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Thread: confused, disoriented and combative elderly patient presents in ER

  1. #1
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    confused, disoriented and combative elderly patient presents in ER

    I am wondering if there is a certain protocol that is to be followed when an obviously confused and disoriented elderly patient is taken to the ER by ambulance from home where the family has called 911 after finding her in this state along with obvious signs of internal bleeding (incontinence of black diarhhea). To begin with, 1 of the 1st responders was a neighbor who knew the woman and specifically offered to ride with the woman to the hospital. A thorough history was taken from a daughter by the ambulance personnel before leaving. They were informed that she was one of Jehovah's Witnesses and had a DPOA and that the daughter would find the document and bring it in her car but that the designated agent would be waiting at the ER with his copy of the document. Upon arrival, the agent and daughter who called 911 went to the ER admitting window and stated that their Mother had just arrived via ambulance but that she was completely incapacitated mentally and showed copies of the document and stated he was the agent and would like to be allowed in with her because she was unable to express her wishes about treatment but was also frightened and they felt they could assist with her behavior. (The day before, she had driven herself to attend the meeting at the Kingdom Hall and was completely normal.) They were told they would have to wait until it was there turn to be spoken to. After approximately 10 minutes of insisting to be heard, a very hostile employee came out and stated, "WHAT IS THE PROBLEM?" The agent stated he was her DPOA and had vital information to communicate regarding her treatment. The employee became verbally hostile and stated in the packed ER that his mother had come in "head to toe covered in poop and blood" and it took 3 personnel to restrain and sedate her, etc. Finally after a number of statements like this and the family explaining they needed to be with her and had a legal right to be, she allowed the agent in but not the daughter who had found her even though the agent stated that she needed to be present as she was more in touch with the patient on a daily basis and could undoubtedly assist in calming her. I won't even go into the gory details of what they had done to her but my question is whether they can refuse to allow the DPOA agent in under any circumstances - let alone, when the patient was in this kind of condition and one of the ambulance personnel even attended her to the ER to try to insure a smooth transition so he had already explained the family relationship. Also, what immediate action can be taken if this happens to anyone else? Thank you so much.

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  3. #2
    Sorry to hear about your bad experience with this particular ER...hopefully the patient is doing better. These types of situations can be difficult to deal with, and definitely should have been handled better, but, let me play devil's advocate and have you try to put yourself in the ER staff's shoes for a minute. Their first priority is to take care of the patient. Oftentimes the exam rooms are limited on the number of people that can be in there at one time...there may be several nurses, someone from the lab, the physician, etc. Having family members present is not necessarily always a priority, and may hamper getting the initial workup done. I appreciate that one of your main concerns was that you wanted to make sure the medical staff was aware that this patient was one of Jehovah's Witnesses, and that her wishes in regards to no blood were respected. The fact that she had completed a DPA in advance was definitely in your favor. Too bad you didn't have a copy available to send with the ambulance crew, just in case they arrived at the ER before the Healthcare Agent got there with their copy. And yes, as family members, you do have certain rights. You wanted to be with her to comfort her and calm her down, which probably would have made things easier for the healthcare workers. But not knowing what was happening back in the exam room, it's hard to say if your presence would have been a good idea right at that time.

    That being said, the hostile employee was inappropriate on so many levels, and definitely needs to be reported to their supervisor, and also hospital administration. When in the middle of a situation like yours, I always like to know who I'm speaking to and their title. Try to remain calm (getting angry and raising your voice just makes the situation worse). If you don't get satisfaction with the person you are speaking to, go up the chain of command. What happened in the ER that day is all water under the bridge, but what you need to do now is let hospital administration know what happened. Send a letter outlining the facts of the incident, and how the behavior of this particular staff member reflects poorly on the hospital. If you are not sure who you need to address the letter to, send a copy to the Nurse Manager of the ER, the Director of Nurses, and the Hospital's CEO. You don't have to necessarily know their names, put I bet you could call the hospital's switchboard operator and get that info along with the hospital's mailing address.

