Bioethics Blogs

PoET Project: Prevention of Error-Based Transfers

Jill Oliver and Paula Chidwick describe a locally initiated Ethics Quality Improvement Project that aims to reduce ethical errors related to transfers from long-term care homes to hospital emergency departments.


Mrs. Thomas, a 92-year-old woman with end-stage dementia, has been a long-term care resident for eight years. She is bed-bound, has multiple large skin ulcers, and has had recurrent aspiration pneumonia.

When Mrs. Thomas was first diagnosed with dementia, but still legally competent, she wrote down her wishes in her Power of Attorney for Personal Care. In this document she included a wish not to be given any life-prolonging treatment if she suffered “from a severe and debilitating physical or mental condition without hope of recovery.”  At the time, she clearly told her daughter that she did not consider her mild cognitive impairment to be “severe and debilitating” but that she believed her dementia would eventually reach that point. As the dementia progressed, she reiterated this view.

With each bout of aspiration pneumonia the staff at the long-term care home asked Mrs. Thomas’s daughter – her substitute decision-maker – to consider palliative care. Each time, her daughter was unwilling to make a decision and her mother was transferred to the local hospital. During her most recent admission for fever and pneumonia, the physician presented the daughter with two care options, a feeding tube or palliative care. Mrs. Thomas’s daughter asked for the feeding tube to be inserted while she considered palliative care, again. Mrs. Thomas was discharged back to the long-term care home with a feeding tube.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.