At Your Hospice, Do You. . .

leslie :-D · Apr 9, 2005

. . 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

in hospice, no- you would not have a vent pt. as that is a life-sustaining measure.

however in palliative care, it would be allowed.....many people do not know the difference between the two but generally speaking in palliative care, treatments can and do continue.

and for mouth care, moistened toothettes are a must, as well as first gently wiping the lips then putting vaseline on them....good mouth care is one of the musts if your goal is to provide comfort. good luck to you kat.

leslie

aimeee, BSN, RN · Apr 9, 2005

Yes, we use the spongy toothettes for frequent moistening of the mouth.

We don't have any ventilator patients and we don't have the trained staff to support them. There are some hospices that do have ventilator patients. There are very few homecare agencies that even have the training to do vents in this area. I think it comes down to a question of training, philosophy and economics. To even consider taking on a ventilator patient I think we would have to see that the ventilator was contributing to quality of life and not just a life extending measure. We would have to look at what role the ventilator is playing in the patient/families goals.

leslie :-D · Apr 9, 2005

quality[/i] of life and not just a life extending measure. We would have to look at what role the ventilator is playing in the patient/families goals.

aimee,

i'm confused, so by all means, educate me.....the hospice facility i worked at would never take pts on vents even though we had vents on our floor (not the hospice unit) as that was considered an intervention to extend their life.

so under what circumstances would hospice allow a vented pt??? i'm really confused.

leslie

Blackcat99 · Apr 9, 2005

At my hospice we don't have any vent patients. We use a lot of pink toothetts soaked with a little water to clean our patients mouth. I don't know if my hospice would allow vent patients or not. Probably not I am quessing. :)

jnette, ASN, EMT-I · Apr 9, 2005

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.

Katillac, RN · Apr 10, 2005

I'm thinking of a case in which a vent patient has good quality of life; the patient is alert and oriented, interacts with family and staff, and other than being on the vent right now leads a "normal" life. Yet the prognosis is less than six months, even on the vent. Doesn't this patient meet crieria in that he or she has the appropriate prognosis and is no longer seeking curative measures? In this case, the vent is palliative, I think.

I know that we often say "we don't prolong life or hasten death" and that we don't take "life extending" measures, but I prolong life every time I give non-symptom mediating cardiac meds to a CHF patient. We also tend to look twice if a referral "isn't in the hospice mindset" but I don't see that's a part of the official criteria, either. There are a lot of unofficial criteria being used it seems to me.

As to the man on dialysis, how is it we get to decide what quality of life means to him? I realize that I'm playing devil' sadvocate here. Hospices could not survive on their reimbursement if their caseloads were full of vent and dialysis patients. But pediatric hospice patients often get feeding tubes. Why do we rule them out as "life extending" in adults?

These are tough questions for me. I don't think there are any easy answers, but I'm getting more uncomfortable with what isn't done in hospice because "we don't do ________".

I've been thinking about all of this since the Schiavo case. The question about the toothettes, which is related but not really, came from all of the reports from the media of her "parched lips". I know they may have been just that, media reports, but if not, where was this important comfort measure?

Thank you to everyone who has responded.

Kat

leslie :-D · Apr 10, 2005

i've cared for hundreds of pts over the years, and no matter what type or how frequent the po care was, their lips would be parched. vaseline would not help- dehydration cannot be disguised.

but the whole concept of palliative care vs. hospice is that it recognizes that people who have late stage copd (but could feasibly live another year) or end stage chf, can still receive treatments and comfort care together. it's a much broader spectrum of hospice care, therefore much more flexible and liberal. it took me awhile to grasp its' concept but now understand that palliative care is the umbrella in which hospice is just one compenent.

leslie

webblarsk · Apr 10, 2005

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.

I would think that the man could be on hospice. Metastatic lung cancer would qualify him. What is the reason for the renal failure, is it related to the lung cancer? Or was he recieving dialysis before the cancer diagnosis? I am still realitivley new to hospice, but it sounds like he could still be on hospice unless the renal failure is related to the lung cancer. Am I making sense?

Katillac, RN · Apr 10, 2005

i've cared for hundreds of pts over the years, and no matter what type or how frequent the po care was, their lips would be parched. vaseline would not help- dehydration cannot be disguised.
but the whole concept of palliative care vs. hospice is that it recognizes that people who have late stage copd (but could feasibly live another year) or end stage chf, can still receive treatments and comfort care together. it's a much broader spectrum of hospice care, therefore much more flexible and liberal. it took me awhile to grasp its' concept but now understand that palliative care is the umbrella in which hospice is just one compenent.
leslie

I totally respect your experience, and in no way am I suggesting that dehydration can or should be disguised. In my experience, it's possible, with emollients, to keep lips from being dried and cracked. That's what I think of when I see "parched". You may mean something different.

And I understand that hospice care does not include curative treatments, while palliative care can. But hospice patients often receive, for example, palliative radiation treatments, not designed to cure the CA but to make the patient more comfortable. That radiation could also have the effect of extending life, but neither that nor a cure is the intent of that treatment, comfort is, so it's appropriate for someone in hospice care. I'd put a vent, in a case like the one I outlined above, in the same category as palliative radiation. It should be OK for hospice patients if the prognosis is six months or less and the patient has abandoned curative treatment.

I'll be giving this more thought as I make my way through a busy On Call weekend. I'd be happy to hear what anyone has to say on the subject, but I'm now officially in "listening" mode on the subject.

Kat

webblarsk · Apr 10, 2005

I totally respect your experience, and in no way am I suggesting that dehydration can or should be disguised. In my experience, it's possible, with emollients, to keep lips from being dried and cracked. That's what I think of when I see "parched". You may mean something different.
And I understand that hospice care does not include curative treatments, while palliative care can. But hospice patients often receive, for example, palliative radiation treatments, not designed to cure the CA but to make the patient more comfortable. That radiation could also have the effect of extending life, but neither that nor a cure is the intent of that treatment, comfort is, so it's appropriate for someone in hospice care. I'd put a vent, in a case like the one I outlined above, in the same category as palliative radiation. It should be OK for hospice patients if the prognosis is six months or less and the patient has abandoned curative treatment.
I'll be giving this more thought as I make my way through a busy On Call weekend. I'd be happy to hear what anyone has to say on the subject, but I'm now officially in "listening" mode on the subject.
Kat

I agree, we currently have a patient on a vent. She is end stage COPD and prognosis is 6 months or less with or without the vent.

leslie :-D · Apr 10, 2005

i definitely see radiation to debulk tumors as a comfort measure....i've just never encounter a vent, yet i suppose if the md states they have less than 6 mos but would automatically die w/o the vent, then i can see them receiving the hospice benefit. 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