Lasix use in CHF?

jlynn2303 · Dec 8, 2011

Hi,

I am a new hospice nurse as well. I have seen lasix used, pretty regularly, actually. It is treated as a comfort measure. It seems that as long as it doesn't treat the primary dx that brought them into hospice, it is ok. So, for example, there was one guy who was still getting dialysis, but kidney failure wasn't the reason he was on hospice, so he could do both. I have a woman right now who is on hospice for debility, and gets lasix for her chf because she is not on O2, so doesn't qualify to be on hospice for chf, but she does for debility. Some of these people - I wonder why they are on hospice, as they are still on all of the heart meds, etc. One woman yesterday spiked a sudden temp and seemed confused, the ltc immediately ordered a chest xray, UA and antibiotic. I am not sure how that will play out. I guess we'll see.

curiousauntie · Dec 8, 2011

Georgenurse

Don't think of lasix as "treatment". Think of it as a "comfort measure". If your patient is having crackles, then there is a good chance breathing difficulties are not far behind. Having lasix on board now would, possibly, delay those breathing difficulties and all that can bring. Anxiety and/or aggitation being the hardest to deal with and most patients that have breathing problems will have some level of anxiety, so be ready for that.

jlynn

I have seen the whole "chest xray, urine cs, antibiotic" cycle at may long term and assisted living facilities. Poor communication between the case manager and the ENTIRE nursing team at the facility may be part of the problem. If you can touch base with both the day and evening supervisors, and the direct care (or medication nurse, or charge nurse, whatever they are called now) nurse, the chance that they will remember to include hospice in their care decisions will increase. At the last facility I worked in we had a very good relationship with the hospice that most of our docs used (whick is the hospice I work for now) and were very conscious of making sure we called the hospice nurse, or the on-call nurse when there was a problem. As an over-worked unit manager, I appreciated the fact that the hospice nurse usually wanted to be the one to call the family and explain what was going on while I got the hospice nurses suggestions for managing the symptoms and called the doc. It made the whole issue, whatever it might have been, easier to deal with. But it takes a LOT of education to get all the staff at the facility on board with the TEAM approach, and to get that when the patient is on hospice, the hospice staff is part of that team.

catlvr · Dec 9, 2011

As an LTC nurse, pulling out the stops for suspected uti/pneumonia confuses me to no end. I had a hospice pt who had a foley r/t urinary retention, and of course she got a UTI - worst looking/smelling urine I've ever seen, foley frequently blocked from sediment, etc. She was convinced that staff was raping her at night because she could feel the foley and didn't understand what was going on (didn't help that English was not her primary language - one of her friends translated her concerns for me). Anyway, hospice repeatedly REFUSED to let us get urine for an obvious *comfort* issue, until I raised the fuss to end all fusses. Same hospice agency and nurse, different patient: admitted to hospice for recurrent pneumonia r/t kyphosis. Every sniffle and cough warrants a cxr and abts.

Why? I would really like to understand how the determinations of what to treat and what not to treat are made.

ErinS, BSN, RN · Dec 9, 2011

Remember that no medication or even treatment is against the rules in hospice. Different agencies will approach things very differently, but some agencies will do more aggressive interventions than others.

In my agency I see TPN, tube feedings, palliative radiation, and certainly lasix (as well as far more aggressive medications) fairly often. Each pt is assessed individually, and if it is the right thing to do for the pt for their comfort and to meet their goals, then we do it.

I would always be cautious if a pt has come onto hospice and had all their meds stopped. Our goal is not to stop maintenance therapy or hurry people along to their death. Our goal is comfort, and while pts do sometimes decide they want to stop all their meds, this is a decision that should not be made for a pt, but with them. That is not to say that the nursing home pt on 30 meds should not have some meds d/c'd if they are no longer appropriate for the pts condition.

There are some hospices that do things that are ethically questionable, if not plain illegal to make or save money. Often the money is the factor of why there is such a broad range of attitudes in hospices, although management and medical directors can also really affect that.

