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I am a nurse in trouble with a capital T! I was terminated from a new job. I think I got caught up in the politics at this facility with lots of behavioral homeless residents and just did not focus on the people who were probably short term and much sicker. I was terminated for not notifying the MD about the results of a test. unfortunately for me...I did not take the time to read the whole statement of impression on the fax. I just glanced at it and thought it was stating she was ok! I am now trying to seek employment elsewhere and am wondering... "Is this RN doomed?" I understand what I did wrong... although I feel that I was not given a second chance. The DON just said..."I don't think this is a good fit for you." I am now wondering if a complaint will be filed against me and my license. This has never happened to me! Why do I have to always learn things the hard way!!!!!

Thanks to everyone who wrote last week. It has helped immensely, since I have had very little support within my hospice company, except for one other nurse. Last Monday, I respectfully requested removal from this client's case and asked for a replacement. It's very sad that I had to protect myself above the patient. The director said, Oh, that's ok....and nothing more. She will now be the one to do the mixing and drawing up of cheaper Dilaudid within the office. Since then I have not had the DON or Owner pull me aside to explain their case re: why it is supposedly 'ok' to draw up Dilaudid out of single dose vials, put in empty sterile IV bag without a hood, then mix Ketamine with it. Nobody's talking to me...so far. Anyway, because of your support, I have finally gone to the Montana Board of Nursing and again, received conformation of my worst fears. They encouraged me to use the Scope of Practice Decision-making model to assist in investigating the issue. The Executive Director was very concerned for my risks/liability as a nurse and also contacted the Pharmacy inspector, who agreed. They emailed me some key points. 1. If a Hospice pharmacist will not draw Dilaudid up and mix it without a hood, why is it ok for a nurse to do so. This confirmed that it is not within the scope of practice for a nurse, it is a pharmacist's function and could be illegal for a nurse in Pharmacy law. They also mentioned that there may be a certain arrangement within the pharmacy and hospice employer contract stating that it is ok for a RN to draw up meds. (If this is the case, my employer did not bother to ease my fears by verifying any contract agreement.) It was also mentioned that I should think about whether or not I have the knowledge and clinical competence to perform the act safely and if so, am I comfortable accepting the accountibility for the decision to do what has been asked of me. Contacting the Board of Nursing was great, I felt like I had the advocate and support of true professionals. Thanks again, hope this helps you someday too.

I have a 46 yr old client with Multiple Myeloma who has intractable pain. We started him on a Morphine Sub Q drip within weeks of admission but due to long term administration of MS Contin PO, the Morphine did not help with pain relief. The MD then switched him to Dilaudid at 10mg/ml concentration( currently at 8mg/hr, although the MD is saying that is too high of a dose). We have also brought on Naproxyn to assist with potentiation of the narcotic so that he uses less of the Dilaudid...and I think it is working. So, I have been asked to wean him down to 6mg/hr now despite liberal original orders that were given for 2-20mg/hr) Along with this...For the last month, we have seen a marked relief from his pain but with it lots of concern by MD director and owner re: high cost of medication. Now the nurse director wants me, a registered nurse to find costsaving ways to avoid the $868/100ml bag cost. One suggestion has been for me to draw the Dilaudid out of a vial, premixed and insert into a empty bag without sterile conditions despite pharmacy's concern that there is no hood being used for sterile procedure. Also suggesting that I might want to mix Dilaudid with another drug like Ketamine for better relief. I am a new nurse(two years) and in addition; my director is also fairly new herself(three years as registered nurse). We really don't have anyone but a long-distant owner who has experience with such options for pain relief. Am I crazy to wonder why I should do what is being suggested when there is noone experienced around who can guide me through this? My director has said she would draw it up for me...but I have a bad feeling in my gut that she does not realize the danger in doing this without proper guidance. What do you think? Ready to bolt...Maggie

Our hospice has just signed on for the second time a patient who has cirrhosis and still abuses alcohol. She refuses most visits and I am thinking that she and her husband are just working the system for free drugs like Ativan and Morphine. When I asked her husband what he was interested in gaining from resigning on with hospice, he said he wanted to get someone to assess his wife after a bad fall, while drunk, down some stairs. I am at a loss as to what I can do as a nurse, if I will not even be allowed to do my assessments. Any suggestions?? Thanks...you nurses have helped me so much, I appreciate it. Maggie:no:

This is an unfortunate situation for all involved. It sounds like there are already some problems with the director and that you have chosen the correct path. Obviously, the director is not thinking about anyone except self here. Don't look back.

