EmptytheBoat

Dear cherokesummer, Please don't worry yourself at this time with possible mets, nothing to be done. From your origianal posting, it appears to me that your FIL is imminently dying, and your focus should be on keeping him comfortable. If this may be done best in an inpatient Hospice, that is the direction you should head. I, personally believe, that this may be done in the home setting, equally as well, so be it, that your husband and other family members are committed to his care. A foley catheter, as mentioned on another post, would appear to be most beneficial. Pain is manageable with the Fentenyl patch and liquid morphine, restlessness may be managed with ATC Ativan/Xanax, Ativan readily available in liquid form. Oxygen would be beneficial with no bad side effects. Appetite not an issue, forcing food/fluid at this stage may be more problematic, refer you to http://www.crossing thecreek.com for an excellent resource. At home, FIL is familiar with surroundings, and loved ones more readily available, and nothing, nothing will take away the memories and satisfaction of being there to ease the transition from this life into the next. Take Care and God Speed!

Dear cherokeesummer, Excellent suggestions from ktwlpn, you may also try a tray of cat litter under the bed, cat litter will absorb some odors. I would also address the source, possible UTI and/or yeast infection which may be pallatively treated with oral antibiotics/ Diflucan. Best wishes!

Dear NurseCherlove, Thanks for your input, you had some excellent thoughts. Bowel obstruction may have been a factor especially with one of the two patients, she had rapid growing tumor(s) in the peritoneal/abdominal areas. I've considered the drug issues, both patients were on the Fentenyl transderm patch, one was being given morphine concentrate frequently, the other was not. Also, as you inquired, I can't be sure if there was mets to the brain, in either case. You're correct, we get several patients in Hospice that have the primary cancer, some mets to other organs confirmed, but the oncologist has stopped testing before getting CT of head, even when mets to the brain may be suspected. But, then again, I've had several Hospice patients with brain cancer or where mets to the brain has been diagnosed that did not have the projectile vomiting just prior to death. Thanks again for your input.

Thank you leslie, I was hoping for your input. Best guess with my two patients would be metabolic imbalance, both patients had extensive, rapid growing tumors throughout their bodies (sarcoma and melanoma). I'm glad to hear this is rare, I've experienced the two cases in my 3 years of Hospice, but they came within a few months of each other, and I felt helpless. Thanks again leslie, and thanks to your medical director. Our medical director is a GP and new to Hospice. I will discuss with him at our next IDT. Take Care!

My experience with assisted living is not good, and unless you are willing/able to provide continuous care, it is unlikely that symptoms will be managed as the patient's disease progresses. The ALF's I've been involved with require the family to be available to administer prn medications, and only provide assistance with ADL's on a scheduled basis. I just experienced a Hospice patient being removed from an ALF because the family was upset that the ALF was unable to provide the care they had assured the family they could provide, and then, refused to reimburse the family's prepayment because the family did not give 30 day notice. Patient went home with 24 hour sitters and died peacefully and comfortably with very attentive sitters, for approximately the same amount of per diem the family was paying the ALF. In this area, the number of ALF Hospice patients is on the rise because Trinity Hospice now owns Sunrise Assisted Living Facilities.

No warning on impending vomiting, both patients semi to fully comatose, non-responsive to verbal stimuli at the time. Neither had brain mets, both had extensive tumors, thus my assumption of the body purging itself of toxins. Do any of you instruct the families that projectile vomiting may be one of the symptoms with impending death? Thanks for your replies.

I've had two cases within the last few months, pt. w/projectile vomiting just prior to death, both cancer patients. I've explained this to the families as the body's method of expelling the buildup of toxins from the cancer. In both cases, the episodes of projectile vomiting caused much family consternation and anguish, tainting the otherwise smooth, peaceful transition into the next life; and leaving this Hospice nurse with a feeling of inadequacy and helplessness. I'm asking for your input. How do you explain the projectile vomiting to families? Is there anything you do to prepare patient or family for this possibility? Is there anything you do to try to prevent or do you think it may be prevented? Thank you for your time, I wish you all the best. God Speed!

Dear cherokeesummer, I'm glad the fever responded to Tylenol. There have been other threads here regarding elevated temps, some Hospice nurses treat the temps, others don't. Others here have addressed causes of increased temp, may I also add the possibility of infection, and, in your FIL case, may be caused by the cancer tumors, and is referred to as tumor fever. Take care, your FIL is blessed to have you caring for him!

Dear Atl John, Dying isn't always pretty, but it's challenging. You present as a very compassionate guy, and Hospice is all about compassion. Best wishes and God Speed!

Hello River, Here in Louisiana, LPN's are used as mc3 describes in Florida, LPN partnered with RN to manage a case load. I've mostly worked with a part-time LPN, or a shared LPN (with other RN case managers) and has worked very well. I've not worked with a LPN who did recerts, IDT reviews, or updated care plans, but would welcome. Some of the Hospices I've worked with have used LPN's on-call and has worked well. LPN's may pronounce death in Louisiana. Take care.

