when is it too much??

[sasha2lady]

just had an interesting night at work......had a lady elderly of course who was started on hospice crisis care b/c her o2 dropped and was brought back up.....our thing at work is that if its a hospice pt then hospice has to be notified first of any type of change....thus.....came the c.c and roxanol on sched q 4 hr with prn q 1 hr....now....this woman was fine monday when i was there ...she was able to talk to me today at 4 pm when i gave her that rox.....the hospice nurse came to me exactly 1 hr later wanting her to have more....said she was restless....i go in and see that shes not restless but this nurse was insistent as 99 % of the hospice nurses we deal with are....that she get that other dose of rox....so ....anyway...vs are stable.....no sob...nothing.....by 6pm til i left at 11....she was so drugged up......didnt open her eyes anymore...didnt talk to me anymore which i expected but my god.......the rule here is if a pt is a hospice pt and lives in a nursing home then the hospice nurses cannot medicate them...they only do that if they are at their home....which i dont understand b/c if they are already in a nh...then that is their home also......so instead they hassle the floor nurses with their rox requests all the time and get ***** if we dont stop right then and there to go give it ...usually its to a person who is just breathing...no specific way....my thing is this..as this persons nurse.....do i not have some say in whether or not i give these strong drugs? if i dont see s/s of pain or labored resps etc....then do i technically have to give it? i am totally in favor of keeping someone comfortable at that pt in life but sometimes too much is just too much.....the way its worked from my experiences with this is like assisting the on out the door....oh...btw....this nurse also wanted me to get an order for ativan for agitation......my pt wasnt even moving....totally unresponsive from the past 8 hrs of roxanol being given to her....i absolutely refused to do that....i told her that she could write and follow her own standing orders per hospice but i would not get any order for ativan ......well....she didnt mention it again ...i dont understand how someone can come in to a pts room and just sit with them demanding all this medicine to keep them "comfortable" as they say.....when its more like comatosed...and have never met this pt.....ive been with this pt for 9 yrs....i think that if anybody would detect trouble with her ..it would be me or one of her regular nurses on the other shifts.....does any of this make sense??? or am i just crazy? it just bothers me! Im afraid that if i do refuse to give the roxanol etc...they'll make it into something its not...like laziness or what have you....reality is this....by tomorrow when i go in...if she's still alive.....itll be the same thing and i bet shell be worse....i fully expect a sad scene. any ideas? suggestions? similar experience??? how does hospice operate in other areas?

[TheCommuter, BSN, RN]

A continuous care hospice nurse from a staffing agency was sitting with one of my patients during crisis care about a year ago, as the woman was actively dying.

The hospice nurse was insistent that I give her more Roxanol (liquefied morphine sulfate) via the sublingual route. The patient's respiratory rate was 7, and no nonverbal s/s of pain or discomfort were present. In a nutshell, I told the hospice nurse I wouldn't give the morphine.

Since hospice patients are virtually nonexistent risks for liability and future lawsuits due to their terminal prognoses, I could have given the morphine when she really didn't need it. However, euthanasia is not a part of my job description. A comfortable, actively dying patient with a respiratory rate of 7 usually doesn't need more morphine.

[chill1965]

let me guess, your in texas?:icon_roll

[sasha2lady]

I am in NC....I couldnt sleep last night for thinking about my pt and I try not to bring work home with me. Tonight was different.....no crisis care nurse was there so i got to take my time with her and do what i felt necessary based on my assessments of her....did i mention before that my pt is about 70 lbs??? anyhow....when our pts become involved with hospice...whether its palliative or more...its like hospice suddenly wants to take over and control every single thing thats done for our pts and that includes whether or not we can send one to the hospital if need be...for ex...if they spike a high temp of 104 or something...we are supposed to call hospice on call nurse FIRST before we even call the doc.....i take orders from the doc..not nurses....but anyhow....i was always taught that even if a pt is hospice they are still entitled to tx if needed.....tonight my pt was pitiful....completely unresponsive....@ this point Im just hoping this all ends for her sake sooner than later.....@ least this forum is a wonderful way to discover how fellow nurses handle the same or similar situation. i felt like kavorkian last night.

[Lexxie, LPN]

My former LTCF was like that. Hospice pretty much ran the show for residents who were in their care. Many of our docs would defer to Hospice and agree to any of the orders that Hospice requested.

When my dad was terminally ill a few years ago, his wish was to die at home. He was stubborn and didn't let hospice come on board until 2 weeks before he died. However, it was the same type of situation: he seemed to be comfortable - no facial grimacing or moaning, no twitching of extremities, etc.. Yet the hospice nurse was hell bent on giving him a dose of roxanol because "he needed it".

Anywho, I guess my point is that there seems to be pushy hospice nurses everywhere.

[systoly]

sasha2lady, you make a lot of sense. You are absolutely correct in not blindly following someone else's instructions. First of all, another nurse can suggest/recommend that I give a prn, but certainly not insist. Secondly, you gotta have some evidence to go along with the recommendation. Having said that, I will also say that terminal agitation is not the same and does not present the same as agitation we most commonly see. I have given Ativan to hospice patient's who were talking up a storm and to patient's who were hardly moving, but the evidence was there. As for your scenario, you know the patient well and you aim for the highest comfort level. Go with your gut feeling unless hospice can objectively present valid evidence. I am rather surprised that hospice chose not to explain and teach their rationale.