End of Life Care Part 3 - the physician and NP

Mrs. C. was under the care of a family practice physician as the primary care provider. A NP (nurse practitioner) in the practice also followed the case. The family was very diligent in bringing Mrs. C in for her appointments and had frequent telephone contact. It was the physician who had made the referral for home health care. It was certainly appropriate for an agency to be following Mrs. C's care as she had become very home bound. It was more and more difficult for the family to bring her to the physician's office. A RN case manager in the home can make assessments and call the physician as her condition changes. The physician and NP documentation doesn't reflect any end of life care discussions until the very end when the communication by the home health agency reflected difficulty with family coping. Instead of suggesting hospice as an alternative, the NP suggested a nursing home. The son was unable to make a decision immediately and she died within a week. At this same time, the NP made a referral to Adult Protective Services (APS) with the concern that the family was not providing adequate care. The son was very conflicted knowing that his mother's wish was to die in the house that she lived in her entire life. The physician did not intervene at the time of death to sign the death certificate. It became a coroner's case because she was a not a hospice patient and likely because of the APS referral. The records did not reflect advocacy for the patient and family in terms of acknowledging the end of life illness and appropriately planning for the care and related issues. This lack of advocacy among other issues that I will discuss led to the upcoming legal problems and heartache for this family.

Part 4 - Advanced Directives