[captain morgan]

This is an extension of my previous thread. Again, thank you to all who took the time to reply. Well..........another day, another learning experience. The same pt called to get sent to the ER as he was in constant pain and could not breathe. When I got to the pts house, he was visably trying to breathe, diaphoretic and panicky. He refused any interventions ( increase Lasix, nebulizer, increase morphine, etc.), and insisted on me calling 911. I had to have him sign a revocation - and I have to tell you that I felt that I had failed this man. I admit that I am inexperienced in hospice/home health and wonder if a more experienced nurse would of handled it differently. The pt's sister (a retired nurse) was in tears, and she felt that he did not want to die in front of her in her house. Anyway, I went home feeling like sh....... and wondering if perhaps I made a mistake crossing over into hospice. The receptionist told me later, via my cell, that the marketing person wanted her to make sure I did everything I could to get him to stay with hospice. Right about now, I feel like applying for a job in Walmart - no kidding...

[AtlantaRN]

If he refused any interventions, then there was no choice other than er visit for him; to get him stable. I've been an RN for 11 yrs, and doing hospice exclusively for the last few months.

Each case you learn a little more. For instance, I didn't know til last week that XANAX is preferable over ativan because of the euphoria effect--I had a patient with critical aortic stenosis, and the ativan wasn't giving him relief---no pain, only dyspnea...Med director said xanax and patient made a marked improvement. lived his last days in relative comfort (the last 3 days I added MS contin 30mg bid as he was using so much of the morphine elixir).

Does your hospice contract with a medication provider? We have hospice pharmacia and we have a book that is like the "bible", whatever symptom, there is an algorhythm to follow. If this doesn't work, then add that.

You didn't fail your patient, everyone is different. Be sure there is someone you can call, another nurse; sometimes all you need to do is review the situation with another nurse; they can see things with fresh eyes. Ultimately, your clinical services director, or administrator should have the answers you need. I tell you, though, that hospice pharmacia book was a Godsend to me--because of the algorhythms...I like when things are chaotic, you can just turn to that section and it makes alot of things clearer (although it was the med director that clued me in about the xanax...and also-if you ever have a patient with a movement disorder like Parkinsons, NEVER NEVER under ANY circumstances use HALDOL---it makes their rigidity worse ( i learned that on this forum).

Stay strong, and I've been told it gets easier...we all learn from our own andothers experiences.

[aimeee]

When people are used to depending on the ER to fix their problems it can be difficult for them to learn to trust someone else. You really haven't had time to form a relationship with the patient yet. As said above, if he refused the interventions you had to offer, your hands were tied. Acceptance is a process, faster for some than others.

[RNKittyKat]

There is that business side of hospice that drives me up a wall. No live discharges. Ugh! I am guided by the principal of simply doing the right thing by the patient. All the rest is someone else's problem. I won't make it mine.

[Rnmomajmj]

AtlantaRN, what is this book you are talking about your "bible"? I'm new to hospice, did PRN for 5 months then started as a Case Manager in early May and have been wondering if I made a wrong move. I'm sure it will be fine once I've been doing this for a while, but I'm looking for anything that may assist me. If this "bible" is available in book stores I'd love to know the name!
Thanks!

[aimeee]

The book she refers to is the Medication Use Guidelines from Hospice Pharmacia. These are issued to all the hospices which are signed up with them as customers but unavailable to anyone else. However, Linda Wrede Seaman's book, Symptom Management Algorithms: A Handbook for Palliative Care is also in algorithm form, is a smaller size easy to slip in your bag, and very helpful.

[RNDYN2CU]

There there! Yes, when unsure, call one of your comrads, chances are 9 out of 10 times? The experienced nurse you consult will concur with your action plan. The cognitive breathless ones will panic!!! It's one thing to sign on to Hospice and ideally believe you accept the "no 911" but I can only imagine or have actually witnessed the last minute decision made by the patients or family members to make that desperate call. SOmetimes they need to go through it one or 2 times before they are done with the denial. Yes, it can be part of the disease acceptance process. And we guide them through it. ANd after an E.R. episode with subsequent failure of course, because they arrive at the same impass... is a good time to review the hospice plan of care, and repeat the mantra:" I Will not call 911, I will not call 911..."

Hey, and the Wal Mart thing? TOTALLY understand!!! I had a pt with a med error re-capped on the SNF orders that wasn't caught immediately, no harm no foul, HOWEVER: It shook me UP!!! I mumbled allllll day that day,,,,"I will become a Wal Mart Greeter" It's a trend.

There is spiritual rewards to Hospice nursing. Chances are, if you caught the bug, you belong here. Hang in there!

[RNDYN2CU]

Thanks Aimeee! I ordered it via your link! BIG thanks!!!

[aimeee]

Originally Posted by RNDYN2CU

Thanks Aimeee! I ordered it via your link! BIG thanks!!!

Great! Let me know how it works out for you.

[tencat]

Hey, I TOTALLY understand. I had a patient last week in intractable pain, and our med director was at a loss as well, so said "if pain continues to be intolerable, have pt go to ER". So off we trot to the ER, and the doc there looks at me and says "What exactly do you want me to do?" Talk about feeling like an absolute IDIOT. As one poster said, I can see how ER visits can be part of the process to overcoming denial, both for the patient and the caregivers. I did learn from that fiasco, though.

Hospice Pharmacia is a godsend, let me tell you! They have been so helpful during this time of trying to control this patient's pain, and the algorhithms are fabulous.