need to put together a quickie inservice for hospital staff

  1. I have a 37 yo cervical cancer patient in our hospital on hospice who will be there until she dies, due to the acuity of her care. she has been there for 4 weeks now, and may last for weeks yet. She is on 660 mg IV MSO4, and has been on high doses of IV Ativan, Versed, Valium, and now phenobarb. The physician is trying, at pt's request, to keep her terminally sedated. It hasn't been easy. Family can't manage this at home (husband also doesn't want her at home with the kids), SNF won't take her with IV pushes, no inpatient hospices in the area. I have been asked by the DON to provide an inservice to staff on hospice, pain mgt (they have never seen these doses of drugs before) and emotional support for the staff. And please don't take more than about 20 minutes. And can I do it within 48 hrs? So, can any of you help me with some online reference materials? I need to pull this together quickly and make it concise - not sure how to fit in the emotional support part in 20 minutes. Any ideas appreciated.

    I have been spending up to 3 hours a day on the floor supporting and assisting staff with her care. It takes 4 people about an hour daily to do her wound/personal care. MSW also visits daily, as does hospital chaplain and HHA. And the hospital staff is doing a wonderful job. It's a challenging case. And heartwrenching. Not many patients these days cause me to lose sleep, but this one does.

    Hope you all can give me a little help.
    •  
  2. 14 Comments

  3. by   aimeee
    Wow! That's a tall order. Right off the bat I would suggest that you do not refer to it as "terminal" sedation but rather "palliative" sedation. Semantics, I know, but really the aim of the sedation is to relieve pain and suffering so why not put the focus there? I'll see if I can find any good links for you.
  4. by   Mandee
    I thought this link was pretty good http://www.hosppract.com/issues/2000/10/eldmorr.htm

    20 min. is not much time at all!!!

    Mandee
  5. by   aimeee
    I'm not sure what sort of "emotional support" is meant...are there some who are struggling with the whole concept of palliative sedation?

    http://www.ama-cmeonline.com/pain_mg...9man/01_02.htm

    This from the AMA website (which in turn borrowed it from the Robert Wood Johnson Foundation EPEC Project sums up the perspective in a nutshell:

    Some patients develop refractory pain or other symptoms, which cannot be addressed symptomatically despite best efforts. If suffering is intolerable at the end of life, treatment options include induced somnolence, a therapeutic intervention that might be best termed "palliative sedation." Sedation at the end-of-life may be controversial, especially if the ethical foundation is not adequately understood.1,23,24 Although it is certainly true that sedation, which is usually induced with a sedative-hypnotic drug, could potentially accelerate the dying process, the ethics of the approach are acceptable if the intention is to relieve suffering and not to kill. This is known as the "principle of double effect" and guides the administration of any intervention that carries substantial risk in the medically frail population.25-28 It should not be confused with euthanasia, and from an ethical perspective, it is founded on the patient's right to be free of suffering, not a patient's right to assistance in achieving death.

    Although there continues to be considerable discussion among palliative care specialists about the role and practical strategies for sedation in the imminently dying, 22,23,29-32 the approach is widely accepted as a specific medical intervention to treat refractory pain and suffering in exceptional circumstances. Sedation should be implemented only after the medical situation has been carefully assessed, a thorough discussion with the patient and family has taken place, consent has been obtained, and the goals of care have been clearly established. Once sedation has been activated, ongoing information should be provided to family and staff, questions should be answered, and ethical and legal implications should be clarified. With prior approval by the patient or proxy, a plan for reducing sedation at times, to determine symptom burden and state of mind, may be put in place.
  6. by   weezieRN
    Not to change the subject but I'm just udderly surprised at the amt of medication she is receiving and has not actually passed away from respiratory depression etc. I don't know her condition and won't pretend to but how can someone want to live out the rest of her short life sedated? Sure I will go for pain free and I know there are ways of doing it instead of sedation. Does she not want to spend "quality time" with her husband and children/family. If that was my mother I would want her comfortable and but I would also like to talk with her and let her express her feeling to her family and have some good meaningful talks with them. It would be good for her as well as her family and it will lead to some closure for them and not making things so rough especially for the children. Just my opinion. What about a pca, fentanyl patches, they seem to work ok, implanted pump etc. Lots of options out there. Don't really know how to help with inservice other than to do what family and pt wishes and keep her pain free.
  7. by   hospicenurse
    [QUOTE=weezieRN]Not to change the subject but I'm just udderly surprised at the amt of medication she is receiving and has not actually passed away from respiratory depression etc. I don't know her condition and won't pretend to but how can someone want to live out the rest of her short life sedated? Sure I will go for pain free and I know there are ways of doing it instead of sedation. Does she not want to spend "quality time" with her husband and children/family. If that was my mother I would want her comfortable and but I would also like to talk with her and let her express her feeling to her family and have some good meaningful talks with them. It would be good for her as well as her family and it will lead to some closure for them and not making things so rough especially for the children. Just my opinion. What about a pca, fentanyl patches, they seem to work ok, implanted pump etc. Lots of options out there. Don't really know how to help with inservice other than to do what family and pt wishes and keep her pain free.[/QUOTE

