Dear hospice nurses,
Some of you were very helpful to me about 6 weeks ago when I posted a question about my mother being able to get a pleural tap while receiving hospice services. (That thread is at: http://allnurses.com/forums/f25/ques...-new-post.html
This is sort of a followup. In brief, if you don't read the background at the above thread--she is 82, has metastatic breast cancer and has recovered from several crises in the past 20 years. I don't know if she'll recover this time, but she is fighting. We've given up in the past & she's recovered, so although she has become cachectic, and is using O2 X 2 months now, she seems to have a very strong constitution.
First my questions, then background:
1) fentanyl patch: how is it usually tapered down? Is it feasible to taper from 25 by putting on a 12.5, then putting on a second 12.5 if the first is not adequate? If not, then how is it usually done?
2) is fentanyl used as morphine is, for dyspnea? We are concerned because of the sedative effect of the fentanyl. Some shorter acting medication might be preferable?
What led to this: She did have a pleural tap about 10 days ago, hospice was revoked and then she started hospice again after the procedure. She was d/c to home yesterday. Pain has never been an issue, but of course she needed pain relief after the chest tube, and is now on fentanyl 25 mcg, with OxyFast for breakthrough pain. Initially, because she still had some pain on the 25 mcg patch, the pulmonologist had upped it to 50. My dad appealed to me to intervene because she was oversedated then, and the doctor refused to listen to his concerns, said, "I'm the doctor and you don't know anything about this." I've had to step up to the plate like this before with doctors or nurses in the past, unfortunately, so I did intervene. We were able to get the regimen changed to the present one. Now we are wondering when and how the fentanyl can be taped off and stopped, as a quality of life issue. And, we suspect the hospice folks want her to stay on it. We really don't want to have a conflict with them over it.
THis is how she is today: On fentanyl 25, she is still drowsy and is unsteady on her feet. She falls asleep while watching TV, but her appetite is still good, and if you talk to her, she converses normally, then falls asleep again. Knowing her baseline, it's very hard for us to figure out if this is advancing disease, or the opioid, but we tend to believe it's the latter. She has, and has for several years, had dyspnea, due to lung involvement and some CHF. She is having no pain and has not needed the Oxyfast for at least the past 2 days.
Is there some school of thought in hospice that the person should spend indefinite periods of time on powerful opiates? Are there some hospice nurses who think the patient is better off on Cloud 9, or is that just my impression? From what my dad is reporting I am wondering if the hospice nurses are lumping my mother in with people who have chronic cancer pain, and are reluctant to consider tapering off the opioids. My dad is frustrated and concerned that he is being cut out of the loop: the hospice nurse says she will only discuss my mom's care with my mom. He has no concerns about addiction and does want her medicated if she has pain, but once the pain is over, he doesn't want her on the patch anymore.
He now wants me to go there and intervene with the hospice nurse when she visits tomorrow. I would like to be able to speak to her with a little more knowledge than I now have.
May 15, '07
Quote from caroladybelle
First, I don't recall ever seeing a 12.5mcg fentanyl patch..
Carol, the 12.5 mcg dosage patch is fairly new....it just came on the market about a year ago, I think. Hospice pharmacia did not include it in their formulary until this year.
Good mention about the http://www.denverbio.com/physician_pleurx_catheter.html
Last edit by aimeee on May 15, '07
: Reason: forgot to add the pleurx stuff