A tragedy based on administrative decisions

I gently rotated his arm as the beads of sweat formed on his forehead.  The pain came in waves.  His face contorted and relaxed in repetitive spasms.  I wondered if my exam was in vain.  The cancer had spread from his lungs to his liver and into his bones.  Once the blood stream had been tainted, the aggressive cells took flight and landed in various organ systems.

We already had the conversation.  I checked the boxes off on the POLST form.

X Do Not Resuscitate
X Do Not Hospitalize
X No Artifical Nutrition

Yet the hospice team had come and gone, and he refused to sign the papers.  He looked me forcefully in the eyes as he spoke.

You’ll take care of it!

But I was starting to feel his confidence was misplaced.  Day after day, I returned to the nursing home to find that our plan was failing to control his late afternoon pain.  Escalating his narcotic dose only provided incremental benefit.  Topical therapy, heat, and massage were adding little.

It was only after a week of failed attempts that he pulled me aside and quietly explained his hypothesis.

It’s the physical therapy, they’re pushing me too hard in physical therapy!

What? I almost fell off my chair. I couldn’t help my voice rising in frustration.

Why the heck are you doing physical therapy?

He took a deep breath before answering.  I could tell he was getting tired of my daft intellect.

Because the hospice people told me if I stopped doing physical therapy, I would be dropped from my Medicare days and would have to pay my own room and board.  And then the physical therapy people told me if they don’t push me hard enough, I will fail to make enough progress and will also lose my funding.

And like a blind man whose cataracts had just been removed, I once was lost but now could see.  He would live out his last hours struggling through futile physical therapy and in constant pain.  But he would labor selflessly to spare his family the financial burden.  He would expend more of Medicare’s resources than if he had just been covered under hospice, and would die sooner and in greater pain.

A tragedy based on administrative decisions made by non-clinical staff working for the government.  The pleas of those in the trenches have been ignored.

These silly rules are killing us, financially and physically.

Jordan Grumet is an internal medicine physician who blogs at In My Humble Opinion.

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  • http://nourishourselves.blogspot.com/ Marie

    I don’t want to seem rude or condescending, but is this post a joke? A
    physician wrote this borderline illiterate and inaccurate essay? Typos happen and are just human. But this is egregious.
    Publishing a piece like this, riddled with the most elementary spelling
    errors ( “vane” instead of vein, “message” instead of massage, “bored”
    instead of board) and ridiculously mixed metaphors (“And like a blind
    man whose cataracts had just been removed, I once was lost but now could
    see.”)
    seriously diminishes the credibility of this otherwise wonderful
    website. Not to mention, his entire premise is simply wrong. There is no such
    Medicare
    requirement for a hospice patient to have physical therapy. I realize
    it is impractical to edit every post, but honestly, this is
    embarrassing.

    • ofps

      Uh, I think it would be vain, not vane or vein.

      • http://nourishourselves.blogspot.com/ Marie

        Oh boy, you got me there! Serves me right. I was half awake and wrote too fast. It illustrates my point, we all make typos, it happens. And I have no idea why my comment came out so oddly formatted. But still, this post is just a shame because there is such an abundance of errors.

        • http://www.kevinmd.com kevinmd

          The errors have been corrected. Thanks for pointing them out.

          Kevin

    • http://www.facebook.com/profile.php?id=120501600 Milinda Houlette

      The way the author wrote this is mistaken, but the Medicare guideline is for skilled care in a nursing home. Whether the patient is hospice or not, when he ceased physical therapy, if he did not have Medicaid then he and his family would be responsible for the nursing home debt. So, literally the hospice patient would have to have physical therapy to keep Medicare paying. I’ve seen it happen as well, and in fact just did an admit on a patient who had been taking physical therapy in her cancer care in her nursing home. She had a mild stroke and could no longer participate and is now in our hospice services under Medicaid pending.

  • southerndoc1

    For starters, no patient in a nursing home should be receiving hospice services. That’s the nursing staff’s job.

    • http://www.facebook.com/josh.hyatt Josh Hyatt

      That is simply untrue. It is not the nursing staff’s responsibility to provide hospice care in any setting, including a long term care setting. Hospice is a very specialized service that requires a unique medical perspective and, towards the end of life, 24 hour monitoring, that a nursing staff in a long term care facility does not have the training or manpower to execute properly. Hospice care and medical care are different and it is unrealistic to expect that LTC nurses and CNAs can simply switch gears at a moments notice. Please learn about palliative care for the sake of your patients who may one day need it.

      • southerndoc1

        “Hospice is a very specialized service that requires . . . towards the end of life, 24 hour monitoring”
        ????
        Enrollment in big bucks, for profit hospice programs is not a pre-requisite for effective, compassionate palliative care.

