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I need help processing my first hospice patient experience.

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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.

eatmysoxRN, ASN, RN

Specializes in Med/Surg,Cardiac. Has 1 years experience.

I don't work hospice so I don't know common practice. However, I'm not sure that I would want to make the patient to the point of being nearly dead. Maybe administer a little less frequently or base administration on vitals and loc. I'm interested to know what experienced palliative care nurses have to say though.

RonCA84

Specializes in Med-Surg, Hospice. Has 2 years experience.

I'm relatively new to hospice, but after training with several other nurses; I've come to an understanding of morphine, haldol and ativan usage.

I would continue to administer morphine as ordered, even if the patient isn't groaning. I felt the same way about holding morphine since patient was unresponsive and resting but not complaining of pain (grimaces or moans) while on morphine but although metabolism slows down, and your pt's hepatitis or hepatitis-like dx is present, we administer to prevent breakthrough pain (many cancer patients) or rebound pain. In regards to feeling youre speeding up the process, do your research on roxanol and haldol and become familiar with dosages so you can use your nursing judgment to advice hospice to increase or decrease dosages. Pt respirations may slow down but it does not happen to every patient. Signs of active phase of death/decline include all the sx you've described. Also if hospice pt have hx/sx of alzheimers/dementia; take a closer look after administering ativan. Active ingredients in ativan sometimes cause lil relief in agitation with these pt, that's when I'd call hospice and ask to switch to haldol for "ineffective relief of terminal agitation."

We're here for the patient, if family can't arrive in time, well they just won't arrive in time. I've had to tell myself over and over that I'm there to comfort my patient and be an emotional support for family; trying to lessen their dosage so family can arrive in time isn't in the patients best interest (pain wise). It's such a fine line, but rest assured you should feel no guilt. I commend you for entering an excellent speciality and wish you the very best with all your hospice patients and families. :)

tewdles, RN

Specializes in PICU, NICU, L&D, Public Health, Hospice. Has 31 years experience.

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.

Because you are practicing in a palliative inpatient unit you can do things a bit differently, more cautiously so that YOU are comfortable as well. That is important.

In the absence of agitation or restlessness, I would have held the haldol and observed. He IS in a controlled environment where you have immediate access to him and other support.

Should we presume that you decided on the dose of morphine because of his pain/relief history and recent trajectory?

If he is moaning then it is correct to assume that he has some discomfort. What is the nature of the pain? Is it physical, emotional, psychological, or spiritual? Do you have access to hospice for support? Use the PAINAD to assess your minimally responsive patients.

I like to put oxygen on them in situations like this, simply because my intent is to promote comfort and not accelerate death.

In hospice care, 16 mg of IV morphine in a shift is NOT considered a huge dose. You are thinking along the correct lines for hospice care. How often do you get to check on your patients during the course of a shift? How many do you care for?

You did fine and had the patient's comfort as your first priority...GOOD JOB

First deaths are hard...we all learn a great deal from them!

I came in yesterday and to my utter shock, my patient was still hanging on. I was with him 16 hours yesterday until this morning because one of the night shift nurses called off, and I couldn't justify leaving him without adequate nursing care. when I got report, I was told he was extremely restless and agitated all morning. I looked at the orders and saw morphine 4mg q4h and morphine 2mg q2h PRN. there was also haldol and Ativan on board still. I called his sister (only family) to tell her that based on my assessment, she may want to come into the unit. She said she couldn't make it but if he was still alive the next day she would come in. so it was just me and this gentleman for those 16 hours. during the course of that time, he was restless, moaning in his sleep, and having trouble breathing. I took a step back and asked myself "what would you do if this was mom or dad?" I decided to give him both scheduled and PRN doses of morphine, the haldol q2h and the ativan every 4 hours. he began to look more comfortable until he was repositioned, and at that time he groaned loudly and even opened his eyes for the first time in 2 days with a grimacing face. I felt horrible. his extremities were weeping huge amounts of fluid, he was bleeding in random spots and I could hear the fluid in his lungs with no stethoscope. based on that, I continued to give him everything in my arsenal to make him as comfortable as I could.

it was definitely a learning curve the first day with him, but I felt more comfortable yesterday and this morning....I told myself, "you have to be confident in this. you are not going to let him die groaning and grimacing."

to the person who asked, I had him and 4 other patients on the evening shift, and him and 7 others on the night shift. I'm so tired today I can barely function.

