advance directives for hospice pts.

[greenbean]

My family is currently in the process of getting my stepdad in hospice care. We had a nurse from VNA Hospice come out to the house a couple days ago and one thing she said I can't believe, and it raised red flags as to being able to believe the rest of what she said. According to her, hospice pts. can be Full Codes. This naturally doesn't seem to jive with "end of life care". I've been an LPN for over a year, plus I've worked as an aid for many years and I've never heard that one before. Is what she said possible? It's kind of a moot point for my stepdad because I doubt my mom would choose that, but it makes me question this nurse and that particular hospice. I'll be calling another one tomorrow morn--one that has a stellar reputation and I've only heard wonderful things about--even from their employees! By the way, my stepdad has Parkinsons and dementia. Though he is definitely hospice appropriate, he's been a joy to my mom and my family for the 10 years they've been married. A testament that it's never too late to find true love.

[traumaRUs, MSN, APRN]

If a hospice pt is a full code, then why are they on hospice? Maybe some experienced hospice nurses will be along and help you out.

[CANRN, MSN, RN]

Yes, we have taken patient's who are full codes. What we do is educate the patient and family related to code status and eventually, they or their POA will sign the DNR forms. Most patients and their families come to Hospice care after treatments for their illness and believing during this time, that they have "hope" that they can be "cured". Hearing that they need to be placed on Hospice care is like having a rug pulled out from under them. It usually does not take long before they accept what is going on and one is signed. We actually have two pt's that I know of on our service who are still full codes. It is not mandatory to have a full code and be on hospice but it sure makes things easier if they are.

[jessica]

I work for an open access Hospice company and we do not require that our patients be a DNR. It's about personal choice. Some individuals and/or families are not able/ready to accept a OOHDNR at the time of admission, or even through to the end. As a Hospice nurse, one of my most important roles is to educate the patient and family about various options in relation to thier care (physically, spiritually, and psychosocially). Of course, the rest of the team is involved as well.

I always inquire about code status and typically through the response of the patient/family I can determine how ready they are to discuss the possiblitity of a OOHDNR, what is actually involved when CPR is initiated, thier current medical state, what would happen if they were found and had already passed, etc.

So, truely the nurse that you spoke to was giving your father and the family many options in relation to code status and honestly, I believe that it should be the decision of the patient/family to decide code status not a company. You may find that with that agency you may have more choices all the way around.

HTH

Jessica

[wonderbee, BSN, RN]

How does a hospice nurse run a code in the home setting? It sounds like it occasionally happens. Are you equipped with a code bag and, if so, what is in it? Or are we talking about BLS without benefit of ACLS drugs?

[jessica]

If the patient is deceased, and death is evident (as outlined by the Texas Nurse Practice Act) then CPR is not initiated.

If I am present when a full-code patient ceases to breathe or the heart stops beating, then I am obligated to initiate CPR at that time. I do have a basic plastic mouth protecter with a one way valve in my car. Compressions would be initiated and 911 would be called. Once the parametics arrive, I would step aside and let them do thier work.

Through my rudimentary research, CPR typically is sucessful in less than 15% of the time (in a "heathly" individual). I personally have never initiated CPR, and within the course of the last year I can only remember 1 nurse initiate CPR and is was not even a hospice patient.

Jessica

[jessica]

i just ran across a book @ nursing knowledge international re:cpr and the palliative care setting! here's the excerpt from the site:

palliative care resuscitation

palliative care resuscitation begins by examining the history of cpr and how the procedures used today were developed. cpr was initially intended for victims of sudden, unexpected cardio-pulmonary arrest, unfortunately it has been applied to less appropriate situations and is now the only medical procedure which is consented against. the media have portrayed cpr as being invariably successful and appropriate, this can lead to anger and confusion from patients and families.

[NRSKarenRN, BSN, RN]

Info you were given is 100% correct.

Medicare +JCACHO Regulations require that you have "patient choice." Patient can opt out of hospice at any time. DNR nor living will not a requirement. Often with education and SW support, choice many make but not all. One does not run a code but calls 911 after starting CPR., or has family call 911. Some just pass away without formal document. All in familys acceptance of death and willing to let go, along with state regulations.

[babynurselsa, RN]

Many patients and families when signing up for hospice care are not ready to sign a DNR.

A big part of hospice care is about what the family is comfortable with. I had a few that did not have an advance directive when I signed them up but it did not take long after working through the whole grieving process and education on the part of the staff to later decide to go ahead and sign an advance directive.