? About treating Hospice pts

leslie :-D · Jun 25, 2005

every doctor will be different. obviously if you have a pt w/late stage chf, you're not going to stop their lasix. if there's an infection, some drs treat it, others don't-it depends on how close to death they are; how imminent. i've had md's adjust insulin dosages and continue w/fs but again, it depends on where the pt is in the dying process. often too much doesn't change at the beginning then you'll see many adjustments and dc'ing as the pt deteriorates. there certainly is no blanket statement that can be made as ea pt is unique in how they present and the stage of dying they are in.

hope this helped.

much luck to you.

leslie

Schmoo1022 · Jun 26, 2005

Thank you!

That did clear things up for me

We only have a few docs that come to our facility, but they do things very different. I know the families have some say too.

We also have issues with our nursing staff, who have their own ideas and feelings about what Hospice should consist of. Some get angry that "dying" patients are having fingersticks and labs drawn, and others are terrified about giving the " death dose of morphine" . I believe very much in giving the patient the most peaceful, pain-free death as possible, but I know TOO many nurses that are afraid to give medications. sad

mc3, ASN, RN · Jun 26, 2005

Thank you!
That did clear things up for me
We only have a few docs that come to our facility, but they do things very different. I know the families have some say too.
We also have issues with our nursing staff, who have their own ideas and feelings about what Hospice should consist of. Some get angry that "dying" patients are having fingersticks and labs drawn, and others are terrified about giving the " death dose of morphine" . I believe very much in giving the patient the most peaceful, pain-free death as possible, but I know TOO many nurses that are afraid to give medications. sad

Hi!

Glad to see your facility is accepting of the hospice philosophy of care. Where I worked in hospice, we d'c's the "non-essentials" such as vitamins, etc. One thing I always looked at was d/c'ing Aricept and Namenda in hospice pt's with end-stage dementia or Alzheimer's. Neither medication is helpful at this point, and it's one less med they have to take orally. Of course, I always discuss any d/c of medications with the family first! As far as pain meds/morphine in end of life care, I am quoting the summary from the ANA as follows: "The ANA believes the the promotion of comfort and aggresive efforts to relieve pain and other symptoms in dying patients are obligations of the nurse. Nurses should not hesitate to use full and effective doses of pain medications for the proper management of pain in the dying patient. The increasing titration of medication to achieve adequate symptom control, even at the expense of life, thus hastening death secondarily, is ethically justified. (American Nurses Association, 1995)". I also quote here from an article in Journal of Hospice and Palliative Nursing (Vol. 6, No. 4, October-December 2004) in part as follows: "Professional organizations, state lawmakers, and the US Supreme Court have asserted their support for administering opioids at the end of life by explicitly or implicitly invoking the rule of double effect. Thus, fear of hastening death as a results of opioid administration does not justify the withholding of pain medication." I also some have information on using opioids and what the intent is, but I just moved and it's still packed away.

My experience as an LTC hospice nurse was that education was the key to correct utilization of pain meds. We used the HOOPS scale, which was a non-verbal behavioral pain scale for cognitively impaired patients. I even gave copies to the nursing staff, and they found it to be a great tool for all their patients, not just the hospice pts. Sadly, I worked with many nurses who swore their patients were not in pain, but when I (nicely) pointed out that Mr. Jones' respiratory was 44, HR 110, and he cried out when he was repositioned was a definite clue that something was up!

In any case, hope this helps.

mc3 :nurse:

Schmoo1022 · Jun 26, 2005

Thank you.

That was some good info! It is very sad that anyone should have to suffer at the end of their lives or at anytime for that matter.

worldsoulrn · Jun 26, 2005

Gotta love these boards! I have followed this hot topic with great interest from Oregon. A very good discussion on pain management indeed.

"As a result of her own personal experience with pain management, Senator Joan Dukes sponsored Senate Bill 885. It requires nurses, physicians, naturopaths, chiropractors, physician's assistants, and psychologists to receive pain management continuing education credits in conjunction with one license renewal cycle." (By time frames indicated in accordance with the bill's implementation date, 1-1-06) http://www.osbn.state.or.us/OSBN/pain_management.shtml

This is great news coming from a State that had no CE requirements for nurses to retain licenses.

" Inadequate pain relief is a recognized public health problem in Oregon and across the nation." OSBN

I have noted the resources listed in your posts: JCAHO, National Hospice Organization, American Society of Pain Mgt., International Pain Society, WHO, HPNA, Pain Mgt. Manual by Margo McCaffery, Journal of Hospice and Palliative Nursing, various web sites http://www.Juneauempire.com,

http://www.capitalhospice.org, http://www.silencetovoice.com,

http://www.pathology2.jhu, http://www.americanradioworks.pub

Each and every one of these posts from experienced nurses have provided me with valuable insight. I can take all the CE classes and read all the available literature and not get this type of hands on, been there, done that education. I applaud all of you and if I ever become terminally ill I will e-mail each and every one of you and invite you to be my care giver. I'd like to invite earle58 to tackle my doctors after I line her out with my wishes. Katallic, I hope to see the latest information from JCAHO posted ASAP as I'm not a member and it will take me a while to figure out that system. I'm not sure I have the time available for the Tele. Conferences and the purchases are spendy. Do you know if JCAHO publishes free literature?

_________________________

The Journey Is The Reward

leslie :-D · Jun 26, 2005

Thank you.
That was some good info! It is very sad that anyone should have to suffer at the end of their lives or at anytime for that matter.

one of the most used phrases i've seen nurses write (even w/demented pts) in their nurse's notes is "denies pain". give me a break. :angryfire i'd bet my bottom dollar that they weren't even asked if they were in pain; but it only adds salt to the wound if the pt was asked and they denied it, in spite of elevated vitals (which were never taken) or grimacing or impaired mental status....oh gaaaaaaaaaawwwwwwwwwwd absolutely my biggest pet peeve are those that just don't take the time to do a real pain assessment. one time (actually a few times,same pt) i've seen nurse's notes that stated the pt denied pain- he was in a pvs. :stone .ugh....don't even get me started.

leslie

DG5 · Jul 8, 2005

mc3, what is the HOOPS scale? I would love to take some info back to my facility on this.

mc3, ASN, RN · Jul 8, 2005

It's a scale used in hospice to assess pain in cognitively impaired patients. As I said, some of the nurses I worked with in LTC wanted copies to use for all their patients. It's very good.

I don't have a scanner, so if you want to PM me your mailing address I can mail you a copy.

Good discussion board!

mc3 :)

txspadequeenRN, BSN, RN · Jul 8, 2005

If a patient is actively dying their routine meds are not going to help anyway. I stop giving meds when their swallowing has significantly changed or lethargy. By no means am I going to give a MVI rectally, and I have seen this done. After this all I give is pain meds ,morphine , oxy, gels or intensols.

Hello,
I really enjoy reading all the Hospice and Palliatve care threads posted here. You all have so much valuable information and seem to truly enjoy what you do. I work in a small LTC facility and truthfully, we just really started using Hospice more.
I have some questions about end of life care. Do you routinely DC all meds except pain/comfort medications? How about insulin and FS.
Do you only have the other meds/FS dc'd if the patient is activey dying? I am a little confused about this because we have very different orders for two different actively dying patients and I am not sure if it's because of family and patients wishes or due to the Drs.
I hope someone can help me out!
Thanks!

aimeee, BSN, RN · Jul 9, 2005

By no means am I going to give a MVI rectally, and I have seen this done.

:uhoh3: Good grief! I've seen a lot, but I haven't seen that, thank goodness!