Not doing what I was hired for

[MomRN0913]

Another vent again. I was hired as a hospice nurse into my company 5 months ago. I was told there would be " a little bit of palliative care". Well, its only me the supervisor and the director in the hospice division of our HH company because they can't keep. Uses ( one left after me being there for 3 weeks) and that can't find anyone. So I am stuck with all of the palliative care. I hate palliative care. I do hospice revisits, but my intention was to be a hospice nurse, as I was told, not the person to just pick up the crap no one else wants to do. Almost 6 mo ths and I haven't done a hospice admission or pronounced. My supervisor knowingly dumps the most awful patients on me that she opens up and announces " I hate this patient, you go see it". I am the dump job nurse, left busting my butt to see the patients no one else wants to see, not even what I was hired for. And my supervisor said " get ready, the palliatives are picking up and they are all yours"So, tomorrow is a progress meeting with the supervisor, director and educator. I have mentioned my desire to really the lean the hospice that I desire to do, they say " yes, we'll start doing it, and they never do. I want to say something again. I am at wits end at this Job, sick of working my butt off and charting all the time on my own time. My happiest times in this last few months I have worked here was in the last 3 weeks where I had 10 days off for a lap chole! It's the only time I have felt free and destresser. Not worrying about having to wake up at the crack of dawn to do paperwork or going to roach infested homes of dirty people who can't take care of themselves and no one else wants to see. My tolerance is gone. I feel like I'm gong to say everything I mean tomorrow and it won't be good.I'm a former icu nurse. Loved it there and had to leave because I couldn't do shift work with my family situation. It's been aMost 2 years since I've been gone and I'm friendly everyone there and they say all I have to do is ask if I want to come back. It's a great system. I wish I could figure out a way to do it. With all that ranting I lost sight of the question. Should I speak up tomorrow? I chose hospic for a reason. I did not want to be a palliative care nurse. I don't mind doing it when needed, I'm a team player, but I want to do what I was hired to do and have a passion for.

[JMBnurse]

Well, I think being full code and hospice simultaneously is nonsensical. There's nothing 'hospicie-ish' about breaking someone's ribs or shoving a tube down their throat. Doesn't that violate the very principal of hospice theory??

I agree. It goes against the philosophy of Hospice care. From the section posted above from the HFA, it says to me that that there is not a law that says a person must have a signed Physicians DNR order to be admitted to hospice. I will not argue with that, especially because in my state, nobody has to have a DNR signed by a Physician. In my state, people can sign their own DNR order, however that may not be the case in all states. It also suggests that there are some hospices that will admit a patient without a DNR with the plan to quickly ease them into that decision. It read to me like this was more the exception, than the rule.

In all of the hospices I have encountered, not having a DNR upon admission to Hospice is non-negotiable. However, it may be the policy of the facilities as opposed to the law. I have seen the Hospice reps. come to the hospital to see patients, go in and talk to them and the family and come out and shrug and leave. When asked if the patient would be transferred to their hospice care, the answer was, "No. He did not agree to the DNR". I've seen many other patients already in hospice being brought back to the ER repeatedly by the family after calling 911 and resulted in their immediate discharge from the Hospice. They were basing these decisions on their policies, not on laws. They never seemed to me to be one bit worried that they would be sued for discrimination against full codes.

As I mentioned before, if a patient is not ready for DNR, then they are not ready for Hospice. It seems as though there may be some facilities where they are willing to, on occasion, admit a patient that may be a little scared and have a few doubts and give them a brief bit of time to agree to the DNR. And that is the ultimate goal. Hospice does not work as designed with the patients being full codes. It's okay to be a full code, the patient just may not be ready for Hospice.

[jadelpn, LPN, EMT-B]

If a person has a terminal illness and wants to be a full code, they could be a palliative care patient for however long they need to be, for management of the illness and best functional level. I am sure there are patients who are not prepared to face an inevitable, and are palliative care patients to the point of not being able to make their own decisions, and then I would think it up to the HCP to decide for a DNR (or not--have had those HCP decisions to code before in my career) when the patient would be an active hospice patient.

