I have finally worked it out to transfer to hospice. I'll be working part time hours there and still 12 hours at my current job on a heavy med-surg floor.
My question is regarding "pain med seeking" behavior in hospice. Do you get it often? I have the least amount of compassion for these types of patients. That is one of the main reasons I wanted to work at hospice-working with patients who have true need of pain relief, who need me to advocate for them in case they cannot, etc.
Please understand my term "pain med seeker" to be someone who is obviously timing their meds. I know we are to treat each patient as their pain is real to them, but in reality, much abuse is present in the current hospital setting.
Please tell me I won't encounter this as much in hospice. That is my true hope in transfering is that I can care for patients as I wish to-and their pain.
Hospice patients aren't so different than any other patients. It's just that they are dying. You'll probably find about the same percentage of people who have been drug users of one type or another. It might not always be pain meds, it might be sleeping meds or laxatives. Or heroin. Their drug tolerance tends to make symptom management more challenging. It can be frustrating to deal with them because it is harder to control their symptoms, and often they have already tried most of what we have to offer. And they have some learned behaviors that can be very irritating. It's evident by your post that you are beginning to examine and deal with your feelings about drug seeking behavior; hopefully you will find some kind of resolution in order to be an effective nurse to these patients. Some more experience and a good mentor will help you greatly. You'll do fine.
Btw, when these patients "push your buttons" it's helpful to ask yourself why - what about the situation is really making you angry. Is it because they called you for more medication, or is it because you were about to go to lunch and you don't want to delay another 10 minutes? Most of the time when I get frustrated with a patient, I eventually realize that it's because I wasn't able or willing to do what needed to be done at the time. Nursing is hard work mentally and emotionally, and it's difficult to maintain the level of energy and empathy needed at all times. One of the things I hope you learn early on is that there is great interdisciplinary team support in hospice. You can often call on another hospice nurse, social worker, home health aide, etc., to help you out when you are on your last nerve. And vice versa.
Another great lesson to learn in hospice is that you are not going to change people's personalities nor their behavior. Families are going to be dysfunctional in a million different ways. Don't drive yourself crazy trying to mold them into something they are not. People won't always die the way you want them to. You really have to let go of what you want for people, and adopt the Burger King motto: Have it your way. (This post paid for by the fast food industry. And now back to our regularly scheduled program :chuckle )
Jacel, I appreciate that your posting about your experience with drug seeking behaviour was in the Med/Surg setting, and not in palliative care, and I agree that there are some patients (most often with a complex psych and/or medical and/or drug abuse history) that could be classed as pain seekers. However, I agree with previous posters who have expressed concern about patients being so classified.
In my second year as an RN I looked after a patient who was the younger sister of an old school friend - when I was allocated her I said that I knew her, and went to check if it was okay with her that I care for her, making it clear that I completely understood if she was uncomfortable with the idea; she said she'd rather I look after her than anyone else :)
She'd come in a few days earlier with diffuse, severe abdo pain. During handover the staff on were fed up - her partner was a medic on another unit and had written her up for (non-analgesic) meds; she ambulated apparently freely much of the time; all of her tests to date had come back NAD; and she 'clock-watched,' requesting meds right on the dot of when they were due, and she would specify that she wanted the maximum dose prescribed. She was also a nurse, who had trained at the same hospital we were working in, though not the same group as me, and not currently employed as a nurse.
As she'd been handed over for the last couple of days as being a suspected drug seeker, nursing staff were waiting for her to request pain relief, would try to give her less than the maximum prescribed dosage, and would leave her alone as much of the time as possible.
Though I didn't know her at all well, and hadn't seen her sister for several years, she didn't seem to me likely to be drug seeking. So, after checking that she was happy for me to provide her care, I spent as much of my shift with her as possible. I explained that the waking nightmares she'd had with her sleepers were a known side-effect, I reassured her that the fact that her tests were NAD didn't mean that she was making up her symptoms (including guarding), and included her in all decision making about her care, including analgesia.
Despite my handing all of this over to the night staff, the next morning she told me that they were tardy bringing her analgesia, and were reluctant to give her the full dose. She expressed frustration and anger at having this extra burden to handle on top of concern about the cause of her pain.
The next day she was discovered to have retrograde bleeding in to her Pouch of Douglas, and a week after discharge was diagnosed with lupus.
I don't know if I would have gone in to her room with an open mind after that handover if I didn't have a history with her, but I always do now. Being forewarned that there are issues with patients (or their family) are helpful, but now I never take for granted another nurses' assessment of a situation.
PS Be prepared to have your idea of what constitutes appropriate pain relief challenged. When I worked in Medical Oncology I had a young guy with metastatic osteosarcoma who was getting 1000mg (yep, 1 gram!) of morph an hour IV plus breakthrough relief of up to 200mg every twenty minutes. He was sitting up, talking to his visitors, alert and oriented.
