At Your Hospice, Do You. . .

[Katillac]

At your hospice, do you ever have vent patients? Does this seem like a life extending measure to you, and inconsistent with the hospice mission?

And, separate question:

When someone is NPO as in the Schiavo case, do you not use moistened toothettes, etc. to keep the mouth comfortable and avoid the "parched" feeling and look?

Just wondering what everyone else is doing out there.

Kat

[aimeee, BSN, RN]

We have a gentleman on dialysis who is in all reality about "gone". He is slowly succumbing to metastatic lung CA. He keeps himself heavily sedated on morphine... he is wasting away daily before our very eyes. He.. to me.. should truly be under hospice care, especially as the son barely looks after him. I don't even know how this man manages to feed himself.. he is so oversedated, he sleeps ALL the time.. DEEP sleep.. barely rouseable.

Just for his own comfort, to see that he has an occasional meal IF he wants one, and a clean bed and clean change of clothes.. someone to look in on him and provide some TLC....I so wish he would go with hospice.

And yet, ... he refuses.. want's to be dialyzed, which is certainly his choice.

He cannot do BOTH, as dialysis is considered "life extending".

If one can be vented and on hospice, why not dialyzed and on hospice?

This man certainly has less than 6 months, either way.

As another poster has said, this man might be able to have hospice care if his kidney failure is unrelated to his lung cancer. Medicare regs require that all treatment related to his TERMINAL diagnosis be paid for under his hospice per diem. If the kidney failure was pre-existing to his lung cancer, then medicare will continue to cover the dialysis, even if he is on hospice.

[aimeee, BSN, RN]

after all, they do have the right for their loved ones to come in and say their good-byes. otherwise, having a machine breathe for you is not a comfort measure.

leslie

I think in many cases the ventilator is a mechanism that is prolonging a state of "existence" that most of us would not consider to be really living. For people whose brain is damaged to the point where they cannot interact and communicate with their environment and who have no higher brain function going on, prolonging their existence with mechanical ventilation is definitely outside what I would consider to be the realm of hospice care. It seems the person is gone already and what is left is the shell that is being maintained. The body is tethering the soul.

Then I think about the other end of the spectrum...if a man such as Stephen Hawking (with ALS) were on a ventilator and referred for hospice care, and I think this might be a man who would feel that "living" entirely inside his head would be okay because he has such a full intellectual life and has spent decades adjusting that concept of life. If his mind were still active and he wished to keep that ventilator support to wring every last thought from his life, then it seems like that would be an honorable request.

And then there are all the cases on the spectrum inbetween somewhere. And it is an unfortunate reality that many decisions in hospice care are forced upon us not by our philosophy, but by economic reality. We have a limited pool of resources and we must choose how we are to spend those resources for the greatest good.

[leslie :-D]

Then I think about the other end of the spectrum...if a man such as Stephen Hawking (with ALS) were on a ventilator and referred for hospice care, and I think this might be a man who would feel that "living" entirely inside his head would be okay because he has such a full intellectual life and has spent decades adjusting that concept of life. If his mind were still active and he wished to keep that ventilator support to wring every last thought from his life, then it seems like that would be an honorable request.

interesting.....i've cared for a couple of als pts. and medicare would not allow the vents.....so why would medicare allow certain pts to have vents but not others?

[aimeee, BSN, RN]

interesting.....i've cared for a couple of als pts. and medicare would not allow the vents.....so why would medicare allow certain pts to have vents but not others?

I just chose ALS as an example. I have no idea what Medicare considers to be medical criteria for payment of ventilator costs. I am assuming though that Medicare would demand that a hospice who admitted a ventilator dependent patient would assume the costs of the ventilator just as they would assume the costs of providing an oxygen concentrator to a patient who needed one.

[Hellllllo Nurse, BSN, RN]

hmmm.... that IS interesting.

We have a gentleman on dialysis who is in all reality about "gone". He is slowly succumbing to metastatic lung CA. He keeps himself heavily sedated on morphine... he is wasting away daily before our very eyes. He.. to me.. should truly be under hospice care, especially as the son barely looks after him. I don't even know how this man manages to feed himself.. he is so oversedated, he sleeps ALL the time.. DEEP sleep.. barely rouseable.

Just for his own comfort, to see that he has an occasional meal IF he wants one, and a clean bed and clean change of clothes.. someone to look in on him and provide some TLC....I so wish he would go with hospice.

And yet, ... he refuses.. want's to be dialyzed, which is certainly his choice.

He cannot do BOTH, as dialysis is considered "life extending".

If one can be vented and on hospice, why not dialyzed and on hospice?

This man certainly has less than 6 months, either way.

Jnette,

We've had hospice pts on dialysis at all the dialysis units where I've worked.

Same thing when I worked hospice- there were pts there on dialysis. These were home care pts, though, none at the inpt units I worked in.

Here's how they look @ it-

If a pt is on hospice for lung ca w/ mets, but is ESRD independent of the ca dx, then he can dialyze while on hospice, as dialysis is tx unrelated to the terminal dx, even though it is life sustaining.

