Department of Veterans Affairs
 

Office of Inspector General
 

Healthcare Inspection
 

Case Review of a Patient
 

with End-Stage Cancer
 

John D. Dingell VA Medical Center
 

Detroit, Michigan
 

Report No. 11-01194-224 July 13, 2011 

VA Office of Inspector General
 

Washington, DC 20420
 
To Report Suspected Wrongdoing in VA Programs and Operations:
 

Telephone: 1-800-488-8244
 

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
 
Case Review of a Patient with End-Stage Cancer, John D. Dingell VA Medical Center, Detroit, Michigan 

Executive Summary
 

The VA Office of Inspector General Office of Healthcare Inspections conducted an 

inspection to determine the validity of allegations that facility staff did not respect a 

patient’s treatment decision, misrepresented the family’s wishes, and treated the patient 

and family disrespectfully. The complainant specifically alleged that: 

	 The patient’s attending physician misrepresented the family’s wishes and was 

unprofessional. 

	 Staff provided more than just comfort care to the patient prior to the patient’s 

transfer from acute care to hospice care. 

	 Physicians delayed the patient’s transfer to hospice care because they were 

unaware transfers were possible on a weekend. 

	 Nursing staff did not show compassion to the dying patient and the patient’s 

family. 

We did not substantiate that the patient’s attending physician misrepresented the family’s 

wishes and was unprofessional. The attending physician believed the patient desired 

treatment and therefore attempted to get another specialist’s opinion on what was 

available for the patient. 

We substantiated that staff did not provide comfort care to the patient prior to the 

patient’s transfer from acute care to hospice care. Documentation showed that the team 

continued previous acute care orders after the patient requested only comfort care. 

We substantiated that physicians delayed the patient’s transfer to the hospice unit. A 

team member stated that the team chose not to transfer the patient over the weekend 

because they did not feel the transfer to hospice care was urgent. 

We substantiated that the nursing staff did not show compassion to a dying patient and 

the patient’s family. During our interviews, management reported that the family asked 

for assistance from a nurse and that the nurse did not provide assistance. Also, the 

hospice staff did not arrange to provide the family with privacy for bereavement. 

We recommended that the Medical Center Director ensure that all clinical staff receive 

training in hospice and palliative care and that the facility follow hospice care guidelines 

to ensure all family members have adequate privacy for initial bereavement. 

The VISN and Medical Center Directors concurred with our findings and 

recommendations and provided acceptable action plans. We will follow up until the 

planned actions are completed. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS
 

Office of Inspector General
 

Washington, DC 20420
 

TO:	 Director, Veterans in Partnership (10N11) 

SUBJECT:	 Healthcare Inspection – Case Review of a Patient with End-Stage 

Cancer, John D. Dingell VA Medical Center, Detroit, Michigan 

Purpose 

The VA Office of Inspector General (OIG) Office of Healthcare Inspections reviewed 

allegations regarding inappropriate treatment of a patient and lack of respect for the 

patient and family at the patient’s end of life at the John D. Dingell Medical Center (the 

facility) in Detroit, MI. The purpose of the inspection was to determine if the allegations 

had merit. 

Background 

The facility is part of Veterans Integrated Service Network (VISN) 11 located in 

Detroit, MI. The facility provides a broad range of inpatient and outpatient health care 

services to a veteran population of approximately 330,994 in a primary service area that 

includes Wayne, Oakland, Macomb, and St. Clair counties. 

The facility provides medical, surgical, mental health, geriatric, and rehabilitation 

services; a Homeless Veterans Program; and a Home-Based Primary Care Program. The 

medical center has 217 hospital beds, which includes a 109-bed Community Living 

Center where the hospice unit is located. 

The goal of hospice and palliative care is to improve end-of-life care by enhancing the 

quality of life for the terminally ill and their loved ones. Hospice and palliative care 

maximizes comfort to enhance the quality of life remaining for patients. Hospice care 

strives to allow patients to die with dignity, pain-free.1 

In November 2010, a complainant contacted OIG’s Hotline Division with allegations that 

facility staff did not respect a patient’s treatment decision, misrepresented the family’s 

1 National Hospice and Palliative Care Organization, www.nhpco.org, accessed February 2, 2011. 

VA Office of Inspector General 1 
Case Review of a Patient with End-Stage Cancer, John D. Dingell VA Medical Center, Detroit, Michigan 

wishes, and treated the patient and family disrespectfully. The complainant specifically 

alleged that: 

	 The patient’s attending physician misrepresented the family’s wishes and was 

unprofessional. 

