Question 1 of 3

“We have a pt. in our SNF, who came from another nursing home, who passed MBS in April 2017 while in that SNF, but S.T. evaluated pt. to still remained high risk for aspiration.

• But pt. and family insisted on feeding pt. pureed with thickened liquids while on tube feeding, so per  their IDT only trained caregiver/family to feed pt. only.

• When pt. was transferred to us this July, we repeated MBS which this time showed that this time he failed ALL consistencies of fluid, but family and pt. still insisting to continue feeding him.  We do not have bioethics committee in our facility. So are about to have IDT meeting with family tomorrow, to set goals and expectations.  We don't have any type of waiver form, and I was told even if we do have one, it does not release us from liability.

• Is it then OK for trained caregiver to continue to feed him as long as they are trained (no staff member should do it since our recommendation will be NPO), while keeping the tube feeding?  If they agree for hospice care,  will that be considered as honoring pt's wishes for quality of life?

Please advise.  Will appreciate any input or advice regarding this issue, since we have a scheduled IDT meeting tomorrow with this family & pt. BTW pt. still has capacity to make his decisions.   Thanks in advance."

Timothy Gieseke, MD: If the patient’s swallow is not safe, it would be hard to justify to DHS that the family had the right to feed the patient with the risk so high.  If the patient was on hospice, small amount of taste feeding for pleasure is permissible, but large feeding that might create a serious harm would still be hard to justify.  In these situations, an ad hoc IDT with ombudsman present usually allows the facility to express their medical legal concerns in a way that are heard and respected.  The family always has the right to move the patient to another facility.  I experienced this sort of jeopardy a number of years ago when a family demanded use of restraints or threatened a lawsuit.  We therefore continued the restraints, but were cited for permitting something that we documented to likely be more burdensome than beneficial. 

Jay Luxenberg, MD:  I personally have authorized allowing patients with clear aspiration risk (and no tube feeding) based on documentation that family understood the (very high) risk and were making an informed decision. I am convinced that patient got most of his caloric intake across his alveoli, but he lived for a year or so with almost constant aspiration. My position is that in situations of truly informed consent we can allow feeding in patients with aspiration, but it needs to be done in a setting of comfort care (not necessarily hospice) and it needs to coincide with a do not hospitalize decision. It makes no sense to feed an aspiration risk patient if every episode of aspiration would lead to an er visit or hospitalization.

Karl Steinberg, MD: It's a resident's rights issue.  As long as there is documentation of a discussion of risks, benefits and alternatives, and that they are aware of the risks of aspiration or death, it's fine for them to feed the resident whatever they want.  MBSs are not the be-all and end-all.  I've had multiple cases like Jay's.  I have allowed that even when the patient/family still wanted hospitalization.  Risk management people may not like it, and of course nothing will protect you from being sued, but it really boils down to a resident's rights issue and they are going to be scrutinizing that stuff much more closely under the new regs.

I personally have authorized allowing patients with clear aspiration risk (and no tube feeding) based on documentation that family understood the (very high) risk and were making an informed decision. I am convinced that patient got most of his caloric intake across his alveoli, but he lived for a year or so with almost constant aspiration. My position is that in situations of truly informed consent we can allow feeding in patients with aspiration, but it needs to be done in a setting of comfort care (not necessarily hospice) and it needs to coincide with a do not hospitalize decision. It makes no sense to feed an aspiration risk patient if every episode of aspiration would lead to an er visit or hospitalization.

I am concerned with the position that inadequate staffing would limit frequency of visits. The discussion is the bare minimum, but if you don’t have the staffing to see residents whenever their clinical condition warrants, you should rethink your decision to provide care in the nursing home. I have seen too many bad outcomes when medical staff doesn’t look at wounds or changes in condition. 

Question 2 of 3

“If Pt/DPOAH chooses, DNR if pulseless/no respirations, otherwise Full treatment if still with pulse/resp.  In this instance, do we deactivate an ICD (esp. if pt. is DNR, comfort care only), to prevent the ICD from firing i.e. during Vifb. which can cause further discomfort.”

Timothy Gieseke, MD:  If the patient is on hospice with a poor prognosis we usually recommend deactivating the PPM, which can be done by a call to the local manufacturer representative.

Karl Steinberg, MD: Of course it's advisable to deactivate an ICD.  The best bet is the company rep as Tim says. That's actually one of the validated NQF palliative and EOL measures.  (deactivation of ICD)

Question 3 of 3

“Since we are short of providers to do rounds in nursing home right now, what is the minimum requirement for rounding in the SNF…every 30 or 60 days?

• New admission….q30 days for the first month x 90 days, for new admission, 30 days each month till 90 days completed, then can be q60 days, esp if pt. is stable and hardly have any new significant changes?

• And MD can alternate visit with the midlevel provider?”

Timothy Gieseke, MD: Unfortunately, there are times when physician providers are thin and facility pressures us to take more patients then we can safely follow and to round less frequently on our long stay patients.  Every physician needs to decide how thin they will allow themselves to be spread.  For myself, I need to provide the care that I would want for my family, which means I’m guided by the medical necessity rule, which is intentionally vague.  The regulations allow visits every 60-75 days for stable long stay residents and every 30 days for post-acute, up to 90 days.  An NP can help meet the medical necessity work, but can only do every other visit on Medicare long stays.

Jay Luxenberg, MD: I am concerned with the position that inadequate staffing would limit frequency of visits. The discussion is the bare minimum, but if you don’t have the staffing to see residents whenever their clinical condition warrants, you should rethink your decision to provide care in the nursing home. I have seen too many bad outcomes when medical staff doesn’t look at wounds or changes in condition.

Karl Steinberg, MD:   Some facilities require q30d regulatory visits.  The "alternate schedule" to my understanding, even though not specifically stated in the law, can't be any less frequent than q60d.  Nurse practitioners or PAs can do every other visit, and I have heard different interpretations of this, but some facilities might allow a doc to see the pt now, then NP in 60 days, then doc in another 60d so actually 120 days between MD visits... but I don't advise this.

The federal minimum for practitioner visits is q30d for the first 90 days, then q60d if the resident is stable.  There's a 10-day grace period.

Here are the California regs:

22 CCR § 72307

§ 72307. Physician Services -Supervision of Care.

(a) Each patient admitted to the skilled nursing facility shall be under the continuing supervision of a physician who evaluates the patient as needed and at least every 30 days unless there is an alternate schedule, and who documents the visits in the patient health record.

(b) Alternate schedules of visits shall be documented in the patient health record with a medical justification by the attending physician. The alternate schedule shall conform with facility policy.