Hospice nurse advice

[cherokeesummer]

Hi everyone, I don't know if this is a good place to go but I really need some information and I thought maybe polling a bunch of hospice specialists would help.

My FIL is in home hospice care now. My Husband is his primary caregiver right now. FIL is 76, has small cell lung cancer (if I remember correctly). Anyway he was fine, hanging on ok and then we took him to the ER at VA b/c he was he was feeling as if he was passing out and turns out he was dehydrated so he was admitted and was there a few days. He now has a diagnosis of CHF, all treatment of chemo was stopped b/c its ineffective and he was on the last try of chemo. So he came home and was admitted to home hospice. In one day he went from being able to walk, toilet and feed/drink, prepare food, do everything for himself that didn't involve heavy lifting to now being able to do nothing for himself...how does that happen? Anyway I assume its just the combination of age and disease process but hospice gave us a list of things for impending death...and we are starting to see alot of it but we don't know if they are attributed to impending death or the tons of meds he is on...he is on duragesic, liquid morphine and tramadol (for pain) all his other meds are for other thigns...anyway the signs he is exhibiting are:

restlessness (most of the time his cannula is off, he pulls it off, his covers are everywhere and somehow last night he pulled the o2 off, his brief off and unscrewed his flashlight batteries (he keeps one beside him).

talking when nobody is there...Hubby has just noticed this.

almost zero appetite, truly if he eats more than a banana a day its a miracle. He does drink a lot - ensure, gatoraid, water, milk...but he really won't eat. On a side note, I guess we need to ask his nurse or doc if we should be trying to encourage more foods but really he doesn't want it.

He no longer even tries to use his urinal. And he has a ton of accidents a day/night...so that is really hard on hubby b/c he doesn't want to move his dad b/c everytime he moves he seems to blank out on us...its kind of scary. We are debating whether he needs to go inpatient hospice (that was an option they gave us) but we really don't want to do that...it would be a last resort you know, its just not something we want to do.

I think these are the only things...how do we know if these are related to his meds vs. death being impending...just wondering...

Maybe there are no answers...but just figured I'd try...I'm going to read a bit more on the hospice boards. I'm a new grad, my ceremony is next month but am officially now an RN applicant. Take the NCLEX in August and start working in the NICU, adult patients are not my speciality, been doing NICU internship for 6 months. But I want to offer as much emotional support to hubby that I can.

[aimeee, BSN, RN]

Ask the hospice nurse about getting him an alternating pressure mattress. I usually advise continuing to turn but medicating with the liquid morphine 1/2 an hour or so before to minimize associated discomfort.

[a21chdchic]

6-26-2007

You really need to start with a very thorough assessment of the patient, carefully evaluating pain, medications, how long he has been on each medication, etc. It sounds like he is on a lot of meds, his age isn't young, so he will tolerate the meds differently than a young person.

1) I would first find out which meds were started when, he may be having an adverse reaction to a med if any were started recently. If he were started on a few at the same time, it could be difficult to figure out which one is doing the damage. You will need your medical director or patient's PCP to allow you alot of autonomy, and you need to be assertive in your 'requests' to get what you want from your physician.

2) If patient is imminently dying, he may be experiencing 'terminal agitation', and Haldol works wonders for this.

3) His med list needs a thorough cleaning up. Is the patient's PCP a Palliative Care Specialist? Tramodol and Duragesic are not the best choices for pain relief in palliative care. If the patient has not been eating, he may not have the subcutaneous fat available that is required for the proper absorption of the medication in a Duragesic patch. To choose the most appropriate medication to treat a particular pain, you must be able to accurately assess not just the where, how much, when, how long, etc. You need to know what the pain feels like. Ex. Neuropathic pain responds better to tricyclic medications, if you want a less sedating medication, pamelor is a better choice than amitriptyline. In this case giving Fentanyl, or Morphine will probably be ineffective in providing adequate relief.

There are many variables in each situation and a patient may have 3 different types of pain that each require different meds to treat each type of pain. This is very common and can be very complex. So a thorough assessment is the basis of seeing the 'whole picture'.

After getting the 'whole picture', you can better evaluate what has been done in the past, what has and has not been effective in the past, what the patient's reactions were to those actions, and you can then make a knowledgeable 'request' from the MD. When he/she asks questions, you will have the answers, and the MD will not only give you what you are requesting, but will begin to trust you and your practice and nursing judgement.

[a21chdchic]

6-26-2007

Hospice patients do need to be turned every 2 hours to prevent skin breakdown. After getting the breakdown, it may or may not heal. So prevention is always the best policy as repositioning is also a 'comfort measure' for the patient. The only time I would not reposition a hospice patient is if I knew he had only hours to live, and the movement caused great distress. I also suggest if the PCP is not a Palliative Care Specialist, get one that is. Perhaps the medical director of your hospice is a P. Specailist? If so, you could request that MD to follow as PCP, if he/she sees any of the hospice patients.

Ana

[cherokeesummer]

Everyone thank you for the advice. My father in law passed quietly at home on June 29th at 1204 am. I was admitted to the hospital on the 28th for back surgery and that night I got the call from my Husband that my father in law passed. He passed quietly and we believe in his sleep as hubby went in to check on him and he was sleeping and the next time he went in he was gone.

Thank you for your advice over these past few weeks. It has been very helpful.

[leslie :-D]

Everyone thank you for the advice. My father in law passed quietly at home on June 29th at 1204 am. I was admitted to the hospital on the 28th for back surgery and that night I got the call from my Husband that my father in law passed. He passed quietly and we believe in his sleep as hubby went in to check on him and he was sleeping and the next time he went in he was gone.

Thank you for your advice over these past few weeks. It has been very helpful.

wishing you peace, cherokee.

leslie

[Allow Mystery]

Dear cherokee,

God Speed! Bless you, your husband and family for

allowing the peaceful death at home.

[chris_at_lucas_RN, RN]

i'm so sorry about your fil.

there are 3 or 4 different types of lung ca.

small cell is sadly, one of the most aggressive.

bone, lymphs, liver and brain are common metastatic sites.

the ms changes and anorexia are to be expected.

again, i'm so sorry.

it sounds like your fil would benefit from an inpt facility.

with peace,

leslie

Hi, leslie, long time no see!

Why do you think an IP facility is indicated? Sounds like the FIL is doing what he is supposed to be doing, and I missed it if the family is so overwhelmed they cannot care for him. We often find we can get friends, extended family, members of the church, even a volunteer or two, to help out, not to mention aide visits daily for ADL's, etc.

But they are at home. So I was surprised to see your suggestion.

Can you clarify for me, so I understand?