Out of Scope of Practice???? - page 3

by ladytopaz

5,214 Views | 30 Comments

Yesterday several family members came in to see their loved one stating that they had heard through other family members that they were now being seen by Hospice. To make a long story short, the day nurse had spoken with a family... Read More


  1. 3
    I agree with Nascar nurse. A Hospice nurse came and spoke to our class last month and she said that anyone can call and get an appt. with hospice. She said that they could make a guess if someone would be eligible but they would need an MD order to actually evaluate them and give a definite response. Mostly they just talk about what hospice means and what they can do for the patient and the family.

    She also said that the hospice nurse can send an order to the MD to sign so a nurse is not needed at all for a consult. The nurses where I work send for a consult (not evaluation) all the time. I think more people in general, and especially nurses, need to be educated about this because it is a great resource, not only the patient, but the family as well.

    As far as what the nurse said there are some doctors that will not tell the family the truth about the patient's true condition. We had this situation in our simulation lab and our role as nurse was to explain to the family what the MD failed to explain. Basically that the patient was dying and what was likely to happen during this process.
    Songbird,RN, wooh, and JulieL like this.
  2. 1
    I'm an LPN and have brought up Hospice to several family members. In my facility its normally the nurses (more often than not the floor/unit nurse who is an LPN) who brings Hospice into the conversations. It is not overstepping my SOP to give information to the family. I am not diagnosising anything.
    nrsang97 likes this.
  3. 1
    I echo what many people already said here: if we nurses don't bring up hospice or palliative care options, who will? Many people don't know about it or have misconceptions, or MDs either don't even consider it or reluctant about it.

    I've had a personal experience with this issue. An extended family member was dying of cancer. She did not know about hospice care or all the pain control and comfort measures available to her until I brought it up. None of her physicians or even nurses throughout her long treatment process discussed it with her. We had to contact an agency ourselves, and then we had to request her doctor to send in the order. Only then, she found some relief from the agonizing pain. She died the next day. I berated myself for not butting in sooner. I thought I was doing her a favor by keeping my nursey mouth shut, because she was a fiercely-independent and stubborn person. Had I known how much pain she was in and the total lack of end-of-life care plan...

    Back on topic, explaining the disease (dying) process, or guiding the patient and family through different treatment options, it is not only within our scope of practice, it is our duty as an advocate. Especially since it ultimately requires an MD order for eval, I wouldn't ever think of suggesting hospice as out of our SOP, but as a collaboration with (or nudging) the medical team for the patient's best interest.
    NutmeggeRN likes this.
  4. 6
    I focus my care on the pt not what any other nurse said or did. If we keep our focus on how to best serve the pt it keeps our practice cleaner.
    If the pt is ready for hospice and the family is receptive it sounds to me like she did a good job.
    Sometimes in nursing we can be so concerned with either rules or paperwork we miss the obvious...The patient!
    The role here with both the pt and family is to be supportive.
    I am not sure how telling the truth can be wrong.
    I watched pt suffer for months on end when open heart surgery went bad. The family was on a roller coaster. Every Dr. showing up is focusing on their specialty. To the renal guys "Yes,lets get CVVH going " The family hears this and think this equals hope. All the nurses can see this pt is notgoing home. Its more how long death can be postponed. Death is still a "failure" to doctors.
    Ask yourself. If you were the pt or family what would you rather...To remain in the dark. To endure suffering . To allow others about you do procedure after procedure that ultimately won't change the outcome ...or .....have someone step forward and speak the truth. Advocating for pt includes their right to die "well " with dignity . I have seen pt suffer intolerably because no one spoke up.
    Last edit by echoRNC711 on Oct 11, '12 : Reason: typo
    Sun0408, itsmejuli, AheleneLPN, and 3 others like this.
  5. 1
    Quote from CapeCodMermaid
    I don't where all y'all work, but where I've worked 99% of the time it's the NURSE who brings up hospice. We are the ones who know the resident and the family. It is NOT outside the scope of anyone's practice to advocate for the resident.


    Absolutely!
    nrsang97 likes this.
  6. 5
    If you have enough time on your hands to worry about another nurse's job you have too much time on your hands. Sure go to the DON. Throw the day nurse under the bus, that's what we do.




