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There are some days when you totally feel like your soul is destroyed and you want to scream at the universe. Today was one of those days. Here is a rant from just one of the day’s challenges, and recommendations for lessons to be learned.
Urgent request for visit to RACF first thing in the morning to sort out a few issues for someone already referred and previously seen several times and discovered a few troubling events had occurred in the previous 12 hours.
Saw a very unwell man, totally delirious, likely to die within 24 hours. I had seen him before, had an ACP in place, and injectable meds charted and prescribed appropriately as he had progressing bladder cancer.
Talked with terrified and helpless staff and nurses who were waiting for me to arrive and felt unable to care for him. Here is why...
1. GPs, it is NOT ok for you to give an order to send a man with severe dementia to hospital for haematuria, elevated K+, severe renal failure, low Hb) if you...
a) are not his regular GP & you have not spoken with the primary care doctor (who happens to have already made a plan with palliative care for review and managing the problems)
b) are acting on the basis of seeing a copy of his blood results in your inbox, you do not know him, have not visited and reviewed him, and
c) you have not considered his goals of care/ advance care plan or spoken with his alternate decision maker.
It is also NOT ok to use a Telehealth item number to rake in the billing for making that call to send him to hospital.
2. Palliative care on-call consultant it is NOT ok for you to give verbal recommendation for discharge medicines that do not take into account regular meds, therapeutic guidelines for doses and frequency, and capacity of RACF to administer them.
It is especially NOT ok to recommend a syringe driver with 1mg hydro morphone and 2.5mg midazolam for a 6’ tall 75kg man who has previously been on regular risperidone for severe aggression and can no longer take oral meds.
It is NOT ok to order Q4hrly breakthroughs at less than the usual recommended minimum dose for someone who is dying. It is NOT ok to assume just because he is from RACF he is frail, elderly and opioid naive.
It is NOT ok that when you take the call, you don’t bother to see if the patient is already referred to your service with another clinician involved, and read those notes to inform your recommendations.
Also it is NOT ok to omit giving a handover to clinician who has seen him regularly for 3 months, or another person in the tea, that visits RACFs.
3. Emergency physicians it is NOT ok for you to a) discharge a man with dementia and delirium to a RACF at 3.30am. EVER. Especially if you have not phoned RACF staff to see if they will accept care, and have staff with capacity to provide care on return.
b) to discharge him at 3.30am having ceased his regular meds AND not sending a supply of what you have subsequently prescribed
AND c) to not have administered any of the meds in hospital prior to discharge.
RACF staff it is NOT ok to leave the delirious man isolated, on COVID precautions, in a room with the door shut, no sheet on the bed, in the dark with curtains closed and heater off (at 10am).
Public Guardian it is NOT ok that your office is only attended Monday through Friday with no emergency contact available, and to not have acknowledged multiple emails that have been sent over weeks alerting you to the need for funeral arrangements to be communicated to RACF.
The system is broken. There are so many frustrating issues here. And this was just the first appointment of the day, but it definitely set the scene for what was to follow.
