Table 4.

Care complexity (theme 3)

QuotationNote TitleExemplar Quotation
Subtheme 1: difficult transitions to hospice
 40Internal Medicine Inpatient Note–PATIENT IS NOW DNR–technically comfort care but we are still treating him w/antibiotics and other meds as well as fluids and dialysis. No blood products, endoscopy, surgery, [vaso]pressors, [cardiopulmonary resuscitation], intubation, defibrillation. Hospice to place and evaluate him on Monday.
 41Transfer Summarization NotePatient will continue to be full code while in the hospital and then transitioned to home hospice.
 42Internal Medicine Inpatient NotePatient is now off of [vaso]pressors. [Gastroenterology] wanted to scope him today but patient is very adamant that he does not want this done and wants to be hospice care… While he is here, he is ok with getting blood products, lab draws, antibiotics and dialysis, but once he becomes hospice care he knows he may not be able to have some of these medical measures.
 43Discharge SummaryIt was explained to family that he has multiple life-threatening medical problems at this time…and that it is not medically advisable for patient to go home. Despite these recommendations patient and his family wish to take patient home on hospice care.
 44Social Work NoteStaff felt that any move may be very difficult as the [patient] very fragile and a move may hasten his death.
 45Palliative Care ConsultThey wish to take him home with home hospice support once his encephalopathy improves and the colitis is appropriately treated. Consider empirical therapy for presumed [Clostridium difficile].
 46Palliative Care ConsultSons are in agreement with [do not resuscitate] and to stop [hemodialysis] when he goes home. I would recommend dialysis tomorrow and to make him as dry as he can tolerate. I think he should be ready to go on Monday with hospice. [Wife] wanted to know if that was a good plan. I told her there is a limited time to get him safely home.
 47Vascular Surgery Consult87 yo male with ESRD who wants to go onto hospice and stop dialysis…Explained procedure for removal as well as option of leaving permcath[eter] in place with risk of infection that could cause a blood infection and take his life. Patient states, “just leave it” and that it isn't bothering him. Both daughters agree with leaving it in place and not removing it and verbalize understanding of risk of infection. [Daughter] states “I don't want him to have any more procedures.”
 48Nursing Inpatient NoteThe goal of patient care is to return him back to his hospice care per family. Throughout the day he has been on 100% non-rebreather, he is unable to leave this facility on this type of oxygen supply and return to his extended care facility. Due to this, we are currently weaning him to 6L nasal cannula per MD order…Patient appears to be agitated and anxious at this time.
Subtheme 2: stretching the limits of home hospice
 49Social Work Care ManagerI spoke with…Hospice agency to see if they could manage pleura catheter in the home setting… They are reluctant to agree to admit patient to home hospice once discharged if he has catheter.
 50Social Work NoteHe is very focused on returning home, but the family does not feel that they care for him at this time (with current catheters, weakness, etc.).
 51Vascular Surgery NotePrivately, his daughter… discussed that caring for him even with the assistance of home hospice has become too much for them over the last few days.
 52Social Work Telephone Encounter Note[Patient’s] daughter… called to discuss his need for inpatient hospice care. He has been followed by [home hospice] for a week…there are seven family members who take turns staying the night but feel they can’t cope with his current condition.
 53Inpatient Admission Attending Evaluation NoteHim and his wife anticipate placement in inpatient hospice due to his weak/almost bed bound state. He came to the hospital with his luggage.
 54Social Work NoteHe has been turned down for inpatient hospice, spouse unable to provide the level of care he requires in the home and he is now a candidate for nursing home placement.
 55Social Work NoteThey are both RNs and asked it patient may be [discharged] with his rectal tube and that they would help facilitate care at the [nursing home]...We stated our concern about discharging but have agreed that we may discharge him with his rectal tube and that his niece would be present at the assisted living home and spend the night with him…Hospice intake will be done tomorrow with contracted group at home.
Subtheme 3: ongoing use of the acute care system
 56Physician Emergency Department NoteOn hospice which sent him here since he cannot remain on hospice with the bleeding, per patient and son in law.
 57Internal Medicine Admission EvaluationPatient presents today for worsening diarrhea and needs beyond the scope of home hospice care…the plan for admission is specific work up of his acute on chronic diarrhea, [intravenous fluid] hydration and potential transfer to inpatient hospice once any reversible etiologies are addressed.
 58Case Manager Telephone NoteShe and Hospice RN are concerned re: [patient’s] [arteriovenous] fistula, which is “much larger than usual,” has become larger in the last 24 hours. Contacted nephrology, who advised options of doing nothing (given hospice status), presenting to [emergency department], seeing her [primary care provider]…they will see [primary care provider].
 59Discharge SummaryPatient requested to be sent home with hospice…Foley removed that was placed on admission removed without issues. Hematuria thought to be secondary to foley trauma, if continues and patient/family requests consider urology consult.
 60Non-VA NoteVeteran rescinded hospice as he was short of breath and very uncomfortable at home. Veteran required BIPAP and was treated with [intravenous] Lasix.
 61Telephone Encounter NotePhone call to veteran. He said that he called 911 rather than Hospice because he “didn’t think of calling Hospice. They needed immediate care.”
 62Physician Transfer Summarization[hospice patient] was having a battery change of his pacemaker. Immediately following the procedure, he had acute onset of [shortness of breath] with rapid deterioration. Patient went into mixed respiratory failure for which he was placed on BIPAP. Diuresis was started and he did require being on Lasix drip at 30.
 63Urgent Care NoteNow under hospice care…patient’s son did not wish for father to be admitted…since goal of care is now comfort care. However, patient went to neurology [follow-up] today and was noted to be tired and pale, and noted a recent episode of chest pain, so was sent to urgent care for further eval[uation].
 64Care Coordination TelehealthInstructed if symptoms worsen and [BP] is any lower to call 911 or come to [emergency department], especially with holiday weekend. Also reminded of nurse line and his hospice team is also available.
 65Social Work NoteIt appears that Veteran was transferred to [emergency department] from dialysis without knowledge of hospice status.
  • Square brackets contain text substituted by the authors to spell out abbreviations, correct misspelling, and remove the names of individuals and institutions. DNR, do not resuscitate; MD, medical doctor; RN, registered nurse; BIPAP, bilevel positive airway pressure.