river1951

Thanks to you all for your helpful replies. river

Hi, We are evaluating how adding LVNs to our staffing could help stretch our RNs. Since we have no experience, if I could hear from anyone who uses LVNs this way it would be very helpful. Thank you in advance! river

As far as utilazation goes, the patient who revokes loses the rest of that benefit period, which is fairly meaningless since there is no limit on numbers of benefit periods. You have to find a good fit with your team, it is your mothers' death, she gets to say what she wants. Well, different hospices vary but any treatment for the qualifying disease process should be covered by the hospice. Some of the hospices in our area do just that, have the patient disselect to go in the hospital, get a tap, etc. We do not unless the care is aggressive, life prolonging care ,not palliative care to address symptoms. good luck, I will hold your family in my prayers. River

People who have pain can have high pain and still talk- some folks will always rate their pain as a 10. But we still must treat- I would use immediate release morphine elixir and have them give him enough to knock the pain back- get a range from the doc of 0.5 to 2 ml (10-40mg) orally every hour. Total the dose for a day, divide by 2, and voila you have your long acting morphine dose for every 12 hours. That is if he (she) has pain uncomplictated by bone pain or nerve pain- for those adjuvant meds are given in addition to the morphine- for bone pain you can give any anti inflammatory if tolerated (if patient is eating), and for nerve pain you can use valproic acid (Depakoate) or amitryptilline or neurontin. Get a good symptom mgt book. And realize that sometimes patients have unresolved psychological issues, till those are relieved sometimes nothing you can do will matter.. And welcome, it's a great place to do good things! River

Methadone can work very well for cancer pain. Best of luck to you and your brother. River

It is the certification in hospice and palliative care.:welcome:

Way to go all of you!

It sounds ridiculous and stupid, if I understand you correctly. So they are transferring the patient to the inpatient hospice unit to preserve their stats? I get their rationale, but their hearts must be stone. It is different if folks are begging to die at home and we go out and admit for that reason even if the patient has a very short stay, they get something they wanted.

Yes, it is different things to different people, sorta like the parable about the blind men and the elephant. For me, it is about letting folks know they do not walk alone, and then being there for them in the way they need. River

do you feel powerless, strongest no 5-4-3-2-1 i can't solve the problem so i feel powerless 5-4-3-2-1,strongest no i feel overloaded 5-4-3-2-1 3 my job interferes with my personal life 5-4-3-2-1 4 too much to do and too little time 5-4-3-2-1 4 emotional exhaustion 5-4-3-2-1 strongest no how do you rate care for your own healh 5-4-3-2-1 most imp is there a focus group available to you 5-4-3-2-1 this is a yes or no- yes do ou attend team support groups monthly 5-4-3-2-1 no are team support groups made available to you 5-4-3-2-1 yes consider teamwork an important part of reference and support 5-4-3-2-1 strongest yes receive positive feedback regarding conduct 5-4-3-2-1 depends- middle answer try to ask for help 5-4-3-2-1 depends, hospice is an interdisciplinary team, help is built in!! miss work more than 3 days per month 5-4-3-2-1 again, a yes no- no years working in hospice 6mo-1 yr 1-3 3-5 >5 >5 employment status full time part time part time 4 days/wk education adn, bsn, msn bsn gender female age >40 marital status m children y good luck

This is totally unrelated to her hospice diagnosis, so I'm pretty sure hospice would not be billed for it. Medicare sshould still cover it, just as it would any other unrelated diagnosis. River

Michael et al, Fatigued with it, I know was being a wise butt being fatigued with human nature- it is very limiting. That of course is why we just need to help each other along thru this difficult life. Aberrancy? Michael- that's harsh. River

"Your hospice should not be revoking the patient during this procedure. It is related to the patient's comfort and should be paid for by your hospice. The procedure is not that expensive and should not require an overnight in the hospital." Right on! I am so amazed at the number of hospices that discharge patients for getting treatments so related to their terminal illness. I don't understand how they read the COPs so differently than we do. I'm glad your mom is doing better, Sukichaz. I will kee pyour family in my prayers. River

Point well made. I am so simplistic, that at times I have thought the lack of caring equals lack of being able to put yourself in another's place, not the denial you will ever be in that place yourself. Sounds very convoluted but I know what I mean. I guess I equated it with being unimaginative, not scared. I thinnk scared is right. I am scared to die too, but I know I will. I hope I've done everything I needed to for my loved ones, but I'm not perfect. My job has taught me to not be a procrastinator- I've given my sons the heirlooms I want them to have. I tell my family every day how much I love them. I tell my coworkers and friends how much I appreciate them. These are all things my job has taught me. Now, when they tell me I'm terminal, I don't have to do anything different. You're so right Michael. empathy is the most important thing. I used to believe it was caring but I know folks can care and still turn tail and run, it's that darn human nature of ours... I'll be frank, I'm a little fatigued with it... River

