New nurse, working with cancer pts with advanced disease...

[5150dx]

Aloha,

I recently graduated and have begun to work in a local hospital. My only experience with Hospice was when my dear friend was dying of leukemia and complications last year -- the Hospice was great! I am 38 and have worked as an EMT on fire dept. and ambulance so am not new to dealing with pts. and family at time of death -- just not the long drawn out kind.

I am finishing my first month, with a preceptor, on the medical unit. 3 CA patients whom I met early on, have all returned, in varying stages of condition. Yesterday, a dear man with lung ca with mets to spine, brain and probably abdominal organs appears to be nearing death. He had been going into Hospice when I met him first, but then a family member convinced him "you cand just do nothing" so he changed his living will to include all efforts.

My pt. is mostly unable to respond, no oral intake to speak of for a week, on iv fluids, getting decadron ever 6 hrs and iv ms every 2 -- ativan appears to increase moaning and thrashing so I stopped using, seeing him mellow more and be more restful with just the ms. HOB elevation, relieves his acute respiratory distress. 2 days ago his feet ballooned up and he and I joked about when they would "pop". Now, they have improved because we have a "compliant" patient who has ended his efforts to sit on the edge of the bed -- of course the fluid appears to have just gone to his belly, sacrum and lungs. As long as he doesn't get moved (which we still have to do to avoid decubs), he seems mostly comfortable.

The poor doctor is so frustrated with the patient's code status, and is even considering interpreting the pt's living will which says he wants the "normal standards of care for his disease process" to mean no cpr or artificial feedings. I feel for him and am impressed that he cares enough to think this way, even if he ends up not risking it for fear of being sued by distraught family.

The other pts. both will likely be called terminal soon -- advanced small-cell lung ca with mets to brain upon diagnosis, doing poorly with chemo and radiation and a lady with met ca to lungs, uterus, bladder and more. Yet another is fighting met. cervical CA, at a point with bi-lat nephrostomies, bili bag and now dialysis, and tpn. She already did chemo and other options which doctors could offer, with no great success.

I guess I am struggling with my own feelings that they should be working with hospice -- trying to balance that with patience that each person needs to figure it out in their own way and time -- and some may never choose it.

It just saddens me and I know I will find a way to choose the best words to help the families and not color them with my frustration about THEIR denial. Thanks for listening!

[chimama]

Don't think of the situation as a long drawn out death. Think of it as the rest of your patient's life.They are living right up untill the moment they die.You can establish a relationship and a trust with them so that you can assist them in acheiving their death in the manner they choose.And you can always reassure them that nothing is written in stone...they can always change their minds.No one knows how to die.We just help each other along the way.

[KraziNurs]

aloha,

i recently graduated and have begun to work in a local hospital. my only experience with hospice was when my dear friend was dying of leukemia and complications last year -- the hospice was great! i am 38 and have worked as an emt on fire dept. and ambulance so am not new to dealing with pts. and family at time of death -- just not the long drawn out kind.

i am finishing my first month, with a preceptor, on the medical unit. 3 ca patients whom i met early on, have all returned, in varying stages of condition. yesterday, a dear man with lung ca with mets to spine, brain and probably abdominal organs appears to be nearing death. he had been going into hospice when i met him first, but then a family member convinced him "you cand just do nothing" so he changed his living will to include all efforts.

my pt. is mostly unable to respond, no oral intake to speak of for a week, on iv fluids, getting decadron ever 6 hrs and iv ms every 2 -- ativan appears to increase moaning and thrashing so i stopped using, seeing him mellow more and be more restful with just the ms. hob elevation, relieves his acute respiratory distress. 2 days ago his feet ballooned up and he and i joked about when they would "pop". now, they have improved because we have a "compliant" patient who has ended his efforts to sit on the edge of the bed -- of course the fluid appears to have just gone to his belly, sacrum and lungs. as long as he doesn't get moved (which we still have to do to avoid decubs), he seems mostly comfortable.

the poor doctor is so frustrated with the patient's code status, and is even considering interpreting the pt's living will which says he wants the "normal standards of care for his disease process" to mean no cpr or artificial feedings. i feel for him and am impressed that he cares enough to think this way, even if he ends up not risking it for fear of being sued by distraught family.

the other pts. both will likely be called terminal soon -- advanced small-cell lung ca with mets to brain upon diagnosis, doing poorly with chemo and radiation and a lady with met ca to lungs, uterus, bladder and more. yet another is fighting met. cervical ca, at a point with bi-lat nephrostomies, bili bag and now dialysis, and tpn. she already did chemo and other options which doctors could offer, with no great success.

i guess i am struggling with my own feelings that they should be working with hospice -- trying to balance that with patience that each person needs to figure it out in their own way and time -- and some may never choose it.

it just saddens me and i know i will find a way to choose the best words to help the families and not color them with my frustration about their denial. thanks for listening!

remember, assisting a patient to a peaceful death is a part of nursing and that is what you are trying to do. it saddens me when we get the referral to hospice too late and the patient has already been "treated to death" as my colleagues say. i have to remind myself that there are many different reasons for this. sometimes the patient isn't ready, but many times the family is not ready. sometimes the physician refuses to "give up" and views these situations as a personal failure, though your physician seems to be very compassionate. all you can do is what you are doing - support your patient and be a resource for this family when they are able to utilize you. i feel strongly that our highest calling as nurses is to advocate for our patients. this is one of the reasons i enjoy hospice nursing because i know i am helping my patients receive the care of their choosing. hang in there - your heart is in the right place!

[Nur_1996]

I think this is how I am feeling. I am fairly new to Hospice and I am saddened by the "lingering" sometimes that happens when people are dying. Tonight I got very teary after talking to a pt. with ALS. She is completly aware of her DX and is having a hard time right now. I feel that I am doing a good job, I guess I just have to get used to the fact that I cannot change things sometimes, and people can and do die. I work nights I think I need more sleep or something..?