	 Staff provided more than just comfort care to the patient prior to the patient’s 

transfer from acute care to hospice care. 

	 Physicians delayed the patient’s transfer to hospice care because they were 

unaware transfers were possible on a weekend. 

	 Nursing staff did not show compassion to the dying patient and the patient’s 

family. 

Scope and Methodology 

We interviewed the complainant by telephone prior to the site visit on 

February 15–16, 2011. We interviewed managers, clinicians, and other employees with 

knowledge of the complaints. We reviewed the patient’s medical records and pertinent 

policies and directives. 

We conducted the inspection in accordance with Quality Standards for Inspection and 

Evaluation published by the Council of the Inspectors General on Integrity and 

Efficiency. 

Case Summary 

The patient was a male in his fifties with a history of coronary artery disease, 

hypertension, chronic kidney disease, and depression who received medical care at the 

facility for over 15 years. A non-VA hospital emergently treated the patient in early 

October 2010 for shortness of breath and chest discomfort. During their evaluation, 

physicians at the outside hospital diagnosed the patient with high-grade B cell 

lymphoma,2 tumor lysis syndrome,3 and acute kidney failure requiring short-term 

dialysis. At the patient’s request, the physicians transferred the patient to the facility to 

initiate chemotherapy to treat the lymphoma. 

On admission documentation, the patient’s internal medicine physicians (team) noted that 

the patient still had significant kidney impairment. The team placed consults to two 

specialty services . One of the specialists determined that chemotherapy could not begin 

until the patient’s kidney function improved. The team initiated treatment in an attempt 

to improve the patient’s kidney function. The team ordered numerous laboratory tests to 

2 High-grade B cell lymphoma is a type of cancer involving cells of the immune system.
 3 Tumor lysis syndrome is a group of complications caused by the breakdown products of dying cancer cells and can
 

include elevated levels of potassium, phosphate, uric acid, and calcium in the blood. Elevated uric acid in the blood
 

can lead to acute kidney failure.
 

VA Office of Inspector General 2 
Case Review of a Patient with End-Stage Cancer, John D. Dingell VA Medical Center, Detroit, Michigan 

monitor the patient’s response to treatment and continued to treat all other medical 

conditions. The patient’s kidney function did not improve to a point where 

chemotherapy could be initiated. 

On the 10th day, during the family meeting, the team discussed the patient’s current 

medical conditions and a specialist’s recommendations. The team recommended 

obtaining a second opinion on treatment options. The social worker documented that the 

patient’s sister would contact the team concerning a second opinion. The patient was 

indecisive concerning the second opinion. 

The patient’s sister made an appointment with a non-VA cancer clinic but cancelled it 

because the patient was still an inpatient at the facility. During our interview, the 

complainant stated that the family wanted to talk to a facility specialist regarding 

treatment options, but the attending physician wanted to transfer the patient for the 

second opinion. 

On the 11th day, a facility specialist discussed the patient’s condition with the patient’s 

sister explaining that chemotherapy was not an option because of the kidney disease, and 

recommended palliative radiation therapy4 (RT) to treat the symptoms if needed. 

On the 16th day, the palliative care physicians met with the patient and family. The 

patient and family wished to discuss possible treatment options with the radiation 

oncologist prior to making a decision on whether or not to treat the malignancy 

palliatively or admit the patient to the hospice unit. 

Later that same day, a radiation oncologist evaluated the patient with the family present 

and recommended a trial of palliative RT. The patient and family agreed to this; 

however, when treatment started on the 18th day, the patient could not tolerate the 

procedure due to complications from the lymphoma. 

