Hospice Nursing Question

calivianya, BSN, RN · Nov 13, 2014

I have questions about that, too. I saw the same thing happen with my grandfather. No morphine, but he looked miserable after being taken off his antihypertensives, blood thinners, antidiabetics, and others. I understand that the premise of hospice is care not cure, but people have uncomfortable symptoms related to their diseases that surface when stable, long-term drug therapy is d/ced. How about the headaches with rebound hypertension, the excessive thirst and urination with hyperglycemia?

Those are uncomfortable symptoms...

stirfried · Nov 13, 2014

I completely agree! Even thyroid! It took me months to get a stable dose & if you took me off I'd be tired, forgetful, anxious, constipated,.....in other words, a mess!

i understand the person will die soon but I think these things make them uncomfortable and speed up the dying process.

i sure hope we get some answers & can have a good discussion. I'm not trying to offend anyone in the profession (which is why I didn't ask "isn't sedating someone to the point of not eating and drinking euthanasia?" ) but I want to get this all cleared up so I can continue my path & decide on a direction :yes:

klone, MSN, RN · Nov 13, 2014

My husband has been a hospice nurse for almost 10 years, and I just asked him. He said that it's totally patient choice. He recommends anything necessary to improve or maintain patient comfort. Thyroid meds? Absolutely. If you have end-stage liver cancer, then no, he wouldn't recommend the patient continue taking their Lipitor, but if the patient wants to continue, absolutely.

klone, MSN, RN · Nov 13, 2014

And from my husband:

Hospice is not interested in hastening anyone's death. They bill per patient day. Not to sound callous, but there is no financial incentive to it.

Many patients who come to hospice, come because of some major event, and the trajectory of their illness goes downhill quite quickly. That's when hospice is called. So that's why it often seems like patients decline quickly once they go into hospice. If my husband had his druthers, more patients would enter hospice earlier than they often do, so they can reap the full benefits of hospice service.

QuiltDog · Nov 13, 2014

I have been a hospice nurse for over ten years. Good practice is to evaluate each patient's medications and continue/discontinue based on many factors. Patient's goals of care, ability to swallow, effectiveness, etc all come into play. It is never black and white. It is also good practice to use comfort meds as needed and to start "low and slow" so as to avoid "snowing" the patient.

heron, ASN, RN · Nov 13, 2014

Hi All!
I've been in healthcare for over 30 years but my experience with hospice is very limited. I was exposed to it decades ago when my grandmother was dying from cancer. It was the very end, she was in terrible pain, and was given morphine until she died.
Lately I've been hearing about people under hospice care for various reasons and I was hoping some hospice nurses can answer my questions. I'll give an example:
93 y.o. Female with end-stage CHF. When hospice took over she was taken off of ALL medications. Thyroid, blood thinners, htn meds, stomach meds, all gone at once. Why would they do this? How does that help? She wasn't at the very end of her life. She probably had 5-6 months to go (if nothing drastic happened like a stroke or heart attack.)
After a couple of weeks she started getting anxious. She was given up to 2mg of haldol every four hours 24/7. It was continuous. She received morphine here & there, even if she claimed to be comfortable. Over time she didn't even wake up. She stopped eating and drinking and died.
Total time was 6 weeks.
It seems like her death was hastened by hospice. I can't see it any other way. Is this normal now in the U.S? Did I miss something over the las few years? I'm shocked.
There are many other stories similar to this online. I never really paid attention because they are found under "hospice kills" or "hospice horror stories" or similar titles. Given what I've read I can't say I disagree.
Can someone help me understand this and how the nursing profession sees hospice care today? I was considering specializing in hospice care but I think I'd have a moral dilemma treating a patient this way. And how can it be explained to the family if I'm not even comfortable with the plan?
Do all hospices follow this protocol or are these isolated cases?
thanks!

Re her meds - it may well have been her own choice. It's not unusual for people with multiple chronic conditions to bear very heavy pill burdens. It gets tiresome to be continually popping pills. It seems to be a relief to some to just be left alone.

Also, once the person decides that it's time to stop, why continue with preventives measures like coumadin, or whatever? Keep in mind that the medications you described are artificial interventions intended to prolong life. When a patient decides that more time is no longer a goal of hers, there is absolutely no point in continuing them. The sole justification for a hospice medication is relief of distressing symptoms. If it doesn't do that, then why take it?

Cost is not an issue, because hospice is only required to provide meds for symptom relief and that's under a flat rate compensation system. They don't bill separately for meds. Anything that's life-prolonging or treating a condition other than the hospice diagnosis is the responsibility of either the patient or her insurers - hospice has no control over it.

