[Roland]

was admitted to in patient hospice and died about a week later. At the time of her admission her Dr. (and a second opinion) had given her from two to six months to live (she had non small cell lung cancer that had spread to her liver). We decided to take her to Hospice due to the fact we were not able to control her nausea at home, and the hospital could find no physiological cause on a CT scan (such as an impaction). Her pain was under under very good control with BID MS Contin (30mg) and immediate release morphine pid (15mg).

The very minute she was admitted the nurse said that the Dr. had ordered Haldol for her nausea. I had never heard of Haldol being used in this context, but figured that the Dr. must be aware of some "off label" application of which I was not aware. That night (her first) mom became progressively more agitated and suffered from both visual and auditory hallucinations (she had never before experienced anything like this). Finally, after struggleing to keep her in bed (she kept wanting to get up due to various hallucinations) I called the nurses and they gave her a shot of Atavan and she slept. From that point on Mom took a distinct turn for the worse. Furthermore, the nurses continued to give her more Haldol almost everytime she would even sit up. Two days after admission they performed an enema and this seemed to releave much of her nausea, and she experienced no more emesis. However, the nurses continued to give her Haldol although they did at least admit that it was also being used for agitation in addition to nausea. Mom, was extremely weak by this point not even able to hold her head up (although she pleaded that I place her on a bedside commode rather than suffer the indignity of a foley or diaper).

I became more concerned after telling my nursing instructor who reacted with alarm at the use of this drug in this context. He said that to his knowledge Haldol was not used for nausea, and espcially not in elderly women on opiates. I confronted the nurses at hospice, and one admitted that Dr. XXXX used the drug to "keep the patients comfortable because most of them were not so fortunate as my mom to have family there twenty four/seven". What galls me is that this was such a beautiful facility with amenities far in excess of any residential care facility that I had ever visitied before. However, there were few if any patients out of there beds to enjoy the facility. My mom died ten days after admission and I feel that she may have been "cheated" of potential quality time with myself and her two year old grandson.

Is the use of Haldol in this context common at other in patient facilities?

[pappyRN]

Hello Roland,

I can't answer your question because I don't know. Plesae accept my condolences on the death of your Mom.

I would just say to trust your gut feeling as a nurse. If it feels really wrong it most probably is. It seems as if the doctor was treating your Mom and her nausea as he would treat someone at such an endstage point that death was expected to be almost imminent. If Haldol can not be recommended for use with opioid pain medicine that is an additional issue.

You must be feeling very cheated about the loss of more time with your Mom and time with her grandson. I'd just say to go for it in trying to find out the truth of what happened. I will also caution you that it is VERY difficult to prove anything but also to get expert witnesses to give testimony against fellow nurses or doctors. I am ver surprised that the nurses weren't more forthcoming with you about the Haldol, especially in hospice where all I have ever experienced or heard has been brutally honest.

I am so sorry for your sadness and I completely understand what you are feeling. I experienced a very similar event when my Dad passed. You just feel cheated and angry and it doesn't feel that anything will make it go away because nothing you do will bring your Mom back. The frustration is enormous.

Warm personal regards,
PappyRN

[renerian]

Yes I have seen haldol used for nausea and the restlessness that comes with the end stage of active dying. People are up and down and restless during this stage. I have cared for several family members, dad and grandmother on hospice. I took anything they could give them to stop the restlessness and agitation. That is not pretty for the family to watch or the patient to go through. I also have been a hospice volunteer over 10 years.

While I am sorry your without your mother I am glad her suffering is over.

renerian

[aimeee]

Haldol is sometimes used as part of a whole cocktail of meds which is used to tone down an over reactive system to bring nausea under control...we sometimes use suppositories in our home hospice which contain ativan, haldol, reglan, and benadryl. This often brings relief to people for whom nothing else works. Other hospices use metaclofen suppositories (I don't know the precise composition but I know haldol is one of the ingredients.) I won't form an opinion of the appropriateness of its use in this circumstance because there is no way I could know the full picture, not having seen her complete MAR, not having seen the patient, not having a history to look at.

What I do wish for you now, is to find a way to peace in your heart and heal the grief and the anger that you feel. I hope you will pursue some bereavement counseling. If you have too much anger with this hospice to accept their services, you can ask for that support from another hospice. Most will be very gracious about accepting you into their support groups.

[caroladybelle]

Agree with above two posters.

And MDs rarily can give an accurate length of time before death will occur - even the good ones. Only G-d can predict death.

My condolences go to you.

[Spidey's mom]

I agree with everyone else . . . I've used Haldol for nausea in terminal patients. And it is difficult to predict death.