When I worked in Medical Oncology I had a young guy with metastatic osteosarcoma who was getting 1000mg (yep, 1 gram!) of morph an hour IV plus breakthrough relief of up to 200mg every twenty minutes. He was sitting up, talking to his visitors, alert and oriented.
it's true.
there is no ceiling for mso4 dosages.
it's what the patient needs.
i've given outrageous amts too with the same ms you speak of, a&o.
Have any that have replied ever worked on the type of floor I currently work? Please don't tell me that you haven't seen these types of patients. There are abusive personalities and it dosen't stop in the hospital. I do not feel comfortable supporting drug habits of patients. Even when my patients ask to go out to smoke, I educate them on the importance of not smoking. I assess their needs to find alternatives.
I turned to this board for advice and from those of you who tried not to judge ME by my response, thank you. I intend to reasearch hospice, palliative care, etc. For those who are less patient to judge a vulnerable poster, please read this and know I was attempting to clarify and educate myself on an important move both in my career and in my beliefs. I was not presenting a case for debate.
I worked in Hospice for several years, then left because our Hospice was taken over by a large hospital corporation. During the 2 years that I was gone from Hospice (I am now working in Hospice again), I worked on an oncology/neurology floor. Most of our neurology patients were there for laminectomies or some other back/neck surgery. We had a contract with the federal prison and the county jail to do all of their surgeries. I can tell you that even though I tried not to be judgemental, there were times when some of the (prisoner and non prisoner patients) would try my patience. I would always give the patients pain medications and never questioned their pain and in fact, I would call the doctor and ask for an increase if the patient was "timing" their meds. I wasn't very popular with the neurosurgeons and many times they would not give me orders to increase the meds. I knew that some of the patients were seeking meds for other reasons than physical pain and because of the unbelievable busy schedule on a med-surg floor, I would find myself feeling very irritated by their constant requests. I was also taking care of cancer patients on the same floor and found myself being more compassionate towards them and angry at the patients who could walk and talk and would be going home to heal after a day or two. I don't think that I showed my anger towards the patients...at least I hope that I didn't. Many of the people we were taking care of on that floor had been abusing drugs prior to coming and I had learned during my hospice years that these people had pain just like anyone else, but require more pain meds to control their pain. Somehow, the MD's that were attending did not understand this principle.
When I worked in Hospice previously, I had a few addicts that came on to service and fortunately their doctors were good to them and would give them whatever they needed to be comfortable. I think that you will find it easier to control a patient's pain in Hospice because most of the time the docs are willing to medicate a patient with a long acting med and increase as necessary. The problems with pain control in the hospital setting are vast. Most of the patients are in there for a short period of time and the docs are just interested in getting them out ASAP and they don't want to think about long acting pain meds.
In the hospice setting, we know the patient is dying and we give them whatever they truly need to help their pain, whether it be physical, emotional, or spiritual. A patient with prior drug abuse history has just as much pain as someone that doesn't. Just remember that they will probably need a great deal more meds than most everyone else.
In the hospice setting, we know the patient is dying and we give them whatever they truly need to help their pain, whether it be physical, emotional, or spiritual. A patient with prior drug abuse history has just as much pain as someone that doesn't..
there you go, in a nutshell.
and it's not about being judgemental;
you would hope that it would be instinctive to feel these patients should get whatever they want. no debate about it.
I had a CF patient once...he was 17 years old and couldn't have weighed much more than 75 lbs. The day before his death, he finally consented to a MS drip to control his pain. We started him at 6 mg/hr. We titrated that drip all the way up to 300 mg/hr. At 250, he stood up and peed in a urinal. I remember going to the pharmacy to get the bag and the pharmacist said she felt like Jack Kevorkian. Why should anyone live the end of their life in pain? When I go, I want to be drugged to the gills if I'm in pain.
I agree with the poster who said that they rarely have seen drug-seekers, only pain-relief seekers.
Good luck in hospice, Jacel. Let us know how it goes.
Remember you are not working in a hospital setting when you are in hospice. Your job as the nurse is to make them comfortable and help them make this transition easier, not to second judge them. Everybody reacts to pain differently and you must grasp that. I have had many patients that I have given PRN Roxanol on a routine basis just to get the pain under control. I have given ungodly amounts of morphine 3 and 4 cc every 15 min (20mg/ml) , but this is normally just in cancer patients. And that is ontop of all the Intensol ,rectal meds and such.. Now of course these are the patients that are close to death..I think hospice is a wonderful are to work,it is one of the places I felt like I have made a difference.:)
I am also a hospice RN and agree that comfort at end of life is parmount. Addiction becomes a none issue. My experience has not been the patients abusing drugs, they need them, but I have had the experience of family and/or friends diverting drugs. I also have had coworkers who have diverited drugs for there own use. They were fired. Hospice is the most rewarding work I have ever done. I feel I do gods work and get paid for it. How cool is that??!!?? What I do matters in the world and makes it a better place. I am studing for the CHPN and am taking it in about a week. I am also starting classes on-line at University of Phoenix at the end of September after the test. Any feed back is appreciated. I also am married to a man who fits the your husbands description. Except mine is a Newport smoking, rock musician, who owns a Harley, and has Black Hair to the middle of his back. Amazing how many of us Angels of Mercy marry these bad bad boys. Great comment e-mail me any time you need support hospice wise or with the Hubby Nice to know you. KIM:rolleyes:
You have given me a lot to think about and also have educated me on what to expect.
I will be going into classroom orientation in 2 weeks. Also I will be taking a math test, I suppose it is to be sure I can calculate proper med dosages (anyone ever heard of this specifically for hospice?). Then I will will begin 2 weeks of on floor orientation for 6 days total.
I intend to keep my eyes and ears wide open during orientation. I also plan to read some hospice books and ask plenty of questions to the nurse I shadow. She'll be sick of me by the end!
I believe my biggest difficulty lies in the transition. I will still be working one day a week on my med-surg floor. It will be so different. Caring for those dying most of the week and then caring for those with abdominal pain/pancreatitis the next. I am praying my compassion will carry over.
A nurse at work told me that I hadn't given Med-Surg enough time yet and that I should just bear with it. In one aspect I can agree with her, I feel green enough to the job but I also feel I have reached a plateau in my experiences-I tend to care for a revolving door of diagnoses. I am searching for bigger and brighter areas of nursing. I hope Hospice will allow me to feel compassionate and caring instead of frustrated and fed-up.
I hope you all will not tire of my questions, I will be back. I would rather ask the questions than presume I can know everything. The latter is furthest from the truth.
I hope you all will not tire of my questions, I will be back. I would rather ask the questions than presume I can know everything. The latter is furthest from the truth.
Questions good!
Regarding the advice one of your colleagues gave you about not having given Med/Surg enough of a chance - if you're feeling burned out and frustrated that will be affecting your care. you owe it to yourself and your patients to recognise and act on this, as you have :) The belief that only those of us who've been nursing for ages can be burned out is mistaken.
I hope you find pallaitive care working better for you - keeping your acute skills up won't hurt, either :) Good luck
I believe my biggest difficulty lies in the transition. I will still be working one day a week on my med-surg floor. It will be so different. Caring for those dying most of the week and then caring for those with abdominal pain/pancreatitis the next. I am praying my compassion will carry over.
A nurse at work told me that I hadn't given Med-Surg enough time yet and that I should just bear with it. In one aspect I can agree with her, I feel green enough to the job but I also feel I have reached a plateau in my experiences-I tend to care for a revolving door of diagnoses. I am searching for bigger and brighter areas of nursing. I hope Hospice will allow me to feel compassionate and caring instead of frustrated and fed-up. [uNQUOTE]
Good luck, JacelRN! I think you will find that in hospice you will gain a new understanding and empathy that will stay with you no matter what area of nursing you pursue in the future. Looking forward to hearing from you again.
hospicenurse
84 Posts
Hospice patients aren't so different than any other patients. It's just that they are dying. You'll probably find about the same percentage of people who have been drug users of one type or another. It might not always be pain meds, it might be sleeping meds or laxatives. Or heroin. Their drug tolerance tends to make symptom management more challenging. It can be frustrating to deal with them because it is harder to control their symptoms, and often they have already tried most of what we have to offer. And they have some learned behaviors that can be very irritating. It's evident by your post that you are beginning to examine and deal with your feelings about drug seeking behavior; hopefully you will find some kind of resolution in order to be an effective nurse to these patients. Some more experience and a good mentor will help you greatly. You'll do fine.
Btw, when these patients "push your buttons" it's helpful to ask yourself why - what about the situation is really making you angry. Is it because they called you for more medication, or is it because you were about to go to lunch and you don't want to delay another 10 minutes? Most of the time when I get frustrated with a patient, I eventually realize that it's because I wasn't able or willing to do what needed to be done at the time. Nursing is hard work mentally and emotionally, and it's difficult to maintain the level of energy and empathy needed at all times. One of the things I hope you learn early on is that there is great interdisciplinary team support in hospice. You can often call on another hospice nurse, social worker, home health aide, etc., to help you out when you are on your last nerve. And vice versa.
Another great lesson to learn in hospice is that you are not going to change people's personalities nor their behavior. Families are going to be dysfunctional in a million different ways. Don't drive yourself crazy trying to mold them into something they are not. People won't always die the way you want them to. You really have to let go of what you want for people, and adopt the Burger King motto: Have it your way. (This post paid for by the fast food industry. And now back to our regularly scheduled program :chuckle )