I need help processing my first hospice patient experience.

[pkateRN]

Hi Guys,

I'm a new grad RN who was hired into a palliative care/hospice unit at a VA hospital. I have no prior experience with hospice (or nursing in general) and was given very limited training in this area- only 4 days before I was on my own. Today I received a new admit who was given days to weeks. His sister was supposed to visit him on Sunday. The resident ordered morphine 2-4mg q2H PRN, and haldol 1-2mg PRN. I also called her to get ativan on board in case he needed it. At the beginning of shift, he was out of it but still able to answer yes or no questions. This gentleman was the yellowest man I've ever seen (think curry powder yellow). He had a hx of alcohol abuse and his liver and kidneys were completely shut down. I decided to give him the max dose of morphine and haldol every 2 hours on the dot because I didn't want him to experience any discomfort. He wasn't very responsive so it was hard for me to tell whether he needed more. After the first couple doses, he went from minimally responsive and very restless/moaning to almost totally non-responsive and fell into a deep sleep. I asked for advice from the other nurse, who thought it was better to err on the side of caution and keep giving him the morphine every 2 hours because he was still occasionally moaning. He received a total of 16mg of morphine, 6mg haldol and 0.5mg ativan from me during my 8 hour shift. By the time I gave report at midnight, he was apneic and only breathing once every 30 seconds or so. I can't help but think I sped up the process too fast since his body can't metabolize the morphine or haldol. What would you have done in this situation? Did I give him too much too fast, in essence shutting his respiratory system down within 8 hours? I know it was inevitable, but I am feeling intense guilt that his sister won't see him because she lives far away and thought he had at least the weekend. Should I have spaced out the doses/given him less when I saw he went into a deep sleep? He is my first dying patient and I'm still not sure how all of this is supposed to work.

[nerdtonurse?, BSN, RN]

What I'd suggest....scopalamine patch (wonderful for noxious secretions/"death rattle"), Ativan, and IV benadryl, along with the morphine. When I've had people with liver problems, they itch and scratch like crazy. You're doing great -- it's hard the first time you have a patient this sick.

If the person has a really strong ETOH history, the sister may never come. You don't know how well they got along, he may have been the world's sweetest brother, or he may have broke into her house to find things to sell for alcohol or drugs (my cousin stole from his own parents, and beat up his dad when he was caught -- went to jail, got straight, and is okay now, but his sisters have never forgiven him and won't believe he's sober, even 20 years later). Just keep her informed, and know there could be the scene of all scenes if she did come in...might be easier for him and you if she didn't.

I only hold morphine for respirations below 8; I've never had s/s of pain when the respiratory rate was lower than that. If I did, I'd still medicate because witholding the meds aren't going to make him better, it's just going to make him hurt. Be grateful you're on a floor where you can treat your patient's pain without some idiot wanting to give your dying cancer patient tylenol and your VIP with an "upset stomach" (read, I need a week to be waited on hand and foot because I don't want my visiting relatives to know I'm hooked on prescription meds) dilaudid, demerol, phenergan, etc.

[pkateRN]

thank you for the insight everybody. the nurse before me put in a subcutaneous port because all of the meds were subQ and he didn't want to poke the patient more than once. I gave one dose of scopolamine subQ and it worked beautifully. does the patch work better/give a higher dose?

[tewdles, RN]

No, the patch is not better but is easier to maintain when the patient is in their own home.

[MomRN0913]

I agree with the others, you did a great job. You are not speeding up the process. If to maintain his comfort he passes sooner, then so be it.As far as the vital signs........ Why none? Vitals five you a better insight to patients status, when the end is nearing, their pain levels, and if they have a fever, it would be comforting to bring it down . And with the alcoholism..... There is a tolerance and you will need a decent amount of morphine. One time there was a 110lb patient experiencing DT's in my icu who we were giving 30mg of Ativan IVP at a time, q 20 min and he was ripping the restraints off the bed.........

[pkateRN]

you know, I've never really questioned why we don't take vitals.

[tewdles, RN]

Many people find the BP cuff uncomfortable, especially at end of life.

We rarely chase numbers in hospice. There are other signs of pain besides an elevated BP. You don't need to use a thermometer to assess whether or not someone is too warm and to provide comfort for them.

