Needing advice

westieluv · Feb 18, 2012

Sometimes you can't, no matter how you put it. So many hospice patients end up getting admitted and dying a day or two later, or just never getting admitted, simply because they or their families are not ready to face the reality that they are dying. I am a hospice intake nurse and used to be an on-call nurse in the field and I see it everyday. It's so easy for us to see that someone is dying and that there is no further hope of a recovery, but convincing that person's child, or parent, or spouse of 60+ years of that fact is sometimes just not possible, no matter how good of a job we do of explaining it to them. It's just a fact of working hospice.

BTW, I'm not sure how other hospices operate in the case of tube feedings, but we have had patients with tube feedings on our hospice service if it is a comfort measure. An example would be someone with esophageal cancer who can no longer take any nutrition by mouth but is not yet in the end stages of death. In a case like that, a tube feeding would meet hospice guidelines.

SappyRN · Feb 18, 2012

unfortunately sometimes people are not ready to actually hear that their loved one ie dying. Something that helps is to be able to fully explain hospice. Every hospice has their own policies, but the family needs to shop for the one that will meet theit goals and needs. You do not have to be a DNR to be on hospice, but we will try to acheive that status. You always have the right to fire a hospice that is not meeting your needs. You should be alowed to continue previous medications as long as they are indicated, not harming you, and in some way helping even if sometimes the help they are giving you is merely the belief that they help. (I say again, reiterating as long as they are not harming you) palliative care is emotional, spiritual, and physical. Our company doesnt require a patient to stop feedings as long as the patient can tolerate it. We teach the family what that means... is the patient aspirating? What are his residuals. How much edema. Lung congestion. It is a process. Can we merely adjust the rate down to a more tolerable lefel. Then teaching further about the outcomes of the intervention. Poss wt loss, decreased nutrition, protein malnouishment, etc.

Patients often live longer with hospice that initially expected because the constant availability of staff to intervein and the interdiciplinary process. The POC/interventions are patient and family driven. What do they wajt at this time. We do not have an expectation really of how long the patient will live other than at the moment of admission the patient has an "expected" limited life expectancy of 6 months or less if the disease process continues on its normal path, which is very vague because human will is not a factor.

We do not tell a patient that they are "not allowed to go to the hospital," but we will explain that if there is not a contract at that hospital, it will be necessary for them to revoke their benefit sovthe howpital can bill medicare, not the patient. We will explain doing this several times will eventually lead to our decision not to readmit.

We have alternate levels of care where we can provide nursing care in the home for block times from several hours daily to 24 hrs daily for symptom, crisis interventions.

Pateints/families need the reassurance that hospice in not just giving up and taking someone home to die. Its about providing the best care possible for someone that is likely dying. If you have a particularly difficult family, tell them honestly that every hospice differs somewhat and ask them to interview several that service youtlr area to determine if one will meet their needs. Have more than one person present at the education visit, write important questions down ahead of time so they dont forget them. They need to find the company that makes them feel good about the decision, one that makes them feel supported.

When somebody dies, the people left behind have to be able to go on with their lives without constant regret that they didnt do enough. Shopping for the right hospice will help them have control and starts them in the mindset that they are still looking out for their lovedone's best interest.

tewdles, RN · Feb 21, 2012

I work on a med/surg unit and sometimes we get hospice patients.
I had a pt the other day who would have benefited from hospice care. the wife after speaking with the pt's children decided that she was not comfortable with what hospice had to offer due to the fact that they would discontinue his tube feeding. I tried to explain that loss of appetite is part of the dying process but she wasn't having it she just wanted to take him home and believed he would rally. He was struggling to breath, had several wounds and non responsive. The doctor was very up front is saying he didn't believe the patient's condition would improve.
So how do you tactfully say that someone is dying and comfort is the best thing you can provide them?

We all find our own words to convey those sentiments about death, dying, dignity, and comfort.

What is important is that patients and families understand that their hospice plan of care is developed WITH them, not for them. Generally, if they do not want to DC tube feedings then the TF's are not DC'd at that time unless it can be documented that the feeding IS currently causing harm or distress for the patient. No matter, the family requires your support, unconditional regard, and expertise as they navigate these frightening and overwhelming choices and treatment options.

Good Luck!

Marshall1 · Mar 2, 2012

Did someone from hospice come and talk to the family or was this the nursing staff and MD? Unfortunately, there is a lot of misunderstanding, still, on what hospice is and what they can do for a family in crisis. Sometimes a family will meet w/someone in hospice and decide it is still not for them or vise versa but I personally think it would be best to let the hospice folks answer questions themselves about their services. I am huge "fan" of hospice, the nurses and other staff who work in this area and what hospice can do for a family/patient.