I need help processing my first hospice patient experience. - page 2

Hi Guys, I'm a new grad RN who was hired into a palliative care/hospice unit at a VA hospital. I have no prior experience with hospice (or nursing in general) and was given very limited training in... Read More

  1. Visit  pkateRN profile page
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    thank you for the insight everybody. the nurse before me put in a subcutaneous port because all of the meds were subQ and he didn't want to poke the patient more than once. I gave one dose of scopolamine subQ and it worked beautifully. does the patch work better/give a higher dose?
  2. Visit  tewdles profile page
    1
    No, the patch is not better but is easier to maintain when the patient is in their own home.
    softrbreeze likes this.
  3. Visit  MomRN0913 profile page
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    I agree with the others, you did a great job. You are not speeding up the process. If to maintain his comfort he passes sooner, then so be it.As far as the vital signs........ Why none? Vitals five you a better insight to patients status, when the end is nearing, their pain levels, and if they have a fever, it would be comforting to bring it down . And with the alcoholism..... There is a tolerance and you will need a decent amount of morphine. One time there was a 110lb patient experiencing DT's in my icu who we were giving 30mg of Ativan IVP at a time, q 20 min and he was ripping the restraints off the bed.........
  4. Visit  pkateRN profile page
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    you know, I've never really questioned why we don't take vitals.
  5. Visit  tewdles profile page
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    Many people find the BP cuff uncomfortable, especially at end of life.
    We rarely chase numbers in hospice. There are other signs of pain besides an elevated BP. You don't need to use a thermometer to assess whether or not someone is too warm and to provide comfort for them.

    It is pretty common to count a pulse and a resp rate, but BPs are definitely optional if the patient does not have acute HTN (perhaps from their recent chemo for example).

    Hospice tries to "normalize" the lives of our patients and their families. We do not focus on VS or other numbers but, rather, will use them if needed as we seek to improve quality of life.
  6. Visit  MomRN0913 profile page
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    My hospice is all about VS. I wasnt so much when I started learning hospice. I refuse to take a BP when I see a patient and they are comfortably sleeping. One time when I didn't take vitals because patient had just called asleep after being given some morphine, my supervisor seemed kind of upset, which I didn't agree with.
    tewdles likes this.
  7. Visit  tewdles profile page
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    It is important to always keep the goals of hospice care in mind. That is sometimes hard to do. Managers often have pressures entirely separate from direct care placed upon them.

    Your responsibility, as a visiting RN (case manager?) is to document the evidence of decline and the progress towards goals related to death. VS are often not relevant to that documentation other than what is easily and comfortably obtained.

    If the families have become focused on the numbers/tests/procedures/interventions rather than on the patient, hospice is a way for them to transition. We will do those things...but we prefer not to, especially if the patient has expressed similar preferences.
  8. Visit  pkateRN profile page
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    My second death was Wednesday, but I wasn't there for it...and for that I am thankful. I had been taking care of a man with leukemia for 2 weeks who was transfusion dependent before coming to me, and they decided to stop the transfusions. when I went into work yesterday I asked about his passing. they were reluctant to give me details, but eventually they told me the truth- that he bled out from every orifice very quickly, and even worse, his family was there. I cried and cried and cried that this is how he passed. when I last spoke with him he was not ready to die, he still had alot of things he wanted to do, and was fighting until the end. when I got off work I sat in the shower and cried some more. I wanted him to have a peaceful death, and some acceptance. does this ever get easier? I feel like I'm not cut out for hospice when I have this type of reaction.
  9. Visit  tewdles profile page
    0
    Quote from pkateRN
    My second death was Wednesday, but I wasn't there for it...and for that I am thankful. I had been taking care of a man with leukemia for 2 weeks who was transfusion dependent before coming to me, and they decided to stop the transfusions. when I went into work yesterday I asked about his passing. they were reluctant to give me details, but eventually they told me the truth- that he bled out from every orifice very quickly, and even worse, his family was there. I cried and cried and cried that this is how he passed. when I last spoke with him he was not ready to die, he still had alot of things he wanted to do, and was fighting until the end. when I got off work I sat in the shower and cried some more. I wanted him to have a peaceful death, and some acceptance. does this ever get easier? I feel like I'm not cut out for hospice when I have this type of reaction.
    Don't assume that his bleeding out was a source of suffering for him, it may have been very quick and peaceful dependent upon his LOC.
    It is ALWAYS traumatic for the family when a patient bleeds at EOL.
    I hope they had dark linens, etc to help with the bloody visuals.
    Not everyone accepts their mortality and it IS hard for us when they go to their grave, seemingly, in denial.
    It DOES get better over time. It is not abnormal that you are emotionally affected by your patient's death. As you gain experience over time you will develop your own professional coping skills that will allow you to provide this care without owning the pain of the family or patient, focusing on the fact that the death is not YOUR loss personally but rather your loss PROFESSIONALLY.
    It really is all about boundaries and good self care.
    Good luck.
  10. Visit  CUMC rn,bsn profile page
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    Hi I just had a couple of questions about some of the things on here. I work on a med-surg Oncology floor and we do all the comfort care and hospice patients in the hospital. A few of you have mentioned using scopalamine, I was wondering what it helps with (I have never seen it used on our floor)? Also I was wondering what a subq port was. And one last question, why do you not give IV medications? Thanks!
  11. Visit  tewdles profile page
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    We use anticholinergics for pulmonary congestion/secretions at EOL...we like to prevent the "death rattle" when we can as it is very upsetting for the family and potentially uncomfortable for the patient.

    We do use IVs in hospice sometimes, but since most of our care is provided in the home, maintenance of IVs is not easy and these folks often do not have good peripheral vascular access. If they have an implanted port or a PICC line we will use those.

    Most of the time we will use a subcutaneous infusion approach as they are easy to initiate, easy to maintain in the field, and represent little risk for bleeding if they are dislodged. SubQ infusions are typically less painful to start and maintain for patients. We use them both for intermittent and for continuous infusions. We can easily teach family to administer meds safely using this approach.

    Of course, there are limitations to which meds can be delivered by that route.
    Last edit by tewdles on Jan 9, '13 : Reason: content
  12. Visit  pkateRN profile page
    1
    tewdles, I wanted to say thank you for giving the advice of "it is your loss professionally, not personally." that mantra is one i repeat over and over and as a result, the deaths have become easier to deal with. thank you for the perspective!
    tewdles likes this.
  13. Visit  tewdles profile page
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    I, simply too much as there is a personal component to it, but the primary loss is certainly professional.

    My weakness is reviewing the case repeatedly in my head, as the difficult cases are the ones we mourn most...many hours have typically been spent with those patients and families. I have to be diligent in giving myself permission to move on, let go...give it to God...

    Funny, how we often have to give patients permission to let go of this world...and then, as nurses, we have to give ourselves permission to let go of them.


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