Abstract
Dear Editor:
As a largely hospital-based palliative provider, I started a palliative medicine consultation program at a local nursing home. If only I had known how different these worlds are, and if only I had been more considerate of factors for my patients I discharged to this setting. These are five things all palliative care medicine providers should know:
1. “There is NO doctor in the house.” In fact, there are often no doctors, no nurse practitioners, no physician assistants rounding daily in the nursing home. A new admission may not be seen by a provider for days. 2. “Call the Nurse.” Most nursing homes do not have RNs in the building 24/7. LPNs and CNAs provide most of the care for the residents. This limits the assessments and skills that can be used to manage patients in house. Did I mention there is not a respiratory therapist either? 3. “100 days.” If you send a patient to a Skilled Nursing Facility (SNF) for rehab, wound care, etc., they are not guaranteed 100 days. In fact they are guaranteed NOTHING. On day 2, if they cannot participate in therapy, or if their insurance reviews the case, they face discharge or need to pay out of pocket. Sending patients under SNF who are at the end of life to “try rehab” or “buy time” helps no one; but I've done it many, many times thinking it will ease financial burdens for some time. Largely it doesn't. It delays pain. It delays planning. Our reliance on SNF placement leaves patients, families, therapists, and facility social workers to scramble to reframe expectations and find appropriate care plans when the insurance decides to stop paying. 4. “STAT does not means STAT.” Most nursing homes receive medication deliveries ONCE A DAY. That means if new admits come at night, they may not receive medications until the next day. Although they have STAT boxes of some medications, these typically do not have many of our comfort medications. We can order a medication stat, but in reality that often takes four to six hours to arrive. 5. Time is slower, the pace is quieter, and the relationships deeper. The urgency and pace of hospital-level care is absent. You see people's true possessions and even their real clothes. Stories that can be shared, old and new, give tremendous meaning to residents, families and staff.
As our field grows from largely hospital-based providers to reach the community settings, we must remain cognizant that there is a world outside the hospital and it is different. Different is hard and raises more questions about how to do what we do. I am still striving to remain flexible and adaptable, with a growing list of lessons and questions for my colleagues who have already learned them.