how does hospice work in other ltc facilities

I will try to answer your question as a continuous care hospice nurse.... The hospice nurse you describe certainly sounds completely wacky and as you know, does not represent most hospice nurses. When I work with a pt in LTC or ALF I am always respectful of their facility and rules as I am a guest and representative of my hospice. I am also an advocate for my pt and family.

Normally when a pt is on crisis care and in the active stage of dying, our primary concern is comfort. Since we are at the pt's bedside monitoring 24/7 we can closely observe for all s/s (including nonverbal - facial grimacing, moaning, etc.) of pain, discomfort, agitation, restlessness or any distress. I have learned that sometimes these are things that you cannot observe by a quick assessment and sometimes to maintain a level of comfort some pts do require PRN meds every hour or more.

I have worked with facility nurses who many times do not feel comfortable with giving meds so often because it is not the norm for most of their pts, but for a dying hospice pt it is normal and the POC. I usually consider myself fairly conservative with PRN meds and will give them unless I see a need or the pt or family asks for it to be given. I think the majority of hospice nurses feel the same way and would not be requesting the pt to be medicated unless they saw a reason for it. I have also learned that sometimes it is helpful to have a new set of eyes to oberve s/s - so many times in LTC situtions the caregivers get so used to seeing the pt and it is more difficult to notice subtle changes especially when a pt is unable to verbalize.

Since you are the nurse administering the med, it is ultimately up to your judgement but please defininetly take in to account the hospice nurse's observations especially since we are so accustomed to caring for a dying pt. I know some facilities allow for the hospice nurse to give the med and sign out for it, but usually it must remain locked in the narcotic box. Trust me, we really want to try to make your job easier and don't like to pester you if we can help it. I have been a LTC nurse so I know and it is a tough a busy job!

All I can say is just wow. The hospice nurses that I've come into contact with at our facility have been nothing but nice. I'm seldom there when they make rounds because I usually work nights. It is very necessary to medicate more frequently; for example we would give Morphine IM q 2 hrs for pain aeb grimacing/groaning. Also administer IM Ativan at the same intervals if needed. The brief contact that I've had with hospice nurses coming into our facility is that they are available as a resource when we need them.

Sorry, I meant to say I will give PRN meds IF I see a need, not unless.

I love working with hospice nurses! I've learned a great deal about EOL care and pain management from them over the years, and some day, when the time is right, I hope to become a hospice nurse myself.

Thanks to hospice nurses, I've learned NOT to be afraid of giving the meds necessary for symptom control, at the appropriate intervals and in the appropriate dosages. I know we all don't really like to be the one who gives "the last dose of morphine", but for the patient who is in pain or respiratory distress, it's a blessing. Most LTC nurses don't realize that, for we are trained to focus on maintaining or improving our residents' level of functioning; caring for a hospice patient requires shifting gears, and we don't always do that easily or well.

I, for one, would love to work hospice someday. (After I've had some more time under my belt). That's due to the excellent hospice nurses I've worked with in the past. Most of them are very good. As with anything, there always seems to be that "one" who is evidently not cut out for that line of work. I had an actively dying pt whose pain was not well controlled with her current medication schedule. So, silly me, I called hospice. This poor lady's hospice nurse told me, out loud and everything, "I don't feel like coming in. Just go ahead and call the Dr. for orders." ??? Fine. I call the MD, get the orders, and get my pt comfortable. She died about 6 hrs later, peacefully. That was not the first time I had issue with this particular hospice nurse. However, she is an exception rather than the rule. Most of them will come in at all hours of the day or night, dressed properly, ready to assist us and especially, the families.