Our director asks that each of the RN's, after two years employment, take the hospice certification test. Has anyone taken the test? What is the best way to study for it? And is it valuable? If we pass the employer will re-imburse for the test, otherwise not. Thanks for your input...I have learned so much thru your wisdom re: hospice nursing. Maggie:bow:

Thanks so much, what you have shared has helped immensely. Maggie

Thank you for your quick reply. This is a very strong of faith and kind-hearted woman of 88yr old. I could communicate more about what may happen in the disease process but she always refuses meds and says "I'm alright, Maggie." Her daughter just wants to respect her wishes also but wants the best for her Mom. Our founder compares the dying process as being as difficult as the birthing process and it may be that people just don't realize how long it takes. Luckily, the mother and one daughter are very close and can talk about what is happening. Thanks again for your kind words. Maggie

Thank you yes the whole interdisciplinary team is involved: Social worker, chaplain, music thanatologist, volunteers, CNA's. As our founder has recently told me, there is always more that you can do-discover it.

Thank you so much...the decision is the patient's based on her strong beliefs; although now that the symptoms are more obvious there are perhaps fears and doubts getting translated from everybody involved. This forum is wonderful and for a new hospice nurse is a godsend. Maggie

Thank you so much for your kind words. Tomorrow our founder will go with me to make sure that enough has been said but also to validate her beliefs and assure her we will be there to help. I am new to hospice but sure this is my niche, so appreciate your wisdom. Maggie

I am working with a client with Abdominal CA who refuses medications based on her faith. Things went well until the realization hit that faith was not keeping symptoms of persistant diarrhea at bay. Now the client and family has c/o but still refuses medications. I have a boatload of options with transdermal to oral/SL and IV but all I get is complaints with what can you do? Thanks for your input on this very difficult issue! I am beginning to be very blunt, describing what I see, what could come but.... not sure if that is helpful considering the circumstances.

I am a relatively new nurse but pushing sixty yr old, also new hospice nurse. Last week, I was confronted with the same sense from other nurses I work with. Words of advise I am trying to live. Define and stick to your boundaries! I am currently realizing that I am not indispensable. On my days off, the on-call nurse can do just as well with my clients, as long as they have a good report and comfort meds in the home. Meanwhile, I am relaxing by the lake...yes!!

I am still wondering what the general philosophy is out there re: time off and imminent deaths. In the last week, three of my people have passed and two more are close to being imminent and here I am at the end of my week. The other two nurses I work with, say "call me if I am off; if you get imminent notification of one of their clients, they come in on their day off" but I still worry that I will just burn up with so much overtime and little control re: on and off time. In the last two weeks, I worked 87 hrs. I'm not a young chicken anymore, so have to manage my energy well. What do you think??

Hi all, I am just learning the dynamics of hospice nursing in a relatively small community (80,000 pop.). I am only 6 weeks into the job and already sensing that nurse case managers are the 'go to person, 24/7' here at this company. This was not clearly verbalized to me when I started, or should I have known this? Along with the fact that I am making $1.00/hr less that originally stated by the off-sight owner. So, after putting in over 40 hr last week and then 45 hrs this week, I am wondering if I should stay. Last week-end, even though I was not the on-call nurse, I was called to assist the on-call nurse when she had an emergency at home with one of her kids. The next night, same on-call nurse called re: a pt of mine; asking if I wanted to follow up with the call. (again, I was not on-call) :argue: My sense is that this job, practiced this way, will create alot of burnt out nurses in the same company. :angryfire As the 4th of July weekend approached, I had to tell everyone, specifically the director; that I would be out of town and not available for calls or whatever. Am I overreacting? I do really love the rest of the job, something that I have dreamed about throughout nursing school; but I am not about to be on-call 24/7 for any job!! Thanks for listening...any enlightening thoughts? I do like the little faces..it helps you laugh about the absurd.