this comes up in a nursing home a lot.

One thing that makes my job easy - the family either insists on ER transfer, or implies that they feel (or their uncle's friend's wife said) that the patient needs urgent CT, MRI, IV "vitaminas" or whatever.

then they go to the ER.

I don't feel good about that, but I gotta protect myself, as nobody else will. I don't EVER want to be blamed for not doing enough, by a patient/family, or some cavalier EMT or ER intern.

I can't count the times I've sent folks to the ER, & they return 5 days later with a medical student hospital discharge summary note implying we're incompetent & sent the patient too late. We'll often diagnose & try to treat at the NH first, but being 90yo & w/ advanced COPD, it's a real bitch to treat pneumonia - sometimes it works & sometimes it doesn't. And sometimes they're DNR and sometimes they're not.

Just the other day I had an EMT tell me that I could figure out if the patient in resp distress had CHF or pneumonia if i just sat them up & saw if they got better (???) - ok perhaps for a nursing or EMS textbook, but in real life for an MD it's just NOT THAT SIMPLE.