Originally Posted by kstec
I just had an interview at a hospice place and they told me that alot of the hospice patients are full codes, I don't understand. How can a patients who is diagnosed to pass away soon, be ethically resuscitated?
There are a number of things at work here.....for instance, an end stage heart or COPD patient may have been resuscitated before and its hard for the patient/family to grasp that it won't work again for them. And maybe it will...who can say with certainty. Another issue is that often at the point of entry into hospice the patient/familly are just beginning to come to grips with that idea that they are dealing with a TERMINAL illness. Signing the DNR is just too much at once for them. Usually, if we have some time to work with them, they come to a point eventually where they are ready to realize that a DNR order is actually a blessing that will allow them to exit peacefully from the world. But if they dont, that's okay too. The important thing is that they make a truly informed choice, and we are very honest with them about what they can expect when they make that choice.
Originally Posted by kstec
I was also told they will put in feeding tubes. I don't understand.
A feeding tube is appropriate when it is believed that it will improve the patients quality of life. For instance, lets use the end stage cardiac patient example again and say it was best estimate that they had a 3-6 month life expectancy at their entrance to hospice (nobody is really that good at prognostication, but lets accept that for the sake of example)....shortly after they enter hospice care they suffer a stroke, which leaves them with impaired ability to swallow but they are still able to communicate with the use of a message board. They indicate that they are feeling hunger and they want a feeding tube. It would be perfectly consistent with the care plan to arrange for that person to receive a feeding tube.
Originally Posted by kstec
As for getting info on pain, I'm just taking this all in for any of my future patients if I get the job. Do they used Fentanyl patches alot, or do they decrease respirations to much? Just curious.
The use of fentanyl patches varies a great deal from practice to practice. We prefer to use them only when there is a true need for round the clock pain relief and the patient is unable to take an oral long acting med. As for decreasing respirations too much, properly applied that should not be an issue, just as it is not an issue with other forms of narcotic. Any narcotic can decrease respirations to a dangerous level if a large dose is given to a narcotic naive person. You never want to start a narcotic naive patient on a fentanyl patch right off. We start with other immediate release forms of narcotic until we have arrived at the proper dose for relief, the body has had time to adjust, and then convert. The other issues with fentanyl are that there can be differences in absorbtion rate (patients with a higher temp absorb more quickly), people apply them incorrectly (put them over bony prominence), there are often adherence problems (sweaty oily skin) and they are one of the more costly forms of narcotic.
As for the ALS patient in the topic, more information is needed to offer helpful advice. Where is the pain? What is the nature of the pain? Are they getting an anxiolytic along with the morphine? Maybe addition of a tricyclic? This might help potentiate the pain relief, and aid in sleep relief and depression relief. Now and then you do get a person that just doesn't respond to morphine the way others do....methadone, fentanyl, or dilaudid would be alternatives but there's no way to know about this individual but to try.
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