Acute Hospice Care Crisis?

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hi guys,

today i had a very intense experience and even though i've gotten a tremendous amt of support from my colleagues in the break room, i'd like to know who else has experienced the following:

i need to keep this as vague as possible. i was called in to replace another hospice nurse who was having alot of difficulty handling a specific pt.

i got report that this pt. was receiving 700 mg (yes, 700 mg) of iv morphine along with sev'l other iv meds. when i arrived, the pt was screaming; his wife was frantic as was his parents. the nurse was crying. i called the doctor. we increased the ms04 w/o any effect. the final step was iv propofol. i discussed this w/his wife, the parents, who readily agreed. they just wanted him to die w/o pain. i titrated the valium up til i got the desired response, and then explained the next step to the pt. this poor man agreed and i told him that this med would more than likely hasten his death. he was all for it. i hung the propofol and ran it in....within 15 minutes my pt. passed.

but he passed peacefully. you could see its' effect within a few minutes. he had looked at me and thanked me, then closed his eyes.

i don't care to get into the many emotions that flooded over me but would like to know if anyone else has been involved in this type of case? i don't know why but i feel so alone. anyone?

leslie

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Specializes in ER, NICU, NSY and some other stuff.

WOW Leslie.

How sad for the poor guy and is family to be in such suffering. I am glad you were able to give this guy comfort and peace.

I did have a younger pt once with stomach ca she was taking 100mg ms sl or nebulized q1 along with with abh topical and phenergan topical alternating along with 150mcg fent patches and she would still rate her pain at a 10+. I begged the doc to admit her for symptom control to no avail. I will always feel bad that we were not able to get this poor dear comfy to the end.

Sounds like you did great work once again.

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No, Leslie, we haven't had any cases that required that kind of intervention (thank goodness) since I have been with hospice. It must have very draining for you and for all involved. I'm glad you were able to bring him to a peaceful state in the end but sorry he had to endure such agony before. I think I can guess a bit of what a complex mix of emotions it brought on for you. And in those moments there was a very intimate bond created between you and that patient, however brief. (((hugs)))

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And in those moments there was a very intimate bond created between you and that patient, however brief. (((hugs)))

and a very powerful bond. you hit it right on the head, aimee. all day today his screams have haunted me. i just have trouble believing he suffered as long as he did. why did they have to titrate all the way up to 700 mg? i would think that something else should have been tried much sooner. he was supposed to be admitted to the icu but he refused. he's peaceful now, thank you God.

leslie

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Specializes in LTC, assisted living, med-surg, psych.

Oh, Leslie, you do get the tough ones, don't you??(((((((HUGS)))))))

I hope you are getting some breaks in between these incredibly heart-rending experiences...........with what you've been through just these past few months alone, I fear for your physical and emotional well-being, my friend.

Bless you for being there for these sad, hurting souls and their loved ones. :icon_hug:

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you're right about that marla.

the cm typically reserves the more complicated cases for me.

but i'm fine.....i really am. and thanks.:kiss

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Specializes in LTC, assisted living, med-surg, psych.

That's good to know, Leslie. Just take care of yourself so we don't have to worry about you!!

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Several years ago, I took care of a 7 yr old child with a type of bone cancer - I don't remember the name of it. Near the end, it affected his facial an scalp bones and he was in excruciating pain. It was horrible to see. We placed him on an versed and high dose dilaudid drip until he died about 24 hours later - but he was peaceful and sleeping for that last 24 hours. We have had a few other pt's on service since then that we used "terminal sedation" on but that one was the most heart wrenching.

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Several years ago, I took care of a 7 yr old child with a type of bone cancer - I don't remember the name of it. Near the end, it affected his facial an scalp bones and he was in excruciating pain. It was horrible to see. We placed him on an versed and high dose dilaudid drip until he died about 24 hours later - but he was peaceful and sleeping for that last 24 hours. We have had a few other pt's on service since then that we used "terminal sedation" on but that one was the most heart wrenching.

how long did the little boy suffer for, before he finally received an effective regimen? and how long were you affected for?

this yr. i had a case with a 6 yo little girl but her pain was well controlled.

i don't know that i could handle watching a child writhe in unrelenting pain.

and finally, how long did pts suffer before criteria was met for terminal sedation?

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He had pain for several weeks and we kept going up on his dosage of narcotic and steroids with no good relief. The excruciating pain lasted a couple of days before the decision was made for sedation. The social worker, myself, and the medical director spent quite a bit of time with the parents for the decision to be made. While I was emotionally torn, I think I was more relieved and exhausted when he died. We've had a couple of cases that have been mostly intractible nausea/vomiting - one woman with ovarian ca with carcinomatosis. We had another with brain mets that his siezures could not be stopped. I couldn't say how long they suffered - it has varied, but the decisions have always been made after every other possible treatment did not work. The woman with ovarian cancer asked for terminal sedation herself. She said goodbye to everyone before the drip was started and lived several days. She had been vomiting stool and was refusing an NG or g-tube to suction. The child is the only one that I have seen versed used. We usually use an ativan drip.

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Excruciating pain physical and/or emotional is the hardest challenge. Think though what would have happened WITHOUT hospice. The last pain challenge I had was a younger pt with spine mets. Pt maintained implanted pump with MS, Baclofen and a 'caine. We ended up with two SQ pumps, dilaudid and versed. He died at home sedated, calm and quiet with our Crisis Team. It was a tough case. He had a tremendous will to live and anger over his impending death but the pain was too much for him. I will say his family felt tremendous relief at his death and was very appreciative of our help. Keeps me very humble.

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i totally agree, beexcellent. i can't think of anything more humbling than working in hospice.

your story reminds me of a pt. i had, who was outraged that she was dying. nothing or no one could help. and she was 96 yo but had the stamina of a young woman; no exaggeration.

one morning i noticed she was cheyne-stoking. i leaned over and whispered to her that it was ok to go home (she was very religious). out of nowhere, this lady sits upright in her bed and yells "STOP RUSHING ME. I'LL GO WHEN I'M GOOD AND READY!":rotfl: it took a couple more days but she finally left us....and thankfully, died in her sleep. aah, the books we could write....:balloons:

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