually due to fluctuating BP. This is to (hopefully) minimize trauma and confusion that a blue light trip to A&E brings.
Her CH are in full agreement and their understanding is so comforting. I must add that Mum .is Late stage/End of life care

 

[jaymor]

Thank you so much for your replies.

The CH has a copy of the Living Will and DNR, so do the hospital as I supplied them with a copy when mum was admitted to hospital in September last year and the doctor requested a discussion on end of life care with me at that time.

I didn't mean to sound harsh in previous post, but mum finds these protracted hospital visits distressing and she seems to go even more downhill after them.

I will arrange a meeting with the CH Manager and separately with GP and see what plan we can put in place.

You were not sounding harsh at all. It was only because of the way my husband was treated when he was first admitted to hospital with pneumonia that I decided that he was not going again for any infections. He certainly was not happy there. He constantly needs hydrating and the nursing home can do this via a subcut so no need for hospitalisation. If and when he stops eating I will take that to mean he no longer wants to fight the disease so no peg feeding. His nursing home can cover everything else so that is where he will be. Surrounded by family and carers who know him and have cared for him so well. Hopefully he will continue to recover and we won't be faced with this for quite a while.

Jay

 

[Pickles53]

I recently have had a discussion with Mum's GP as we already have a DNR form in place. This was to agree on an Emergency Health Care Plan.....EHCP. This is a separate plan and is designed to set out the plan of action for Emergency care. What we agreed is that Mum may be taken to Hospital in the event of a trauma such as a fall causing skeletal damage or significant blood loss, but in the event of a Chest Infection for example she would be treated trip with oral antibiotics but no hospitalization for IV treatment likewise with her frequent faints which are usually due to fluctuating BP. This is to (hopefully) minimize trauma and confusion that a blue light trip to A&E brings.
Her CH are in full agreement and their understanding is so comforting. I must add that Mum .is Late stage/End of life care

Thanks craigmaid. Mum isn't at this stage yet, but it's definitely something to think about as she is about to move into a care home. This will mean a new GP, so something to talk to him/her about.

 

[Witzend]

I didn't mean to sound harsh in previous post, but mum finds these protracted hospital visits distressing and she seems to go even more downhill after them.

.

You didn't sound remotely harsh to me - rather the opposite, in wanting to save your mother unnecessary stress and upset.

 

[mrsapple]

Thank you all for your replies and support - this forum is always my first port of call now if I need advice!

Nitram, thank you for the info regarding a DNACPR notice. All mum has is a note in her care plan - this specific form has not been completed as far as I know, and nothing was sent in with her to hospital. I have asked for an appointment with her GP and also with the CH Manager to discuss this further. She does have a Living Will which is very explicit.

Cragmaid, thanks for the info about EHCPs. I've found comprehensive guidance on Treatment and Care Towards the End of Life and Advance Care Planning on the GMC website, which gives some pointers for discussion with GP and CH Mgr.

 

[nitram]

There are >>>GUIDANCE NOTES<<< associated with the model DNAR form on my previous link.

 

[mrsapple]

Just a quick update.

Had meeting today with manager at Care Home - mum does in fact have an EHCP, which was signed by GP on 22 July 2014 - a fact I was totally unaware of. Clearly staff were as well, as they sent her to hospital twice a week later. Mum also has a proper DNAR Notice - apparently these were kept in one file in the manager's office, which is locked at night and at weekends. Now they are going to put them in the individual's Care Plan file, kept in the unit.

Had a meeting with Nurse Practitioner at surgery as well and went through the implications of the EHCP and DNAR in detail, requesting some amendments. Mum will also be taken off statins. The GP or Out of Hours Service will always be contacted in the first instance in the event of an emergency, and I will be contacted as well before any decision of treatment or otherwise is made.

Hopefully this will mean fewer unnecessary trips to A & E. I realise that refusing treatment is very much easier said than done, but I do know from mum's detailed Living Will and from many previous discussions we had, that this is what she would want.

Thank you all, for your help and advice - very much appreciated.