When to start administering "hospice medications."

  1. I've been an LPN for roughly a year and a new issue has recently came up for me that I'm unsure of. I work LTC and have several patients on hospice although they are still seemingly a ways away from death which seemed to be the case with one of my patients up until the last few nights where she's experienced a major decline. She's recently contracted Another infection after recovering from a few other major infections. Family is debating on whether or not to proceed with treatment. Recently she's experienced an increase in Dyspnea. Respirations hit the 40+ mark this evening. I am 100% about medicating and treating symptoms. I am comfortable with administering Roxanol, Ativan, etc. But I am still unsure of WHEN to begin it. Although I realize that in that moment, she needed to be medicated. I've struggled with my decision due to the family still wishing to pursue further abx treatment despite the obvious signs that it's nearing the end. One daughter was onboard with my choice, but another voiced her displeasure saying they weren't "ready to give up and give into that." How do I get more comfortable making decisions such as those?
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    About LPN9200, LPN

    Joined: Oct '15; Posts: 24; Likes: 34

    15 Comments

  3. by   blondy2061h
    Did she have the medications ordered? What were the PRN indications? If I had a patient with an infection whose family opted for comfort measures only I use PRN medications quite generously. No one wants to watch their family member die forever as they pant away.
  4. by   LPN9200
    She did have PRN Roxinol ordered From 0.25ml q1 hour upwards to 1ml q1 hour for dyspnea and pain. Family stated they wanted comfort measures but has been fighting hospice every step of the way. Example; wanting to aggressively treat infections (VRE, ESBL, MRSA, C-diff x2), IV hydration, declining palliative symptom management. Some family is coming around to accepting the facts but others are not. I felt confident in my decision to medicate with the roxinol until the family was upset by it and my RN supervisor stated "if they aren't ready for the end then you don't use the medications." But if my assessment revealed the need for them, wasn't it the right call?
  5. by   blondy2061h
    Well everyone is entitled to comfort measures whether they're hospice or full treatment. We use pain management and symptom management for people who are no where near end of life and are full codes. People having aggressive surgeries to remove cancer or on ventilators with pneumonia get opioids. That doesn't mean they're ready for the end. If they have a PRN ordered and they're experiencing those symptoms, it's appropriate to give the medication. I'm solidly on your side here.
  6. by   BSNbeDONE
    Quote from blondy2061h
    Well everyone is entitled to comfort measures whether they're hospice or full treatment. We use pain management and symptom management for people who are no where near end of life and are full codes. People having aggressive surgeries to remove cancer or on ventilators with pneumonia get opioids. That doesn't mean they're ready for the end. If they have a PRN ordered and they're experiencing those symptoms, it's appropriate to give the medication. I'm solidly on your side here.
    ^^^^I was just about to say this.
  7. by   loriangel14
    You medicate when she has the symptoms. Refusing to manage her symptoms is not going to help or prevent death. The process is not in your hands. Do what you need to go to keep them comfortable. Treating her dyspnea is not "giving in".
  8. by   LPN9200
    My patient did ultimately pass this evening on my shift. Family was present at the time of passing but still fighting any and all comfort medications up until her passing. They did permit me to give the lowest dose of morphine about 2 hours prior to her passing but once she was gone attempted to blame it on me and my medicating her. Of course I understand their grief. I'm just more upset that it just truly wasn't a peaceful passing and I wish I could have done more.
  9. by   southern rn
    Quote from LPN9200
    My patient did ultimately pass this evening on my shift. Family was present at the time of passing but still fighting any and all comfort medications up until her passing. They did permit me to give the lowest dose of morphine about 2 hours prior to her passing but once she was gone attempted to blame it on me and my medicating her. Of course I understand their grief. I'm just more upset that it just truly wasn't a peaceful passing and I wish I could have done more.
    Good Lord. I'm sorry you had to deal with that and that poor woman wasn't allowed to be comfortable.She probably died to get away from them.
  10. by   quiltynurse56
    Sounds to me like they had needed reviewing of how the roxanol works. Many people believe it hastens death. Where as it makes them more comfortable during this process.

    There are always going to be family members who want everything done in spite of the patient's condition and other who can not accept death at all. We do the best we can teach them about what is happening. Yet, it sounds like, even though, they put her in hospice care, that they really were not on board with it.

    You did right by giving her the medication she needed at the time.
  11. by   nowim clean
    This is the hardest part of being a nurse when family has unrealistic goals and hopes. I deal with this also from occasion to occasion, I simply ask the family do you want mom/dad comfortable or do you want a long painful death because barring a miracle from God they are dying but it's your choice if it's peaceful or painful9/10 times family goes for comfort.
  12. by   AliNajaCat
    I had an epiphany like that once when I was a much younger nurse and got told to do CPR on an ancient woman who was so loaded with cancer that her lymph nodes were like buboes all over her emaciated body-- some small, some the size of marbles, smoky blue in color. I didn't know enough about nurses being patient advocates then, or at least not enough to feel strong enough to refuse. I will never, as long as I live, forget the feeling of her bones breaking underneath me as I did this. And I never, ever refused to advocate for a less horrible death again.
  13. by   la_chica_suerte85
    Quote from LPN9200
    My patient did ultimately pass this evening on my shift. Family was present at the time of passing but still fighting any and all comfort medications up until her passing. They did permit me to give the lowest dose of morphine about 2 hours prior to her passing but once she was gone attempted to blame it on me and my medicating her. Of course I understand their grief. I'm just more upset that it just truly wasn't a peaceful passing and I wish I could have done more.
    Grrrr.... This kills me about the way people conceive of death and they want a family member to live at all costs. It's insanity! I'm so sorry they tried to blame her passing on you merely trying to make her comfortable. You did your best.

    I'm curious, though, what kind of education was the family given regarding the dying the process? I think sometimes providers aren't very blunt when it comes to describing symptoms or are afraid of saying something that will get them into trouble (i.e. saying to expect certain symptoms when different ones end up manifesting). I have such a hard time with that. The lack of education about end-of-life symptoms really gets in the way of managing suffering.

    Sometimes, when family are present and I get certain vital signs or they ask me to check pulses, I will gently explain what my findings mean and try to reassure them as best as I can. A respiratory rate in the 40s is not comfortable for any adult and watching a sternum bounce up and down as the patient struggles for air is frustrating when the family won't do anything about it because they want them present at all times. They are the ones who need to be present instead of thinking about future hopes for the patient's recovery. It drives me up the wall. It happens too frequently.
  14. by   4boysmama
    rr of 40 is an absolute indicator for use of roxanol (whether or not the person is on hospice) that level of respiratory distres is very unpleasant. I'm sorry your patient passed in less than ideal circumstances.

    I do want to follow up on one point - you mentioned that they weren't ready for comfort measures because they wanted to pursue.... they are not mutually exclusive. I've had plenty of hospice folks doing abx, while still utilizing morphine/ativan for dyspnea. sometimes the abx are treating the family who aren't ready to "give up" or don't want to feel like they didn't "do everything" later on, but it's ur job to educate that while the abx might/might not work, we NEED to treat the current symptoms to give the patient comfort right now, while we're giving the abx the chance to work.

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