Patient care question

softrbreeze · Nov 23, 2015

Hospice focuses on comfort care as you said and, depending on prognosis, preventing pressure ulcers. If a person seems to be pre-active, I would focus on keeping them comfortable even if that meant minimal turning, bathing, etc (depending on their wishes if able to state them). However, predicting death is extremely hit-or-miss unless they are actively dying and even then, the dying process can last for up to a month. Pressure sores are nearly impossible to prevent if a person is going weeks without any PO intake or IV hydration. Catheters at EOL are typically not used, at least not outside of inpatient hospice, unless there's a decubitus that needs to be kept dry or if the PCG is incapable or unwilling to do all of the necessary work. The informed patient always has the right to decline care. Some are perfectly happy to die and have no interest in sustaining that quality of life. I would do all I can to make him comfortable with his heels floated but if that is not possible, let him have his way. Definitely DON'T force the SCDs. It's the rare pt who refuses to be turned. I'm curious why the MD, pt, family or whomever would allow a GT to be placed when he has advanced cancer though. That seems counter-intuitive, if not outright abusive.

LadybirdRN · Nov 23, 2015

It was extremely ridiculous that he was even admitted. The tube was placed by IR while he was in the ED. Being admitted mean multiple lab draws, IV, Wien up for vitals, not mention being away from home- pretty much the reason most people choose hospice. My charge nurse and I tried to get him discharged from the ED. The admitting physicians response was "I already admitted him so he has to stay overnight." I felt pretty bad about it, I thought it was inappropriate. And, I could never get his code status changed either.

quiltynurse56, LPN, LVN · Nov 23, 2015

I am confused. Was he a hospice patient? I am asking because of the G tube and the lack of a DNR.

Jensmom7, BSN, RN · Nov 23, 2015

Hospice is all about choices. Some of them are ultimately better for the patient than others.

That being said, if the patient was still making his own decisions, he had every right to request a G-tube (yes, I cringe at the thought, but...choices).

The thing is, that would NOT be recommended by the Team as part of the Hospice Plan of Care.

Once this was (hopefully) explained to the patient, if he still wanted it, he would have to revoke Hospice for the duration of his stay (has to do with Medicare will pay for EITHER aggressive treatment or comfort care, not both. When the Hospice benefit is revoked, the patient flips back into traditional Medicare). Once he's home, he can again be admitted into Hospice.

Except that now he has a flippin' feeding tube that's going to prolong his existence and cause any number of problems. But...choices.

Also, you don't have to be a DNR to be on Hospice. Seems counter productive, but it is what it is. I've had a few, and they are told from the get-go that should anything happen, they will have to call 911 and go to the ER. I'm also not above educating them on what CPR and codes are REALLY like (as opposed to what people see on TV). Usually doesn't take long for them to decide it sounds awful.

I have had a few hold-outs, though. Usually that one family member who sincerely believes MeMaw is one day going to get up out of bed and dance around (MeMaw has Stage IV breast cancer with bone mets, probable brain mets, and hasn't been out of bed for a month). Choices.

And people think Hospice is easy.

Anna Flaxis, BSN, RN · Nov 23, 2015

It was extremely ridiculous that he was even admitted. The tube was placed by IR while he was in the ED. Being admitted mean multiple lab draws, IV, Wien up for vitals, not mention being away from home- pretty much the reason most people choose hospice. My charge nurse and I tried to get him discharged from the ED. The admitting physicians response was "I already admitted him so he has to stay overnight." I felt pretty bad about it, I thought it was inappropriate. And, I could never get his code status changed either.

You can bet that the ED staff weighed in too, and yet this is what was chosen. We can educate the decision makers (sometimes it's the patient, sometimes it's an MPOA, sometimes it's a neighbor/friend/distant relative because the patient is unable to communicate, has no Advance Directive, and no family members. etc.) but in the end, we have to abide by the wishes of the decision making individual.

In this instance, since the patient was able to communicate his own wishes, I would make sure he knows what the SCDs are for, but if he still doesn't want them, leave them off and document a refusal. Same with turning and positioning- pretty much anything he doesn't want. Offer a rationale for the intervention, but honor the refusal and document appropriately.

I agree the feeding tube placement will most likely just prolong his suffering. At end of life, it's not really a comfort measure. However, he made the choice and I would honor that.

As far as discharging home from the ED after an invasive procedure, I agree with keeping him in the hospital overnight. The respite may be beneficial for his caregivers, and I feel it decreases the likelihood that he will just return to the ED within 24 hours when he or his caregivers feel overwhelmed.

LadybirdRN · Nov 23, 2015

To the last two responders, this man speaks only Viatnamese, he lives in his daughters home and she works at the hospital in the pharmacy, which I personally believe is the reason the decision was made for the tube. He has nasalpharalengal cancer with mets to the lungs. He was skin and bones and is asleep or in pain, with additional pain now, due to the tube insertion. The family never brought in the advanced directives; I tried to find them somewhere on a previous hospital visit and couldn't find them. It was the weekend and he got admitted over the phone and the admitting physician didn't see him until the following afternoon. The on call doc wasn't going to change a code status on someone else's patient. The admitting orders did not include pain meds; it was change of shift but I called and got the pain meds ordered. The man normally takes one Vicodin for pain, plus oral morphine drops. The doc spoke to the NOC RN and gave IV morphine 1-3Q 4. I wanted him to have his normal meds; I pondered calling the doc from home and getting the Vicoden added. When I came in the next day, he was in pain; I called and got the Vicodin added and an increase on the morphine 1-4. I kicked myself for not making the call from home that night; the doc could have just ordered it on our EMR. I just knew this whole thing was going to be a debacle from when I got report and tried to avoid all this unnecessary nonsense for this man. He should not have been admitted.

Anna Flaxis, BSN, RN · Nov 23, 2015

That ^^ explains a lot. This poor man. I totally agree with the decision to admit, if for nothing more than comfort.

https://geriatrics.stanford.edu/ethnomed/vietnamese/delivery_of_care/end_of_life.html

LadybirdRN · Nov 23, 2015

I'm not very senimental but he pulled at my nursing, and prob mother's, instinct. I checked on him a lot; touched him and smiled a lot, I just really wanted to help him however I could. We all want to help everyone, of course, but you all know how some patients just grab at your heart a bit.

Anna Flaxis, BSN, RN · Nov 23, 2015

Sometimes we admit for reasons of compassion, not necessarily medical necessity. Thank you for taking such good care of this man.

quiltynurse56, LPN, LVN · Nov 23, 2015

Thanks for the clarifications everyone. I asked because I work LTC where things can be very different. I appreciate any opportunities to learn more as a new nurse.

Jensmom7, BSN, RN · Nov 23, 2015

That ^^ explains a lot. This poor man. I totally agree with the decision to admit, if for nothing more than comfort.
https://geriatrics.stanford.edu/ethnomed/vietnamese/delivery_of_care/end_of_life.html

Um, no, it was BECAUSE he was admitted that his pain med regimen was jacked up in the first place.

Hospice can manage some really severe pain right at home.