Please someone help me understand..........

[TinyRNgrl]

Twice this past week we received two hospice pt's, two days apart, who were actively dying. Mind you these hospice pt's were DNR/DNI/DO NOT TOUCH ME I WANT TO DIE IN PEACE! One pt wasn't even in the ER 20 minutes and she passed. Thankfully the family made it to the hospital and was at the bedside. And it was a horrible night in the ED. We were getting our butts kicked bad. Every bed filled, flying out a critical, and several other critical pt's to care for. I was so angry that this poor pt was uprooted from her bed, taken from her normal surrondings, shoved in an ambulance and brought to us. The bright lights, hard beds, unfamiliar faces, weird sounds and sometimes horrible smells. What happened to dying with dignity in your own surrondings. But the nursing home didn't want to do the paperwork so they sent her to us. The pt's nurse was tied up with the critical pt being flown and I couldn't stand the family in there by themselves. Her sats were in the 60's, HR in the 20's and she was only giving an occasional gasp. I went in and stood by the bed quietly. I explained that her heart was slowly stopping and that her breathing would soon stop. After a few minutes I watched her heart go into v-fib then a few seconds later asystole. I stayed a few more minutes with the family until the other nurse could take over.

The next night again, another hospice pt, actively dying. This time because the dr. didn't want to give the hospice nurse V.O. to increase the morphine to make her comfortable without being medically cleared! Granted she was getting a pretty hefty dose of morphine Q1 hour, but her lungs were diminished in the bases and full of fluid you could hear her breathing from across the room. So, we had to do as the family and dr wished. Put her on bipap, put in an iv, push lasix yadda, yadda yadda. I believe these were comfort measures because it did help her breathing but the poor lady just wanted to be free from her pain. She did pass later that night.

Is this common where you guys work?

[0402]

What about the ones that get admitted? We had a 103 yr old that we had just sent home about a week ago, on hospice, who was sent to the ED because the "nurse" (I put it like that because I don't know if it was an RN or an aide, and I'm thinking it was an aide but the word nurse was being used) didn't "like her breathing." She was covered in pressure ulcers and had to deal with being transported to the ED, getting transferred to our unit, only to be transported home again the next day. Why in the world wasn't she kept home and just had orders adjusted to keep her comfortable? She was 103, for goodness sake!!!!!!!

[demylenated, BSN, RN]

At the hospice I worked at, if they get admitted to, or go to the hospital, they get dropped from hospice. They are on hospice for a reason!!!

Let them die, at home, in peace. UGH!

[DixieRedHead, ASN, RN]

There is relatively no that much paper work in an LTC facility for the passing of a no code resident. This is truly a shame.

As for the doctor who didn't want to give the morphine, that should have been handled by the hospice doctor and or nurse. Someone is always on call.

As for the 103 year old, somebody needs to give the hospice team an inservice.

[Nascar nurse, ASN, RN]

In my facility it would take more paperwork to send someone out to the ER then it would if they died in the facility while on hospice care.

As stated in another thread recently I think this is a systematic problem. I see at least 2 potential problems with the situations you describe.

1. Families just aren't equipped to take care of these seriously ill people in their homes. If a patient is 103 then just think how old their "kids" must be - easily in their late 70's and maybe in their 80's! Elderly taking care of elderly. They physically can not do it, ie: the pressure ulcers and other indications of poor care.

2. We have a society that believes death is unacceptable. People must be saved at all costs and I'm learning that all of us seem to attempt to be educating the general public from our own unique settings but the message does not seem to be getting thru. Just today I dealt with a horrified daughter of an 80 year old LTC resident. She just couldn't believe I was suggesting to let her Mother die (she refused to hear the word "peacefully") or that Mom could benefit from hospice. I swear she looked at me as if I had 3 eyes and 2 purple horns growing out of my head. You would have thought I planned to go down the hall and shoot Momma as soon as the conversation was over. When this poor lady takes the inevitable turn for the worse and death becomes imminent I will probably have to send this lady across town to the local ER or face getting sued by this daughter that believes Mom's condition is reversible....sorry dear daughter, but I can't make her a happy/healthy 40 year old again! I don't want to send her to you ER people either. The resident is a lovely little lady that we all know well - we WANT to care for her to the end but the choice isn't ours to make.

[cosmicmama, BSN, RN]

Yes, very common everywhere, probably. Hospice or not, people are uncomfortable with dying. Families don't realize that there are things far worse than death. It's just part of our culture, the fear of death. In my opinion, birth and death are two normal processes that, most of the time, belong at home.

[Jess_Missouri_RN]

I watched a 60 minute episode last night about the cost of dying patients in the hospital and it was $55 billion last year to taxpayers for mainly the use of ICU, consults and tests. One elderly lady with liver and renal failure spent her last 2 months of life in and out of a hospital with 23 consults, tons of labs and tests and ended up passing away in a hospital anyway. Bottom line, one doctor stated that families are afraid to allow their loved one to die and are looking for a medical miracle. It was an informative episode that everyone needs to watch especially those who are afraid to allow death (which is a natural part of being human) happen to their elderly frail 103 year old mother.

[sapphire18]

These situations make me so angry and sad. People seem to forget the meaning of the word "hospice" or the term "comfort measures only"....

[Jess_Missouri_RN]

http://http://www.alzheimersreadingroom.com/2009/11/60-minutes-cost-of-dying-video-and.html

The link if you would like to read about it :)

[Anna Flaxis, BSN, RN]

If I understood it, I'd be happy to help you understand it, too.

[VICEDRN, BSN, RN]

We had one recently who's discharge instructions read (in bold capital letters): PT is DNR/DNI. DO NOT DRAW LABS. DO NOT RETURN TO ER. CONSULT XYZ HOSPICE GROUP."

Pt was returned to ER 11 hours after discharge for AMS. The MD called the facility and personally spoke with the "nurse" who apparently said no one had ordered the consult so she had no choice but to return the patient to us. She also said she did not know the patient was dying. (??!!)

Either you laugh or you cry.

[subee, MSN, CRNA]

When Medicare stops paying for hospice patients to be sent to ER, the practice will stop. This sounds like sloppy hospice to me.