Comfort kits

[Mandee]

We have a comfort kit but would like to maybe change it some, so I was wondering what other hospices have in your comfort kits, I have heard of different kits for different diagnosis, ie: specific kits for COPD and a different kit for Ca patients. Thanks!

Mandee

[Hospice Nurse LPN, BSN, RN]

Dear Rock-Chalk,

I am not a nurse, but rather a family member/caretaker of someone who just started receiving hospice services at home. Today, a pharmacy delivery truck pulled up to the house, and they delivered a small box that's sealed shut and labeled "for use by hospice nurse or physcian only". It is also labeled "not child-proof." They told us to refridgerate it, and, when we asked the hospice nurse about it today, she replied that it's not for us (the family) to use but rather just for the nurse in an emergency. She offered no further explanation. From reading several web sites, I assume it is either a comfort pack or a cardiac pac, and I now know the contents of both.

Quite frankly, I can offer a family member's perspective by saying that I don't like having something in our fridge without knowing what it is or how it's to be used, and I worry about potential liability because we pay for three other caregivers during the day who are in and out of the house, including one who lives close and has young children. And, per your astute question, I don't know what the heck we'd do with it if my dad were to pass. We had no further instructions other than basically not to touch it!

Primarily because of the poor communication, I'm on the verge of calling hospice and telling them to take us off the list and get their stuff out of our fridge!

Your sister Jayhawk (but displaced to a land with less coordinated health care),

pjkt

Oh my goodness! I always let the family know the the E-Kit is going to be delivered and to just store in in a safe place and I'll explain it all when I make my next visit. I break the seal and teach them how to measure the morphine (and a return demonstration). I re-seal the box and have the family put it away. If something is needed during the middle of the night, I want to be able to tell the family over the phone what to give and what to expect. Sometimes one dose of medicine will do the trick and we all (family and myself) can go back to sleep. If not, I can head out to make a visit, but at least one dose of medicine will have already been given.

Our E-kits are simple:

Roxanol 20mg/ml

diazepam 5 mg

scopal patch

If anything else is needed when can have it delivered the same day. As far as destroying meds: for my home pts, I dispose of all narcs and have a family member witness it and sign the med destruction form. For nsg home pts, the facility is responsible for destroying narcs. Hope this helps.

[pjkt]

That seems entirely reasonable! Thank you very much!

[tewdles, RN]

We do not currently have "comfort pacs", but we want them. What are your protocols? Our pharmacies are willing to make them up for us and want to know about CII accountability and monitoring? If drugs are not used prior to patient expiring or dismissal or drug expiration, how are drugs disposed of? Is there any in home drug accountability? Do you as the nurse using the med, sign out for it?

Completely sort of unrelated issue.... What are your Hospices standing orders and would you mind sharing them?

Thanks... Peajay:nurse:

I have worked for hospices who use Hospice Pharm and those that don't. The hospices that didn't created their own "comfort packs".

The comfort packs are signed out by the RN delivering them to the home...when they are not delivered by the pharmacy. The expiration dates on the packs are documented monthly until the patient dies. Meds are disposed of by the RN at time of patient death and cosigned by a witness (may be a family member). Disposal is often agency and region specific...we use coffee grounds or kitty litter or similar in a baggie.

Meds are not "signed out" once they are in the home. Once delivered to the patient they belong to the patient and not the hospice. We certainly monitor use and if we suspect misuse, diversion, etc we will change the POC to eliminate opiates or benzos in the home when and where possible.

We currently have a for profit hospice in our area that is promising the sun the moon and the stars to our best staff from admin to bedside. They are in the process of acquiring as much info about the other hospices in the area so that they can use that info to decrease our market share. Because of that, I am hesitant to share our standing orders...we just spent considerable time revising and updating the algorithms and I am not interested in helping out my competitors. However, your medical director and you can outline standing orders...just remember to consider the primary symptom constellations we see in the field and then design your orders around that. Just discuss what the intent and goals of the standing orders are at the outset...the orders must give the field nurses some autonomy so that symptom relief can occur rapidly, BUT, the S.O. must require MD involvement and you have to be careful to keep nurses practicing nursing and not medicine.