I forgot to add, our residents are idiots this time. we get new ones every 2 weeks and I have no idea where these people came from. this morning, myself and my charge nurse FINALLY convinced them to give this man a morphine drip. I could tell by this morning that his pain was getting progressively worse so I'm thankful he has that coming.

thank you for the responses so far. I am eager to learn about what other nurses would have done here. as I said, he is my first dying patient and I'm flying by the seat of my pants.

after typing the last response I feel like I should explain why I said "these residents are idiots." we are primarily a rehab unit, with one hallway of palliative and hospice. the residents generally have no hospice experience, so our most experienced hospice nurse sat down and explained that on this unit:

1. we do not take vital signs on dying patients

2. we cannot IV push medication, so it has to go through another route

3. this patient is minimally responsive on admission, so PO route is not an option

after this conversation, the resident ordered vitals qshift, activity up with assistance daily, and all med orders in the computer were PO and IV push. all orders had to be changed before I could take care of this man. she also told me that she didn't want to give him much medication because his liver is shot and it will build up. it has been such a struggle for me to advocate for this man when I'm new myself and am still learning. last night the resident said "do you know how hard it is to take care of these people? do what you feel is necessary and I'll sign the order." I just haven't totally learned what all is necessary, or what all my options even are.

MarcyRN

Specializes in Intensive Care. Has 7 years experience.

Honey, many (most?) residents are idiots! LOL. You'll get no argument from me!

I think it sounds like you're doing an absolutely awesome job, especially as a new grad! Are you in a hospital setting? I guess you must be to be dealing with residents. I have been a nurse for just over three years now, and started in a hospital cardiac stepdown and a year later moved to the ICU. I am new to hospice, too -- I started with a hospice company in September. I travel all day, though; most of my patients are in SNFs or in their own homes. Would love to hear more specifics about your job....I've been doing this for two months, and even though I went to nursing school in my midlife specifically to do hospice nursing, I'm not sure this is the right fit for me. The paperwork and administrative duties are overwhelming -- my job is about 20% patient interaction and 80% marketing and documenting.

Anyway, don't know how long you've been out of nursing school, but it sounds like you are a brilliant nurse and are definitely in the right specialty for you! Good luck, and continued success!

MarcyRN

Specializes in Intensive Care. Has 7 years experience.

Ooops. Just saw that you were hired at a VA hospital. Sorry. Missed that. (I'm having wine with dinner!) LOL!

tewdles, RN

Specializes in PICU, NICU, L&D, Public Health, Hospice. Has 31 years experience.

If your patient has rhonchi and and pulmonary congestion you can ask for atropine 1% gtts and transdermal scopalomine.

Marcy,

I am in an inpatient unit in a VA hospital. the general name of it is the Community Living Center, which is mostly rehab patients, but we have 14 palliative/hospice beds, depending on the need. I know other VAs have their own freestanding hospice units. the paperwork you do sounds like no fun at all...I just do one free text note on my hospice patients every couple hours or so with my assessment and how they are progressing. because of this, I'm able to spend more time with them while they are actively dying. most of my palliative patients have terminal cancer, and I mostly do symptom management for them. I bounce back and forth between palliative patients and hospice patients.

I'm a brand new grad and this is my first nursing job. I did one of those MSN bridge programs because I already had a BS in bio.

Sterling-RN

Specializes in Hospice, LTC, Behavioral Psych. Has 8 years experience.

I hesitate to use oxygen with patients in active/terminal decline as it dries the mucous membrane and the body's requirements for O2 is reduced. Evidence shows a gentle fan on low hitting the trigeminal nerve is more effective in maintaining comfort. Also, atropine is indicated for hypersalivation or TRS (terminal respiratory secretions) and will be more effective if used early as it will help reduce additional secretions, but will not clear up existing secretions/rhonchi. Atropine crosses the blood-brain barrier and can cause delirium, and can add to mucous membane dryness/discomfort.

nerdtonurse?, BSN, RN

Specializes in ICU, Telemetry.

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.

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

Specializes in PICU, NICU, L&D, Public Health, Hospice. Has 31 years experience.

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

MomRN0913

Specializes in ICU.

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.........

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

tewdles, RN

Specializes in PICU, NICU, L&D, Public Health, Hospice. Has 31 years experience.

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.