On the surface, it appears to be routine. A family member panics as their loved one struggles to breathe or slips into a state of unconsciousness. He or she does the first thing that comes to mind in an emergency situation and dials 911. An EMS team races to the location and does what they are trained to do: After stabilizing the individual, they transport him to the nearest emergency room.
However, this is not a run-of-the-mill dispatch. This is a hospice patient, and that changes the ball game.
It’s a scene with which John Sponholtz, RN, AEMT, has had plenty of experience with as an emergency medical responder with the Tisch Mills Fire Department near Green Bay, Wis., and as a case manager with Unity Hospice. When a patient’s medical condition no longer responds to cure-oriented treatment, he is often transitioned to hospice care, which provides comfort and support to patients and family members as they deal with end-of-life issues.
“There are a lot of conditions that may qualify a patient for hospice care, but as a general rule, it is for patients whose doctors would not be surprised if they died of their diagnosis within the next six months,” he said. “Of course there is no stamp on their head or anything. It can be longer than that or less. We had a guy who was in hospice for five years, but that’s definitely the exception and not the rule.”
When an individual transitions to hospice care, whether in the home or at another facility, a hospice nurse becomes the first point of contact for all of his medical needs. This nurse checks in with the patient on a regular basis and administers any medications needed to keep him comfortable while also preventing unnecessary 911 calls, emergency room visits and hospital admissions. In addition, hospice nurses help patients and family members know which symptoms may be a natural part of disease progression and which might require a different level of care.
“When everyone follows the chain of command it works well, and the longer someone is in hospice, the better the system functions,” Sponholtz said. “However, in those early days, family members may still be in denial about what is happening. When they see a change in their loved one, they immediately call 911 because they think 911 can fix everything.”
Unfortunately, it can’t. Although there are times when a patient’s injury or situation is unrelated to his terminal diagnoses, it is important the hospice nurse be the first call in order to get clearance to call 911. Medicare and Medicaid pay for hospice, and once someone is in that end-of-life-stage of care, they will no longer pay for medical services that have not been authorized by the hospice team.
“If it’s a true medical emergency, the hospice nurse calls 911 and then enters a code so that Medicare will cover the expense, but if the family bypasses the nurse in order to call 911, the EMS team will show up at the door and do what they have been trained to do, without knowing the service isn’t covered.”
Uncovered services cost EMS, families and hospitals millions. Sponholtz has been working with communities, EMS personnel and families to encourage an understanding of how hospice works, what to look for and how best to deal with an uncertain 911 call. He has also been working with fire departments in Atlanta and other cities to create protocols that determine if an individual may be a hospice patient; and if so, to direct the caller to contact the hospice nurse. He also encourages EMS workers to take note of signs in the house that may indicate the individual is a hospice patient, like oxygen tanks, syringes of morphine or a do-not-resuscitate order, so that they do not preempt someone’s plan of care.
He reiterated that it’s important to educate the family on the hospice chain of command so that they don’t make a mistake and dial 911 first.
“It would be nice if we could just register all hospice patients so that EMS teams would know who they are. But HIPPA regulations prohibit that kind of blanket registration,” Sponholtz said.
Voluntary mobile integrated health care programs have been established in the Fort Worth, Texas, area and are showing promise in creating an opportunity for hospice and EMS providers to work together in the patient’s best interest. In this type of system, patients elect to enroll in a MIH, which partners with local 911 dispatch to let responders know that the individual is a hospice patient. When a 911 call is received from an MIH patient, a mobile health care paramedic joins the EMS team in the ambulance while a call is placed to the patient’s hospice nurse.
At the scene the MHP assesses the situation to determine if the issue is part of the person’s hospice plan. EMS responders may administer on-site comfort care and remind the family of the patient’s wishes until the hospice nurse arrives to take over. This alleviates the need for costly transport and the accidental revocation of a person’s hospice benefit and insures everyone complies with the patient’s advanced directives.
“More has to be done to educate the public on the chain of command involved in a hospice situation and find ways of helping EMS and hospice personnel interact better for the benefit of the patients they serve,” Sponholtz said.