On the evening of the 18th day, the patient became medically unstable, and the sister and 

patient requested comfort care only and transfer to the hospice unit. The team contacted 

a palliative care physician who recommended comfort care because the patient was not 

stable enough for transfer to the hospice unit. The team was to provide the patient with 

only comfort measures and symptom management and allow the patient’s family to be at 

the bedside 24-hours a day. A palliative care physician was to re-evaluate the patient the 

next day. 

On the morning of the 19th day, the team documented that the hospice unit could not 

accept a transfer until the 21st day; however, during our interview with a team member, a 

different palliative care physician contacted the team later that day and asked about 

transferring the patient to the hospice unit. The team member reported that the team did 

4 Radiation therapy is a treatment that uses high doses of radiation (x-rays) to kill cancerous cells and shrink tumors. 

Palliative radiation therapy is used to treat cancer symptoms and is not considered a cure for the disease. 

VA Office of Inspector General 3 
Case Review of a Patient with End-Stage Cancer, John D. Dingell VA Medical Center, Detroit, Michigan 

not feel transferring the patient to the hospice unit at that time was urgent. However, 

documentation noted that the patient received care consistent with acute care needs 

despite orders and a request for comfort care only. 

On the 21st day, the patient transferred to the hospice unit. Facility policy is for any 

seriously ill patient to transfer from one unit to another in a hospital bed. The staff 

transferred the patient in a wheelchair despite the patient’s serious condition and inability 

to sit upright in a wheelchair without assistance. Staff confirmed that the assigned 

caregiver did not provide assistance when requested by the family. 

The patient died later that night. The staff contacted the patient’s family. Upon their 

arrival, staff did not provide privacy for bereavement. The complainant reported that 

when the sister requested information on donating the body to science, a staff member 

was unsure of the process, made an insensitive remark, and did not assist the family with 

the donation process. 

Inspection Results 

Issue 1: Misrepresented Family Wishes and Unprofessional Conduct 

We did not substantiate that the patient’s attending physician misrepresented the family’s 

wishes and was unprofessional. The patient’s attending physician did not agree with the 

specialist regarding treatment options. The attending physician believed that the patient 

desired pursuing treatment options and therefore attempted to get another opinion on 

options for the patient. The attending physician felt a second opinion was warranted and 

discussed obtaining a second opinion with the sister, who agreed with the request. 

The sister, after speaking with a facility specialist, agreed with the treatment plan and no 

longer desired to pursue other treatment options. 

Issue 2: Comfort Care 

We substantiated that staff did not provide only comfort care to the patient prior to the 

patient’s transfer from acute care to hospice care. Documentation noted that on the 

18th day after admission, the patient requested hospice care. The patient desired only 

comfort care. However, the team drew blood, prescribed medications other than for pain 

and anxiety, and restricted the diet against family and patient wishes. 

Issue 3: Delayed Hospice Unit Transfer 

We substantiated that physicians delayed the patient’s transfer to the hospice unit. The 

patient requested transfer to the hospice unit on the 18th day after admission to the 

facility. The transfer did not occur until the 21st day. Facility policy is to transfer a 

patient to the hospice unit when needed. On the 18th day, the hospice physicians did not 

transfer the patient because of medical instability. The hospice team does not transfer a 

VA Office of Inspector General 4 
Case Review of a Patient with End-Stage Cancer, John D. Dingell VA Medical Center, Detroit, Michigan 

patient if they believe the patient may die within the next several hours to avoid 

additional stress on the patient. 

A team member stated that the team chose not to transfer the patient because they did not 

feel the transfer to hospice care was urgent. The team felt staff could provide hospice 

care on the acute care unit. Per facility policy, the staff on the unit are to receive training 

from the palliative care consult team to provide comfort care to patients who are in need 

of hospice care. However, standing orders, blood tests, and restrictive diet orders 

continued after the patient and family asked for comfort care only. During our 

interviews, we found a palliative care physician was on-call and involved in the patient’s 

care, determined that the patient was stable for transfer, and contacted the team on the 

19th day to transfer the patient to the hospice unit. 

