Hospice

[Blackheartednurse]

What do you think about hospice? Do you think that MDs and nurse practioners abuse the concept of hospice, do you think that in some instance they push for hospice too soon? I always thought that it is extremely difficult to qualify for hospice and it really takes someone to be terminal before getting aproved for those types of services (since all the meds and treatments are covered) I have a patient who is 90 years old, full blown dementia, family took her off antidepressant since they believe the medication is too expensive (around 100 per month), she is also on haldol for agitation and temazepam for sleep, used to be able to bear partial weigth, lately she developed slight knee contracture and is now wheelchair bound, her apetite is ok, healthy heart, healthy kidney and liver, they say they want to make her comfortable,she is not in pain, just agitated due to dementia. Do they mean sedating her?

[ShaBBy23]

I cannot think of a time when I saw a patient referred to hospice too soon.

I cannot count the times when I've seen patients referred to hospice too late.

As an ICU nurse, I define my career as "torturing people to death". This is what I do: I torture people to death. Eighty, ninety, freaking one hundred years old: I torture them all. They suffer and suffer. This is how I earn my pay.

It's shameful. But this is what the family wants. They want me to torture their "loved" one to death for their own sick and sad reasons. I have performed CPR on a 95 year old man who was so far gone with Alzheimer's Disease that he hadn't been out of bed for a decade. He didn't know who he was, much less who anyone else was. He was so contracted that his bony knees interfered with my CPR. Of course I felt his ribs break under my hands.

I've done many, many horrible and shameful things because the family insisted I "do everything". They say that to relieve their own guilt. Instead of them having to make a decision, I carry their guilt and hold the responsibility for their relative's death on my hands. When 90 year old grandpa dies, it's not THEIR fault. It's mine.

I hate myself for this. It's wrong. It's horrible and barbaric and wrong, but I continue to do it. What the family wants is what I have to do.

What does that say about me? I am a horrible person for doing these things. I am a criminal, in my mind. I make myself sick.

@HollyHobby, I completely agree with you. I too feel guilty about prolonging someones suffering. This hits so close to home for me. Four years ago my dad was diagnosed a terminal illness. The family all saw how he was declining everyday.

Ironically, my dad had a DNR/DNI in place, however when people see a loved one suffering for that gasp of air they seem to panic, at least in our case we did. So we revoked the DNR/DNI that awful night and had him intubated to help him breath better.

At the time we certainly didn't feel we were harming him. As the first day passed on, we were dismayed about our decision because we only saw that it was more detrimental than beneficial. Who were we kidding?

The only thing we managed to do was make the last 3 days on earth miserable. The moral of this true story is to honor the living their wish while they are still of sound mind. We should have never caved in because in the end the hospital where he died is still a business making money which ever way they can and if that means prolonging the inevitable then so be it.

So in agreement with my colleagues although we requested hospice for my dad, we did not get it in time for him. I still have issues about our last minute decision but by the same token I've learned so much.

Today, I make sure I educate all my patients about the importance of having advance directives in place and the benefits of hospice should the patients situation's warrant such care.

[nursinmama921]

Honestly I think hospice is a wonderful thing. If a patient is terminal you are NEVER going to cure them so why not make them as comfortable as possible?? Nurses in LTC facilities sometimes care for 30+ patients which makes it darn near impossible to spend any "quality" time with patients. Hospice nurses have 1 on 1 time with patients who really need it...how is that a bad thing!? They are giving those patients what the LTC nurse cannot(not bc they are bad nurses but bc they are VERY busy nurses!) There are so many family members that just cannot let go of their loved ones and continue to put them through suffering bc they are too selfish to realize the reality of things. Honestly sometimes I get so disgusted and just think to myself "If I were their mother/father I would haunt them for doing this to me". And as far as sedation goes I still do not understand how family members still sometimes opt against the medication. How is angry/aggitated and in pain better than resting comfortably? After witnessing the pain and suffering some of my residents go through bc of their selfish families I will be sure to make my wishes VERY clear! I am with stargazer...if I am terminal, in pain and anxious...Bring on the Benzos!