Don't wait until he gets worse, titrate medication until you get your patient comfortable; and let your total assessment determine his comfort level, use your education/experience.

In this situation, the pleural taps are pallative, and Hospice needs to step forward. Your mother needs to be supported throughout, but issues need to be addressed and resolved, denial/avoidance isn't an option. God Speed!

Why the rush to judgement? Drive-by Hospice? Where's is your coordinator/administrator? Is marketing dictating nursing care? What pallative care can you provide with this situation?

Spelling and literacy would be a start. Best wishes!

Duragesic came out with a 12 mcg patch, I understand they are expensive, relative to higher strengths, but gives another tool when titrating medications.

Dear Sukichaz, I'm sorry your Mom (Happy Mother's Day) is going through this but what a loving and supporting family she has. To answer your questions: (1) You don't necessarily need to taper down the Fentenyl patch, if your Mom is not having any pain, you may discontinue. You mentioned you had Oxydose and that may be used for any acute pain your Mom may have. Oxydose is a quick-acting pain medication and is not sustained so frequent dosing may be required if your Mom has consistant pain. I would suggest another short-acting medication such as Lortab or Darvocet on an as-needed basis, these meds provide more sustained relief and will help you provide better pain management. (2) Fentenyl is a derivitive of morphine and may be used for dyspnea, but in patch-form, is not the preferred route for acute dyspnea. Yes, I believe a shorter-acting medication would be preferable. For dyspnea, I like to use Ativan/Xanax, either scheduled or prn, starting low and titrating if needed. These medications may also cause sedation, but usually not as much side-effects as the opiates. Best wishes to your Mom and family, God speed.

LPN's in Louisiana are invaluable, we couldn't manage without them. skittlebear, don't fret, not much to chart on a death; no pulse, no respirations.

Being a Hospice nurse means that God has entrusted you with the compassionate care of the terminally ill to transition from this life to the next in peace and comfort, and to provide strength and support for the caregivers and families to accept His Almighty Will with courage and faith.

As a fellow Hospice nurse, I'm empathetic with your situation, psychosocial issues are challenging. Sometimes it's difficult to distinguish if someone is being nosy or genuinely concerned. Once I establish a boundary, I usually use diversion/humor, eventually the boundry is respected. Good luck!

Dear mim-o, I'm sorry you and your family are going through this experience with your loved one, and I'm thankful that you have a good Hospice team and your loved one is comfortable. Hospice is a wonderful program and under utilized. Please use your experience to educate your community. God Speed!

I've had it both ways, SW helpful with consents and allieving some of the families' fears; then, merely present to complete their psychosocial assssment and distracting/delaying the admit. I've also had both the SW and Chaplain present at an admit, overwhelming and chaotic. My druthers would be to have the SW/Chaplain do consents and address psychosocial matters prior to my nursing assessment.

Dear Windsong, I'm sorry your posting was not an April fool, if I were to think of an April fool for hospice, or either a nightmare, I couldn't have come up with a more demanding situation. I can't imagine the stress you must be having, you are not a cry baby, but you must be super human to keep up with your work load and 24/7 on-call. You ask, what would you do? I would find another job! As for the patient 100 miles away, I'm unable to think of a manageable situation other than to convince your patient to go to the in-patient unit or to revoke from your hospice and utilize a hospice within the service area, hopefully with adequate staffing. Take care of yourself and may God bless you for your perseverance.

April fool or just a fool?

cookie102, the fact that the patient (and/or family) does not want to officially sign on with hospice may have been the cause of your frustration. If taking call, you should of had access to the patients medication profile before your visit to determine what medications were available at the house. You handled the situation well by calling the physician for orders. I believe that your agency needs to discuss the patient's needs and wants, develop a plan of care, and communicate. It appears that this patient fell in a crevice between HH and Hospice, and is not being adequately managed. The patient (and/or family) need to be educated on pain management.

mpingo: I'm a hospice nurse, I've worked with/for several different hospice organizations, and I've not been made aware of any specific protocols concerning medication. Each pateint is assessed and evaluated and an individual plan of care is established and adjusted on-goingly. The hospice organization may have established standing orders, not all do, from the medical director for medication, the standing orders are not considered protocol for every patient, but are used to allow hospice nurses to react quickly and efficiently to manage individual patient's symptom(s). You mentioned that you recently took care of a patient that was chronically ill but not terminally ill. Hospice is for the terminally ill, terminal illness being that two physician's have diagnosed and determined that the patient has less than 6 months to live. Hospice already has government regulations concerning hospice-appropriateness, and hospice agencies are bound to follow specific guidelines.