It is pretty common to count a pulse and a resp rate, but BPs are definitely optional if the patient does not have acute HTN (perhaps from their recent chemo for example).

Hospice tries to "normalize" the lives of our patients and their families. We do not focus on VS or other numbers but, rather, will use them if needed as we seek to improve quality of life.

[MomRN0913]

My hospice is all about VS. I wasnt so much when I started learning hospice. I refuse to take a BP when I see a patient and they are comfortably sleeping. One time when I didn't take vitals because patient had just called asleep after being given some morphine, my supervisor seemed kind of upset, which I didn't agree with.

[tewdles, RN]

It is important to always keep the goals of hospice care in mind. That is sometimes hard to do. Managers often have pressures entirely separate from direct care placed upon them.

Your responsibility, as a visiting RN (case manager?) is to document the evidence of decline and the progress towards goals related to death. VS are often not relevant to that documentation other than what is easily and comfortably obtained.

If the families have become focused on the numbers/tests/procedures/interventions rather than on the patient, hospice is a way for them to transition. We will do those things...but we prefer not to, especially if the patient has expressed similar preferences.

[pkateRN]

My second death was Wednesday, but I wasn't there for it...and for that I am thankful. I had been taking care of a man with leukemia for 2 weeks who was transfusion dependent before coming to me, and they decided to stop the transfusions. when I went into work yesterday I asked about his passing. they were reluctant to give me details, but eventually they told me the truth- that he bled out from every orifice very quickly, and even worse, his family was there. I cried and cried and cried that this is how he passed. when I last spoke with him he was not ready to die, he still had alot of things he wanted to do, and was fighting until the end. when I got off work I sat in the shower and cried some more. I wanted him to have a peaceful death, and some acceptance. does this ever get easier? I feel like I'm not cut out for hospice when I have this type of reaction.

[tewdles, RN]

My second death was Wednesday, but I wasn't there for it...and for that I am thankful. I had been taking care of a man with leukemia for 2 weeks who was transfusion dependent before coming to me, and they decided to stop the transfusions. when I went into work yesterday I asked about his passing. they were reluctant to give me details, but eventually they told me the truth- that he bled out from every orifice very quickly, and even worse, his family was there. I cried and cried and cried that this is how he passed. when I last spoke with him he was not ready to die, he still had alot of things he wanted to do, and was fighting until the end. when I got off work I sat in the shower and cried some more. I wanted him to have a peaceful death, and some acceptance. does this ever get easier? I feel like I'm not cut out for hospice when I have this type of reaction.

Don't assume that his bleeding out was a source of suffering for him, it may have been very quick and peaceful dependent upon his LOC.

It is ALWAYS traumatic for the family when a patient bleeds at EOL.

I hope they had dark linens, etc to help with the bloody visuals.

Not everyone accepts their mortality and it IS hard for us when they go to their grave, seemingly, in denial.

It DOES get better over time. It is not abnormal that you are emotionally affected by your patient's death. As you gain experience over time you will develop your own professional coping skills that will allow you to provide this care without owning the pain of the family or patient, focusing on the fact that the death is not YOUR loss personally but rather your loss PROFESSIONALLY.

It really is all about boundaries and good self care.

Good luck.

[CUMC rn,bsn]

Hi I just had a couple of questions about some of the things on here. I work on a med-surg Oncology floor and we do all the comfort care and hospice patients in the hospital. A few of you have mentioned using scopalamine, I was wondering what it helps with (I have never seen it used on our floor)? Also I was wondering what a subq port was. And one last question, why do you not give IV medications? Thanks!

[tewdles, RN]

We use anticholinergics for pulmonary congestion/secretions at EOL...we like to prevent the "death rattle" when we can as it is very upsetting for the family and potentially uncomfortable for the patient.

We do use IVs in hospice sometimes, but since most of our care is provided in the home, maintenance of IVs is not easy and these folks often do not have good peripheral vascular access. If they have an implanted port or a PICC line we will use those.

Most of the time we will use a subcutaneous infusion approach as they are easy to initiate, easy to maintain in the field, and represent little risk for bleeding if they are dislodged. SubQ infusions are typically less painful to start and maintain for patients. We use them both for intermittent and for continuous infusions. We can easily teach family to administer meds safely using this approach.

Of course, there are limitations to which meds can be delivered by that route.