End Of Life Issues---The Good, The Bad, and the Ugly - page 3

by VivaLasViejas Guide

11,854 Views | 42 Comments

If I ever become a hospice nurse (which is what I've decided I want to be when I grow up), the varied experiences I'm collecting in long-term care should stand me in good stead. Right now I have three different residents in... Read More


  1. 4
    Thank You! Thank You! Thank You! to all of the nurses who do LTC. I can't for all the reasons that are listed above. I LOVE working at Hospice. Occasionally we get the family members that do not want the patient medicated because they want them to be "alert". I have become very good at pain control education. If the patient comes to us and can still verbalize pain, we medicate per patient. If they cannot, I teach the family the non-verbal signs and symptoms I look for and explain what I am doing and why. Usually, the family will get on board and look for those symptoms with me.

    I too am one that has made it very clear to my family what I want when I cannot advocate for myself. I want standing orders for a glass of wine after dinner (or two!) I expect to have chocolate readily available. If I can't eat or drink, then I'm done. NO FEEDING TUBES. I've threatened to have that tattooed on my stomach so that if my family decides I need one, the doctor will see how I really feel.

    Again, Thank you! LTC nurses do a job I know I couldn't do. You are truly angels.
  2. 0
    Quote from tencat
    It's not just the families that don't understand that death happens. So many in our profession and so many physicians see death as 'giving up' and 'losing' the battle. And so many are woefully ignorant about what hospice does and why we use the drugs we use. The medical profession needs WAY more education about hospice as well.
    I wonder if some of these docs don't want to lose the gravy train i.e. a dead patient doesn't earn them any money. I have suspicions about one particular doc who works at my facility who seems to dissuade pts/family members from DNR's and always wants aggressive treatment for his frail elderly pts with poor quality of life.
    When a patient goes on hospice, does their PMD lose a patient-does the hospice MD effectively become their PMD ? I would appreciate clarification from any hospice nurses out there.
  3. 1
    Well put. Too bad we can't post this in the hall for all the "POA's" to read!
    sharonp30 likes this.
  4. 2
    Don't look now, Viva, but you're already a hospice nurse ... and a pretty good one judging from the original post.

    It would be a great thing to learn more about what LTC/AL/Rehab nurses need or want from those of us working for the more formal hospice industry.

    One of the medical directors for my hospice ... 2 owners ago ... was trying to get a consultation service started. If our respective owners can figure out how to make money out of it ... what a great thing to have as a resource for the work you're doing for these elders.
    Last edit by heron on Apr 28, '10 : Reason: added thought
    VivaLasViejas and Spidey's mom like this.
  5. 1
    That's a great idea, heron!

    Speaking for my peers in LTC, I'd have to say that our primary need is EDUCATION---about what hospice is, what it does for the patient, family, AND facility staff, and especially its philosophy regarding medications and comfort. So many LTC nurses are so afraid to give meds in the amounts recommended---afraid they'll be accused of killing the patient, or hastening his/her death---that they don't medicate properly, thereby causing unnecessary suffering and perhaps even prolonging the dying process.

    In fact, I'm one of the few LTC nurses I know who's comfortable with giving meds in the amounts needed to relieve pain, air hunger, terminal agitation etc. I've had to do a lot of encouragement with my fellow nurses to get them on board with comfort care procedures........usually when I've spent most of my shift working to get on top of a hospice patient's pain and distress because the previous shift gave only 5 mg of morphine all day.
    Spidey's mom likes this.
  6. 2
    Of course, there is the issue of where does education/consultation/support stop and marketing begin. It would be exploitive to conceive of LTC/rehab/ALF as mere "feeder facilities" in service to an aggressive hospice company's profit margin.

    We would need to be clear on the business ethics of how referrals are generated ... but one would think that, since hospice was originally developed as a low-cost option for end-of-life care, facility owners might be interested in looking at it.

    Unfortunately, my own company disbanded the team dedicated specifically to caring for hospice patients living in LTC, so, for us, it's up to the individual field nurse to suss out what facility staff need from them and find a way to provide it. It's unrecognized/uncompensated work and must be piled on top of some pretty intense paperwork demands ... some field nurses do what they can, some not so much.

    All that being said ... hospice providers need to have written contracts with the facilities where they see patients. Maybe inquiries to the hospices that contract at your facility would be a place to start.

    I also wonder if it would be possible or desirable for interested members of facility staff to be certified in hospice and palliative care. Then you'd have resources on staff who don't have to answer to another company.

    Medical directors, aka hospice docs, might also be interested in doing consultations ... though I don't know how the billing might work.

    Meanwhile, the national organization for hospice nurses has some cool CEU offerings on their site. Unfortunately, they make you pay for ceu's if a non-member, but it's a good source of information:

    HPNA.org
    VivaLasViejas and Spidey's mom like this.
  7. 1
    We are opening a patient tomorrow - from our hospital's LTC.

    She has breast cancer and terrible pain - but the nurses aren't comfortable with the orders for pain control given by the doctor - I really want to do some more inservices . . but really unless you work around it, it can be hard (scary) to understand the high doses.

    Marla - I applaud your insight my friend.


    steph
    VivaLasViejas likes this.
  8. 0
    Quote from Spidey's mom
    We are opening a patient tomorrow - from our hospital's LTC.

    She has breast cancer and terrible pain - but the nurses aren't comfortable with the orders for pain control given by the doctor - I really want to do some more inservices . . but really unless you work around it, it can be hard (scary) to understand the high doses.

    Marla - I applaud your insight my friend.


    steph
    Would you have to do those inservices on your own time?
  9. 0
    Quote from heron
    Would you have to do those inservices on your own time?
    I'm looking for ways to give myself more hours my dear.

    They changed the benefit schedule - used to be if you worked 24 hours per week, you got medical bene's. That is what I used to theoretically work - before I quit working acute/ER/L&D. And I got full bene's for my family too. I always ended up working way more than that though . . . .

    I've been working casual with the idea that after school (my BSN) I would work part-time with bene's. My boss said she has been trying to do this since last Nov. I finally took the bull by the horns - found out that the CFO changed things when she found out people were working 24 hours for bene's and then working elsewhere too. Not really sure why that is such a bad thing - but they upped it to 36 hours per week. There is no way that I've been able to find to increase my hours that much.

    So, yeah . .. . I'd love to do inservices on THEIR time.
  10. 1
    Go for it!!!

    The worst that can happen is they'll say no. If you pitch the marketing aspect to them, you might pull it off.

    Let us know how it turns out.
    Spidey's mom likes this.


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