I wouldnt allow her to die -Hospice

[Aznurse711]

I am a newer nurse with Hospice. It seems you don't have to be on board too long before you experience a handful of natural deaths. I have been here for about 8 months now.

There is one patient where something is really bothering me all day today. I have had her in my care for a few months. She has COPD and emphysema. She has progressively been getting better each day since admission, more alert, more active, increased appetite, regular bodily functions and she hardly wears her O2. Friday she was showing symptoms of a cold and having slight dyspnea. I figured dyspnea from congestion and stuffy nose where the O2 wasnt as effective. Yesterday she had a COPD exacerbation at home. By this time she was already on morphine 0.5ml-1ml, albuterol breathing treatments every 4 hours, predisone 5mg, for her cold: afrin, sudafed, robitussin, and her choice of OTC pain reliever/ fever reducer, her Oxygen was on 2-3L normally when she needed it. IMO, this was not a patient who was taking the natural way out, she was not going to die soon and did not have any signs of imminent death. She appeared to be a sick patient who needed help and was suffocating. I had no other interventions for her and she needed immediate action- her family decided to send her to the hospital. (which i was entirely on board)

When i went to check on her in the ER, they had stabilized her with a bipap, breathing treatments, Solumedrol, IV abx..etc. It was a relief but she still had to be admitted.

I had the ER doctor ask me to educate her because she was not aware hospice patients could be hospitalized. Even the SW at the hospital did not understand.

I am very disappointed to see that even though hospice is to keep our patients comfortable that sometimes they do need outside help also. Now if i felt this was a pt who was going to die rapidly or naturally, i would have acted differently but she needed help. Why is so shocking that i wanted to help her and not let her suffocate? Im very torn to think that our community believes that once you are on hospice, you are only to be kept comfortable and there are no exceptions. I couldnt have imagined trying to manage her as bad as her exacerbation was and just "keep her comfortable." what? with morphine? sedate her while shes breathing horribly? DNR does not mean do not intervene. I may have left out some parts, but i cant wrap my mind around it; this is more of a vent/ discussion/ opinions

[krisiepoo]

What I don't read in your post is what the client wanted

[Altra, BSN, RN]

From what you've written, I'm not understanding where the conflict is. Is the patient herself upset that she was admitted? Did she attempt to refuse transport to the hospital?

If the patient's clear, detailed wishes have not been delineated in written form (ideally a POLST, if your state utilizes them) -- it opens the door for this kind of gray area when dyspnea is involved. Family, hospice clinicians, EMS, and hospital staffed can be faced with the "is this a dyspnea-hypoxia-altered mental status-incapacity for decision making" dilemma.

The other possibility, of course, is that the patient has specified that she does not want to go to the hospital, but in the throes of her dyspnea, her family chose to disregard her wishes.

Yes, generally speaking, hospice patients can be admitted to the hospital for conditions which are expected to resolve. The patient's directives, her insurance provider and your hospital agency can give you more specific relevant information than we can here.

If the patient does not want medical treatment for anything other than what is being provided by hospice - that is her right. The best thing you could do, IMO, would be to have this conversation with her (and her family, if she wishes) as soon as she recovers from this acute episode. Then follow through with your agency to take whatever steps are necessary to ensure that documentation/legal requirements have been completed to comply with her wishes.

[SoldierNurse22, BSN, RN]

When death is imminent? Yep--often times sedating with morphine to control pain and decrease O2 hunger is exactly what you do.

When a patient is afraid, competent and asking for treatment? You do as they wish.

Just because a patient has a DNR order doesn't mean you don't treat, especially when treatment provides comfort. I used to explain this concept ad nauseam to the docs on my oncology floor, sometimes to no avail.

[imintrouble, BSN, RN]

Maybe the pt shouldn't be on Hospice at all. I'm not a Hospice nurse, but I've taken care of thousands of COPDers. Unless they're sedated, the end is agonizing for pt AND nurse.

I'm afraid I would have been one of those nurses, who would have wondered why this end stage COPDer on Hospice, was being admitted for a COPD exacerbation.

Please don't sling mud at me:sorry:. I only know basics about Hospice nursing.

All of the above is moot if the pt said "Call the ambulance".