[texan2011]

Hospice is wonderful. I volunteer with a for-profit Dallas hospice (IMO they offer more services than the not-for-profit.) Medicare pays for this. We provide an RN, LVN, aide, music therapist, physical therapist, volunteer, all med supplies. The doc certifies a patient that may only have 6 months to live. We do not want the patients to die. Hospice wants a high census. It is very competitive, and the good companies fall all over themselves to have a good rep and give great service. We provide quality of life.

The patients are not overmedicated, but the nurses are very experienced in pain regulation. We also watch out for the patients in the facilities and at home to make sure they are treated well. A patient can be recertified many times and can come off hospice if they improve. I have 3 dementia patients, and I can see their slow decline. However, my 99 year stroke patient was recertified twice, improved and is now off hospice doing fine. It truly is in hospice' best interest not to hasten death in any way.

Also, the hospice RNs for the most part love their jobs so the patients get happy nurses. Always a plus.

If you are interested in volunteering in the Dallas area, let me know. You can go as little or as much as you have time. We have several nursing students in the program. It's great prenursing experience, and the patients are always happy to see you. :))

[leslie :-D]

If I were a LOL agitated due to my advanced dementia, I would want that addressed. An agitated person is NOT a happy person. An agitated person is a scared, angry, frustrated, lonely person. The risks of sedation, in my opinion, are far outweighed by the benefits of feeling safe and calm. When I am that LOL, bring on the benzos!!!

i do agree with this...if it pertains to demented folks who are miserable.

and while i do agree that overall, hospice is tremendously underutilized, i have seen drs/nps encourage elderly/demented pts go on hospice...and have to ask why.

short of having a terminal illness, why is dementia deemed as an automatic qualifier?

oh boy, that really ticks me off...and i've seen it a hundred times.

re this 90yo pt....i'm not certain if this antidepressant was working or not...

but why not get this pt an advocate in trying to find him the right med to address his depression...

and try to r/o pain et al, as an accelerant to his agitation?

for some, death comes too soon because WE say he's old and demented, so why not?

for this population, we surrender so easily.

i like notflo's post, about trying a dementia unit, which would have interventions solely for these folks.

and for those demented folks who are care-free, happy souls...why the heck do they need hospice?

but sure enough, i've seen it time and time again...just because they were demented and old.

yes, hospice is underutilized for those who truly, truly need it.

conversely, it is too darned accessible for those who shouldn't qualify, but do.

it's a discouraging imbalance that needs attn and correction immediately:twocents:

leslie

[texan2011]

The dementia has nothing to do with "saying someone is dying." The doctor certifies the patient because physiologically the organ systems are failing. We don't treat the dementia -- it is what it is. We just work around it. The patient is dying because his/her body is clinically shutting down. The hospice docs have certain indices they follow to certify.

Not sure what you mean about the antidepressants and 90 year old patient. Must be a different post you are referring to. Regardless -- statistically, many many people are on antidepressants -- all ages. I don't think that is necessarily a hospice issue. Sorry if I am offbase -- I probably missed that post.

[leslie :-D]

the dementia has nothing to do with "saying someone is dying." the doctor certifies the patient because physiologically the organ systems are failing. we don't treat the dementia -- it is what it is. we just work around it. the patient is dying because his/her body is clinically shutting down. the hospice docs have certain indices they follow to certify.

you'd be very surprised what they'll use to qualify people for hospice...without organ failure. if you lose 10% of your baseline weight within 6 months, you're qualified. 'failure to thrive' is another, with its own qualifiers. it's very easy to get hospices services, and advanced dementia and the subsequent inability to sustain themselves, is all they need. those "indices" are manipulated all the time.

not sure what you mean about the antidepressants and 90 year old patient. must be a different post you are referring to. regardless -- statistically, many many people are on antidepressants -- all ages. i don't think that is necessarily a hospice issue. sorry if i am offbase -- i probably missed that post.

read the post again.

family took pt off antidepressants r/t being too expensive.

and i think you are missing my point about antidepressants.

if these specific drugs could change one's qol from horrible to bearable, then that'd be an intervention worth pursuing.

and yes, it is a hospice issue...

anything is a hospice issue that could potentially make our pt's lives better.

leslie

[texan2011]

OK -- I can only speak for the hospice companies that I am familiar with. Maybe some don't give good care. I can't speak to that. There are good, mediocre, and bad doctors, nurses, hospices. Can't paint everybody with a broad brush.

