End of life liquid meds vs crushed

nutella, MSN, RN · Mar 15, 2016

So, if you have a pt that is within 1-2 days of end of life, has thrush causing difficulty swallowing, when do you change meds to liquid vs crushed? What would keep you from opening the comfort kit at EOL? Is it ok to give pt the [COLOR=#444444]Hyoscyamine[/COLOR] from the comfort kit, even though it "causes urinary retention"? If a family member calls you on a Friday at 1630 with c/o pt having pain crisis and family requests visit to utilize EOL kit, is it ever ok to say no and direct family to continue to crush all meds or give them rectally vs visit to open comfort kit for liquid meds and not visit? Yes, your guess is correct, this happened. It makes you want to open your own hospice in that town.

I have a hard time following the intent of your post.

In any ways - if a patient needs a visit the nurse needs to go out.

For many patients the liquids are easier. If somebody can not swallow crushed meds without problems, the nurse needs to make sure that there are other ways of administering the meds.

If a visit is requested by the family it should be done.

coffeetalker · Mar 15, 2016

part of hospice care is providing PRN visits per family request- if the family has not opened the comfort kit, a visit should be done to provide instruction on how to utilize these meds. I also would not give po meds per rectum unless you have contacted the MD and got an order to do so. Also, a pain crisis is in itself adequate reason for a visit, let alone if pt is imminently dying and family is unsure what to do.

Race Mom, ASN, RN · Mar 15, 2016

Sorry for the confusing way I typed this. As you can tell I was a little angry. I have been a hospice RNCM and have worked for two really good hospices. Unfortunately, my young sister went on hospice (in another state) and this is the story of her death. No one would open the dang kit! I was so mad! It would take 3-5 hours to get the oncall RN there for a crisis at nighttime. Her CM refused to come over and open the crisis kit when I called and asked her to please come and do this. Her response was to crush what can be crushed and give her MsContin rectally (they don't supply gloves or lube, even though they supplied suppositories PRN).

So, in a nutshell, my intent was to ask if any of these situations were ok and I was just being out of line by requesting them. The whole hospice experience for my sister's death was a horror story. (They wrote on FMLA paperwork that her hospice dx was brain cancer, and CM verified it with me when I questioned it, only to tell me a week later she didn't have it but offered not one glimpse of an apology for what that did to our family. She discussed her "next pt visit" with the SW while sitting at our table during the visit, mentioning how difficult the pt was.) There is SO much more that is even worse than these examples, but I'm not going to mention all of it, cause it would just be a rant. Thanks for your reply. It is greatly appreciated :)

4boysmama · Mar 16, 2016

I'm confused - why couldn't your family open the kit themselves? I mean heck yeah that cm should have gone out or sent a runner. but once she refused, why couldn't your family ust override her and open the kit themselves and use the meds? Our kits are cardboard boxes, with explicit instructions on each med. And....we open and instruct on each med as soon as the kit is delivered, and then periodically during visits prior to transition, so that when family does call at time of active dying, the triage nurse over the phone can immediately educate on what to use right at that time, even before a prn visit can get there. They're comfortable administering the meds themselves at that point because we've educated them frequently on when/how/why to use each of them.

I'm so sorry that your sister's death was an even more traumatic experience because of thos hospice's poor care

nutella, MSN, RN · Mar 16, 2016

Sorry for the confusing way I typed this. As you can tell I was a little angry. I have been a hospice RNCM and have worked for two really good hospices. Unfortunately, my young sister went on hospice (in another state) and this is the story of her death. No one would open the dang kit! I was so mad! It would take 3-5 hours to get the oncall RN there for a crisis at nighttime. Her CM refused to come over and open the crisis kit when I called and asked her to please come and do this. Her response was to crush what can be crushed and give her MsContin rectally (they don't supply gloves or lube, even though they supplied suppositories PRN).
So, in a nutshell, my intent was to ask if any of these situations were ok and I was just being out of line by requesting them. The whole hospice experience for my sister's death was a horror story. (They wrote on FMLA paperwork that her hospice dx was brain cancer, and CM verified it with me when I questioned it, only to tell me a week later she didn't have it but offered not one glimpse of an apology for what that did to our family. She discussed her "next pt visit" with the SW while sitting at our table during the visit, mentioning how difficult the pt was.) There is SO much more that is even worse than these examples, but I'm not going to mention all of it, cause it would just be a rant. Thanks for your reply. It is greatly appreciated :)

Race mom, I am sorry for your loss, you must be grieving right now.

It must be so hard to have had this experience with your sister's death.

When the ones that are close to our heart get sick and die, we just want them to be comfortable and not to suffer.

The hospice I worked at had emergency kits at home and the family got educated the first day how to use it so that in a situation like yours, the nurse would be able to direct the family to start treating the symptoms but also drive out if the patient needed a visit.

I am sure you are angry and grieving. Please take good care of yourself - I hope you have some support !

