Hospice patient requests to smoke

[eatenalive365]

A hospice patient at the LTC I work at requested a cigarette which was held in our med cart. Why not? It's not like he'll acquire bladder cancer (he's already got it, the end-stage form!) from smoking another cigarette. So, I gave it to him under the condition that he smokes outside in a designated smoking area. He was very compliant, a very nice patient. The nurse working with me the next day had that patient and asked me, did the patient an order for the cigarettes?

...Really? The man is in pain, anxious, and dying, and the nurse really needs an order to let him have his cigarette? I don't smoke, but I don't care. This man knows he's going soon. Why withold the things that relieve his anxiety about dying, over an extremely trivial "order." If you're really uncomfortable giving him the cigarette, get the damn order!

Another resident on hospice wasn't putting out urine during my shift, but with no complaints of discomfort, and the relief nurse asked, did you call the doctor? ... What's the doctor supposed to do, order lasix? Order an in/out foley cath? Would an elderly woman want to spread her legs so a stranger can put a tube in her privates? That's the last thing she cares about.

Geez. I get really ticked off when some nurses don't think. I feel like at my LTC there's so much ignorance about hospice and comfort care. Liability preceeds every thought, every action, I feel terrible for the hospice patients here when the nurse don't use their humanity to think.

[Roman1]

I can not like your post enough! I still work PRN at a skilled/LTC facility and deal with hospice resident's quite a bit. Recently had a resident actively dying with a lot of agitation, even on good doses of Morphine and Ativan. So I called hospice and they increased the meds.

Finally was able to get the agitation down and make the resident comfortable. Along comes this other nurse and she tells me I have to give the resident a suppository, she is on the alert list for no BM.

I am like really! I don't care if she is on a no BM alert, she is dying leave her alone. It's like use some common sense. Very frustrating lol!

[heron, ASN, RN]

Actually, no bm is a common cause of both pain and agitation. On my inpatient hospice unit, we tracked bms pretty closely and made sure to note them in change of shift report. We admitted more than one hospice patient for obstipation and/or sbo.

As for the cigarette thing, if it's facility policy to get an md order for smoking then that's what you need to do ... although I agree that witholding a cigarette is pretty meaningless in the context.

[Roman1]

Heron I understand what you are saying, yes constipation can cause pain and agitation. I should of added that the hospice nurse had been out that morning and had given a suppository and it was very effective. Myself and the other nurse were told this in report. When I called the hospice nurse that afternoon the first thing she said was well the agitation is not from constipation, so that's why the meds were increased. Hospice doesn't chart in the emr, so that is why the resident came up on no BM alerts.

That was why, I was like really, and told her to just leave the resident alone.

[heron, ASN, RN]

Yes, that changes the picture ... but in defense of the other nurse, if the bm isn't charted in the EMR, how was she supposed to know about it?

I guess I'm a bit protective of LTC nurses and don't like to see the stereotype.

It's awful hard to let go of some of the principles of "wellness" and prevention we were all taught. It's like turning one's brain inside out.

Deferring diagnostics, treating symptoms instead of fixing the cause ... these are foreign ways of thinking for many who have never done hospice.

[Omaapecm, ASN, RN]

I agree with Heron that policy's need to be followed, however things are never black and white. Sometimes compassion needs to come before policy. On another note my grandma was on Hospice then taken off it. she was on dialysis for years and decided she didn't want to do it anymore. she wasn't expected to live very long but miraculously she lived 2 more years without dialysis. My point is I would have hated for her to die from a bowel blockage because her bm's were not being tracked .

[Roman1]

When a resident enters into hospice care at the facility I work for, all charting/ I&O's/ notes etc are paper charted in a seperate hospice chart. Basically do not chart in the emr any more. Not sure why it's done this way, but that's what this facility does.

In report the nurse I was referring to was also given the information that the resident had received a suppository and it was effective. I'm not bashing this other nurse, she is very nice but as one resident said to me one time "she's not the brightest crayon in the box". She knows where hospice resident's charting is at, and not to go by the emr. (She is not new to the facility either).

This particular resident was very dear to everyone. The hospice nurse believed she was dealing with a lot of internal struggles and this was a big reason for her agitation. So there was no need for a suppository to be given. I have learned and am still learning a lot about hospice nursing. I admire hospice nurses it is a tuff area of nursing.

[vampiregirl, BSN, RN]

If this was my patient, I would try to get the order ASAP. There are probably fire codes, state regs, policies, and care planning in place that need to be followed. Failure to follow all the steps could result in interruption of his smoking privileges (and those of others), which could results in more stress for the patient. It may seem like a "trivial" order, but it may be a bigger deal than it seems in the world of compliance:( It's usually best to just get the order in situations like this so you know the resident can have his cigarettes.

If only some staff allow him to smoke other's don't, the patient could resort to "sneaking" cigarettes which present additional safety risks.

[MunoRN, RN]

I'm not sure why a doctor's order matters here. It would appear smoking is allowed at this facility in a designated area, which is all that really matters. Doctor's "orders' in this case aren't actually orders, they are just a suggestion to the patient about what they think would be best, which a competent patient is absolutely free to decline to follow.

[Red Kryptonite]

Reading this (and another recent thread about hospice patients in LTC facilities) makes me glad my hospice employer runs its own inpatient units. We can get our patients in our environment, if they need to leave their homes, and implement care in a way that conforms to hospice values.

[Farawyn]

We always needed an order for a patient to smoke, more because he was leaving the floor and having to go outside, accompanied.

[imintrouble, BSN, RN]

We are all slaves to our rules and regulations. If an order is required to smoke, then an order must be documented. Do I think it's incredibly stupid? Of course. Would I let him smoke? Of course. I would have also called so I could document an order. I'd do it as a courtesy to those nurses who, like me, have to follow the rules.