New hospice nurse with questions

toomuchbaloney · Sep 4, 2014

Holy moly.

I am not even sure where to start with this one.

How many nurses and how many patients in this hospice agency?

Are you doing field hospice work or facility hospice work?

It is not normal to be the 24/7 rep of the hospice as a brand new clinician, at least not in my experience, unless you are hired in as the oncall and afterhours nurse.

What is your title?

heron, ASN, RN · Sep 4, 2014

You're being had. Sadly, the hospice industry is going the way of the rest of health care: never mind quality, just get the billing.

A hospice nurse needs top-notch assessment skills, which you probably have in your area of expertise. However, you will be caring for people who are dying from a whole range of physical illnesses with which you probably have no experience. Agencies seem to be assuming that problem-solving in hospice amounts to more morphine and ativan, with a little haldol thrown in if the patient seems restless. They no longer allow time for hand-holding, so they've dropped that one.

It's waaaay more complicated than that.

From your description of your job, you're being thrown to the wolves. If you choose to continue, PLEASE utilize this site's hospice nursing forum ... as well as the links you'll find there. It'll be a do-it-yourself education.

Kerber · Sep 4, 2014

I am a RN I never done this type of nursing before. I have a dying patient right now and I struggle what to do. I went with another hospice nurse for 4 days and now I am alone. What do I do? I quit a job of 15 yrs to try something different

Kerber · Sep 4, 2014

There was no hospice nurse they had home health nurse doing it till they hired me. Right now censes is 10 I think it's field work. I work mon- fri usually start 9 am - 5 pm then I am on call in evenings every evening since I am only one

heron, ASN, RN · Sep 4, 2014

I am a RN I never done this type of nursing before. I have a dying patient right now and I struggle what to do. I went with another hospice nurse for 4 days and now I am alone. What do I do? I quit a job of 15 yrs to try something different

Have you tried looking for info over on the hospice forum? What is it you're struggling with?

Kerber · Sep 4, 2014

Example I have a patient with liver cancer Monday he was up talking tue he was bed bound disorientated not making sense. Today I noticed jaundice in his eyes. The family keeps asking how long he has. I instructed them to use Ativan and morphine for comfort. What more can I do?

heron, ASN, RN · Sep 4, 2014

A lot depends on what might be going on medically that could cause these symptoms.

The confusion and yellow eyes make me think about liver failure. It would need to be discussed in IDT, or with the doc managing medical care. Lactulose can reduce or eliminate the confusion but will probably prolong his dying process. Not to mention increase the physical burden on his caretakers, since success with lactulose requires multiple bms a day.

Is the confusion distressing to the patient or the family. Are there any other symptoms that might be upsetting or painful to the patient?

I'm answering off the top of my head right now. I'm getting ready for work and have more questions than answers without more information. Will check in when I get home in the AM.

Kerber · Sep 4, 2014

The patient has liver cancer. I think death not too far off. I can't seem to calm family they call all time and in middle of night. Last night it was because there dad was shaking and coughing when I got there he was resting quietly in bed.

toomuchbaloney · Sep 4, 2014

Assess his lungs, consider if he is going to die wet or dry and adjust the medical plan accordingly (levsin vs atropine vs scop vs nothing).

Look for signs of the dying process affecting his LOC, temperature control, CV stability, etc. Does he have bowel sounds?

You need to drop yourself into a bucket of hospice nursing and learn as much as you can in a short a time as possible in order to feel comfortable in your role...whatever that is.

heron gave you good advice.

good luck.

heron, ASN, RN · Sep 4, 2014

What you're describing is quite typical and there are no easy answers. Generally, people who don't work in healthcare get quite anxious when witnessing the terminal process. They want to DO SOMETHING to fix it NOW. The thought of actually seeing someone die or a dead body can be panic-inducing, too. Don't be surprised if they wind up calling 911 - it can happen no matter how much teaching and support they get. It is NOT a reflection on your work or your expertise.