So, a person can be a full code on dialysis, but a no-code for the terminal dx. i.e., if a pt's bp crashes and he codes on dialysis, he can be a full code for indidents r/t dialysis, but a no-code for death r/t his terminal ca.

Goofy, huh?

However, by the time a pt is actively dying from ca, he will very likely not be going to dialysis any longer. So, his death from ca can be easily differentiated from a dialysis related death. Although not dialyzing will contribute to his death, it is a seperate issue from his terminal ca dx.

Clear as mud?

[Hellllllo Nurse, BSN, RN]

I just chose ALS as an example. I have no idea what Medicare considers to be medical criteria for payment of ventilator costs. I am assuming though that Medicare would demand that a hospice who admitted a ventilator dependent patient would assume the costs of the ventilator just as they would assume the costs of providing an oxygen concentrator to a patient who needed one.

Hmmmm.....

Food for thought. Let's say an ALS pt is admitted to hospice for metastatic ca. Okay.. but if the ALS advanced to a stage where the pt needed to be vented, the ALS would probably be added on as a secondary terminal dx, and would probably not be allowed on hospice.

A ESRD pt who has been dx w/ terminal ca is different, as ESRD is in itself not a terminal dx, if the pt accepts dialysis tx, and is able to tolerate it.

I mean, if a pt who has been on dialysis for years develops terminal ca, Medicare is not going to tell him that he cannot receive hospice benefits r/t his ca, unless he discontinues dialysis.

I believe an individual hospice can reject the pt for tx, however. I know of a catholic hospice that does not accept terminal lung dx pts, if they are still on SVNs and/or MDIs.

[Hellllllo Nurse, BSN, RN]

As another poster has said, this man might be able to have hospice care if his kidney failure is unrelated to his lung cancer. Medicare regs require that all treatment related to his TERMINAL diagnosis be paid for under his hospice per diem. If the kidney failure was pre-existing to his lung cancer, then medicare will continue to cover the dialysis, even if he is on hospice.

Exactly.

[steelcityrn, RN]

This is a interesting post in that I also thought hospice patients could not be on vents.

[Hellllllo Nurse, BSN, RN]

When I worked inpt hospice, we once had a pt on a Dobutamine drip.

She wanted go out to smoke constantly, which really annoyed the RNs. At the time, I was an LPN, but because of the drip, an RN had to take this pt out.

She died about 2 weeks after being admitted.

[OneThunder, BSN, RN]

hmmm.... that IS interesting.

We have a gentleman on dialysis who is in all reality about "gone". He is slowly succumbing to metastatic lung CA. He keeps himself heavily sedated on morphine... he is wasting away daily before our very eyes. He.. to me.. should truly be under hospice care, especially as the son barely looks after him. I don't even know how this man manages to feed himself.. he is so oversedated, he sleeps ALL the time.. DEEP sleep.. barely rouseable.

Just for his own comfort, to see that he has an occasional meal IF he wants one, and a clean bed and clean change of clothes.. someone to look in on him and provide some TLC....I so wish he would go with hospice.

And yet, ... he refuses.. want's to be dialyzed, which is certainly his choice.

He cannot do BOTH, as dialysis is considered "life extending".

If one can be vented and on hospice, why not dialyzed and on hospice?

This man certainly has less than 6 months, either way.

Yes, he can be on dialysis, as long as his terminal diagnosis is NOT associated with renal failure. I have had a few patients on dialysis, but as time goes on, they do decide to stop as it becomes increasingly painful to be transported, hooked up etc. If that is the patient's choice, a hospice nurse MUST be an advocate, as long as she continually educates the patient and family.

[angel's assistant]

hmmm.... that IS interesting.

We have a gentleman on dialysis who is in all reality about "gone". He is slowly succumbing to metastatic lung CA. He keeps himself heavily sedated on morphine... he is wasting away daily before our very eyes. He.. to me.. should truly be under hospice care, especially as the son barely looks after him. I don't even know how this man manages to feed himself.. he is so oversedated, he sleeps ALL the time.. DEEP sleep.. barely rouseable.

Just for his own comfort, to see that he has an occasional meal IF he wants one, and a clean bed and clean change of clothes.. someone to look in on him and provide some TLC....I so wish he would go with hospice.

And yet, ... he refuses.. want's to be dialyzed, which is certainly his choice.

He cannot do BOTH, as dialysis is considered "life extending".

If one can be vented and on hospice, why not dialyzed and on hospice?

This man certainly has less than 6 months, either way.

FYI--

I saw at patient today that gets dialyzed 3x weekly. But her hospice diagnosis is peritoneal CA. I guess you just have to find a hospice that would accept him for lung CA and continue the dialysis and an unrelated treatment.

[Blackcat99]

What a coincidence! Last night we got a man who is dependent on a bi-pap machine. He can only take it off for a few minutes at a time. He is expected to die anyway with or without the bi-pap machine.