I'm very sorry about your loss.

steph

[canoehead]

It's funny that they continued to use Haldol when the Ativan was what worked. I would have considered hallucinations evidence of an intolerance to Haldol, and gone to another med for nausea.

There could be some reason they continued with Haldol that I don't know about of course. I'm sorry you were left with doubts about her care. If you are ever in that situation again, remember that you or your family member can refuse any treatment or med you feel is unwarranted, and ask for alternatives to be discussed.

Unfortunately if the doc orders it in spite of expressed nursing concerns there has to be a really huge reason for them to refuse to follow his prescription. We'd have to be present for that discussion to be able to have an opinion on whether the care your mom got was inadequate.

[ktwlpn]

Originally posted by Roland
was admitted to in patient hospice and died about a week later. At the time of her admission her Dr. (and a second opinion) had given her from two to six months to live (she had non small cell lung cancer that had spread to her liver). We decided to take her to Hospice due to the fact we were not able to control her nausea at home, and the hospital could find no physiological cause on a CT scan (such as an impaction). Her pain was under under very good control with BID MS Contin (30mg) and immediate release morphine pid (15mg).

The very minute she was admitted the nurse said that the Dr. had ordered Haldol for her nausea. I had never heard of Haldol being used in this context, but figured that the Dr. must be aware of some "off label" application of which I was not aware. That night (her first) mom became progressively more agitated and suffered from both visual and auditory hallucinations (she had never before experienced anything like this). Finally, after struggleing to keep her in bed (she kept wanting to get up due to various hallucinations) I called the nurses and they gave her a shot of Atavan and she slept. From that point on Mom took a distinct turn for the worse. Furthermore, the nurses continued to give her more Haldol almost everytime she would even sit up. Two days after admission they performed an enema and this seemed to releave much of her nausea, and she experienced no more emesis. However, the nurses continued to give her Haldol although they did at least admit that it was also being used for agitation in addition to nausea. Mom, was extremely weak by this point not even able to hold her head up (although she pleaded that I place her on a bedside commode rather than suffer the indignity of a foley or diaper).

I became more concerned after telling my nursing instructor who reacted with alarm at the use of this drug in this context. He said that to his knowledge Haldol was not used for nausea, and espcially not in elderly women on opiates. I confronted the nurses at hospice, and one admitted that Dr. XXXX used the drug to "keep the patients comfortable because most of them were not so fortunate as my mom to have family there twenty four/seven". What galls me is that this was such a beautiful facility with amenities far in excess of any residential care facility that I had ever visitied before. However, there were few if any patients out of there beds to enjoy the facility. My mom died ten days after admission and I feel that she may have been "cheated" of potential quality time with myself and her two year old grandson.

Is the use of Haldol in this context common at other in patient facilities?

My condolences on the loss of your mom...I think your anger is a normal part of the grieving process and with time you will heal...It is easy to try to blame in this type of situation..Much easier then bearing the burden of your own helplessness over it......Your family was cheated-by the cancer.....You could not do a thing other then try to give her a comfortable death.....It's areal shame that your nursing instructor offered his opinion in an area not within his expertise and without knowing the details of your mom's condition..He alarmed you needlessly...It's good lesson for us all-he should have offered you nothing but support......We have to be so careful when people ask for advice-see the kind of harm we can cause?

[Roland]

that this hospice is essentially practicing "chemical restraint" in order to minimize the work load on their nurses. My opinion is based not only upon my observations while my mother was a patient, but also by those of my wife. She spent time this semester as a "student nursing student observer" as part of her ASN program at the same facility. Of course I cannot prove my hypothesis, and I could be wrong. In addition, we have bigger fish to fry (like trying to get out of school and earn a living) than going on some hopeless crusade that would probably only end in our being ostracised (or worse) with regard to school. What is the fundamental basis of my opinion?

Well, probably the strongest element is the fact that several of the staff nurses told me point blank upon persistent questioning that Dr. XXXXX uses Haldol upon admission with almost ALL of the patients admitted to the facility (and that while she they like it, that they were only a nurses and what were they to do).

[obeyacts2]

Our local hospice uses haldol as a remedy for agitation, but it is a step-up drug when the Ativan isn't working. It doesnt work for some. The lady I care for now at home thru a hospice is like this. She was on Ativan 24/7 (big dose) plus a stiff sleeper and they werent doing one iota of good. It got to the point where she was a danger to herself climbing out of bed, etc. She forgets she is non ambulatory due to CVA plus end stage IDDM and CHF.