Over medicated? If she had no symptoms. I don't understand why any hospice nurse would medicate. So you will have to tell me more so I can understand what you mean. Hospice doesn't mean medicating patients to oblivion; palliative sedation is only considered for those patients whose suffering (i.e. symptoms) cannot be relieved by routine medications. Not that all hospices do everything correctly, broad sweeping statements can't be made. If you don't think we aren't already evaluated to death by joint commission and the government, you are not aware of what is happening in our field. Abd we do regulate ourselves as well- I will tell you this story, I got a patient some number of years ago who had a gangrenous foot and was refusing amputation. We hated to see anyone die needlessly, so we found out the reason she refused the amputation- her surgeon refused to give her adequate pain medication during her previous surgery. We worked to get her pain under control and got her an antidepressant. She then made a decision to have the surgery (from a different MD) and we happily discharged her. I visited her last year and she is still with us. So, though I can understand you believing a specific patient was overmedicated, I think your sweeping statements about hospice needing more regulation is .... I can't even state my feelings about how bad I think that would be- We can barely get folks' pain under control now. Sincerely, river

We do palliative pleural taps all the time and it sounds as if that could be of help. Also positioning and tiny does of oral morphine- very helpful. If this hospice is not interested in helping you have a right to one who will. God bless you for advocating for your family. Best of luck to you and your family- river

There are those black and white thinkers who cannot flex. For ethical principles, I have always been taught it is the desired end of the treatment that makes a difference- If we sedate to relieve suffering and physical death occurs- there was nothing that was going to prevent the physical body from dying anyway, but why should the patient be tortured? We have gone through this with families who insist on feeding by extraordinary means to prolong life, while they are truly only prolonging the patient suffering IMHO. Good luck on your paper. River

Don't give up. We encourage ride alongs if a nurse has never done any home care especially. Good to know if it's the right thing before jumping in. Where are you in the country? River

My thought is that birth and death are not that far apart. Your teaching skills are very important as well as your ability to listen or just be present. I would think oncology would be a great bridge.

At some point the doctors have to give it up! They don't know everything and for some MDs (perhaps many) that is a difficult realization- one never addressed in some cases. I do find, as a hospice nurse that the docs many times turn my requests back on me, as in "Do whatever you think will help." This is not always a good thing, I know I don't know everything, and sometimes really need help figuring out what to do, but usually, I call another hospice nurse first. I have learned after years of calling doctors, that I had better just have a plan they can sign off on. Looking for the doctors to understand hospice, unless they are here with us in hospice seems futile. I remember an episode of MASH where Dr. Winchester tried to find out about the afterlife by interviewing dying patients and then by taking apart all the jeeps in the motorpool in his frustration. I am not ssure where MDs are on this entire issue, even if they are good about referring to us, they may still have not had THE conversation. And many times when I call them, there is a certain irritation present, verbalized by one doctor as "That's why I called you people so you would take care of this for me!" I don't know how many other nurses have had this experience, or if it is only our area. Thanks, Beki

At our hospice we do realize docs look to us to know what to do without pesting them to death. Our solution is to call, let them know our plan and request a return call if the doctor wants something different. This wastes less of their time and our time. We very seldom have a doc not sign and if that happens our medical director backs us up and signs for it. It only happened once to me and it was a cardiologist not signing for a foley in a dying patient- puleeze! Have a lovely weekend, River

not stupid, yes it does. We had a patient on the Actiq which also caused lots of buccal irritation.

In California, it's in the 30's per hour, but you can't buy a house here on that! So think before you move anywhere for better money. :nuke:

Leslie- that is soo hard. I will hold you in my heart and thoughts. I agree self awareness is the way to peace, but I see that for nearly everyone, self awareness is depressing, being human we are all horribly imperfect. Self awareness forces us to look at our own imperfections. How can we move on, when we've done such bad things? This can stand in the way of our patients moving on. It does not seem satisfactory to ask people to forgive themselves; most seem unwilling to accept imperfections, thuis denying their true nature. And I may add, making it difficult for them to pass through till the next phase. At this risk of seeming too simplistic I believe helping our patients accept themsielves starts with our acceptance of them and believing what they say they need. If we are able to accept them as they are, I believe it makes it easier for them to share their needs, etc, etc. We have used ceremonies of forgiveness to assist patients at times. Does anyone else have other things they have found successful in assisting patients to accept themselves and their place on the wheel? River

Well, I can't explain it. Fool that I am, I actually thought lots of people would be talking about their patients and how they were able to help them resolve issues so they could have relax and be ready and not worry. I never thought we'd be just the 4 of us talking to each other. So, the question is open, whay aren't more of you guys in the discussion? River