[ErinS, BSN, RN]

Our administration feels that e-kits can not be used because they do not allow for individualization of plan of care that JC requires. Instead we usually provide a liquid narcotic, and lorazepam and/or haldol depending on current symptoms or disease. We teach families how to use these meds and then change as needed down the road, including adding medications like scop patches.

[tewdles, RN]

Our administration feels that e-kits can not be used because they do not allow for individualization of plan of care that JC requires. Instead we usually provide a liquid narcotic, and lorazepam and/or haldol depending on current symptoms or disease. We teach families how to use these meds and then change as needed down the road, including adding medications like scop patches.

Honestly, I have heard this before and I think it is a load of ... well you know. Having a comfort pack in the fridge of a hospice patient is similar to having a crash cart in a hospital. The plan of care is individualized but the constellation of symptoms commonly encountered at end of life can be predictable.

Basically then, those hospice administrations are saying that they don't care that many people benefit from Atropine (for example) when they near death...they will only have it present in the home AFTER the patient demonstrates his/her INDIVIDUAL need for it...thus unnecessarily delaying treatment...same with nausea or fever or anxiety...

I, for one, am willing to play the odds when it comes to pro-actively anticipating the needs of the individual patient as they travel a common pathway toward death rather than simply reacting to the symptoms reported or observed.

[volsfan]

To pjtk,

As a home hospice nurse I review all comfort pak contents with my families b/c the families are usually the first to give the medications in the middle of the night or on weekends while they await for the weekend nurse to arrive. I have found it to be a good practice since there are multiple medications and when there is an "emergency" for the families they should be educated and feel comfortable about the contents of the kit. If they are left uneducated they are more likely to make a mistake if the hospice nurse is trying to instruct them over the phone. This generally takes an additional 20-30 minutes to review during a visit, but it sure does help. I would call the hospice you are with and speak with the manager. If how your nurse treated you is the company policy regarding the kits I would interview other hospices. If not, I would request a different nurse. Education is the major part of our job and at the very least she/he should have spoke to you in greater detail regarding the kit.

Gail

[volsfan]

Our administration feels that e-kits can not be used because they do not allow for individualization of plan of care that JC requires. Instead we usually provide a liquid narcotic, and lorazepam and/or haldol depending on current symptoms or disease. We teach families how to use these meds and then change as needed down the road, including adding medications like scop patches.

Many hospices use ekits b/c they are cheaper to have than getting each of the medications individually.

[ErinS, BSN, RN]

Many hospices use ekits b/c they are cheaper to have than getting each of the medications individually.

I actually am really lucky because although our administration does not approve of e-kits, they are fine with spending the money to have emergency meds on hand, even though it is close to $100 for the stuff we provide. I think they just feel we can document an individualized plan better. It ends up working okay for us, although an e-kit would be cheaper and more convenient.

[PoetOfMyHeart]

Our comfort kits are give to each pt when they begin to transition or beforehand. Sometimes the contents vary but is usually as follows:

MS 20mg/mL

Ativan 1mg tabs

Tylenol supp

promethazine supp

Atropine gtts

Also, the narcs are not signed for regularly unless CC is in place. When a pt passes, the narcs are destroyed by two nurses with a witness's signature as well. The kit should always be explained to family/caregivers.

[leslie :-D]

when my mil was on hospice, her comfort kit had a healthy variety of meds.

but the times i wasn't at the house, no one else knew what ea med was used for.

i wrote out their uses, next to ea med.

morphine- pain

ativan- anxiety/agitation

haldol- confusion but also nausea and agitation.

they would then pick the med that best suited her symptoms.

i do wish all e-kits had this.

leslie

[rnicupcu]

Is hospice covered under most insurances?

[Hospice Nurse LPN, BSN, RN]

Is hospice covered under most insurances?

Hospice is covered under most insurance and is a Medicare/Medicaid benefit.