Comfort care med protocol?

[sistrmoon, BSN, RN]

We have a loose protocol for comfort care, but it doesn't seem to include meds. We are oncology and deal with this a LOT, but lately the doctors seem resistant to something I thought was pretty standard: pain medication drips and PRN IV Ativan. They are doing things like ordering around the clock po Morphine tabs in a dying patient who can't swallow and PRN pushes on a patient who isn't really in a condition to request meds. Sure we can use the FLACC scale but are we adequately controlling pain? No. I don't understand this resistance to keeping someone comfortable who is comfort care! A doctor told us a drip wasn't "medically indicated." What? Does your comfort care have meds included in the protocol? Have you found this resistance?

[klone, MSN, RN]

Maybe they need to be formally admitted into hospice, and then the hospice protocols will take over. Hospices generally are quite liberal with comfort care medications.

[sistrmoon, BSN, RN]

Hospice doesn't seem to deal with inpatients at this facility. They either go home with hospice or go to an inpatient hospice elsewhere if approved. This last patient I'm referring to didn't qualify for hospice.

[loriangel14, RN]

We have a printed order set for palliative care. The doc ticks off what he wants to order and signs the bottom.It includes medication, sedation, scapolomine, etc. All of our palliative patients go on PCA pumps.It makes no sense to order po meds for people who cannot swallow.

[MunoRN, RN]

Health departments tend to take adequate symptom control at the end of life very seriously and rarely tolerate under-treatment. It's not unusual for physicians to be a little hyper-vigilant in avoiding actively speeding up the dying process, which is a reasonable concern, but there are palliative care guidelines they can refer to. You might suggest that, and if that doesn't work consider involving your department of health anonymously.

[toomuchbaloney]

Hospice doesn't seem to deal with inpatients at this facility. They either go home with hospice or go to an inpatient hospice elsewhere if approved. This last patient I'm referring to didn't qualify for hospice.

How did the dying patient not qualify for hospice?

[suanna]

Health departments tend to take adequate symptom control at the end of life very seriously and rarely tolerate under-treatment. It's not unusual for physicians to be a little hyper-vigilant in avoiding actively speeding up the dying process, which is a reasonable concern, but there are palliative care guidelines they can refer to. You might suggest that, and if that doesn't work consider involving your department of health anonymously.

Unfortunately Boards of Medicine and BONs and the Hospital Assoc.have shown little support to the staff members who medicate an end of life patient without absolute evidence of unmanaged pain. There have even been attempts to seek criminal prosecution for someone who "murdered" a terminaly ill patient by "euthanasia" when in course of treating the patients pain you end up hastening thier death. I for one do not want to end up rooming with a large lonely lifer in the local penitentiary when I was just trying to keep my patient comfortable; Let alone spending my life savings to defend myself against the charges.

[sistrmoon, BSN, RN]

How did the dying patient not qualify for hospice?

I don't know the specifics but there are often dying patients who don't qualify for hospice. Just because you are dying doesn't mean you qualify. My father worked as a nursing home administrator and said Medicare Part A covers it but private insurance sometimes won't? And the family often can't afford to pay for it.

[aortas]

At my facility I often see a lot of "hospice" patients. Until the pt is formally admitted to hospice or even after they are...the hospice recommendations and recommended orders are just that. The physician at the facility who is the pts assigned physician ultimately reigns over the hospice and still has to approve or change the recommended orders. Live had hospice pts still on 15 meds. I have had hospice pts on just rox. My idea as a nurse taking care of a hospice to is to keep her comfortable and the family at ease (which hospice aides and contracted hospice are good at doing),

[toomuchbaloney]

I don't know the specifics but there are often dying patients who don't qualify for hospice. Just because you are dying doesn't mean you qualify. My father worked as a nursing home administrator and said Medicare Part A covers it but private insurance sometimes won't? And the family often can't afford to pay for it.

Dying people qualify for hospice care. They may not have an insurance policy that will pay for it, but they certainly qualify for the care. Some hospices have charitable foundations which will cover the care for uninsured people. So it is not a question of qualifying, it is a question of payment. Typical of our American health system, you get what you individually can pay for.