When a person chooses to become a DNR, then I would think they could still be palliative care, and perhaps when they get to the point in their terminal disease process where there's a change in functional level, then they become a hospice patient (when they are in a more active dying process) and at that point, I would think that patient's "control" comes into play and they can make their own decisions on DNR status.

My understanding is that there is little difference between a general home care patient and a palliative care patient, except for the paperwork part that for diagnosis, and the expected outcome.

Regarding the OP, I think that when one expects to be a hospice nurse, and to go into a case when the patient is in the active phase of dying, which is a specific type of nursing using a specific skill set, but instead have patients that require just general nursing management at home and are still quite functional, all of the venting comments aside, that is a whole different type of nursing which is seemingly not what the OP was interested in pursuing when she took the job. There are nurses who are specific to palliative care and who transfer care when the patient goes into an active dying phase. But I think that the company that she works for, although communication is better, perhaps hired her downplaying the part that perhaps she was not really into pursuing. So it has been a learning experience for many (myself included) that if one wants to be a specific hospice nurse, then it is perhaps better to seek a job that is hospice specific, and not pallative care as well.

[PMFB-RN, RN]

Geez peeps it's not so hard. And no PM you don't get to decide.

*** Actually I DO get to decide who I will code and who I will not code. I will not knowingly cause harm to my patients, nor will I preform codes on them when I know they don't want it, nor will I subject them to imorral treatments. In my state I am protected under the concious clause.

I have refused to code several full code patients in my roll as ICU RN and rapid response RN. In each case I had reason to know without a doubt that the patient did not want to be coded but remained a full code anyway. Usually as a result of family member interfering with the patient's wishes after the patient can no longer make their needs know.

[edmia, BSN, RN]

*** Actually I DO get to decide who I will code and who I will not code. I will not knowingly cause harm to my patients, nor will I preform codes on them when I know they don't want it, nor will I subject them to imorral treatments. In my state I am protected under the concious clause.

I have refused to code several full code patients in my roll as ICU RN and rapid response RN. In each case I had reason to know without a doubt that the patient did not want to be coded but remained a full code anyway. Usually as a result of family member interfering with the patient's wishes after the patient can no longer make their needs know.

Wow, that is playing with fire. In my state, you go by the papers at hand and if the patient cannot express their wish, there is a clear decision making hierarchy to follow. No RN or MD gets to decide. That's just nuts.

Part of being a nurse is to understand that my own opinions about issues are that-- my own. The patients will often have different opinions and may make choices that I would never make, but it is unethical to override their decision. In my opinion anyway.

Sent from my iPhone using allnurses.com

[dudette10, MSN, RN]

*** Actually I DO get to decide who I will code and who I will not code. I will not knowingly cause harm to my patients, nor will I preform codes on them when I know they don't want it, nor will I subject them to imorral treatments. In my state I am protected under the concious clause.

I have refused to code several full code patients in my roll as ICU RN and rapid response RN. In each case I had reason to know without a doubt that the patient did not want to be coded but remained a full code anyway. Usually as a result of family member interfering with the patient's wishes after the patient can no longer make their needs know.

Several? Did the family members find out that you refused to code their family member after the code status was changed?

I would like to know the consequences because I find it hard to believe there weren't any consequences to deal with.

[enchantmentdis, BSN, RN]

How do you know that?

Because i'll walk into a particularly dirty house and the daughter or son will apologize right off the bat that, "Mom's house has been this way for years, sorry, let me make some room for you to sit". Also there are different levels of dirt and some of these folks have been on hospice only weeks or days, yet their walls are caked with dirt, the carpets are laden with funk, and the cobwebs are hanging in your face. However, the folks are just as nice, or even nicer and more relaxed than the people who have spotless, upscale homes. I just have to wash my hands even longer afterward. No problem. We also have shoe covers if we are so inclined to wear them.