silverwillow

We also post the memorial service times in our office and someone from our department will attend to represent us all.

It is in our medical director contract that they will be willing to assume care for patients who are from out of town and have no primary physician. He is always great about taking them, and we have never had a problem. In many cases, as stated by others, our medical director becomes the default physician that we call for new orders and many primary physicians prefer it that way. When I send the initial certs to the primary for signature, I sometimes put a statement there that the medical director may be called for orders. I have never had a problem with the primary MD not wanted to allow that.

Exactly, and in my patient's case, the Ativan is not for chemical restraint. It's unfortunate that hospice patients in SNF are subject to the red tape of it all. For patients at home, we make Ativan, Roxinal, etc available for when they get imminent and really need symptom control. Patients in facilities should have no less.

We have a patient that went out of service area and is now having symptoms and wanting to go to the hospital. Does he need to sign a revocation before he recieves care in the hospital? What do we do if he doesn't sign one?

Does anyone else have any experience with skilled nursing facilities asking hospices to lower patient's Ativan doses so that the patient meets Obra 22 guidelines? I have a patient that takes Ativan 1 mg every 8 hours prn. She has COPD and needs it. She's been at this dose for years. They want me to change it to every 12 hours so it fits in with Obra 22. Does that even apply to a hospice patient not taking the med for behavioral reasons? Hope to hear from someone on this real soon. Thanks

That's the same kind that we use. The direction of the bevel is a non-issue because it points straight down and is just secured with a tegaderm.

Thanks. I feel much better after your post. He is not eating. I figured since we weren't going to be able to transfer him anywhere we might as well start him on morphine IV since he's inpatient anyway. He was still pretty restless. We now have him up to 20mg/hour with S.L ativan and he's still restless, but settling down and having cheyne stokes, etc. So my gut instinct at this point was to just leave him in the hospital. Glad you felt the same way. Sometimes it's just having another opinion that makes the whole difference. Thanks for replying.

Thanks for your response. He has occasional agitation where he tries to climb out of bed, but I'm not sure how much more we can actually sedate him at this point. He's pretty sedate already, just arouses occasionally. His symptoms are otherwise managed. We do have a contract with the hospital where he is staying. He has metastatic ca, end stage. I am suprised he has made it this long actually. We have him on a Fentanyl 100 patch and ativan. He is still inpatient because we have not found a SNF willing to accept him.

Second time this year, I just had a spouse completely fall apart and become completely unable to care for the patient, called 911 in the middle of the night and called me after the paramedics left with him. Now I have him inpatient and can't seem to get him placed anywhere. Does anyone have any experiences like this? Any ideas on the documentation I need to be doing to justify the hospital stay?

The more I read this, the more I realize I should count my blessings. We work 40 hours Monday-Friday, with 7 days on call, then 7 days off. 4.75/hour for carrying the beeper from 1700 to 0800, two hours automatic call pay if you're called out, in addition to the time and a half you get while being out. 44 cents per mile. Very small agency, rural area.

I agree, and do them on a case-by-case basis. Often, family members expect it, perhaps trying to keep their own type of 'death gauge' going, so they can prepare themselves. I often remind them that I would be happy to take the patient's vitals, but I also review signs and symptoms of dying with them so they can know what to watch for as the time draws near since vitals alone are often not a good indicator. Sometimes when caring for a fairly alert dying person who is alone, I feel kind of guilty when taking their vitals, almost as though am I nonverbally asking "are you dying yet?" I do vitals about once a week on all of our patients, mainly for the chart's sake.

Sorry to hear that you had so little orientation. If they are so busy there, they should have just let you do revisits for awhile to let you get ahold of the hospice philosophy, which as you know is alot to learn in itself. Gaining confidence about decisions you make is important, and your agency should be allowing you to focus on symptom management, etc before throwing the heavy things like recerts at you.

Thanks for the support everyone, it helps. At least I have the weekend to recover. :) It was a 3-4 day stay. Not sure if that is normal. Lots of work trying to chart it all since our agency has one method and the hospital another.

I just had my first GIP. It was a hard case. Caregiver breakdown (complete) and acute management of symptoms. She had hospital GIP. It lasted a few days and I'm still exhausted. I hope I don't get another one for a long time.

Just curious on what others' experiences were as far as needing to use GIP for management of acute symptoms/caregiver breakdown? How long in? Any trouble placing patients?