A situation in LTC with a hospice patient

[CoffeeRTC, BSN, RN]

Background: I've been a nurse for 13 yrs in ltc, I mostly work per diem, but alot of times end up every weekend or every other weekend. I do get to know my residents. We have hospice pts every now and then and often the facility tends to discourage hospice involvement (grrr)

Had a patient a while back that for the most part was the average LTC pt. 80ish with mild dementia, pleasantly confused for the most part, makes all needs know and will answere short questions appropriatly. Mostly has a cardiac history, developed urinary retention and dysphagia. Before coming to our ltc he was very functional at home but had a decline in his physical mobility (cardiac event...the rest came with that). So...he had been having periods of confusion and would pull out his foley. This would often require a send out to the hospital for reinsertion due to prostate problems. This happend about 3 times in a two week period. Family was dealing with his placement in LTC and a ailing mother (younger, A and O x3 but with a cardiac and copd history)

After the 3rd send out to the hospital the son cam in and said...I want hospice for dad, cut his meds, keep him comfy with morphine...no more send outs cut his tube feed. The doc agrees, hospice comes in and admits him (havent seen a terminal dx listed in his chart yet)

So...I come in for my shift...all this is news to me of course there is poor charting except for what the son stated and it was put in quotes. Day nurse tells me that he is more alert and very appropriate for the last day or so. (other staff had been giving him around the clock ativan and morphine that was both ordered straight and prn) Prior to all of this this pt has not had any complaints of pain and just an occasional period of agitation in the pm (normally he just needed to go to the bathroom and get pm care)

This day....he was asking staff for food (his tube feed had been cut now for about 3 days) He even told staff "I know I can't eat food in my mouth, but wouldn't even mind something in that tube" All day long he was begging for food. Yes...he was begging.

Sooo...what would you have done in this situation. I know what I did and I would do it again and again and again. The social worker was adamanat about not giving him any food because his "POA said so" I called the on call hospice nurse that came in and assessed him and was somewhat upset that a "dying man" would be denied food. In the mean time I called the doc and got at least a prn order to feed when he requests food.

So many things were wrong in this situation, but now I seem like a trouble maker. I asked the social worker if she would like to come in and sit beside this resident and listen to his requests for food. (no response from her)

[leslie :-D]

has it been professionally determined that he cannot swallow, i.e., a swallowing eval by a speech therapist?

if you cannot find any records in his chart, call doc and get order for eval AND ask what dx md is using to justify hospice care.

make sure your nsg notes reflect pt requests/concerns.

(hoping hospice nurses also do same)

bottom line?

i don't give a rat's behind who the poa is:

if there is not any medical basis that shows he has 6 mos or less to live, it is indeed, assisted suicide, and therefore, illegal.

i'm hoping that hospice nurses would be ethical enough to not continue services w/o med'l dx.

leslie

[CoffeeRTC, BSN, RN]

It really wasn't assisted suicide, but on the son/ poa part...assisted homicide.

Yes, he did have a swallow disorder. MBS was done, but heck...even hospice pts should have their dying wishes for food taken care of. What bothered me was

the SW telling me to do nothing

lack of documentation in the chart saying why this man was hospice

lack of daily nursing documentation

D/Cing food on a pt that was still alert (no medical reason to dc fluids etc..no chf, no breathing probs, no gurgling)

the fact that other staff let the man c/o hunger

when I called his primary doc...she said "that is what the son wanted"

so many other things this list could go on and on

This happened a while ago. I did get ahold of the son and told him I got an order for feed as requested by the pt. He seemed okay with this. He was kinda totally misinformed of his fathers prognosis and was "just tired of dealing with this (and my mother in the hospital)"

The hospice nurse and I tried to explain in nursing way that dad really wasn't actively dying and to withhold food is cruel. The son kinda thought that you just stop feeding them..pump him full of morphine and ativan and he would die in a few days:bluecry1:

This happen a few months ago and the resident did die about 2 months after this event. I haven't been back at this place for a while, but this had bothered me.

[leslie :-D]

ok...

i have a clearer perspective on it now.

sadly, it is legal to withdraw artificial nutrition, at least in my state.

to this day, i struggle w/this, esp w/the pts that are alert.

i'm glad md wrote that order about food as tolerated.

michelle, there's going to be many things in hospice (as well as other specialties) that feel ethically contentious.

inevitably, it's going to narrow down to your interventions in acting with beneficence.

it sounds like you're doing tremendous work.

and thank you.:redpinkhe

leslie