  4. #3
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    Thanks for the response

    Leslie Richards
    Thanks for taking the time to reply. I have appointment with CNO Monday.
    I appreciate your explaining what the staff has to deal with. I'm pretty familiar with it having myself been an ER admissions clerk, a unit clerk in the ER, and the manager of all admissions staff but my experience is almost 10 years old now and we had systems in place to preevent this. That is what my question specifically is - are there any regulations in place whether the hospital has procedures or not, that a person can utilize at the immediate moment when the personnel are behaving so inappropriately? All of my siblings are medically trained and in the medical field in one capacity or another and were trying to take the staff;s problems into consideration. But the entire concern was that they needed information specific to her care as well as believing that she required their presence for comfort and assistance to all concerned. Just to clarify, the ambulance personnel knew she had a DPOA and also knew her agent would be at the hospital before they arrived since he was on his way and only lived 5 minutes from the hospital and it was a 40 mile drive for the ambulance. Additionally, one of the 1st responders knew her personally and rode with her to insure the hospital knew all the circumstances. The concern on our part was what they were NOT doing because she wouldn't take whole blood - not what they WERE doing. We figured they knew from the ambulance personnel that she was one of Jehovah's Witnesses and this hospital has a reputation for doing nothing if they have have that knowledge. Just recently, 3 of our friends were left untreated until their DPOA agent specifically stated some things they could try. Many of us are willing to take minor blood fractions if our conscious will allow it. And since our Mom was bleeding internally, we were concerned about stopping the bleeding and utilizing clotting factors. These were the exact issues that our friend went through there recently where they didn't try anything because he was of our religion. That is why we were so adamant about needing to get the info to the treating Doctor and when they were denied entry, they requested that the info they had be taken back to the Doctor by an employee and it was refused.
    What can a person in the situation do to receive immediate action? We were trying to save a life. There must be something that can be done for the sake of the patient's rights - not just protecting the hospital. Thannks for all your concern and assistance.

  5. #4
    Whether there are any specific laws in your particular area that would have helped in this situation, I really couldn't answer that 100%. Different States have different rules, (I'm assuming your in the U.S.) but I do know that the American Hospital Association adopted a Patient's Bill of Rights back in 1972 (revised in 1992) with the expectation that it would contribute to more effective patient care. This Bill of Right's provides a basic foundation of patient's rights-hospitals could tailor it to meet the needs of their particular community. Most hospitals will have a copy of these rights posted in the facility. There are essentually 12 basic rights:

    1. The right to considerate and respectful care
    2. The right to obtain information concerning their diagnosis, treatment and prognosis.
    3. The right to make decisions about their plan of care, and the right to refuse a recommended treatment.
    4. The right to have an advance directive concerning treatment, and the right to appoint a surrogate decision maker. The hospital will honor the intent of the directive, or must notify the patient in a timely manner about hospital policy that may limit its ability to implement fully a legally valid advance directive.
    5. The right to privacy.
    6. Medical communication and records will remain confidential.
    7. The patient has the right to review their medical records.
    8. The patient has the right to expect that, within its capacity and policies, a hospital will make reasonable response to the request of a patient for appropriate and medically indicated care and services. When medically appropriate, and legally permissible, or when a patient requests, a patient may be transferred to another facility, but the receiving facility must first accept the transfer.
    9. The right to be informed of the existence of business relationships among the hospital and other healthcare intities that may influence the patient's care.
    10. The right to consent or decline to participate in research studies.
    11. The right to expect reasonable continuity of care when appropriate.
    12. The right to be informed of hospital policies and practices that relate to patient care, and the right to be informed of available resources for resolving disputes, grievances and conflicts.

    The size of the particular hospital also has alot to do with how quickly care can be done. I work in a small community hospital. Our ER is staffed by physicians trained in emergency care...they stabilize the patient and then transfer the care to the specialist. In your family member's case, the fact that she was passing dark stools would most likely indicate an upper GI bleed, but not necessarily something actively bleeding. To truely assess the situation, she would need to have an upper and lower endoscopy, but to do these, she would need to be prepped--nothing to eat or drink for several hours to make sure the stomach was empty, and laxatives or enemas to clean the colon. The GI specialist would have to be called in. He could be doing a case at another hospital, or seeing patients in his office. They don't necessarily drop everything and come right over. The use of clotting factors for this type of bleeding is not necessarily appropriate and would definitely be considered "off label" use, which not all physician's feel comfortable with doing. Also, these recombinant clotting factors are extremely expensive, and the hospital may not even have any in stock.

