General rant

Just a query do you not do syringe driver observations? We do 2 hourly checks on how much infused, site ok, battery life etc.

I work in home based so we don't use syringe/IV interventions, but I did have a patient that had a lot of agitation that nothing seemed to work for, we adjusted medications for weeks, it wasn't until he was non-responsive (final 72 hours of his life) that the family felt themselves and the patient were at peace. It's hard, I do believe sometimes even our best will not be enough.

It sounds like the patient should have been set up as a continuous care case or inpatient for symptom management??

I'm curious, too, as to the details of the situation. Was the patient at home, with family monitoring symptoms? Or was it in a clinical setting? It seems there would be, as others mentioned, more safeguards in place to prevent this scenario, i.e. more frequent monitoring. If not, putting them in place for the future may give you peace of mind.

I've had patients, too, whose symptoms were just plain hard to control, with endless hours and multiple med changes needed. In most cases, the family appreciated the fact we stayed in the ring fighting for their family member's comfort, even when it was elusive.

Afterward, I analyze the case with my colleagues and do my own research to see what, if anything, I may have done differently to relieve symptoms more quickly. I try to redeem the experience by incorporating the lessons into my practice, so my future patients can benefit.

The specific successes and failures in any given case should be addressed by the hospice team after the death of a patient. In that retrospective review the team can identify things that might be improved to decrease the possibility that something similar will happen in the future.

Does your team conduct such reviews during IDT?

We need to take every patient situation as a learning experience. We only have so many medications and interventions at our disposal and sometimes despite our best efforts it just isn't enough. I have always felt that my co-workers are a tremendous resource. Many times it takes someone else on the outside looking in to think of a new approach that you haven't thought to try.

Best of luck to you in the future :)

I had an update with this case. The specialist team took this to their meeting.

The communication is superb with this facility (not), only found out just recently re this almost three months after.

The general feeling from the specialists is that that this person most likely had an additional brain bleed. The raise in the ICP would have accounted for the ongoing discomfort, agitation, and anxiety and the fact that I gave this person enough midazolam and morphine to drop a horse; several horses actually and it didnt do anything

Unfortunately, sometimes we don't get them to where we want them to be before they go. Realize that will happen sometimes, but also realize if you weren't part of his care his death may have been much worse. I think it is important to recognize the grief you are feeling now is just as important as the hard work you put in trying to make him comfortable. Merely by the fact that you woke up with this patient (now deceased patient) on your mind shows that you did your best and this is a lesson to learn from.

Also, I have found that very often a patient who had a difficult life, will have a difficult death. Sometimes all the meds in the world won't settle them. That difficult death has nothing to do with poor hospice care. We cannot always fix something at the end of life that was unfixable all during life.

Be at peace, as is your patient right now.