[adrienurse]

I am primarily a LTC psychogeriatrics nurse, but have a growing interest in your field. Do you also consider yourselves to be palliative care nurses? Does palliative care mean the same to you as hospice care. Please discribe the facilities or agencies you work for. Do you work primarily with inpatient or outpatient clients. During the active dying phase, do you follow protocols for symptom management that are preset by physicians? What kind of analgesia do you use on a regular basis? What route? How do you treat respiratory congestion in those final hours? Do you use scopolamine or atropine? As you see, I have a lot of questions for you experts.

[aimeee]

I'll get started on this answer tonight and write some more in the morning when I am fresh.

I guess I think of myself as a hospice nurse and palliative care as part of what I do. You see, in hospice care the client is not just the patient, but the entire care giving unit as well. Educating and supporting the care givers is a huge part of our role. I work for a hospice which provides care at home or in the extended care facility. We usually have 80-90 patients and we cover a three county area. We have three teams, each covering its own geographic area. Each patient is assigned a primary nurse, possibly a home health aide, possibly a volunteer, a social worker, a spiritual counselor, and a bereavement counselor. The primary physician is also considered a part of the interdisciplinary team. In addition, our medical director is available for additional physician support.

...more tomorrow....

[adrienurse]

Sounds like a great program!

[aimeee]

I think it IS a wonderful program and I am so proud to be part of it.

We provide durable medical equipment related to making the patient comfortable (hospital bed, w/c, commode, oxygen, etc) as well as medications directly related to easing their symptoms (analgesics, anxiolytics, antinausea, bowel aides, etc) We know how the course of illness is likely to run and what things we are likely to need so we try to have the things we are going to need in place ahead of time to avoid stress and suffering.

We have a fairly extensive list of standing orders that were developed with and approved by our medical directors. At the time of admission the primary physician is asked to approve these standing orders. This gives our phone triage nurses and team nurses what they need to solve most problems immediately. We do use atropine but more often levsin for terminal secretions.

Analgesia is a whole topic in itself. On admission we do a thorough pain assessment. We use a 10 point pain scale and we look at location, duration and frequency, quality, and intensity of pain as well as accompanying factors. We use whatever works and is well tolerated by the patient. Frequently that is a form of long-acting morphine or duragesic patch with roxanol for breakthru pain. Oxycodone is also used often. Dilaudid is sometimes used when the others are not tolerated. Combination drugs, such as Vicodin, are usually appropriate when the patient needs temporary or occassional pain relief. Bone pain is often relieved with the addition of an NSAID. If there is a neuropathic pain component then a tricyclic antidepressant or gabapentin often helps.

Since we know that GI motility will be decreased by the narcotics we keep a close eye on bowel performance. Senokot or Senokot-S is our drug of choice for prevention. It is well tolerated and a wide margin of safety in dosage allows us to individualize treatment. If a patient was not on a bowel regimen previously that is what we usually start with.

Whew. I hope that answers all your questions!

[adrienurse]

Wow thanks.

Hospice care seems somewhat archaeic in my city. The more mainstream programs are mostly impatient units. One of the two main units has an outpatient and respite component. Unfortunately, most people have to pay privately if they choose to die at home. Not an unusual concept for you I'm sure, but I live in Canada -- and this seems to me as if people are being punished for not buying into the medical model concept. The only actual hospices are private small homes that care for the dying.

I've never heard of using levsin of terminal secretions. I do have a patient who takes it for Irritable Bowel Syndrome. Please tell me more.

[aimeee]

Levsin/hyoscyamine is an anticholinergic. You mentioned scopalamine in your post which is a cholinergic blocker. The advantage of levsin is that the tablets can be given SL. We have an emergency kit that is placed in the home on admission and levsin is in it.

I didn't really address route before...we use whatever route we have available, starting with the one that is most comfortable for the patient. Injections are usually the last resort...patients often have a lot of muscle wasting that make IM's difficult and uncomfortable and the families are usually not comfortable with doing injections. Many things can be given rectally when you really need to, such as vicodin, dilantin, with good results.

[Jenni Shand]

Hi, I work in a palliative care unit we are part of a statewide service which also has community based specialist nurses who act as consultants for people in the home setting as well as a specialist nurse in the major teaching hospital. The analgesia which is used are the opiods such as Morphine etc as well as coanalgesics NAISD's, panadol etc. The route the opiods are given is dependant on the patients condition either orally or subcutaneously we never give IMI or IV. For SCI we use safe-t-intima needles and leave them insitu for about 3 - 4 days.
For respiratory congestion in the terminal phase we mainly use Robinul SC although sometime if the patient is unconscious Hyoscine SC may be used (tended not to be used earlier as may cause confusion) Hope this helps. Cheers Jenni

[Tookie]

This is a really interesting thread to read - l beleive that all nurses should have a good grounding in the care of the dying and see that what you are doing - if it be called hospice nursing or palliative care needs to be understood and see it as an ultimate area of caring