Hospice question from a new-ish LTC nurse

[bugvw70]

Hi. I am LPN who graduated last June and have been iin my LTC facility for exactly one year now. I have a 20 bed wing and have had about 12 residents paa away on my wing since starting. We don't have a designated hospice wing but I have had up to 6 hospice patients on my wing at any given time.

Now, my question... I currently have a lady on hospice who has been declining significantly for about three weeks now. This lady has always been very independent and has been known to refuse certain medications and treatments for the entire time that I have known her. She was just placed on hospice about 2 weeks ago. She has some dementia but is fairly oriented, has no POA, and signed her own hospice consents. This is a lday who has certainly always made her own decisions and has expressed to myself and other nurses that she intends to continue to do so. On hospice, she was prescribed prn ativan, prn morphine concentrate, fentanyl patch, and haldol gel. She has repeatedly refused the morhpine, although not all the time. Occasionally she will acknowledge that her pain has gotten worse and will accept the morphine. She has, however, told the nursing staff that she does not like how the morphine makes her feel and would rather not have it.

My thought is that she has every right to decide when she takes it and when she doesn't. We were always taught that the right to refuse was part of any med administration. My NM, on the other hand, seems to believe that she should be taking it anyway. She has placed in the resident's drink without her knowledge and has encouraged the nursing staff to drip it into her mouth SL while the resident is sleeping. The DON seems to go along with the NM on this. I work with this lady every day amd have for a year. She has very little family that comes to see her and I feel that it is unethical to purposefully not follow her obvious wishes. I believe that if we do this then we lose credibility and trust that we floor nurses have built up over the past year and that, since she has almost no family, that we should advocate for her wishes to be respected as a family member might were they here. At the same time, I am worried about continuing to push the issue as both the NM and DON have made it clear where they stand. I feel very torn between standing up for what I believe to be right and backing off to protect my job. Does anyone have any ideas on how to best handle this situation or similar situations that may come up in the future? Any thoughts at all are appreciated.

[ktwlpn, LPN]

eww- Isn't sneaking her meds in drinks and into her mouth while she is asleep and against her expressed wishes assault? Talk to the resident-tell her you see that she is having times of increased discomfort and you want to help her. Do you contract with a hospice-does she have a hospice nurse coming in? Does she have a fentanyl patch in place? Why don't you suggest increasing the dosage of the patch?.Or try a long acting morphine. Maybe she can get better baseline pain relief and not need the prn roxanol. Do you contract with a hospice-does she have a hospice nurse coming in? If so use her to make these suggestions and save yourself from future retribution.

[Whispera, MSN, RN]

She is not imcompetent. You can't sneak meds into her. It's sooo illegal and you could be charged with battery! Don't do it!

Sometimes pain is preferable over the side effects.

[Tomball]

eww- Or try a long acting morphine. Maybe she can get better baseline pain relief and not need the prn roxanol.

Possibly the pt can describe the specific feeling that she does not like when taking the roxanol - then take it from there. That is a very very big part of hospice - micro management of detailed description so the best choices can be made.

[bugvw70]

I appreciate everyones input. Unfortunately, this particular lady has since passed but I am wondering how to handle this more effectively in the future. I have even considered contacting our ombudsman for the region. I feel very strongly that what they were trying to do is highly unethical and probably not legal. Is there someone who I could give this info to anonymouslyand expect that something productive will be done? I don't believe anyone here had bad motives but I do believe they acted badly. Alll I know is if my mom is ever in that situation I expect that her wishes will be followed.

[Whispera, MSN, RN]

I don't know if this is old information or just limited to where I live, but about 5 years ago, I recall hearing about an Area Agency on Aging, and there was an ombudsman there. Such things as you've mentioned could be reported to the ombudsman, who is required to investigate.

Is there anyone in the higher-ups where you work, that you would feel ok talking to?

I can't say it strongly enough...it is not legal to sneak a med into a patient who is competent and has said he/she doesn't want it. Getting to the reason is VERY important, since appropriate changes can be tried.

[marachne]

My thought is that someone needs to talk to you board of nursing about the behavior of the DON and NM. I would call them and ask about annonymous reporting, explaining, if necessary your concerns about your job/work relationships. Have you spoken to anyone in the hospice agency you worked with? They may be able to do an in-service on symptom management, that includes a discussion of the kinds of uncomfortable side effects that people can experience with opioids (and morphine often has the most uncomfortable effects, whether it is itching, or nausea, or just a feeling of vauge, general, discomfort), as well as a strong emphasis on patient-centered care, and how sometimes when we are medicating for (percieved) discomfort we are medicating the caregivers (paid or unpaid) as much as the patient!

Good luck with this. I understand you being in a difficult situation regarding the work relationships, particularly in this economy, but you also need to be comfortable with your co-workers/superiors, and you do have an obligation both to future patients and the profession to report unethical/illegal behavior.

One other thought, if going through channels does you no good -- contact a local television station and tell them you might have a story for them. Health care issues are allways good stories, and if you make it clear that you need to protect your annonymity, they will. I'm not saying this should be your first course of action, but if nothing else helps, bad publicity can be a very stong motivator to change bad practices!