    I empathize with your frustration with the situation...hopefully, you got some satisfaction after your meeting with the CNO. If, as you said, this hospital has a reputation for being uncooperative with Witnesses, or they generally give poor care, I would make plans to use a different facility in the future. But, if this is the only hospital in the area, that may not be a viable option either.

  6. #5
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    There is something you can do immediately. You can request (if after office hours) the administrator on call. And when they arrive, explain the situation and you will most likely get results. If it is during office hours, request someone from administration to come to see you. As far as I know they cannot deny you this visit. I personally have used this on more than one occasion with success. Regarding the situation where they do nothing and refuse to do any kind of treatment, this is called "patient abondonment" and is a legal term. If you use this phrase you will get immediate response.

  7. #6
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    Also, please let your brothers who can contact HLC know about this hospital's practices. Sometimes they can develop a better working relationship with administration. But they have to know there is a problem before they can help.

  8. #7
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    Thanks to everyone who responded. The next closest hospital is another hour away and the insurance will only pay for the ambulance to transport to nearest ER. HLC was also contacted. They've been working with them for a number of years. So was Administration when we had another nightmarish situation arrive in the ICU. I went to Admin. and was told they were all gone on a retreat. Asked for Admin. of the day or House Manager or whatever they called it - and was told he wasn't in the building! The only reason I am posting this is to let people know what they may run up against. As far as I still know, there is no guarantee of any immediate response to assist you. Perhaps it was just a fluke that ALL systems broke down. The good news is, we received excellent care for the most part once out of the ICU.

  9. #8
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    Quote Originally Posted by vanderheyw View Post
    I am wondering if there is a certain protocol that is to be followed when an obviously confused and disoriented elderly patient is taken to the ER by ambulance from home where the family has called 911 after finding her in this state along with obvious signs of internal bleeding (incontinence of black diarhhea). To begin with, 1 of the 1st responders was a neighbor who knew the woman and specifically offered to ride with the woman to the hospital. A thorough history was taken from a daughter by the ambulance personnel before leaving. They were informed that she was one of Jehovah's Witnesses and had a DPOA and that the daughter would find the document and bring it in her car but that the designated agent would be waiting at the ER with his copy of the document. Upon arrival, the agent and daughter who called 911 went to the ER admitting window and stated that their Mother had just arrived via ambulance but that she was completely incapacitated mentally and showed copies of the document and stated he was the agent and would like to be allowed in with her because she was unable to express her wishes about treatment but was also frightened and they felt they could assist with her behavior. (The day before, she had driven herself to attend the meeting at the Kingdom Hall and was completely normal.) They were told they would have to wait until it was there turn to be spoken to. After approximately 10 minutes of insisting to be heard, a very hostile employee came out and stated, "WHAT IS THE PROBLEM?" The agent stated he was her DPOA and had vital information to communicate regarding her treatment. The employee became verbally hostile and stated in the packed ER that his mother had come in "head to toe covered in poop and blood" and it took 3 personnel to restrain and sedate her, etc. Finally after a number of statements like this and the family explaining they needed to be with her and had a legal right to be, she allowed the agent in but not the daughter who had found her even though the agent stated that she needed to be present as she was more in touch with the patient on a daily basis and could undoubtedly assist in calming her. I won't even go into the gory details of what they had done to her but my question is whether they can refuse to allow the DPOA agent in under any circumstances - let alone, when the patient was in this kind of condition and one of the ambulance personnel even attended her to the ER to try to insure a smooth transition so he had already explained the family relationship. Also, what immediate action can be taken if this happens to anyone else? Thank you so much.
    Hi guys, Im a newbie. Nice to join this forum.

  10. #9
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    This goes to show that even the best plans can have negative outcomes. There is no excuse for rudeness and patient care includes the care of relatives. Giving a soothing and calming response helps to diffuse the situation from the perspective of either party. In the case of the relatives that may not be easy when the way they are spoken to is unacceptable. Fortunately your experience is not common these days. Thank you for sharing it with us.

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