rnboysmom

The general public is so misinformed about hospice care as it exists today. Start by praising him for all of his hard work. Acknowledge his efforts and his wish to keep her home. Tell him that you have some knowledge about a service that can help him honor his wife's wishes and help him keep her at home. Remind him that the service is probably covered 100% under her Medicare benefit if she qualifies and that this services goals are THEIR goals. We do not come into the home to change wishes, wants, desires, only to assist, as best we can with helping the family meet their goals for a peaceful passing. Hospice is probably the best opportunity he has to assist him in keeping her home! Good Luck!

We are not worried about diversion of lasix (although I have seen some pretty strange happenings in homes with severe diversion issues). Lasix is an alternate option to consider as an alternate to morphine when there may be diversion issues in the home (as I stated originally).

There are a lot of short studies on nebulized lasis, some favorable some inconclusive. Lasix, like morphine works to selectively vasodilate capillaries in the lungs (same as morphine). Some of the benefits of lasix (if it works for your patient) are lack of diversion risk, lack of potential sedating effects and lack of need for a hard script. I have seen nebulized lasix work wonderfully for some but not for others. Trial and error may be the key. But lasix is definitely an option (especially in the home setting where there may be issues with medication diversion). We usually start with 20mg and have gone to 40mg.

Even after 10 years in hospice nursing, I keep a sing up in my office that says... "Being a hospice nurse is....waking up each day knowing your schedule is going to change!" Versitility and flexibility are two of the most important traits of a good hospice nurse. Good Luck!!

WooHoo, what a touchy topic. Responses are interesting here, even in this column. Interesting response by leslie "infections hurt and need to be treated(as long as it's not related to the adm. diagnosis)". Hmmm, I have seen too many of Leslie's responses to believe that she means "we can treat them if they hurt for something that's not related to the terminal diagnosis, but not if it is related to the terminal diagnosis". Leslie's responses are too humane for that type of intended response. We all have personal opinions here, so here goes mine: We treat symptoms and promote comfort. Hospice is a philosophy of care, and that philosophy is different to different cultures, families and individuals. We really do "have to listen and know our patients", asShariWN admirably states. This is not about our opinions, but rather, about the patient and the family unit. How often does an AIDS patient actually die from the disease itself????(very rarely--death is usually from an opportunistic infection) If we treat every single opportunistic infection that pops up during the course of the hospice AIDS patient, we are, in all likelihood, going to cause suffering to that patient, and to that family unit. Our jobs as hospice professionals is to listen, to guide (when asked)and to promote comfort always. Many disease courses, Alzheimer's, Failure to Thrive, have a very, very low mortality rate of themselves. The "killers" in FTT or Alzheimer's patients are the pneumonias, UTI's and aspiration events. How long do we continue to treat these? Always, per request, sometimes per guidance, and rarely if we are at a point where the family is on board, the patient is ready and if the infection is causing no discomfort. If the patient and family have accepted the philosophy of care----we treat the symptoms and provide the comfort and the tools to say goodbye. Recently read a large study with geriatric population and mis-use, abuse of antibiotics for common infections URI's,UTI's----arrrrgggghhhhh, can't find the reference for this column, but the results were favorable towards not treating every infection in the elderly. Along with treating infections comes the risk of C-Dif, fungal and yeast infections and thrush (all of which can be more uncomfortable than the original infection) along with unintended potential side effects, diarrhea, decreased appetite, confusion, psychosis and the set-up for super-infections if we are not able to get every single dose down the patient .Several studies show "less is best" when it comes to adding medications to the elderly patient's regime. Absolutely, DNR does not mean Do Not Treat--- but personal preference is treating the symptoms and allowing nature to take it's course if the patient and family have accepted the philosophy. Very, very frequently, the current pneumonia or UTI (that could lead to sepsis and death) is a much, much more humane death than what is around the corner for patients of certain diseases (metastatic bone cancer, COPD, SC lung, ALS, etc). Okay, that's my personal opinion, now, have at it.....

