Coordination upon discharge
In the interviews, the nursing home doctors stated that the dialogue upon transfer to the nursing home was non-existent and saw this as a problem. Many of them believed that the hospital doctors’ approach to the patients was not sufficiently comprehensive, that they only addressed acute medical conditions and that the patients were discharged too quickly. They were concerned about the unethical aspects of exposing seriously ill patients with unclarified conditions to a transfer and possible readmission. Some also referred to resistance to readmissions on the part of the hospital.
Information from the hospitalisation is a purely clinical discharge summary. The nursing home doctors were not contacted for discussion of medical, practical or ethical questions, not even when seriously ill patients were discharged during ongoing medical treatment.
It’s not a problem in itself that patients who need to continue their intravenous therapy are transferred to us, but the problem is when this is not clarified and they have not been stabilised into this therapy. It would have been better if they had seen that this is effective, the patient has been stabilised, things are clear, what should be done after the end of the intravenous therapy and how long it should continue. Then it’s OK. But when the patient is so poorly and nothing has been clarified, then I believe that this is wrong.
The nursing home doctors also raised the issue of the contrast between advanced hospital treatment and their own emphasis on palliative treatment and care in the nursing home. They felt that the hospital doctors engaged too little in dialogue with the patients and their next of kin, especially with regard to life-prolonging treatment, and that they rarely provided any indication about treatment types and levels after discharge. The nursing home doctors had to inform the next of kin and apprise them of the reality, correct high expectations for treatment and recovery, discontinue treatment that had been initiated, and find themselves left with a number of difficult ethical dilemmas. Some, however, felt that the hospital staff were good at informing the next of kin and assessing treatment levels.
... the only real ethical dilemma is often about things that the hospital has initiated and whether they should be continued, and the expectations this raises in the next of kin and all that. And then there are terminally ill patients discharged from the hospital with a nasogastric tube, and when I call them, they cannot give any answer as to what they had in mind and why they did this. And there’s no note in the discharge summary, and then we need to decide what is to be done about the whole thing, and ... In such cases the coordination is not good enough, really it isn’t.
The hospital doctors confirmed that they never contacted the nursing home doctor directly at discharge to inform about or discuss the patient, they sent a discharge summary. They referred to lack of time as the reason for this. Many of them said that they saw their job as resolving an emergency situation, they had no time to speak with the patient or the next of kin, and believed that at discharge it was still too early to draw conclusions about the prognosis.
Some stated that they deliberately provided general recommendations in the discharge summary, while others admitted to having a potential for improvement. Any recommendations provided were most often focused on avoiding a readmission, and in some cases on communicating a decision not to initiate cardiopulmonary resuscitation. Some reported to have experienced that their message failed to reach the nursing home and that the patient was readmitted, others had succeeded in establishing a positive collaboration with the nursing homes.
It is much faster to write a sentence in the discharge summary than to make a phone call, where you first have to reach someone who needs to go and find somebody else who has the time, and then you are on the phone for 15 minutes, and often you don’t have that time.
But, obviously, if we haven’t had a proper dialogue with the next of kin, and they can see that dad now has a tube and he is fed ... Because they are in shock when they come to us, and there’s denial, and then they come to the nursing home and have the feeling that the hospital doctors have taken this optimistic, aggressive approach. And then the nursing home doctor comes as an apostle of death and has that role, and that’s not OK, is it? However, I don’t think we do it deliberately, but it could be linked to our roles, that we need to push people through the system, everything happens in a rush, then they come to the nursing home and two more weeks go by, and then the nursing home staff are the ones to assume that «death role».