Reading between the lines though -- it seems like you are saying that hospice is a bad thing -- "manipulate the indices." Hospice is there to help. It is not a death sentence, and again -- an improved patient can go off hospice at will.

Personally, I hate antidepressants, tranquilizers, etc. so please don't think I am defending their use. They have never worked for me, but I have family members that are on them (of their choice), and I don't interfere.

Anyway -- I need to jump off the discussion board now. Have a great weekend.

[leslie :-D]

There are good, mediocre, and bad doctors, nurses, hospices. Can't paint everybody with a broad brush.

Reading between the lines though -- it seems like you are saying that hospice is a bad thing -- "manipulate the indices." Hospice is there to help. It is not a death sentence, and again -- an improved patient can go off hospice at will.

i'd be happy to say it loud and clear: there are definitely some hospices that are despicably managed, and should be shut down.

just as you noted, "there are good, mediocre, and bad doctors, nurses, hospices."

ftr, i am a hospice nurse, and have seen the very best and very worst of what hospice is...and isn't.

leslie

[nurseprnRN, BSN, RN]

these are the criteria for the medicare hospice benefit, which are pretty much duplicated by most private insurances for persons not qualified for medicare. for those who wrote that it's too hard/easy to get hospice services, for those who think nps or primary care physicians are too quick to refer, for those who think dementia alone isn't reason enough...read on. the idea is to have the end of life be comfortable and with as much symptom relief as possible. as someone else said, i can't think of anyone who got to hospice too soon but i can't tell you how many i've seen who got it way too late to be of full benefit to them and their families.

as an inpatient case manager i referred a lot of people to hospice, once i learned about it; the first was a man with refractory heart failure who just didn't want to come back to the hospital (he was four months in care, and his wife said it was the best time of their lives together, the end of it) and the second was a demented woman who kept aspirating and then spent her admissions in the hospital terrified and restrained (her family didn't know hospice would keep her comfortable at home, and make her comfortable the next time she aspirated and got pneumonia, and let her go quietly of it; three months). i still have notes from those families thanking me for the effort it took to get the primary care physician to write the referrals and saying how wonderful it was once they got home.

eligibility criteria for common diagnoses

als

dyspnea @ rest

vital capacity less than 30%

declines artificial ventilation

critical nutritional impairment

rapid disease progression or complication in the preceding 12 months

cancer

clinical finding of malignancy with widespread, aggressive or metastatic disease

patient no longer seeking curative treatment

palliative performance scale equal to or less than 70

dementia

inability to ambulate or dress without assistance

urinary and fecal incontinence, intermittent or constant

no consistent meaningful verbal communication

one of the following within the last 12 months:

aspiration pneumonia

pyelonephritis or other uti

septicemia

decubitus ulcers, multiple stage 3-4

inability to maintain sufficient fluid and calorie intake

fever, recurrent after antibiotics

failure to thrive

palliative performance scale equal to or less than 40% (mainly in bed, requires assistance with adls) (you can look this scale up--it's published)

body mass index below 22kg/m2; bmi=703 x (patient's weight in pounds) + {height in inches)2

the patient declines or is not responding to enteral or parenteral nutritional support

heart disease

poor response to optimal treatment with diuretics, vasodilators, or ace inhibitors

presence of nyha class iv chf or refractory angina

ejection fraction less than 20% (helpful but not required)

not a candidate for, or has declined, revascularization procedures

liver disease

pt prolonged more than five seconds over control or inr greater than 1.5

serum albumin less than 2.5gm/dl

must have one of the following:

