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“Saving” Bonnie

Kathleen Bartholomew, RN, MN1
[+] Author Affiliations
1International presenter, currently without institutional affilations
JAMA Intern Med. 2014;174(1):13-14. doi:10.1001/jamainternmed.2013.12104.
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My mother in law, Bonnie, stopped eating just after her 88th birthday. A Christian Scientist, she had only seen a physician a few times in her entire life. Bonnie never talked about death because her religion did not acknowledge it. But as 50 pounds dropped rapidly away, she finally acknowledged to my daughter that she was dying.

Still, when I arrived at the emergency department, I was surprised at her motionless, emaciated body. Only yesterday evening, the Christian Science house where she had been living had discharged her to a skilled nursing facility (SNF) because she was too weak to stand. In the morning, her sons had visited and panicked: her legs were grossly swollen and suddenly leaking copious amounts of fluid. Without a physician present at the time, they were advised to take her to the emergency department.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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Submit a Comment
Misguided anger
Posted on November 21, 2013
Kim Dutton-Johnson RN
UT Southwestern Medical Center
Conflict of Interest: None Declared
I find so many mishandled steps in this woman's journey, none of which in my judgment is owned by the emergency room staff. I wonder if this article was written due to a bit of self imposed guilt for being part of the creation of this situation. She was clearly very ill at the time she was transferred to a skilled nursing facility. At that very moment, the family, social worker AND patient should have had a conversation directed at hospice or palliative care. Instead, she was transferred a step higher to an emergency room. Treatment is anticipated by most people who present to an ER. As the D-I-L, you did not have the first line decision making for her although your input was clearly well intended, simply after the fact. The ER physician was absolutley appropriate in asking to speak to his/her patient in private. If this patient's family who has known her for many years has not felt comfortable preparing medical directives, why would you think an ER physician who has known her 2 hours would feel comfortable. While I appreciate the difficulty and pain the family experienced. The medical staff acted appropriately.
Hospice & Palliative Care in the ED
Posted on January 27, 2014
Gail Austin Cooney MD
Hospice of Palm Beach County, West Palm Beach, FL
Conflict of Interest: None Declared
This story demonstrates another important reasons for hospice and palliative care to be available to patients through the emergency room. Too often, appropriate discussions have NOT been had earlier in the course of disease - the reasons are myriad. But this should not prevent health care providers from offering palliative care when it is needed and wanted. No one should die in pain, being shuffled from one health care setting to another.
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