(((((Race Mom)))))))

Race Mom, ASN, RN · Mar 16, 2016

Two days before she passed, she had a seizure (only time she ever did). At that point, she transitioned to active dying. When we got her into bed, after calling hospice (which took multiple tries...getting voicemail but it didn't allow you to leave a message) I made the quick decision to open the kit. Her seizure was at 3am and it was about 6 am before the OC nurse arrived. He said "who opened this kit?" I told him I did (although I didn't use anything, just got it ready and looked to see was in there). He said "well, I don't know if there could be any legal ramifications for you since there isn't an order for those meds." I told him I didn't care. I couldn't get ahold of them and she was non-responsive. He was a really nice RN, but that just hit me weird. Then next night, when she was in a large pain crisis, I called the oncall (this is after her CM wouldn't come and open her kit). I asked her, when she called before making the visit), if I had permission to open the kit. I was told no. It took over 3 hours for them to arrive. So, while waiting the 3 hours, I opened the kit. If they weren't going to take care of their hospice patient, I certainly was. I pulled out enough morphine for 3 doses, giving her one, and fridging the other syringes. Taped the box back up, and put it in the fridge. I made this decision after I was told the OC nurse was in a town 1.5 hours away and wasn't done with that visit yet. So unacceptable.

I really did see my sister's death as being something more peaceful and spiritual, but it was the opposite. I will struggle with this for a long time, I'm sure. This went against everything hospice was supposed to be.

Jensmom7, BSN, RN · Mar 16, 2016

Two days before she passed, she had a seizure (only time she ever did). At that point, she transitioned to active dying. When we got her into bed, after calling hospice (which took multiple tries...getting voicemail but it didn't allow you to leave a message) I made the quick decision to open the kit. Her seizure was at 3am and it was about 6 am before the OC nurse arrived. He said "who opened this kit?" I told him I did (although I didn't use anything, just got it ready and looked to see was in there). He said "well, I don't know if there could be any legal ramifications for you since there isn't an order for those meds." I told him I didn't care. I couldn't get ahold of them and she was non-responsive. He was a really nice RN, but that just hit me weird. Then next night, when she was in a large pain crisis, I called the oncall (this is after her CM wouldn't come and open her kit). I asked her, when she called before making the visit), if I had permission to open the kit. I was told no. It took over 3 hours for them to arrive. So, while waiting the 3 hours, I opened the kit. If they weren't going to take care of their hospice patient, I certainly was. I pulled out enough morphine for 3 doses, giving her one, and fridging the other syringes. Taped the box back up, and put it in the fridge. I made this decision after I was told the OC nurse was in a town 1.5 hours away and wasn't done with that visit yet. So unacceptable.
I really did see my sister's death as being something more peaceful and spiritual, but it was the opposite. I will struggle with this for a long time, I'm sure. This went against everything hospice was supposed to be.

The response that "there are no orders for these meds" is inappropriate and patently wrong. There had to be orders to get the kit sent in the first place, and no pharmacy is going to send meds without instruction labels.

Also, a CII script had to be signed by the physician (or the order called to the pharmacy by the physician) for the Morphine.

I'm so sorry your sister had that experience. I'm just gobsmacked that no one would come out for a change in condition. Even if her CM was tied up with another patient (and it happens), the office should have sent another nurse.

nutella, MSN, RN · Mar 17, 2016

Two days before she passed, she had a seizure (only time she ever did). At that point, she transitioned to active dying. When we got her into bed, after calling hospice (which took multiple tries...getting voicemail but it didn't allow you to leave a message) I made the quick decision to open the kit. Her seizure was at 3am and it was about 6 am before the OC nurse arrived. He said "who opened this kit?" I told him I did (although I didn't use anything, just got it ready and looked to see was in there). He said "well, I don't know if there could be any legal ramifications for you since there isn't an order for those meds." I told him I didn't care. I couldn't get ahold of them and she was non-responsive. He was a really nice RN, but that just hit me weird. Then next night, when she was in a large pain crisis, I called the oncall (this is after her CM wouldn't come and open her kit). I asked her, when she called before making the visit), if I had permission to open the kit. I was told no. It took over 3 hours for them to arrive. So, while waiting the 3 hours, I opened the kit. If they weren't going to take care of their hospice patient, I certainly was. I pulled out enough morphine for 3 doses, giving her one, and fridging the other syringes. Taped the box back up, and put it in the fridge. I made this decision after I was told the OC nurse was in a town 1.5 hours away and wasn't done with that visit yet. So unacceptable.
I really did see my sister's death as being something more peaceful and spiritual, but it was the opposite. I will struggle with this for a long time, I'm sure. This went against everything hospice was supposed to be.

I am so sorry!

There are usually standing orders - so I am not sure what they were talking about....

In any way, I am sorry that your sister death was stressful and that hospice was not helpful.

chopwood carrywater · Mar 17, 2016

I would file a complaint. And I would absolutely put this down on the survey. Also bring it up with their ethics committee.

tyvin, BSN, RN · Mar 18, 2016

I am so sorry that happened to you and your family. As a hospice nurse I've seen way too many messed up passings due to the incompetence of the hospice team. Burns me so badly that many people have to have a horrible experience. Your sister knows you tried and still loves you.

khooker200 · Mar 19, 2016

OP, it sounds like she may have gotten referred to a for-profit agency perhaps? Either way, if the patient has difficulty swallowing, cannot take their medications, and family is requesting to open to comfort kit for EOL symptom management, you do it. I cannot think of any reason in that situation that it would be appropriate to say no. Also the response time is very questionable. Usually Condition of Participation dictates we respond within an hour. Now as an ON-Call RN for Hospice, this is becoming more and more unreasonable to ask of us considering the work load we are carrying, but it should never take 5 hours for a visit of that nature. Scheduled dressing change, maybe, but not for symptom management issues.