I don't really know much about your knowledge base, so I hope I'm not being too elementary or talking over your head. Here are some things that can help:

Get support for yourself. There must be more experienced people in the interdisciplinary group that can provide both support and a sounding board for you. It may or may not be another nurse ... it could be the chaplain or social worker or even the medical director. Put it out in the IDG meetings that you need this, if you have to. That's what they are there for.

Teach the family as much as you can about the dying process and what they might expect ... when you get the phone calls, relate them back to what you've been teaching. It may be that you don't have to go out for every phone call. Be specific about the fact that it's impossible to predict timing. Talk about the body shutting down as death approaches and that "abnormal" symptoms (confusion, not eating, not voiding, changing level of consciousness, suddenly increased levels of pain and agitation) are completely normal parts of the process. Think about it ... you are expecting them to accept and tolerate symptoms/events for which they would otherwise be calling emergency services and running for a hospital. Be aware that you may have to repeat yourself - it's a lot for them to take in

Do you think the caregivers in the home need a break? Do they need teaching on how to provide complete physical care to a bedridden person? Is the patient receiving CNA visits? Is continuous care a possibility through your agency?

Would the family benefit, do you think, from spiritual or social services visits? Again, something to discuss in IDG. Are there support groups locally for families of the terminally ill? If your agency can't put you in touch with them, try calling other hospice organizations in the area. Talk to a hospice social worker or chaplain ... they're the ones who do the heavy bereavement counseling.

Remember, you're the one doing the care-planning - it's totally appropriate to call for these services and support. Again, that's what the IDG is for.

How is the patient doing, generally? Does he seem comfortable/peaceful or is he having symptoms that look distressing and scare the family. As I've said before, assessment is key. What is going on, why is it going on, how can we relieve the symptoms? The more peaceful the process, the less likely the family is to freak out.

"Shaking and coughing" could be anything from seizure activity to aspirating secretions or vomitus to the tremor associated with liver failure. What do you see when you examine the patient? Does he have a lot of respiratory secretions that might be reduced by atropine/hyoscamine/scopolamine patch or even robinul injections? Are the secretions oral (atropine/scop patch) or lower down in the airway (robinul is better in that case)

Are they trying to feed him? You'd be surprised at how many families try to force feed even obtunded patients. Again, it's the DO SOMETHING response. Do they need to learn how to suction? Do they need to learn how to position a person who can't manage his secretions on his own?

Is he vomiting? Is he distended, either from ascites or tumor load in the abdomen? Does he have brain mets that could cause vomiting? Zofran, Compazine or haldol can bring that under control.

Or is he seizing? The ativan is quite useful for that. Seizures are not typical of liver failure, but he could have brain mets. Or he could have metabolic changes going on related to hepato-renal failure or other damage from mets.

Some limit-setting might be in order, too. That might be tricky, though. It sounds like your agency is either inexperienced in provided hospice services or too profit-driven to do the job right (24/7 call!!!! YIKES:no:). Maybe you can head some of the intrusiveness off at the pass with a scheduled phone call, say in the early evening, to check in and answer questions?

Remember your goals: comfort/peace for the patient and support/solace for the family. Unlike any other area of health care, the "unit of care" is the terminally ill person AND his/her family of choice. The care of the family IS your job.

All the above being said, please accept the fact that you cannot make every death the peaceful, spiritual, happy-dolphin-music experience you might see in a movie. The best you can do is all you can do. Most of this process is beyond anyone's control - intervene where you think you can do some good and after that, it's a matter of support, validation and presence.

Gotta make a bank run before I go to sleep. I hope there was something here you can use.

Kerber · Sep 4, 2014

Thanks that's helpfull I noticed today his lungs sound wet 02 sat dropping 89 I ordered 02 for him today. His skin is turning yellow he's incont bowels and bladder. V/s stable good un labored breath sounds. Un responsive though his family keeps asking how long? Heart sounds strong.