Issue 4: Staff Compassion 

We substantiated that the nursing staff did not show compassion to the dying patient and 

the patient’s family. During our interviews, management reported that staff are required 

to transfer seriously ill patients from the acute care unit to the hospice unit in their 

hospital bed. The patient was seriously ill and unable to sit upright in a wheelchair. The 

staff placed the patient in a wheelchair while they changed the patient’s bed. The family 

asked for assistance from a nurse to get the patient out of the wheelchair. The nurse did 

not provide assistance or request another staff member to provide assistance. Staff left 

the patient for over an hour in the wheelchair and then transferred the patient to the 

hospice unit in the wheelchair. Management reported that this staff member no longer 

works at the facility. 

Staff are to provide privacy for the family to be with the patient on the unit after death. 

The hospice staff did not provide the family with privacy for bereavement. 

The patient was on the hospice unit for less than 12 hours prior to death. The patient’s 

sister asked the evening staff about donating the body to science. They were unaware of 

the donation process. In general, staff discusses arrangements for donations during the 

day shift and prior to the patient’s death. After this incident, the facility initiated staff 

training on this process. 

Conclusions 

The patient entered the facility with a serious medical condition. The physicians 

involved in the case did not agree on treatment options. After the patient and family 

requested hospice care, the team was slow to act on their wishes. The transfer to the 

hospice unit did not follow facility policy. Staff failed to honor the dying patient’s 

comfort care wishes. Staff did not provide compassionate care to the family during the 

initial bereavement period. 

VA Office of Inspector General 5 
Case Review of a Patient with End-Stage Cancer, John D. Dingell VA Medical Center, Detroit, Michigan 

The facility provides hospice care outside of the hospice unit for patients that are 

imminently dying or waiting for transfer to the hospice unit. Education is required for 

staff outside the hospice unit to carry out this provision. All clinical staff should know 

what comfort care includes and excludes, as well as, be able to discuss this information 

with patients and families. 

Recommendations 

Recommendation 1. We recommended that the Medical Center Director ensure all 

clinical staff receive training in hospice and palliative care. 

Recommendation 2. We recommended that the Medical Center Director ensure staff 

follow hospice care guidelines to allow all family members to have adequate privacy for 

initial bereavement. 

Comments 

The VISN and Medical Center Directors concurred with our findings and 

recommendations and provided acceptable action plans (see Appendixes A and B, 

pages 7–10, for the full text of their comments). We will follow up until the planned 

actions are completed. 

JOHN D. DAIGH, JR., M.D.
 

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 6 
Case Review of a Patient with End-Stage Cancer, John D. Dingell VA Medical Center, Detroit, Michigan 

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: June 24, 2011 

From: Director, Veterans in Partnership (10N11) 

Subject: Healthcare Inspection – Case Review of a Patient with 

End-Stage Cancer, Detroit, Michigan 

To: Director, Dallas Office of Healthcare Inspections (54DA) 

Thru: Director, Management Review Service (10A4A4) 

Please find attached response from the Detroit VAMC. If you 

have any questions, please contact Kelley Sermak, Acting 

QMO, at 734-222-4302. 

Michael S. Finegan
 

Director, Veterans in Partnership (10N11)
 

VA Office of Inspector General 7 
Case Review of a Patient with End-Stage Cancer, John D. Dingell VA Medical Center, Detroit, Michigan 

Appendix B 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 June 22, 2011 

From:	 Director, John D. Dingell VA Medical Center (553/00) 

Subject:	 Healthcare Inspection – Case Review of a Patient with 

End-Stage Cancer, John D. Dingell VA Medical Center, 

Detroit, Michigan 

To:	 Director, Veterans in Partnership (10N11) 

1.	 This is in response to the above subject OIG Case Review 

of a patient with end-stage cancer at the John D. Dingell 

VA Medical Center. 

2.	 We agree with the recommendations and have identified 

clinical staff that will be trained in hospice and palliative 

care. 

3.	 If you should have any questions, please contact 

Raghuram Matta, M.D., Deputy Chief of Staff, at 

313 576-4341/3090. 

(original signed by:) 

Pamela J. Reeves, MD
 

Director, John D. Dingell VA Medical Center (553/00)
 

VA Office of Inspector General 8 
Case Review of a Patient with End-Stage Cancer, John D. Dingell VA Medical Center, Detroit, Michigan 

Director’s Comments
 

to Office of Inspector General’s Report
 

The following Director’s comments are submitted in response to the 

recommendations in the Office of Inspector General’s report: 

OIG Recommendations 

Recommendation 1. We recommended that the Medical Center Director 

ensure all clinical staff receive training in hospice and palliative care. 