My only concern with returning meds to pharmacies are your local and state laws regarding transportation of medications. In some states, the only time a nurse or other entity can transport medications is when they come directly from pharmacy and are in a stapled or sealed bag with labels attached. If you are in the posession of an opened drug and are stopped on a traffic stop--what is the liability for your license? In our state, if you are stopped and your car is searched (and they can do this even on a speeding violation and especially if a drug dog sniffs the drug) and you are in posession of a drug that you personally do not have a script for, you can be jailed and charged with a felony---no questions asked and no time to offer explanation. I like the idea of the dish detergent. I know one nurse at a company who carries a small container of "sac-crete" (sp?)(quick set concrete) and pours a small amount into a baggie with the medications and adds water. Our company still disposed into the septic system, but I wish we were more environmentally friendly. We supply all of our patients with disposal information.

ABSOLUTELY!!! You deserve better!!!!!!

Went into home based hospice 6 months after graduation but had worked on a busy med surg floor as a student nurse for a year then 6 months as a graduate nurse. Would I do it again----probably not. I had a lot of life experience even prior to starting nursing school at 30 so I dove in head first. I probably wouldn't have done it at a younger age and agree with the above about the psych experience. Definitely, you need to have some significant life experience or some psych experience, if at all possible. Death is one of the biggest stressors of the family unit and people tend to do strange things that they wouldn't ever THINK of doing at any other time in their life. It takes a lot of composure, compassion and sometimes some quick thinking on your feet. Good luck with whatever you decide to do!!!!!

What it takes to be a good nurse is not the same as what it takes to be a good test taker. I know some co-students I went to school with that passed with 75 questions and 8 years later still have weak clinical skills--I work with a few of them. As soon as I read your post, I knew you were a nurse at heart (you never give up, get back on the saddle, pull your resources, seek resolution, and do whatever it takes to complete the task). Congratulations!!

just read an article on www.advocatefornurses.typepad.com if you click on the link and read the article it states that the reason for the hold is that reporting infractions of nurses in the state of Indiana ;goes through the Attorney General's office and REPORTS to the Indiana State BON which is different than in most other states. Inidana is working with the NLC to revise the rules for Indiana. The end of the article states that they are aming for a target date of July 2009 for Indiana to have status in the NLC Hurray!!!!!

Jimminy, the pitfalls of being a hospice nurse and getting what we need in a timely manner for our patients. I think the pharm laws vary state by state. In our state, the pharmacy has to have a hardcopy script on hand within 5 days (some of our local pahrmacies have a policy stating three days so that they are well within the range). Any of our pharmacies will take a schedule 2 order by phone from our hospice nurses. Our contracted pharmacies will meet us 24 hours a day to fill for us, even if the pharmacy is closed so that we can get the meds we need for our patients. One of our pharmacies is a compounding pharmacy and will even compound 24 hours a day for us. The pharmacies deal with obtaining the scripts, we just deal with taking care of the patients, getting the doctors order and calling it into the pharmacy.

Google the terms "southerncare" and "24.7 million" and "whistleblower" as mentioned in another post on another topic. Is this the company you work for? If not, the reading is interesting and if you really believe the company you work for is committing fraud--report them (only be sure to report them to the government--not their corporate company). You might make enough under the "whistle blower" law to retire!!

Agree with the others although morphine is usually our first chice. Dyspnea, tachypnea, even mild is distressing to any patient, and should be considered a priority. We utilize roxanol 0.25 to 0.5ml every 15 minutes until symptoms resolve then calculate how much it took to get the patient comfortable and utilize a range PRN Q hour thereafter (ie, 4 X .5 doses= 40 mg ) would be 20-40 mg hourly as needed to control dyspnea. We try to get a "may repeat" for the 15 minute order as well. We make the mistake of telling our families that hospice will make their loved ones death a peaceful experience---sometimes that is not true. We should, instead, tell them that we will do everything we can to make the experience as comfortable as we can possibly make it. I have been in the field, and on call for hundreds of deaths, and there are those VERY FEW that, despite everything you have available in your orificenal, aren't as comfortable as you would have wanted them to be. We are only human--what allows us to sleep well at night is the clear conscience of knowing that we did everything within our human powers to make them as comfortable as we could have possibly made them, to do less, is to have failed them and ourselves as hospcie nurses.

at, My intent was not to gain an argument, but rather to explain the benefit. My apology is sincere. I left a better message on your profile page.

