blame the morphine

[pnhopeful]

I have been running into this a lot lately with my hospice nurse coworkers. Patients' declines and decrease in level of consciousness are being chalked up as "over-medication". This misconception is happening with actively dying patients as well as those with simply an increase in or uncontrolled pain. The patient is typically medicated PRN with morphine for pain or SOB. These are patients who are on starting doses of 5mg range. The knee jerk reaction from this particular small hospice company is that the patients are over sedated from pain meds. I expect this from lay people, but is difficult to deal with from professionals. No one in the company is hospice certified, including the medical director. I have seen a few deaths with uncontrolled symptoms that make me cringe to think about. How would you deal with people who attribute normal declines involving increase in sleep/increase confusion to morphine???

[gonzo1, ASN, RN]

As hard as it is I believe you must educate and tell these coworkers and families involved that this is just not true. We all have a tendency to downplay that the pt is dying and there is no hope for recovery. I see this all the time in my ICU. Families just won't let go, and we are afraid to talk about the truth with them for fear they will think we are trying to kill their loved one.

[bbuerke]

This can be a truly challenging thing to discern, even for those who are trained! All it takes is one encounter with an over-sedated patient who was discounted as actively dying to make someone gun shy with narcotics. For example, a patient with seven fentanyl patches on who was of course confused but still complaining of pain. Family and clinic docs thought he was reaching the end based on his presentation, when he changed into his gown for the exam the nurse saw the patches and maybe that's what's wrong...

After switching out his meds and giving the fentanyl time to wear off, he returned to his old self and lived for several more months. Did he still have a terminal disease that warranted hospice? Yes, but in his case that day it really was the meds, not the disease process causing his symptoms. I imagine this is something that is particularly challenging with the elderly population as the reaction to narcotics may be more pronounced, and it can be difficult to discern, is it the disease or the meds? An experienced individual should be able to put the pieces together and determine what's going on, but you're right, sounds like these people need more education...

[curiousauntie]

I think they believe breathing 50 breaths a minute is just fine and dandy.

That is just unbelievable! I run into this in long term care facilities, but not as often as I used to. But when the hospice RNs are this ignorant of how to medicate at end of life, it is just so wrong. Does your hospice offer any education, be it formal "inservices" or just printed material in your mail box at the office? If not, then you have to be proactive and educate yourself and them. There is plenty of information on the web, in books, on the HPNA website...like a poster above said, google it! If your bosses and co-workers don't want your education, then you may need to rethink you choice of employers.

Do you work for a stand alone hospice, or for a larger multi-office one? I ask because I work for a large, nation wide hospice, and believe you me, when a nurse is hired with no hospice experience, they are given an orientation based on CoP, NHPCO guidelines and are never left to believe that there is no one to help with the end of life problems. In fact, those of us with lots of hospice experience just about make a pain of ourselves when a new nurse is dealing with an almost or actively dying patient. And we do this for months...longer then we usually need to, but better safe than sorry! (although we are a large company, our office is small, 50 pts and 3 full time and 2 part time case managers, so we are all very close.)

@bburke...I actually have seen this...multiple fentanyl patches, when on call one night I got a call from a patients wife complaining how her husband was soooo confused. I made a visit and found patches all over his chest. She said she thought the doctor had said the patches would fall off when they were done working! And that if he still had pain she was supposed to put on another patch! I went over his meds with her and found the label on the fentanyl patches was really vague, (the ol' "use as directed") and he didn't have anything for breakthrough pain. In our defense, he had only been on service for 2 days and the case manager had been trying to get BTM from his MD. I educated the wife on the patches, took off the old ones, set up a calender for REPLACING the patches q72 hours...Long and short of it was he was fine, got his meds the next day and we had a good giggle over it.

[rngolfer53]

Well, I suppose if the Fentanyl patches were all 12s, 7 of em might make sense.

I started to work for my current agency about 9 months out of nursing school, and I had no hospice experience, other than as a caregiver for a parent on hospice 15 years before. My job was to be night call.

We had several days of classroom orientation on the course of a dying patient, symptom management, etc. Then a few weeks of riding along on calls with experienced nurses. While I was nervous, make that scared being out on my own at first, I at least had a good grounding in what to expect, how to assess and manage symptoms.

We are a good sized, one city, non-profit agency. One of our strengths is the quality of our medical directors. I would be really leery of working for any organization that didn't have hospice certified MDs.

[pnhopeful]

Thanks all! Believe me, I know this is wrong and that is why I am disturbed. I have been reading some resources myself, but they are too advanced for the people I am referring to. I am looking for some really basic straight forward stuff. As in, easy to read. I have found some helpful tidbits/ info and passed it on to coworkers already, but looking for more. The Fast Facts posted above look handy.

[leslie :-D]

Lets just say their pain assessments are different than mine. Them missing non-verbal s/s of pain among other issues! I think they believe breathing 50 breaths a minute is just fine and dandy. I am considering a change, but before I do I am looking for some easy and quick educational materials for staff/family.

this is outright disgraceful.

i am really upset to read this ****.

sadly, you can present all the educational materials ad nauseum, and it still won't matter (for the majority).

you are dealing with a deeply ingrained mindset that typically doesn't respond to facts.

i don't know if you mentioned this already, but what does your DON or med'l director have to say about this?

yes, i know all too well, there are many unqualified folks in these positions as well.

i was just wondering if that is the case where you work, too.

if the pt was having pain, he shouldn't be getting prns in the first place, it should be scheduled atc.

50 rr is NOT acceptable.

actively dying pts DO sleep more, eventually lapsing into unconsciousness for many.

that doesn't mean they don't feel pain!

i know you know all this, i am lecturing to an ignorant sect of those you're dealing with.

frustrating to say the least.

if you cannot get assistance from don/med'l director, is there family who would rally for better pain mgmt?

is there an ombudsman at your place?

this **** drives me nuts, my adrenaline just shoots through the ceiling.

thank you for being the advocate that you are.

many of us appreciate what you're doing...

with your pt, being the most grateful.

leslie

[pnhopeful]

sadly, you can present all the educational materials ad nauseum, and it still won't matter (for the majority).

you are dealing with a deeply ingrained mindset that typically doesn't respond to facts.

Yes! So true! Total uphill battle.

if the pt was having pain he shouldn't be getting prns in the first place, it should be scheduled atc.[/quote']

THANK YOU!

thank you for being the advocate that you are.

many of us appreciate what you're doing...

with your pt, being the most grateful.

Thank you :-)

[tewdles, RN]

Are you familiar with the PAINAD?

Google it and download it for your peers, it will inform their assessments of nonverbal and cognitively impaired patients.

You should be able to find a copy that includes instruction for use.

[Bubbles]

One does not need to be certified to be an excellent hospice nurse. It takes hospice experience to be eligible to take the exam for certification. But they should have good clinical experience and some orientation to hospice philosophy and practices.