ascites

hepatic encephalopathy

history of recurrent variceal bleeding

spontaneous bacterial peritonitis

hepatorenal syndrome

multiple sclerosis

critical nutritional impairment

rapid disease progression or life threatening complications in the preceding 12 months

critically impaired breathing

non-specific terminal illness

recent rapid clinical decline and disease progression

decline in functional status

weight loss

dependence on assistance for two or more adls

recurrent aspiration

increase in er visits, hospitalizations or physician contact

progression of cognitive impairment

progression pressure ulcers in spite of optimal care

dysphagia with recurrent aspiration

parkinson's

critical nutritional impairment

rapid disease progression or complications in the preceding12 months

pulmonary disease

decreased functional capacity

evidence of disabling dyspnea @ rest, or with minimal exertion

poor response to bronchodilators

progression of disease as evidenced by increasing visits to physician, er, or hospital for pulmonary infections

hypoxemia on room air less than 88% by oximetry

fev1 less than 30% (helpful but not required)

renal failure

patient is not seeking dialysis

creatinine clearance less than 10cc/min {

serum creatinine greater than 8.0mg/dl {>6.0mg/dl for diabetics

not a candidate for dialysis

stroke

palliative performance scale of 40% or less

poor nutritional status with weight loss over 10% in the past months or 7.5% in the past three months

coma with three of the following on third day of coma:

abnormal brain stem response

absent verbal responses

absent withdrawal response to pain

serum creatinine greater than 1.5

patients are also eligible if they meet some of the above criteria but have significant comorbidities or rapid decline suggesting a six-month or less prognosis.

even if the patient does not meet any of these conditions, he or she may still be eligible for hospice if based on documented data and in the judgment of the physician the life expectancy is six months or less. one of the best hospice nurses i ever knew used to ask the family members if they thought the patient would be alive at (the next major holiday in about 6 months). often enough the answer was no, and that was a good exercise to begin the process for everyone.

[leslie :-D]

very true, that when hospice is used ethically, sincerely, and appropriately, everyone benefits and is one of the most remarkable experiences for all.

leslie

[No Stars In My Eyes]

Hospice , in my experiences with it , is WONDERFUL. It can add a depth to life that isn't available anywhere else.

[netglow, ASN, RN]

So many medical folks are totally confused about hospice. No, it doesn't mean that the patient is going to be taken to the vet and euthanized. All hospice does is have everybody take a look at the plan of care. If the patient qualifies, thank you GrnTea, we are looking at 6 months survival time. However the patient is not taken to the vet and euthanized if they are still kickin beyond this time. Lots of stuff suddenly becomes paid for if the patient is on hospice, usually LTC/family is happy as hospice can cough up an extra CNA to help with caregiving for that patient. Stuff like air matresses, lifts, and other DME just for that patient can be rented and hospice will pay for it. Also, every little comfort care item should be addressed by that patient's case manager in the treatment plan so the plan is palliative, and no longer geared to aggressive tx to cure. Now, the normal goings on will be treated, so don't worry. It's just that when something new pops up, everybody discusses what to do about it. Does the patient now want it treated? Well then that is fine, hospice is revoked and the patient can pursue agressive tx for the condition that pops up. It's just that the patient can no longer be on hospice benefit during that treatment time. They can always be considered once again for hospice. You have to understand what hospice means to an MD in regards to a patient, it's a different focus. The patient's MD is still in control, but he/she can look to symptom management entirely. This is a huge shift. If you talk to some oncs, they are very happy when the patient and family are OK with hospice. It means they don't have to participate in actually torturing the patient anymore. Think about it. Cut that chemo, build the patient up, let them feel OK for a while before they die. Maybe they can take that trip that would never happen if still in aggressive treatment till the day they die.

I have to say there are A LOT of hospices popping up. Some are not on the up and up. You really have to try and check them out if possible before you work for them. They can be secretive. See who the clinical leadership is. Research backgrounds. Is the owner private? Some big money can be had in hospice. Take a look at your owner! If you find your hospice is run by, and staffed by just about all new grads you got a huge problem. If your owner dresses like, drives a car like, and parties like a real playa -- you got a huge problem.