Frustrating case

donnag128 · Mar 25, 2013

I have a palliative care case that might be hospice I'd they had insurance. It's of a Spanish speaking lady with pancreatic cancer.
Her daughter cares for her who is very emotional and " needy". The patient does not want to go to the hospital. She was recently vomiting blood. I had to have the serious talk with the patient about DNR and comfort care at home. She is AAOx4. I had a translaotor with me. She says she doesn't want to go to the hospital. When I explained a DNR, she says she wants everything done to save her life.....
I'm confused to be honest. She understood me too. It also says int he ER note when she had a visit in jan that hospice was discussed with patient with a translator and that they fully agreed and understood.
I had brought this up to the doctor and he got frustrated and said " these people can't decide, you shouldn't even bother going"
True, we would pay for pain and comfort meds out of a fund we have, then the patient would refuse to take them. After much education. Then I would leave the house and get a call 10 min later " momis in so much pain"
Completely draining. I don't know how to tackle this one. My hands are tied.

I can relate to your case completely. What I usually do in a situation like this is try to explain to the patient and family that my goal is for them to be the at the best level they can be on any particular day and to keep them out of the hospital and at home if that is their wish. My hospice offers charity care so we can give same services whether or not there is insurance. Sounds like the Social Worker needs to be involved in this case to take some of the pressure of the emotionally needy family off you. Most people are not "ready"100 percent to "give up" which is what most people think going on hospice is doing. I try to educate patients, their families & doctors of the benefits of hospice/palliative care to help guide them through disease progression and end of life.

uRNmyway, ASN, RN · Mar 25, 2013

Keep in mind there might also be a religious/cultural aspect to this. With some people, it is not acceptable to sign a DNR or do anything that might make death come quicker because it should be 'in the hands of God.'

Could pastoral perhaps be brought in to evaluate if this is an issue?

tewdles, RN · Mar 26, 2013

signing a DNR does not make death come sooner, it simply prevents us from trying to stop death when it visits.

MABSNRN · Mar 26, 2013

I totally agree with you jeweles. This really sounds like a cultural issue to me as well. Bringing in spiritual care could be the key for the patient to be able to understand.

uRNmyway, ASN, RN · Mar 26, 2013

signing a DNR does not make death come sooner it simply prevents us from trying to stop death when it visits.[/quote']
If this was in response to my post, I know a DNR does nothing to make death go faster. However I have had patients tell me their religion prevented them from signing DNR, that it was essentially playing God. Some people also believe that signing the DNR is basically the end and that HC staff will no longer try to keep them alive at all costs barring resuscitation efforts.

tewdles, RN · Mar 26, 2013

I am certain that you know the difference, but patients often don't.

Fortunately, it is not a requirement for patients to elect DNR in order to participate in hospice.

Too often cultural, spiritual, religious, or other factors adversely affect the choices our patient's make.

We just have to walk THAT path with them.