    Thanks Aimee and Weezie, I've been doing some searches but hadn't found either of these sites yet. Weezie, I think your questions are exactly what some of the staff are asking - and yesterday, when they started Phenobarb, replacing the versed/ativan which was not working any longer, everybody expected her to stop breathing. But she has an amazing tolerance for medication. I've only known this woman for 4 weeks, but apparently she has suffered severe pain for many months. Whether she was undermedicated or the medications just didn't control the pain, I'm not sure. (It does happen sometimes) Some of the most intractable pain I've seen is in young women with end stage ovarian cancer. This lady presents similarly with metastatic cervical cancer - which I've not seen, maybe because cervical cancer is more likely cured, which justs adds to the tragedy of this situation. She has a wonderful husband, sister, mother and young children who are at her bedside 24/7. She is awake and perfectly lucid though lethargic several times a day. She cannot move a muscle without going from 0 to a zillion on the pain scale. About every 3 days her pain increases and the meds are bumped up - one day from 350 mg to 500 mg/hr. Her respirations never wavered - always 12 -14 min. She asks nearly daily for it to be over - I've been at her bedside when the doctor (an anethesiologist, btw, the ony doc who dug his feet in, fought all the inital staff reactions and did what needed to be done to make her comfortable and sedate her) asks her what she wants and she always says "put me out". This woman fought bravely for 2 years, she took all conventional treatment and then went to the bahamas for 4 months for more treatment (don't ge me started on that one....) I do not question her wishes - I've not been in her shoes. I want her suffering to end because that's what she wants. I don't know how soon she will die. It may be weeks. Unfortunately, she is getting a significant amount of fluid with all these IV drugs. I believe it is prolonging her life. I want to talk with the doc and pharmacist today about options. Maybe switching to IV Fentanyl. Can't do patches - she'd be covered with them.

    Aimee - I'm thinking maybe the best way I can support staff in 20 minutes is to just make it a question/answer session. Let them do most of the talking. I would love to start a support group for them, but the time factor is always there - I don't want to create more stress for them. I've thought about putting a large card/poster on the wall, where they can write something to her and the family which could be given to the family when this is over. Maybe in the staff lounge where it's usually quiet.

    Gail
  8. by   weezieRN
    Not to take anything away from the family but staff also needs some emotional support in this situation also. Does your facility have an employee assistance program? I know the tears shead for a former employee at our facility who came in with a possible bowel obstruction to find out that she has CA all through her and a short time to live. I didn't know this gal but she sure got to my heart quick, These nurses need support also you always get emotionally involved with these situations especially if they are staying at your facility for 2 months or more. Keep us posted. In my short career i have never seen someone take so much medication and still be having that much pain.
  9. by   suzanne4
    WeezieRN,
    Unfortunately, as you practice longer, you will see patients on double that amount of medication and be lucid and talking. The pain that these patients are experiencing is just unfathomable and I hope that I never have to go through it myself. Their system builds up a tolerance to the higher doses and you just ha ave to keep going up in the amount. I would much prefer for my patient to be comfortable, than worrying about the amount. Thank goodness for this patient that she has an anesthesiologist taking care of her pain meds.

    HospiceRN,
    Perhaps give them just a brief overview of the patient's treatment plan and then open to questions. If these nurses have been lucky in their practice and have never had to work with a patient like this, it can be quite draining on them. Physically as well as emotionally. As nurses, you are taught not to give more than MS 10 mg or so, unless questioning the order, etc., then you have patient receiving hundreds of milligrams and you feel lost.
    I wish the nursing school would begin to offer a course in hospice care, that may be the most helpful or even just a few week rotation through a hospice type setting.

    I lost one of my best friends about this time last year from breast cancer with mets. She actually was an OR nurse also. She went into a coma the week before she died, and had been on phenomenal amounts of morphine before and it just wasn't working. Glad that I got to spend her last vaction with her, and it was just a few weeks before........she died four weeks to the day that we returned.
  10. by   canoehead
    what about concentrated morphine drops that get absorbed through the mucus membranes of the mouth, or suppositories, to decrease the fluid she gets IV?
  11. by   hospicenurse
    Quote from canoehead
    what about concentrated morphine drops that get absorbed through the mucus membranes of the mouth, or suppositories, to decrease the fluid she gets IV?
    Weezie, you are so right - staff needs a lot of support. In hospice/facility situations we consider the staff to be the primary caregivers and support them much like we do family.

    Suzanne - I think your idea is right on. That's what I'm going to try to do - the staff need to talk more than I do.

    Canoe - Both good suggestions as alternate routes for pain med. For this patient, though, the conversion from 600 mg/hr IV to po would be 1800 mg/hr. With Roxanol 20 mg/ml, that would be 90 ml/hr po - just not realistic for the patient or staff to deal with. Same deal with suppositories - even if we could turn her every 4 hrs, which she refuses - it would take too many suppositories to be practical.

    Gail
  12. by   renerian
    I think I would ask the hospice clinical director to stop by and talk with your staff. They are the experts. Just a thought. Hubby runs a hospice and he and the clin director do that all the time. Good PR.

    renerian
  13. by   renerian
    I have had several patients on MS drips at 100 mg hour and were very functional.

    renerian
  14. by   aimeee
    Roxanol does come in a 50 mg/ml concentration, but that doesn't help much in this situation.

    I think the idea to let the staff ask questions is a good one because then you can speak to the issues that are most important to them. Perhaps your bereavement counselor can do some pre-bereavement sessions with them.

close