[mc3]

I've been having what seems to be a run of difficult cases since I've joined with this hospice. I've done a lot of soul-searching, and I'm coming to the conclusion that the folks who live in this region of the country are just not ready for hospice. I've already written a posting called "Family Dynamics" about one such situation. I'm running in to more and more each day. Today, for example. The first patient I saw is an elderly female with dementia, not end stage but definitely mid-stage. Myself and another nurse have had her since February. She made it clear on the first visit that she "knows what hospice is, and I don't need it". Even since, she's verbally and sometimes physically abusive to me. We are at the point now where we cannot do a physical assessment at all. She won't let us touch her. She tells us to get out when we enter the facility, never mind her room. And on and on. Her son says "oh, she just gets this way. She doesn't mean it". Well, after I got hit in the face, I stopped believing him! She has ongoing skin tears and edema, for which we are responsible for taking care of. The family disagrees with most everything we recommend. Today, I found out that the facility Med Tech's think "hospice wants to keep her doped up because she doesn't like you. She likes everyone here but you people" And that with her boss sitting right there, saying nothing. The reason we recommended the patient take Ativan on a scheduled basis was due to their report that the patient was combative and agitated, refusing care and spitting pills out at the staff. And the family didn't want her on Risperdal which had been recommended by her Geri Psych MD. I give up!!!! How can the DON tolerate Med Techs holding orders because they don't agree with them???

The next person I see is concerned because her aunt may no longer be eligible for hospice, after 2 years on the program. Why? Because then she'll have to move her to a SNF because she can't afford 24 hour care that the facilty would require. Evidently we are considered an option for people who really don't need hospice, but want to stay where they are in an ALF so we're called in. And our managers not only accept it, I swear they promote that idea to keep the census up. And who ends up playing middleman?

I don't know. I'm just tired of all this b------. I think the people that truly need hospice aren't getting it until too late, because some holier than thou MD can't accept the fact that the patient might in fact be terminal. Pain management is atrocious here. All these docs here love Darvocet. Nothing else. Now, I see I'm getting cynical, and that's not good, either....

Well, thanks for letting me ramble on. Does anyone else have similar issues, or is it just this area of the country (mid-Florida). Or do I need a really long vacation? I just can't see myself doing anything other that taking care of my terminal patients.

[earle58]

no mc, it's not like that just in fla.
the same b.s. happens everywhere.
some hospices are better run than others.
and there will always be pts and family members alike, that look at hospice as a death sentence, and so, resist all interventions.

i recently had a run of very trying cases and needed to take some time off.
i know not all hospice nurses can do that.
the turnover in my neck of the woods is exorbitantly high.

what i've recently accepted is there is so much i can do.
i really need to learn when to let go and accept decisions that pts/families make, no matter how seemingly destructive.
you can only do your personal best; nothing more, nothing less.

as for those md's who only prescribe darvocet ( ), it often helped me when i told the dr. that i was noting pt's reaction to said med, with very poor effect; and would further note any conversations between me and md re: need for stronger analgesia w/md refusing.
md's do not like any sort of charting that could legally implicate them for negligence.....many times they ask in frustration "well what do you want for this pt?". and i answer, very specifically.
i fight like the dickens if any of my pts are suffering in agonizing pain and their md is one of those darvocet prescribers.
but yes, all of this takes its' toll on you. very draining work we do.

if you can, try to arrange for some time to yourself.
and do continue to be your best, even when the world is fighting you every step of the way.

with peace,

leslie

[doodlemom]

MC, you have my support. I agree wholeheartedly with Leslie. You will see these kinds of pt's everywhere - particularly in nursing homes. Also, there are hospices out there that are very poorly run. The one you work for will eventually get dinged for keeping inappropriate pt's on service. I don't know where you live, but if there is another hospice around, I would be inclined to go there. Good luck.

[TORRIA RN]

Hang in there. We all hyave had those difficult families, and facilities. You may want to consider scheduling a inservice on pain management and commonly used hospice drugs for the facility. Most nursing homes will not comply with the hospice recommendations unless the drugs are on a scheduled dose. PRN ......the patient will never recieve the med.

Also you said your patient was not end stage but mid stage. It might be tme for discharge before you and your agency anr both in the hot seat for contining to re sert a inapporiate patient. If you have a lot of these type of patient on your census GET OUT QUICK

[mc3]

Thanks for the advise. IMHO I think we do have too many patients that don't meet criteria anymore and have been on for far too long. We are told to "find something". I'm very uncomfortable with this!

[LJLeach]

What I'm curious about is: Why, after being struck by this first patient, do you still have her on your caseload? Doesn't your agency have a policy in place that would protect you?
(At my agency there is a criteria for admission that clearly states that admission will be denied and/or revoked if there is any risk to the safety and well-being of the nurse.)
You shouldn't be at risk for physical abuse.
God bless you,
Linda

[saribeth]

I agree, we all come into situations like that but poor you...hang in there. When we have pts that are poor but chronic, we draw blood to see what the serum albumin is...less than 2.5 gm/dl is considered one criteria for keeping a pt on hospice but there are several other criteria...there is an excellent book that NHPCO provides...Medical Guidelines for Determining Prognosis in Selected Non Cancer Diseases...it was $10 several years ago but it is really helpful. I believe it is standard practice that one can refuse or revoke a pt if there are safety issues involved. Do something fun for you to escape the craziness that we all encounter at times.

[req_read]

mc3

There are occasional problem patients, families & MD’s, but this sounds more like a problem agency… or perhaps problem managers within an agency. It would be interesting to know if the policy of keeping inappropriate patients is coming from the board of directors and administrator or from the managers.

Also, if your agency has a habit of keeping chronic patients on the roles, how is it doing in regards to capitation? What is the average length of stay? Does your agency pick up short term patients; i.e. patients who you know will die within a few days of admission?

[EmptytheBoat]

I'm sorry for your situation, you deserve better; unfortunately, as others mentioned, you are not alone, I hope that fact alone brings you some consolation; it did me to read your post.
You have received some excellent replies here, I find myself agreeing with each one, but especially with the replies that suggest that you consider
other Hospices for employment; sometimes, you have to accept the fact that
circumstances are beyond your control. You now know what to look for in a Hospice Agency and can ask the right questions.
Good Hospice nurses will always be in demand because our society lacks
the basic principals of caring.
Best wishes, keep the faith, and you may want to consider some time off
between jobs (very helpful).

[GoLytely]

You know, this is the same type of crap I deal with almost daily. Unreasonable families with unrealistic expectations who act like you are some kind of fool. This is why I'm looking for another line of work to get into. When management and families jump in and whine about the nursing shortage, I wish they would take things like this into consideration. But they just act all wide eyed and bewildered.

I was excited about starting home health. But I'm getting very cynical lately and am afraid I will not be able to put on the show much longer. What's sad is that there are patients who steal your heart and you can't help but love them. What ruins the job are the patients and especially family members (not to mention other entities like laboratories and snobby nurses in doctor's offices-boy oh boy didn't I ever get slammed by one of those a couple of days ago and for no reason within my control!) it has made me very depressed. I don't sleep well at night anymore, I just want to hide in my room and go to bed, the situation with the nurse abuse has gotten so bad.

Part of it is the agency. This agency is trying to regain its reputation after being under some very bad management and right now this means they are accepting the "worst of the worst" as far as patients go. But I'm sure it's no cakewalk with any other agency, either.