PsychNurseWannaBe, BSN, RN · Dec 10, 2011

Hospice offers wonderful services to the patient and to the family. It is important for facilities and hospice agencies to have open communications. Each patient is unique and their needs need to be addressed with the patient's input. Many times it always requires quite a bit of family education. We are thankful for our hospice agencies in our area, but I will call them if I don't agree with something. In our state in our SNF, hospice is simply a payor source. They are not to change medications and treatments without speaking with staff and the patient. Additionally, the staff nurses should be calling hospice with updates so they can determine what they suggest.

What can't happen is for hospice to change the plan of care without alerting, more than likely a nurse manager, so the SNF can update their care plans as well. I have seen some hospice D/C all meds, without cause. Or SEVERAL times I have seen orders from hospice to "stop feeding the patient". :confused: We can't accept an order like that. But through collaboration between the hospice agencies, we have seen great improvements in maintaining a continuity of care. And for new hospice nurses, please do not discontinue an antidepressant. It does help them with what they are going through. :heartbeat

netglow, ASN, RN · Dec 10, 2011

Many hospices are run by those who are in it for the huge money it can make them. Keep your eyes and ears open, and you will quickly understand if yours is one.

Audits of hospice are increasing because payors are now aware of this horrible problem.

If you find you are an employee of such a place, you do need to leave...

curiousauntie · Dec 10, 2011

PsychNurseWannaBe,

Hospice should never be "just a payor source". First of all, the hospice nurse is, or rather, should be well trained in end of life care, both for the patient and the family. As a nurse with 22 years of long term care, much of it as a unit manager, and now 5 years of hospice (and a certification in hospice) that sentence kind of made my eyes bug out! No long term care facility allows the hospice nurse to write orders. We are not employees of the facility, we are not the primary caregivers, the facility nurses/staff are. When in a facility I talk to the charge nurse for the patient when there is a problem or concern and changes in meds or treatment need to be made. And, just an FYI, the newest regs from the feds on hospice in long term care basically say that once the patient is on hospice, HOSPICE should be driving the care, not the LTC. But since we want to be welcomed in your facility, not seen as a hard nosed interloper, we will ask for your input and educate the staff as needed to the hospice way.

And I agree, any hospice nurse that feels that the first thing that should be done is d/c all meds is not acting in the patients best interest. Who's best interest she is acting in is beyond me, as each patient is different and blanket orders are not what we are all about. Don't get me started on the "don't feed the patient" order. I could go on and on...

As for antidepressants...I am grateful that LTC sees that many residents in facilities are at some level of depression. The problem I have most often is the home patient who is clearly depressed, but feels that antidepressants are for weak people and they should be able to just "buck up" and deal with it! When my patients are at the last few of the multitude of medications that they were probably on when they were admitted to hospice, one of them is bound to be an antidepressant. First of all they NEED it, second, the side effects of abrupt withdrawal usually mean we have to use antianxiety or antipsychotic meds...so they stay on those little pills til they can't swallow them.

And a big thanks for all you long term care nurses out there who see that hospice is something that benefits your residents and helps the families and you to deal with the last part of the resident's journey. A good hospice nurse in a facility will understand that those residents are part of bigger family then just their kids and grandkids, but the family of the nurses, aides and other staff that have cared for them, usually long before we got involved.

volsfan · Dec 11, 2011

I wanted to add that you must also consider that the families and patient's can choose whether or not to treat an infection.

PsychNurseWannaBe, BSN, RN · Dec 11, 2011

hospice write orders for the patient in our SNF. For example, Ativan, Roxinol, Scopolamine, etc. So I don't understand what you are saying. I'm kinda confused.

SappyRN · Dec 15, 2011

I work for a "for profit" hospice and my medical directors would never stop lasix on a CHF patient unless they were imminent and no longer able to swallow. It is good symptom management to treat pulmonary congestion in a CHF patient. Nobody should be left to drown in their own fluids. Now having said that, was it a patient ir family choice to do this and if so were they educated of the consequences.

FLArn · Dec 31, 2011

Is the patient whose Lasix was d/c'd normotensive and still making urine? If not, there may have been a valid reason to stop using the Lasix. Just saying not all meds are stopped just because the patient is placed on hospice care. Sometimes the hospice referral comes late in the dying process and meds are stopped on admit because the patient is already imminent.