I can't address the haldol she was given, unless either refractory nausea, severe agitation or adverse reaction to benzodiazepines were a problem. The morphine, however, could have well been meant to relieve dyspnea related to pulmonary edema, for which it used to be a first line treatment.

Without knowing more than I should about her terminal time, I would have to say that it sounds like a fairly normal natural dying process, and that she was as comfortable as possible. Q4hour haldol and occasional morphine is a very light level of intervention, compared to what we sometimes have to do to preserve comfort and tranquility for the patient and any family involved.

I've read those same horror stories. They were instructive because they gave me some insight into the level of denial present in our society as well as the ignorance of the general public over what hospice - and the dying process - actually is. The point of hospice is not to squeeze out those last few months. It is to allow the dying process to proceed as calmly, painlessly and peacefully as possible.

I have witnessed the abuse of the hospice model more than once. It most often consists of inappropriate admissions and the provision of too much life-preserving care in order to keep census up.

Hospice is paid by CMS as a flat rate depending on level of care. Most private insurers use the same system. Out of that flat payment hospice is required to provide meds, dme, counseling and bedside care as needed by the patient. Keeping a high head count for as long as possible of patients with relatively few really "terminal" needs is good for the bottom line.

Been there,done that, ASN, RN · Nov 13, 2014

Jesus , Mary and Joseph! That is NOT hospice protocol! Hospice means no heroic measures to prolong life.

Most certainly not withdrawing current meds for underlying conditions.

Most certainly that would hasten death.. not the hospice goal at all!

The goal of hospice care is to help a terminally ill person live a life of dignity, with less pain and discomfort. Period.

Tenebrae, BSN, RN · Nov 13, 2014

My experience of hospice care has been mainly in the community.

Hospice is used more for symptom control than actual end of life care. Most people wanted to be kept in their own homes, if that was able to happen it happened. Sometimes if we couldnt get sufficent support into a home, or it became clear the patient couldnt be cared for at home, then we looked at residential care for end of life care. .

The focus of hospice and community was to very much to support the patient an their family. Generally unless the patient declined, I would administer their oral meds as long as it could be done safely. Working with someone today, they refused some of their oral meds, so I focused on getting the important meds into them, anti seizure, and steroid. I have noticed that as a patient moves into end stage, doctors may cut down or remove all of their oral meds.

If someone declines their medications, or is unable to take anything orally safely, we would consider use of sub cut boluses and a syringe driver.

heron, ASN, RN · Nov 13, 2014

It's important to recognize that hospice is not "one size fits all". Decisions about treating co-morbidities, continuing specific meds, etc. are a delicate balancing act with very different risk/benefit considerations than anywhere else in healthcare. What may be right and appropriate in one case might be flat out abuse in another.

The bottom line is that the controlling voice has to be the patient's. The decision to discontinue all treatment except comfort care is not just taken when the pt can no longer swallow. As I said, it's not unusual for a pt to decline all tx purely out of exhaustion ... or for a POA to make the decision when it's clear that extending a loved one's life in any way would just prolong their suffering. The issue is not the quantity of life but its quality. In terms of the OP, the lady might have had six months more with all her meds, but six months of what.

Theoretically, hospice concerns itself with the dying process and is legally empowered to address only the terminal diagnosis, only when life-prolonging treatment of that condition is no longer a viable - or possible - choice. There are certainly situations in which life-preserving treatment continues for co-morbidities. The classic one is the patient on dialysis who is on hospice for a diagnosis of cancer. (I get leery when hospice providers take on the management of non-hospice conditions, for reasons I touched on above.)

What's missing from the OP is any hint as to the patient's own wishes or the quality of her life when she signed onto hospice. I think that's an interesting reflection on our general assumptions about death and dying.

I'll always remember something my medical director said once: we in hospice do not help people die ... we help people who are dying. Think about it ...

Caffeine_IV · Nov 13, 2014

All hospices are not created equally.

I worked hospice before and the patients that were able to take their meds continued to do so. Some patients or family may opt to d/c the meds and just do symptom control.

Some of these pts would get recertified many times and be on hospice for years.

Red Kryptonite · Nov 13, 2014

I've read those same horror stories. They were instructive because they gave me some insight into the level of denial present in our society as well as the ignorance of the general public over what hospice - and the dying process - actually is. The point of hospice is not to squeeze out those last few months. It is to allow the dying process to proceed as calmly, painlessly and peacefully as possible.

I'll always remember something my medical director said once: we in hospice do not help people die ... we help people who are dying.

:up: To quote the illustrious RuPaul, "Can I get an amen up in here?!"