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!

[lifelearningrn, BSN, RN]

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.

This isn't something that is normally arranged by medical director. I have personally never dealt with a patient or family wanting the pace maker discontinued, but I've heard of families requesting it. Like all hospice, it's patient driven. We educate on the defibrillator, if a patient has one and leave it up to the patient/family. Only if the family requests would we discuss discontinuing the pacemaker.

[R. Obias Jr., R.N.]

my comment is a matter of opinion, observation and analysis of the reality in everyday lives, why are we asking all these questions regarding how these hospices perform their duties. a lot of these hospices are what we commercialized, meaning they take in the elderly patients as a form of business, on their ads or brochures , the hospices shows how their patients will be taken care of theoretically, but behind all these ads they take care of their patients differently. We may say that different hospices perform their duties differently, some follows what the patient's doctors have prescribed for their patients, others have their own way of providing care for their patients. Despite all these practices the so called relatives or loved ones of these patients continues to put their patient's care unto these hospices hands. It may be hard to believe but the truth is that hospices may have been created not for the patients but for the relatives and their loved ones who lost the time and effort to take care of their patients due to a lot of reasons. I am not here to give defense to any form of hospice care , may it be good or bad to the opinion of the public, I gave the comment to provide insight on why there is hospice care , and if we find fault in whatever bad things we see in hospice care, also do find fault in the people who puts them there, irregardless of how it may come out on the condition of the patients. Now we all have something to talk about.

[ktwlpn, LPN]

I am not here to give defense to any form of hospice care , may it be good or bad to the opinion of the public, I gave the comment to provide insight on why there is hospice care , and if we find fault in whatever bad things we see in hospice care, also do find fault in the people who puts them there, irregardless of how it may come out on the condition of the patients. Now we all have something to talk about.

What do you mean by "people who put them there"? Only a small number of hospice patients are in an inpatient unit,the majority remain in their home.They are not "put" anywhere.

We have talked about the history of LTC in other threads and why it exists today.Same reasons daycare exist.

[CrazierThanYou]

What do you mean by "people who put them there"? Only a small number of hospice patients are in an inpatient unit,the majority remain in their home.They are not "put" anywhere.

We have talked about the history of LTC in other threads and why it exists today.Same reasons daycare exist.

I couldn't make sense out of any part of that post!

[ktwlpn, LPN]

you referring to me ?

[CrazierThanYou]

Of course not. I was referring to the post you were commenting on. I was unsure what s(he) was getting at until you commented with a quote.

[Red Kryptonite]

my comment is a matter of opinion, observation and analysis of the reality in everyday lives, why are we asking all these questions regarding how these hospices perform their duties. a lot of these hospices are what we commercialized, meaning they take in the elderly patients as a form of business, on their ads or brochures , the hospices shows how their patients will be taken care of theoretically, but behind all these ads they take care of their patients differently. We may say that different hospices perform their duties differently, some follows what the patient's doctors have prescribed for their patients, others have their own way of providing care for their patients. Despite all these practices the so called relatives or loved ones of these patients continues to put their patient's care unto these hospices hands. It may be hard to believe but the truth is that hospices may have been created not for the patients but for the relatives and their loved ones who lost the time and effort to take care of their patients due to a lot of reasons. I am not here to give defense to any form of hospice care , may it be good or bad to the opinion of the public, I gave the comment to provide insight on why there is hospice care , and if we find fault in whatever bad things we see in hospice care, also do find fault in the people who puts them there, irregardless of how it may come out on the condition of the patients. Now we all have something to talk about.

How did someone who writes this badly pass nursing school?

I have no idea what this person is trying to say.

[heron, ASN, RN]

I could be wrong, but it seems to be a comment on the commercialization of elder care and hospice, along with disapproval of families who don't do it all themselves. Maybe?

[QuiltDog]

I couldn't make sense out of any part of that post!

I am confused as well!

[lifelearningrn, BSN, RN]

I'm glad I wasn't the only one completely confused by that post.

[heron, ASN, RN]

Maybe English is not his/her first language.

Anyway ... OP: have your concerns been addressed? Any comments or reactions?

[ritit123]

In hopes of shedding light on this argument I will tell two opposing stories that demonstrate the importance of the nurse to patient relationship in terms of hospice. Though I work on a sub acute rehab floor as a skilled nursing facility I always have one bed that is a hospice case. A while back I took care of a fairly young woman dying from lung cancer from second hand smoke of her husband. She was a Jamaican woman who had been a very proud and strong woman and was now a fragile skinny little thing with a non healing hip fracture since the cancer went to her bone and a son with whom she had an up in the air relationship but which I know was important to her. Though she had no other symptoms from the cancer besides a broken hip and weight loss she had a slew of chronic problems. Per POA request ( who was an RN) patient was on all meds plus insulin. From the first day I saw the misery in the woman's face when she had to swallow a med. I'm talking 15-30 minutes if holding the small pill in her hand while I pleaded with her to take her stool softer. When I came to check her sugar she had every excuse in the book why she wasn't available right now. She would play with her sheets, rub her back, message her scalp.....anything to avoid a finger prick or even the tiny dose of morphine I would bring her after hearing her wail with pain when repositioning. The straw that broke the camels back was when the POA wanted vancyclovir for an exacerbation of herpes. I stepped in I verbalized to the team that as comfort is my patients greatest concern and she being so miserable taking anything by mouth why don't we hold off the horse pills. In fact, I did not give the patient regular doses of morphine until she was almost non verbal. I did so then because I knew she was dehydrated and uncomfortable. I knew she didn't like morphine because it made her loopy. When her son came to see her from prison I was glad that she was alert and able to speak with him. A few days after he left she declined greatly and finally passed.

Some time after this I had another patient who was an end stage kidney patient who was actually doing very well off all her meds for a few months. She was completely independent with her ADL's and pretty much just lived on my floor like it was her apartment. After some time though her ckd symptoms began to flair up, mainly an uncomfortable itch. The gist I got from her POA was that he couldn't wait to get on with his life and was waiting for her to pass. He asked me if I can start her on a morphine drip to relieve the discomfort. I KNEW that is not what my patient wanted. Yes she was uncomfortable but she loved to knit and volunteer with the recreation department during activities. Over the course of a few weeks I, the hospice nurse as well as the pharmacist worked on a series of med adjustments to alleviate her symptoms.

The importance of listening and observing your patients is detrimental to creating a personalized care plan even for hospice patients .

.