  • Wendy

    Wow- He’s right-I see it all too often. And yes, Hosprice nurses are visiting with residents all the time while in nursing homes/rehabs.
    I am an Ombudsman Representative in the state of TN, where in the homes I visit, I see all too often people ‘taking’ rehab just so they don’t lose the funding of Medicare. These people really have no hope for gaining anything from it really other than a change in source of payment…its stupid and sad.
    I really think the whole system of trying to keep people alive beyond what is really acceptable to them and letting them actively die in peace and with love and as pain free as possible need to be closer to the forefront of what doctors and nurses are being taught in school and in the institutions I visit. Dying needs to be taught from an early age to be really a part of life….

  • http://www.facebook.com/christie.downing.7 Christie Downing

    As a physical therapist, I can understand the plight. All too often to the rules of Medicare/Medicaid (if and to whatever extents in exists in a particular state) pigeonholes patients into a situation that not only is not in their best interest, but may actually cause physical and/or emotional harm or at the very least, be a waste of resources. This is why we send patients to ECFs only for the fact they need IV antibiotics, why we send them to a hospital and keep them there for at least 3 days before they can have a skilled care day at an ECF and about a hundred other nonsensical rules that do nothing to improve the quality of care.

  • Hornblower1810

    We currently have 7 BILLION bi-peds roaming the planet. As a society we will be forced to face the reality that everyone must die. We simply do not have the human or financial resources to keep a body alive when all hope for at least a minimal quality of life is gone.
    So like every other problem in America today, we will face this problem when it becomes an inescapable crisis. But then again there is a fair chance climate change will solve the problem for us.

  • http://CANDIDMDEXPSLAINSHIGHCOSTDECLININGQUALITYUSHEALTHCARE.COM Alan D. Cato MD

    Dr. Grumet, your point, that MDs are not the only parties at
    fault

    in the annually sky-rocketing-cost of health care, is spot
    on. Today, thanks

    to misapplication of regulatory over sight, non physician
    entities and forces

    are responsible for an increasingly larger part of the
    problem.

    The following is
    excerpted from the book The Medical
    Profession Is Dead and the Doctor

    Is “Critically ill!”:

    ——

    ‘In the past, when doctors had total
    accountability for patient care, defensive
    medicine was limited to physicians only. Today, though, new
    philosophy by regulatory agencies has swelled the ranks of those spending
    money in the practice of defensive medicine. The Joint Commission,
    the Centers for Medicare & Medicaid Services, and state regulators
    have tremendously upped the ante for defensive medicine costs, by
    insisting that more and more allied health professions take an active
    part in case management, whether they are needed or not.

    When medicine was still a profession, the
    accountability for

    end-of-life
    tests and procedures lay entirely with the attending physician, patient,
    and the patient’s family. These were the only parties that needed to
    be satisfied as to what constituted the patient’s best interest. In past times, there were no bureaucratic
    paper trail

    requirements
    being generated, by individuals exemplifying that a

    little
    knowledge is a dangerous thing; and the paper trail then being

    over-interpreted
    by facility administrators, made paranoid by

    regulatory
    agencies’ increasing demands for documentation from

    multiple
    medical disciplines. This is the status today though, and

    it has led
    the administrations of hospitals and nursing facilities to

    become
    engaged in the practice of medicine, by way of developing

    policies.
    These policies are neither physician nor patient friendly, and

    frequently
    impact the patient’s overall best interests and the health

    care economy
    adversely. They are designed expressly for making

    regulatory
    agencies such as the Joint Commission, the Centers for

    Medicare
    & Medicaid Services, and State OIGs jobs easier to perform, and in the
    mistaken belief that such policies will lessen the facility’s exposure
    to adverse publicity or loss of licensure. In reality, such attitudes
    are responsible for tremendous additional unnecessary dollars being
    added on to the cost of care through needless testing and

    consultations,
    to say nothing of the needless discomfort and risk to

    the patients undergoing them.’ —Alan D. Cato MD,
    F.A.A.F.P. (retired), and author of The
    Medical Profession Is Dead and the Doctor Is “Critically ill!”

    (Oct., 2010)
    Amazon Books.com

  • Molly_Rn

    We still need a “diagnosis”
    of dying so that we can properly care for our patients when death is imminent. Yes,
    we all must die, but you shouldn’t have to die a miserable death. If patients
    were able to have a discussion (include their families so they know the patient’s
    wishes) about death and what the patient wants done for them. The discussion must
    be honest so that the patient knows their illness and prognosis and what the
    different aspects of prolonging life will mean to them (pain, unable to speak,
    etc.) so that they can make a choice based on understanding the consequences of
    their decision. Death isn’t defeat; it just is. We should provide death with
    dignity and as little pain as possible. And our insurance should pay for it. I
    am a strong advocate for the same healthcare that our senators and congressmen
    have for all citizens of the United States. It is only fair. Former ICU/CCU nurse.

  • LymphActivist

    The Medicare requirement that functional improvement be shown in order for therapy to be reimbursed is about to be institutionalized if proposed changes to the therapy reimbursement rules are ratified. CMS-1590-P has just been announced (see Federal Register dated July 30, 2012) which will replace current therapy reimbursement rules with functional improvement rules. Comment period is open until early September, so if you have some constructive suggestions relative to this issue speak now or forever hold your peace. (I hope my spelling is correct and my metaphors appropriate.)