End Of Life Issues---The Good, The Bad, and the Ugly - page 2
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... Read More
Apr 26, '10That's just plain selfish of the families to keep these people from moving on to the next life. I'm currently a first semester student working in LTC now and I have had so many people tell me they just wish to die. We need to educate the families that sometimes the best miracle is "to let go and let GOD". It breaks my heart the way some of these people are kept alive for no one's good except the family that isn't willing to let go yet. And bless you hospice and LTC nurses for doing this day in and day out!!!!
Apr 26, '10Quote from VivaLasViejasI agree, when our parents die there is no longer a generation between us and the grave. I do think being nurses helps us to get there more gracefully thoughMaybe so many of us are afraid to let go because that means we're next; maybe we cling to our forbears so fiercely simply because they are our last connection with the younger selves that we will never be again.
Anyway, that's a lot of generalization, but it sort of makes my point.
Apr 26, '10I work in the ICU at a fairly large hospital. I totally understand about the inability for people to have a 'good death' because of family members that are clueless. Too bad everyone is afraid of trial lawyers or we could practice medicine in an ethical, sensible and financially responsible fashion. Until things change however I guess we are stuck letting lay persons run the show. What we see is appauling to say the least!! I totally hear ya!
Apr 26, '10This goes on at the other end of the spectrum too - with tiny preemies. But the core issue is still the same. Just because we can, should we? In whose best interest is it to keep people alive that are trying to tell us (verbally or otherwise) that they are dying? I think too many times we fight to keep bodies around when souls want to go gracefully.
Apr 27, '10Would it make you feel better if I told you there is one person who will not allow it to happen to their family member. My mom will be 86 shortly and her dementia is getting worse. She made it perfectly clear to me when she started to feel herself slip that she did not want what you are describing to happen to her. She always disliked medical treatment, the more invasive it was the more she disliked it. It would be obscene to subject her to treatments she would refuse if she were in her correct mind. I do worry how far we can go with this. Take for instance the fact that she has mild heart failure and her feet swell on some days. I know she would refuse treatment for the heart failure and accept whatever the consequences of that would be, but could it be misconstrued as neglect on my part if I follow that path? I worry about that. I do have her medical and durable power of attorney.Last edit by oramar on Apr 27, '10
Apr 27, '10I think as nurses we have to be reminded every day that dying with dignity is important to everyone. I, too, don't understand why some family members don't understand this. But as patient advocates we must offer our understanding to both patients and family.
Apr 27, '10It'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.
Apr 27, '10Thank 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.
Apr 27, '10Quote from tencatI 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.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.
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.
Apr 28, '10Don'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
Apr 28, '10That'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.
Apr 28, '10Of 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: