end of life care falling short in LTC

[ktwlpn, LPN]

I've posted several times before about our LTC's resistance to bringing in any hospice agency.I believed we where making progress when we finally added a "comfort care" protocol to our P & P.It was wishful thinking. We continue to wait until the last days/hours to intitiate "comfort care" Today the emergency med box was out of roxanol! This just frosts me.Then-I overstepped and caused a ******* contest between myself,the don and supe (o well) because I called the don and told her right away.Then they both pushed me to get a one time order for a fentanyl patch because " we have those" Well--I know that would not be in the best interest of the resident especially since we do have anti-anxiety meds available and I am well aware of the onset of action of the patch.I called the doc,told him exactly what was available-actually as I listed drugs on hand I started with the fentanyl.He interrupted me and said "You know that won't help her tonite" Well.....duh....I'm an idiot...We are all idiots.

It's a freaking LTC-it's the last trip these people go on and we are NOT helping them plan it-there is no excuse.Turns out we did have other deaths over the weekend and the e -box stock was depleted.HELLO-today is Tuesday-that box should have been changed out Monday am-someone dropped the ball and I hope the don takes care of that tomorrow.

And if I get called to the office for overstepping I'll take the PDR with me.I have had a few really bad end of life experiences in th past years there -trying to manage symptoms that got out of control before I even arrived.It has taken a toll.I can't say I am an expert and aleays right,I'm NOT -but it is something I feel strongly about.And I have experience with home health hospice and hospice involving my own family.I would like to believe that the lessons I have learned from the people I cared for can be applied to people I care for today.But a ******* contest between rn's and lpn's in LTC usually ends in one way....I can't win......and the residents loose,too.... not a good day

[BeExcellent]

Well, thanks for being there for your patients. You don't always know when but you WILL get blessings. LTC's are a business and ALWAYS interested in money. Two calm approaches may work. First, hospices started going into LTC facilities not because they are so wonderful and giving but because it was good business. Both the hospice and the LTC facility benefit by the Medicare Hospice provision. Also, I understand some LTC facilities are doing palliative care under the skilled nursing provision. In my area LTC's are HIRING palliative care nurses to coordinate this care. I am not saying this is ideal hospice care but a start. This is sometimes marketed by the LTC as "aging in place". Do your homework on who is paying for what type of end of life in like LTCF's and propose a "money for you...end of life care for them". Established hospices going into a facility will also often be generous to support the LTC with CEU supported inservices and even support many activites within the LTC remembering "kickbacks" are illegal! Be cool to your school. BEACH BOYS

[AtlantaRN, RN]

I'm with you when it comes to LTC facilities. We have one facility where the DON won't ALLOW us to place a comfort kit. Therefore, if there is a crisis, an RN has to run and deliver roxinol, etc...then the DON doesn't want us to leave it there stating "then the staff has to count it." The staff has stated that they WANT us to have the comfort kits there---it's the DON who doesn't want to "waste time" with her nurses counting the roxinol, etc...

yes, the patients lose as a result...

[rnboysmom]

Good luck to you on your endeavor to unite LTCF and hospice. I can tell you a little of our story. Our company was started three years ago when the president of a LTCF decided that hospice wasn't doing much more than "collecting a daily rate" for hospice patients inside their LTCF. All this guy wanted was for someone to sincerely care for his facilities patients at end of life and assist the families of these patients with end-of-life issues. I have to admit, when I was hired, I had a lot of experience with hospice and LTC as a case manager for several large hospice companies, and the general philosophy was "they don't need as much care as they have 24 hour caregivers". I was at a loss as to what this guy really wanted us to do. Turns out, we are busier with facility patients than we sometimes are with home patients, there is sooooo much to do in the facility. Education of nursing staff r/t end of life symptom management consumes a lot of our time. What we have found out is that these nurses WANT to know and be able to take care of their patient's properly. We do more continuous care in facilities r/t improper staffing ratios for the patient's symptoms than we ever do in home settings. We realize that the staff considers these patients as family and want them to have the best care they can possibly give them.

I will tell you that when we came into this facility as the company's new hospice, the owner refused to allow it to be a monopoly; we were essentially competing against 6 other hospices in the facility for business. The nursing staff attitude was "You're different? Yeah, right, that's what all of the other hospice companies said,too." We had to literally "earn our stripes". It took about a year of responding when they called and actually showing up in the middle of the night when they called (as opposed to saying, thanks for calling, you can take care of that ). We now have an excellent relationship with our LTCF and other LTC companies in the area are actually calling us! to come talk to them about the type of care we provide in a facility.

Try sitting down with your administrator (maybe with a small group) and eat some humble pie (sincerely apologize for your frustrations) and expalin to them that you feel that your facility is sorely (don't use that term!) lacking in end-of -life symptom control. Then ask what you can do to make a change. Offer to get palliative care certified (an RN or LPN can get certified) so that you can get some expert experience. Offer to research a palliative care program or go to some seminars in palliative care. Maybe together you can find a hospice company that truly is invested and is willing to support your LTCF. Maybe she will allow you to call some other facilities and see if they are having success with any hospice companies in the area. It may be that your administrator and DON have a bad taste in their mouths from bad experiences in other settings with hospice. I would hope this to be the case instead of not wanting what is best for their staff and patients.

GOOD LUCK!!!!