RIP Evelyn Gabbs

http://www.cbc.ca/news/canada/manitoba/story/2012/03/08/mb-fred-douglas-home-delay-iteam.html

As a nurse reading the article there are numerous questions I have, and I think the CBC did not do justice by getting the full story out.

Essentially a long-term care resident, aged 95, was found to have symptoms of a stroke in her wheelchair.  After a delay, family was contacted and the resident was transferred to an acute care facility. Once assessed at the acute care facility, she was transferred back to the nursing home for palliative care, where the family stated she was not given proper care.   The family was quoted in saying that "they might have been able to help her...brought her back a little bit".  It was an emotionally charged article and many comments are very angry at the "abuse" and "lack of care" that nursing homes provide.

Was there a DNR/Do not transfer order?  Many long term care facilities have lengthy discussions with family regarding this, and it sounds like this may be the case for Mrs. Gabbs.  Typically only with consultation with family do those with the DNR/Do not transfer order get transferred to the hospital for acute care.  If this was the case, the LPN was working within the parameters/goals that the facility and the family had initially agreed upon.  In strokes speed is of the essence, so I don't know what happened to cause of the delay but perhaps the DNR/Do not transfer played a factor.  Perhaps consultation between the LPN and RN and possibly MD took some time and who knows what really happened prior to contacting family.  It also sounds like there was a delay in the family responding to the nursing home's repeated call.

As an Emergency nurse I care for many of those nursing home transfers, and some patients are quite sick, whereas other patients we oftentimes do not know why they were transferred.  Most that arrive do have the DNR form, but have transfer modifiers.  Please note that in Ontario all nursing home patients have a physician on call for any concerns (day or night), as well as an Registered Practical Nurse and a Registered Nurse to assess the patient.  Having not worked in a long term care facility (but having had rotations in one as a student), I'm not speaking to all nursing homes but typically there are distinct policies about who to contact about transfers if it's deemed needed.  Sometimes the wishes of the family override the policies, and at that point the ambulance is called.  The family would pick up the tab for the cost of the ride, as well as the transfer home. In Ontario, some of the cost of the ambulance is not covered by the government, and billed to the patient.  Intra-facility non-emergency transport is also covered by the family, or is billed to the family from the nursing home.

As for the palliative care, if there is no order for analgesia or it is deemed to not be needed, the LPN/RN would only give a moderate dose and would be titrated according to resoponse.  If the order is not satisfactory for the patient needs, then a call to the MD is needed.  If the MD does not order more analgesia or sedation, then it would be illegal for the RN/LPN to provide any further medication beyond the parameters set out by the physician.  Again, without the health care record right in front of me I cannot comment on what occurred after Mrs. Gabbs returned.  All we have is family reports of how their mother looked when she was dying- something that is never easy to see.  My condolences to the family, and I hope they get more answers for their questions, and some peace.

To go saying the nursing home is corrupt and only thinking about money is placing judgement without the full picture.  There are many long-term care facilities where the care is exemplary.  All the patients we receive are clean and looked medically cared for.  The emotional care is the responsibility of the family.