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Based on interview and document review, the Hospital was found to be out of compliance with the Condition of Patient Rights at §482. 13, Patient Rights. The hospital failed to provide care in a safe setting for 1 of 10 patients (P1) hospital staff initiated a process to provide P1 palliative/terminal sedation when P1 was not imminently dying. The effect of this systemic problem resulted the hospital's inability to ensure care in a safe setting for one patient. Findings include:

See A144

Based on interview and document review, the hospital failed to provide care in a safe setting for 1 of 10 patients (P1) when hospital staff initiated a process to provide P1 palliative/terminal sedation when P1 was not imminently dying.

Findings include:

The facility policy Palliative Sedation dated 12/8/20, directed the purpose of this policy is to guide providers in providing palliative sedation to relieve intractable suffering for imminently dying hospitalized patients. The policy also indicated this practice is also sometimes referred to as "terminal sedation" (deep continuous sedation in the dying patient, sedation to unconsciousness in a dying patient). The policy indicated imminently dying is defined as death is expected in hours to days, or very close to death. The policy listed the decision to provide palliative sedation was made by consensus among the attending physician, palliative consulting provider and the patient or their surrogate decision maker. The policy identified at least 12 acute care hospitals within their corporation this policy applied to. The policy listed the following commonly used medications were administered via intravenous (IV) infusion pump:

- Midazolan (used for sedation during surgery and to treat seizures, can cause serious or life-threatening breathing problems such as shallow, slowed or temporarily stopped breathing that may lead to permanent brain injury or death)

-Pentobarbital (a depressant or sedative used to cause patients to fall asleep for surgery and emergency treatment of seizures, can cause respiratory depression and respiratory arrest)

-Phenobarbital (barbiturate slows activity in the brain and nervous system, treat or prevent seizures and can cause sedation, weak or shallow breathing or respiratory arrest)

P1's emergency department (ED) record dated 4/25/22, revealed P1's diagnoses included early-onset dementia, agitation, post traumatic stress disorder (PTSD), bipolar disorder and depression. P1 was in an assisted living for a short time, and was displaying behaviors of hitting, kicking, and choking other residents. The assisted living called emergency medical services (EMS) and P1 was sent to the hospital on 4/25/22, and admitted.

On 5/24/22, at 1:00 p.m. palliative care physician (MD)-A was interviewed. MD-A stated the facility had not been able to control P1's behaviors, having tried numerous antipsychotic medications (made her behaviors worse and produced side effects) and ketamine (sedated her and caused excessive drooling). The facility had suggested ECT treatments, but P1's family was against this, believing it would make her catatonic(immobile or unresponsive stupor). MD-A stated another physician also expressed concerns it would not treat her dementia behaviors, only her depression. MD-A stated P1 was not appropriate for a psychiatric hospital because her dementia would not allow her participate in treatment, and no skilled nursing facilities would accept her because of the 1:1 supervision and her aggressive behaviors. MD-A stated P1's family had declined other psychiatric facilities. MD-A stated her plan for P1 was to initiate palliative/terminal sedation. MD-A stated palliative sedation was deep, continuous sedation provided until death occurred. When asked if P1 was imminently dying, MD-A stated she believed palliative sedation could be administered to patients who were not imminently dying. MD-A stated the intent was to help alleviate intractable suffering that was not able to be helped in other ways. MD-A stated the plan would be to give P1 medications until she was no longer displaying symptoms, would likely be unconscious, she would not be able to eat or drink, and would eventually die. MD-A stated she has not used palliative sedation prior to this case. MD-A stated P1 was able to get up, walk, and was able to eat and drink. MD-A stated she had consulted with bioethics, who had agreed with her plan. MD-A stated the facility had a care conference with the family, and multiple providers were present. MD-A stated the family and providers were all in agreement with her plan. MD-A stated the medications to be provided to P1 to initiate palliative/terminal sedation would be propofol, Versed, or phenobarbital infusion. MD-A stated she had discussed this with P1's family, and they wanted to wait a couple of days before it was initiated, so she had not yet written the order. MD-A stated she was unaware the policy directed palliative sedation was only to be used on imminently dying patients. MD-A stated she had not read the policy, and would review it at a later time.

On 5/24/22, at 1:50 p.m. MD-B was interviewed. MD-B stated P1 was not imminently dying. He was not familiar with the facility palliative policy, nor was he aware the patient needed to be imminently dying to implement the policy for a individual patient.

On 5/24/22, at 2:30 p.m. family member (FM)-I was interviewed. FM-I stated he understood palliative sedation, and understood it would sedate P1, she would stop eating, and she would be allowed to pass peacefully with the aid of sedation. FM-I stated the hospital had his full support, and he was in agreement with the palliative sedation.

On 5/24/22, at 3:15 p.m. the bioethicist (B)-H was interviewed. B-H stated she does not have the clinical expertise to know if a patient was imminently dying. B-H stated she would depend on clinicians to determine if a patient was imminently dying. B-H stated when she was contacted by MD-A, the focus was concentrated on P1's suffering and the dying process.

On 5/25/22, at 9:00 a.m. registered nurse (RN)-K was interviewed. RN-K stated she had seen the term "terminal sedation" in P1's chart, however was not aware what the terminology meant or what that would mean for treatment for P1. RN-K stated there were some interventions that would alleviate P1's symptoms for short periods, such as staff giving her some space, walking with her, letting her sleep and wake on her own, and giving her finger foods. RN-A stated there were times P1 seemed terrified, and there was nothing they could do to do to help her.

On 5/25/22, at 9:50 a.m. RN-L was interviewed and stated she understood palliative sedation was a low dose medication to make a patient comfortable. RN-L stated when she was made aware of what palliative sedation was, she had concerns about it, and asked MD-A to address the staff concerns with P1 treatment plan for palliative/terminal sedation. RN-L stated P1 was able to ambulate independently, was independent with bed mobility, and could eat finger foods and drink fluids without choking.

On 5/25/22, at 10:30 a.m. RN-Q was interviewed and stated she was under the impression P1 was going to receive medications to make her comfortable, let her eat and sleep, and be comfortable enough to go on hospice. RN-Q stated she was not comfortable knowing P1 would be given propofol, and would not eat or drink and this would lead to death.

On 5/25/22, at 12:55 p.m. the vice president of medical affairs (MD-N) was interviewed. MD-N stated he reviewed P1's case, and he had initiated a full stop on P1's palliative sedation because she was not imminently dying. MD-N stated P1's care team would meet the next day to work on a treatment plan for P1.