Concur Target Completion Date: December 31, 2011 

Facility’s Response: Hospice Education Network (HEN) is a web-based 

End of Life training curriculum that allows access to any of 8 Hospice/End 

of Life modules anytime, and all clinical staff will be enrolled and tracked 

until completion. These courses are presented by nationally-known 

speakers throughout the country. The program is complete with 

administrative tools for documentation and reporting, is user friendly, and 

at the end of each module, there is an evaluation and certificate of 

completion. These modules may be accessed from the following website: 

http://hospiceonline.com/faq.html. In addition, Hospice/Palliative Unit 

Staff currently provide a weekly one hour interactive educational session 

held each Thursday to all clinical staff from MICU/SICU, Community 

Living Center, and the acute medical and surgical units. This is a face-toface one hour weekly meeting with a total of 11 sessions that addresses 

various topics related to caring for hospice patients based on EPEC 

(Education on Palliative and End of Life Care). Finally, Palliative Care has 

a monthly session as part of the Medicine Service morning report schedule 

covering Hospice and Palliative Care issues, including the use of narcotic 

medications in pain management. These sessions are attended by 

hospitalists and rotating medical residents. 

Status: A list of names is being developed from various disciplines, 

including MD, RN, LPN, PA, Ph.D.s, and Social Workers from all inpatient 

units that will be identified and informed by their quad member/supervisor 

that they must complete all 8 modules of the web-based HEN training. 

VA Office of Inspector General 9 
Case Review of a Patient with End-Stage Cancer, John D. Dingell VA Medical Center, Detroit, Michigan 

Recommendation 2. We recommended that the Medical Center Director 

ensure that staff follow hospice care guidelines to allow all family members 

to have adequate privacy for initial bereavement. 

Concur: Target Completion Date: August 31, 2011 

Facility’s Response: The Hospice & Palliative Care staff are developing a 

Standard Operating Procedure (SOP) to ensure as much privacy is afforded 

to the family of the dying patient as possible. The following information 

will be identified in the SOP for attempting to honor family requests for 

privacy at the end of life: 

1. Staff will recognize when a patient has transitioned to a more active 

phase of dying and relay this information to the physician providers and 

nursing staff. 

2. Staff will recognize the increased need for privacy for patients and 

family during the last hours of life and at the time of initial 

bereavement. 

3. If space is available on the unit, either the patient or their roommate will 

be moved allowing the former patient to have a private room. In most 

instances, the roommate will be the one moved. 

4. If a	 private room cannot be provided, appropriate measures will be 

taken to enhance privacy: 

a.	 Privacy curtains must be pulled between patients. 

b. Door closed, excessive noise/distractions (from TV or other sources) 

minimized. 

c.	 Additional chairs/seating will be provided for family/visitors. 

5. If a private room cannot be provided, additional support and preparation 

will be provided to the roommate: 

a.	 Encourage out-of-room activities, providing patient with a 

comfortable alternative. 

b. Offer	 increased psychosocial support: social work or chaplain 

referral. 

Status: This SOP will be communicated by management to the 

appropriate staff on all shifts. 

VA Office of Inspector General 10 
Case Review of a Patient with End-Stage Cancer, John D. Dingell VA Medical Center, Detroit, Michigan 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720. 

Acknowledgments Cathleen King, RN, Project Leader 

Gayle Karamanos, PA, Team Leader 

Larry Ross, MS 

Robert Yang, MD, Medical Consultant 

Misti Kincaid, BS, Program Support Assistant 

VA Office of Inspector General 11 
Case Review of a Patient with End-Stage Cancer, John D. Dingell VA Medical Center, Detroit, Michigan 

Appendix D 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans in Partnership (10N11) 

Director, John D. Dingell VA Medical Center (553/00) 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: Carl Levin, Debbie Stabenow 

U.S. House of Representatives: Hansen Clarke, Sander Levin, Candice Miller, 

Gary Peters 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 12