I have a resident in my nursing home who is 102 years old. She has been through the ringer the past year that I've been working here, but she has always pulled through (example: two falls in one day).
She's been fairly sick lately with pneumonia, and even got sent out to the hospital last Friday for an evaluation. She's been yelling out all day and night, obviously in some kind of pain, but she cannot localize where it is (appears to be abdominal). Yesterday and this morning she has coughed up frank blood clots. Normally this would be the type of situation where I'd call up the covering and ask for some advice (and probably end up sending her out to the ER again), but as of two days ago she is now a Do Not Hospitalize on top of her DNR. I really do not know what to do for her anymore. She is on PRN roxanol 2mg q 2 hours, but it's a hassle to even try to get this small amount of liquid into her mouth. She's beginning to fight away staff, won't eat or drink, and barely gets meds down.
I know she is probably going to die soon, but I hate to see this woman in that kind of pain and feeling helpless toward making her comfortable.
Thanks for listening, this poor lady is just making me too sad. :redbeathe
Specializes in psych, addictions, hospice, education.
Have you considered that some people feel they must feel pain in order to meet their God, as a way of atonement for whatever they think their sins are? I see the terrible position you're put in, and my heart is with you. I think an increase in fentanyl patch dosage might help too. Family has been called to come? I'm wondering if she's actively dying and beginning her stage of terminal restlessness?
Specializes in LTC, assisted living, med-surg, psych.
Magic 4---it's the best stuff EVER! It's a topical cream made up of Ativan, Haldol, Phenergan, and I forget which pain medication.......you rub some on the inner part of the forearm, and it works miracles. You have to get it from a compounding pharmacy, they don't just have it lying around at the drugstore, but I know that every time I admit a hospice pt. to my wing at the nursing home, I ask their nurse to get an order for Magic 4 if they can't take meds orally..........giving meds PR when there's a better and less invasive way is NOT 'comfort care', in my opinion.
She has no family locally as far as I know. I found out last week her HCP is all the way in Arizona (and we're in Massachusetts).
I also wonder if the roxanol is making her even more confused than she actually is. I saw an awful reaction with roxanol and one of my other residents where she would become very defensive and paranoid, when she was normally friendly and A+O. Maybe we can just DC the roxanol and up the fentanyl patch. It's only 12.5mcg q 72 hrs.
How about a small one time dose of IM haldol just to get her calm then getting the roxanol increased to at least 10mg every hour along with some liquid ativan. We use the roxanol and ativan scheduled in hospice and it works very nicely. Once she's calm you should be able to get the dropper at least inside her lip which is good enough. Fentanyl patches give such a low hourly dose that alone probably won't do much to relieve her acute pain.
12.5 of Fentanyl...hmm...are you sure she won't become addicted??!
Give that woman 25, at least, and top her up with morphine drops Q1H, or rectal whatever-works-fast, until she's comfortable. What is the point of waiting?...snow her, and then let her come out gradually until she needs meds again, and then give enough to maintain comfort. Somebody get on the phone and call the doc Q30 minutes until she is comfortable...bring the phone down to the room so he can hear her if that is what it takes.
There are enough horrible things we can't fix. This is one we can. Try presenting it to the doc and family that way. She's had enough, let's make this easy for her.
Have you considered that some people feel they must feel pain in order to meet their God, as a way of atonement for whatever they think their sins are?
With respect to your beliefs.....but my belief is that we do what we can to ease suffering. If there is a God surely he/she can come up with something better as a teaching tool. Agony without understanding is pointless- what could the patient possibly be gaining from the experience? Your statement is a "maybe" at best, and a myth at worst. If it was my grandmother I would have her pain free unless there was a clear and understandable benefit.
With respect to your beliefs.....but my belief is that we do what we can to ease suffering. If there is a God surely he/she can come up with something better as a teaching tool. Agony without understanding is pointless- what could the patient possibly be gaining from the experience? Your statement is a "maybe" at best, and a myth at worst. If it was my grandmother I would have her pain free unless there was a clear and understandable benefit.
canoe, respectfully, there are too many pts who indeed, believe they need to suffer before they meet their Maker.
while i'll never understand it, it's something we have to honor.
granted, i incessantly bug those pts until we come to some sort of compromise.
but my point is, this phenomenon is out there.
it happens.
my instincts are telling me that an increase in fentanyl, wouldn't do the trick.
i'm thinking her circulation is compromised to the point where absorption would be variable at best.
and, i too am thinking the mso4 may be causing a paradoxical excitation...
only IF she's getting steady enough doses.
otherwise, she may be grossly undermedicated and need atc scheduled doses.
and none of this 2mg crap.
i'd start w/5mg q2h and 5mg prn qh.
someone that she trusts/gets along with, needs to sit down w/her and have a 1:1.
only then will anyone get enough feedback as to what her resistance is.
if she's having psychotic based episodes, then haldol is the place to start.
and that comes in many forms.
i just don't know enough about this lady, to be able to advise anything w/certainty.
God bless her.
she sounds like it's a part of her personality, where going out kicking would be in complete sync with who she is.
and check her bowels!!!
i've seen pts homicidal when it came to being constipated.
Specializes in psych, addictions, hospice, education.
I personally don't believe that anyone should suffer for anything but I have had patients tell me they need it, so I have to fight my own thoughts about it and honor their wishes....
I actually thought about liquid ativan while I was (unsuccessfully) trying to sleep today. I remembered that another resident had it in the past, and thought it might be easier for one of my other residents on ativan as well.
Never before have I been so concerned about someone that I bring it home and CAN'T sleep. I hope something changed today to ease her suffering... I was doubtful about the fentanyl patch as well, and for some reason the type we now get continually fall off the residents into bed. I'll see what I can do to make some kind of change tonight... if she hasn't met up with Henry yet
Whispera, MSN, RN
3,458 Posts
Have you considered that some people feel they must feel pain in order to meet their God, as a way of atonement for whatever they think their sins are? I see the terrible position you're put in, and my heart is with you. I think an increase in fentanyl patch dosage might help too. Family has been called to come? I'm wondering if she's actively dying and beginning her stage of terminal restlessness?