Hospice Nursing Question

[stirfried]

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!

[Tenebrae, BSN, RN]

It's important to recognize that hospice is not "one size fits all".....

Thats what I love about palliative care and hospice nursing is that treatment/nursing interventions are very much tailored to the needs of the patient.

[NightAngel2]

I have been a Hospice nurse for 17 years. I can't think of any case where we indiscriminately discontinued all meds for no reason. There are too many questions that are not answered. In ES CHF there is a very delicate balance fluid volume overload vrs/hypotension. If she was hypotensive she would have to come off her HTN meds including diuretics. Was she aspirating? ES CHF often accompanies aspiration pneumonia. If this was the case any non-comfort meds would be discontinued. I have done this a long time, Hospice nurses don't stay in Hospice for the paycheck. It's hard, emotionally and physically draining. I would certainly hope that ANY nurse would leave a position if they were expected to anything that was ethically and morally wrong. That is certainly not what Hospice is about.

[toomuchbaloney]

I agree.

After many years involved in hospice care the only times I have seen all meds discontinued at EOB was at the request of the patient (one fellow also wanted not only the defibrillator function but the entire pacing function of the device deactivated at EOB).

[lifelearningrn, BSN, RN]

We've had many patients elect to disconnect the defib, and later, when decline starts, having the pacemaker deactivated as well.

[CrazierThanYou]

It appears that hospice is a highly misunderstood service. Just recently, I had two different Facebook friends with parents under hospice care. After each patent passed, both people were threatening to sure the hospice agency. One for 'not saving my mamas life' and the other for neglect because the hospice nurse didn't stay with her father 24\7 and actually called our state BON to report the nurse because there was blood when she inserted his catheter. Really?

As far as the use of haldol, morphine and other drugs, often patients and their families prefer sedation. I've had families ask for a dose of whatever any time the patient stirred, afraid that meant they were uncomfortable. These people are dying, we should help them make it as easy as possible.

[Sixtyseven]

The questions regarding end of life are just too difficult to answer. We can only hope we are providing comfort - sometimes, you just can't tell whether your measures are effective and/or if you are doing what the patient really wants. We can only do our best. Sometimes, there really is no overwhelming illness that causes the death, but the quality of life is gone and the patient makes a decision to go. They are just ready, it is their time. So, we do the best we can to give comfort, which may include not forcing them to pop a bunch of pills in their last days, providing pain management, and being there for them. (I am not a hospice nurse, I work in long-term care.)

[holisticallyminded]

I work with hospice patients very frequently through my facility, though I am not a hospice nurse.

Hospice is typically brought in when the prolonging of life no longer produces QUALITY of life. There are typically medications prescribed that help to comfort those who are dying. Ativan for anxiety, morphine (for SOB, not so much for pain until doses are higher and more frequent), Haldol (not as common), atropine drops for secretions, etc. I've not seen it hasten death, so much as ease it, though I have certainly given the final dose of morphine more than once. If I think it's that close, I will tell family (if present) before administering it. Typically by that time, there isn't any question that the patient's suffering should end. Death isn't pretty- a closing of the eyes in peaceful slumber.....it can be awfully hard to watch in some cases. I've only once seen a man say goodbye to his family, lay down and die within minutes.

I think hospice nursing is nursing at its absolute best: comfort for those who are suffering, including the patient's family (by far the most difficult part). Kudos to all of you who take this task on every day. You are awesome.

[toomuchbaloney]

I have worked with 5 different hospice agencies in several states now.

I have never worked with a Medical Director of hospice who would arrange the DC of a pacemaker. We deactivated defibrillators all the time as that could/would be very unpleasant at time of death and might prolong the process.

All of those MDs advised the patient and family that they would not discontinue the pacemaker simply to accelerate the cardiac decline of the patient (which, in thier view, would be the result of such intervention for the pacer dependent individual). In every instance that this was encountered (which is maybe a half a dozen over the years) the patients/families were asked to obtain that level of intervention from the cardiac specialist outside of the hospice benefit.

As I reflect on these cases, I am not certain that any of them actually ended up discontinuing pacemaker function but I'm not sure. I don't think that hospices should DC pacers. That action has nothing to do with comfort, does not improve quality of life, and will likely hasten death, IMHO.

[dflowersrn]

It is usually done because the patient refuses to take the medications most of the time or they can not swallow. My last patient had been refusing her meds twice a day ordered at least 8 times a week if not more when hospice came in they discontinued all her meds she was not taking them anyway

[dflowersrn]

Even if hspice has ordered the meds we in long-term care don't give them until they are neede. I the patient is not ready they are not given

[holisticallyminded]

A pacemaker is medical treatment that is prolonging life; it is not comfort care. If someone is unable to eat, drink, take medications or is generally unable to have any quality of life with continued medical treatment, then a pacemaker doesn't make any sense.

I think this is about changing the way we think about medical care. Is going in for dialysis four times a week and then laying in a bed all the rest of the time LIVING? How about tube feeding for those who will never eat again (because they are dying)? Not in my book. Not in my family. Never. So much of the time the family will make a decision to prolong treatment because they can't bear to see their loved one go. And they don't understand their own decision. I've had many a patient tell me they want to die and are ready. They've lived. The families however...

Though when hospice is finally on board, the family is typically agreeable to the decision.

What I've learned: if you allow anyone to become your POA for health, make sure they UNDERSTAND the issues and really will respect your personal decisions. Don't just expect it to go well because you trust the individual elsewhere.

I've also seen it go the other way when the family wants rid of the loved one for money. That's always interesting.

[toomuchbaloney]

I appreciate the notion that the pacer is not comfort care and is prolonging life.

I have never worked with a Hospice Medical Director who favored participating in the discontinuance when the patient is pacer dependent and the DC would hasten death.

I think it is because it is viewed as a passive measure that is simply allowing the heart to beat at a rate which is life sustaining while the disease related to the hospice dx is killing them. Compared to dialysis, or TF, or ventilation, etc it is doesn't require regular or routine intervention.

It is an interesting ethical discussion and I can see the value in both sides of the consideration.