What I am saying is that "billable" continuous care has specific guidelines under regional and federal guidelines. NHPCO lists an excellent set of examples in their Hospice Operations Manual that are viable reasons for continuous care,including the following: Severe pain,acute respiratory distress, acute nausea/vomiting, seizures,hemorrhage,severe agitation,confusion with safety threat and suicidal ideations or related actions..... As you can see, all of these are quite different from the normal dying process. And no, the normal dying process is not a need for continuous care. The symptoms that you describe are normal dying process symptoms that are easily managed (decreased LOC, non-responsiveness, temp, apnea, etc.) and are not reasons for initiating continouous care unless they are causing the patient distress or are not easily managed by routine meds and education. Some hospice companies have care teams that do sit at bedside with their dying patients; we sit at many bedsides of dying patients and provide support through the process, but assisting the patient through the normal dying process is not continuous care that is considered "billable" under the hospice benefit. Sitting at bedside is a wonderful benefit that a hospice offers patients, but if a company is billing at the higher level of care--the continuous care level of care that requires an acute crisis and acute symptom management, I take issue with that, as I am sure do others. We all have to be stewards of the benefit, or it will dissappear. You are correct that the RN case manager determines the level of care, but if your company is BILLING for the continuous care level of care for sitting at bedside during the normal dying process, what they are doing is unethical at best.

Very scary that you are describing continuous care hours for "hardly any symtoms or symptoms that are very easily controlled". CMS is very clear in the regs that continuous care is for short periods of crisis. Palmetto GBA describes continuous care coverage as follows in section 4.5.2.1 Coverage: 1. Continuous home care should be provieded only during a period of crisis as necessary to maintain the terminally ill individual at home 2. A period of crisis is defined as a period in which a patient requires predominantly nursing care to achieve palliation or management of acute medical symptoms. Be careful to document that you are controlling acute symptoms that are out of control. Also, the continuous care benefit is not appropriate for the normal dying process.

Ibuprofen suppositories or Ibuprofen gel has to be formulated by a compounding pharmacy or apothecary but we have had success with both. We tend to use the transderm gel more in hospice to avoid having the family administer the suppositories as some are uncomfortable with that task, but we have had remarkable results with the transderm gels. In fact, we have a wonderful compounding pharmacy that is constantly working with us to utilize meds in suppositories and gels.

Have worked for this corporation and won't comment on a public level. I can tell you that even huge corporate companies all function a little differently at local levels, so be sure that the local company practice is in line with the corporation practice and vice versa. Manager dynamics make a huge difference especially at local levels. On a more professional level, I have made several posts regarding questions you may want to have answered before you begin work with any hospice company, including this one. Best bet here is to ask to interview at least 2 different case managers (or a case manager and another discipline)with the company to be able to ask them these questions. This shouldn't be a problem if "there are no problems". What you have to remember is that you are a professional nurse, and if you want to be a hospice nurse, there are many different companies that can vary widely on policy and practice. The company you end up working with may determine your success as a hospice nurse. 1. What does your normal day look like? How many visits do you typicallly make in a day? What does your back-up look like if you run into an emergency during the day? Who does admissions? What allowances are made for regular visits if you do have an admission? Does management kick-in during staffing shortages or do they overload the nurses with the extra visits? How are nursing shortages handled? If you get to interview the case managers--How happy are you with your job? How many hours do you typically put in during a week? Do you take paperwork home? Are you expected to take paperwork home? What does a typical day look like for you? Visits? What is your caseload average? Do you feel that your management is behind you and backs you? What is your driving time on a typical day? Is the mileage aspect factored into your day? 2. Compare benefits against other hospice in the area. How likely are you to be able to get the day off if you are exhausted? Benefits don't seem important until you find out you can't access them. (a previous company I worked for offered a ton of PTO time on a yearly basis, but, you could never take it. Anytime you did on-call. you were out from 5pm to 8am and were physically exhausted the next morning. All of your PTO was used on going home to get the sleep you missed out on from being out for 24 hours straight--8 for your regular shift and the 16 hours you were in your car for on-call.) 3. HOW IS ON CALL HANDLED? This is a biggie as a poor on-call system, or lack of back-up from primary or other core services can sink even the best of hospice nurses and contribute to rapid burnout. HOW IS ON CALL COMPENSATED? Beware of somebody telling you "we just give your time back or give comp time" because: a. it never happens and b. almost every state in the country does not recognize "comp time" under its labor codes--so if you decide to leave the company and they owe you 300 hours of "comp time" the labor law says TOUGH LUCK. The monetary aspect of on-call may not seem important at first and may be smaller in some smaller companies but is should seem fair overall and be comparable against other companies in the area for the size of the company. Read the posts here in this forum regarding on-call compensation. Have the interviewer explain the compensation clearly and explain to you what will be expected for that compensation. 3. Does profit status make a difference to you personally (if so, ask). Ask what the hospice is involved with within the community. Are you salaried or hourly? If you are hourly, will they put this in writing? 4. Don't be afraid to ask for, or to seek references about this company. What LTCF's are they in? Where and how do they get their referrals? I know that this is a long list, but hospice nursing (heck any nursing ) is tough. Hospice nursing is especially trying as you are frequently "flying solo" in the sense that you do not have a whole building of experts at your fingertips during times of crisis. The key is in finding a company that is supportive, compassionate and whose ethics and moral principles align with your own. Good Luck!