    On a less harsh note..... What everyone else said is completely correct. Also, never run to the boss about another nurse without talking to said nurse first....
    KelRN215, Nascar nurse, echoRNC711, and 2 others like this.
  7. 2
    Quote from ladytopaz
    Yesterday several family members came in to see their loved one stating that they had heard through other family members that they were now being seen by Hospice. To make a long story short, the day nurse had spoken with a family member and stated that the resident's organs were shutting down and that their only option was to talk to Hospice. Number one, isn't that considered diagnosing? And number two, isn't it also considered under the same, practicing beyone scope of practice, that you never mention Hospice to a family? A doctor makes that decision and the Hospice agency then does an eval, depending upon that they request a meeting with the family! I'm sorry, but this is way out of scope of practice for a nurse, especially an LPN. (sorry for that comment) Should I go to the DON with this? I'm afraid that if the family really wanted to pursue this, the LTC facility could be in big hot water!!
    It is certainly within my "scope of practice" as an LPN to open up that dialogue.It is within my scope of practice to lay out every option available to any of the resident's in my care.I would not imply in any way what I think is appropriate.I always make it clear that is up to the family and they must consider their loved ones wishes Perhaps the physician had told the day nurse that the resident was failing.It's pretty easy to come to that conclusion when you are with these folks day after day and see the wt. loss and withdrawal.The families are aware of it too and are often waiting for someone to bring up the topic.
    It is up to the resident and the family-NOT the doctor.In my facility we must obtain a physician's order for a consult with hospice and then we must write an order for hospice care if the res. meets the criteria and the family chooses that path. I have called the doc a few times for a request for a hospcie consult which they believed was not appropriate but if it's what the s.o. and res. desire then we get the order.
    How exactly is anyone "going to be in hot water?" If the s.o. did not agree with the nurse's assessment of the situation and called the doc themselves I could see the doc throwing the nurse under the bus (they always do that were I work).That's why I am very careful in my communications with families and visitors and have a witness whenever possible. I think you should talk directly to that nurse and then maybe your supervisor and social services.You need to know your protocol so you can be an effective advocate for your residents without worrying about "getting into hot water" You need to educate yourself. I often bring up end of life issues to families,sometimes I start that dialogue upon admission (especially on people with full code status and tons of co-morbidities)
    echoRNC711 and Sparrowhawk like this.
  8. 3
    Everyone else has already done a wonderful job of addressing your question. What concerns me beyond that is this when you said:

    Quote from ladytopaz
    To make a long story short, the day nurse had spoken with a family member and stated that the resident's organs were shutting down and that their only option was to talk to Hospice.
    How do you know this is what the day nurse said to the family? Were you there? Were the family members who told you this there? Is this what the day nurse told you she said?

    Unless you were there and heard with your own ears, you have no idea what was actually said, nor the tone in which the message was delivered. Be very wary of second (or third) hand information! The conversation could have been completely different from what you were led to believe.

    I would hope that if you really had concerns, you would speak with the day nurse first and get her side of things before you go knocking on the DON's door.

    I work in an outpatient, primarily patient education capacity. I am very careful about what I say and how I say it and I do frequent perception checks to make sure the patient is understanding me. Yet still, it sometimes amazes me what perceptions people walk away with. Sometimes things come back to me where the patient said to another nurse that I said X, when I remember very clearly that I said Y. In reality, the patient *heard* X when I said Y.

    I've seen this in the inpatient environment as well, especially when you're hearing it second hand from the family members who weren't even there.

    Any time a patient or family member reports something concerning regarding another staff member, of course you want to take them seriously and listen to what they have to say. But often, their perception (or misperception, as can sometimes be the case) is only part of the story. Best to get the other side of the story and keep in mind that the truth often lies somewhere in the middle. Don't be so quick to throw the other nurse under the bus.

    Imagine if the shoe were on the other foot, and a patient said something involving you, and nobody bothered to get your side of the story before deciding you were guilty!
    Last edit by ~*Stargazer*~ on Oct 11, '12
    PMFB-RN, DSkelton711, and wooh like this.
  9. 1
    If it happend the way you say it does the ONLy thing she said she shouldn't have is the

    "that their only option was to talk to Hospice"

    Of course they have other options. There is no requirement they talk to Hospice. Other than that what she was just doing what nurses do. My advice is not to worry about injecting your opinion about her comments. I would certainly not go to the DON.
    Of course she wasn't diagnosing. It's silly to even call it that. Never mention Hospice to a family!!! In my experience it is usally nurses who talk to the family about Hospice, organ donation, palutive care and lots of other issues. I assume, given your post, you are a brand new nurse. With experience you will realize that.
    Talk about nurses eating their young.................
    Sparrowhawk likes this.
  10. 1
    Quote from BrandonLPN
    One question. Doesn't the actual consult to a hospice provider have to be an official order from the physician?
    Everywhere I've worked, the consult to the hospice comes from the Case Manager. The hospice requires physician orders but very few physicians (other than oncologists in my experience) even know how to consult hospice.

    To the OP, no it's not outside of the nurse's scope of practice. I have raised the question of hospice countless times with families. It's also not inappropriate to explain to a family that grandma's organs are shutting down. That's not diagnosing, that's sharing information.
    PMFB-RN likes this.


Top