Never have liked the term "negative charting". I prefer the term "charting toward decline". As a new grad in hospice, this may acctually be easier for you than if you were in some type of previous position that "charted by execption" or charte improvement. Each visit, simply look at your patient assessement and note what the patinet is 1. no longer able to do or is now having difficulty with 2. how their disease process is affecting their or their loved one's life and 3. what you are educating them about. Even if it does not show on your physical assessment, you can sum it up by writing a simple short narraitve that starts with the following phrase..."This patient continues to meet hospice criteria a.e.b......" or "This patient continues to show evidence of decline a.e.b......"

"Your patients probably don't ask you because they're embarassed. I'm guessing that you're not horrible and mean to your patients, and who wants to ask their provider what the heck her position is again once they've already said it? Who wants to go, "So what is it that you do again, dear?" " What was that??? The nurse would be the one making sure that the patient DOES know the position of all of the people in the room. The nurse is the one who stays to decipher the physicians message for the patient and the nurse is the one coaching the patient prior to the meeting that they have the RIGHT to ask questions and to know the titles of those present in the room.

HaHa, I totally agree with making the grass more digestible! As a hiring manager, this is a difficult area to deal with. I would ask your company for thier pay scales, they should have a published scale if they are a corporation. And state your case as it pertains to you. Have you precepted these new employees? What makes you marketable? When I started on the floor straight out of school, I was making as much at the hospital as a floor nurse and a brand new RN as my preceptor was with 22 years of experience. (I was mortified and embarassed and I wasn't even at fault). Sometimes, hiring decisions are based on the immediate need,;the right candidate may present itself and you have to match, or beat, their previous pay in order to get them on staff in time not to have to wear out your current staff--not that any of this is fair, but it is the truth.

Our local college has a fresh start program as well. If you are out of school for so many years and make a formal written request, they will wipe your record clean of any grade less than a C and any I's. You do not get any credit for any of these classes that are expunged from your record, it's as if they never existed. Our state college also allows you to repeat the class in question and replace the grade. This would probably be appropriate for your general classes but you would have to be in a program to replace the nursing grades. Good luck to you. I was in the exact same situation as you were and I filed a written request that was granted. I started pre-med as a single mom right out of high school and bombed, then I started nursing school several years later, still young, met the love of my life and moved mid-semester (young and stupid) to another state (got I's in all of those classes). Finally married, settled down, and by then had 4 children, went back to a very stringent program (was actually accepted over candidated that had never been in school) and graduated top of my class. I will be praying for you!!! PS. One thing that my "help the cause" is to go to a community college and get a year of general classes under your belt. If your grades are exemplery, it will add you your case that you deserve a second chance.

Just as an FYI, I am a hospice nurse and our pharmacies formulate ibuprofen gel for us to use transdermally. Hope this info helps

We do not practice this concept in our hospice even though we do have a foundation and several of our past patients have contributed (we have used these funds for everything from paying for utility bills and safety monitoring systems for patients to paying for plane tickets to get loved ones home; we have even bought eyeglasses for patients who could not afford them so that they could see their loved ones). We have a really good relationship with most of our funeral homes in the area (we do excellent post mortem care and have all of the paperwork ready, etc.) and most of them suggest hospice as a donation source when the family does not have a specific charity of choice for donations in memory of their loved one.

Go Manny!!!