Sharry RN

In my last clinical rotation which was in one of our 2 local hospitals, one of the nurses told my clinical instructor that I would never "make it as a nurse" because I didn't know how to make a bed. At the time, it was very disheartening because the clinical instructor didn't try to work with me (probably because she didn't know how to make a bed the way this nurse did either). But I made it through the last school tests, passed my boards the 1st time (didn't have to make a bed for the Boards). I've been a working RN for 25 yrs now in the other Hospital in our community. I don't make beds nor have I ever needed anything I ever learned (not retained) in Microbiology. Ignore the dragons! Keep moving toward your goal of being a Registered Nurse.

I realize this subject line was started about 8 months ago & I'm now another year older, but at 62 I plan to work in Hospice until I retire in 4 yrs. I job share, work a week then off a week. No nights & very few weekends. My case management partner & I do SNF, ALF, & Alz Units. Generally speaking there are available CG's to help me with any heavy lifting or care. This is a dream job for me & I'm very grateful.

Just this last Sunday I was having lunch at a restaurant. When I looked across the room I got this sinking feeling, there was DR. M & JR. Just looking at them gave me the same feeling I had 23 yrs ago as a new nurse on a post surgical floor when JR threw a foam donut at a nurse & screamed at her. My feeling then & now is that we don't have to put up with that, I suggest you talk to your nurse manager, nurse director or keep going up the chain to get to someone that can talk with this MD. It has been my experience that surgeons are some of the worst Prima Donnas' & because they bring in a lot of money for the hospital generally they are often tolerated by the administration.

I usually give a gentle smile & say something like this, "For me it is a wonderful priviledge to be with folks at the end of their life & to do everything I can to make them comfortable." Often times it opens a door to minister to their pain around someone in their life who died or their own fear of death.

I would highly recommend extra Liability Insurance like NSO: http://www.nso.com/ As one nurse said, if something happens to a patient while you are stressed to the point of breaking or even if you aren't the organization will point to you 1st. I've been in Home Health/Hospice for over 15 yrs & have had this extra insurance from day one even though I haven't had to use it. Our union rep recommended it to all of us. Personally I work in a great Hospice as a case manager where we have only 4-5 pts in a 10 hr day. We have wonderful managers that really support us. Even with that we can get burnt out quick if we take on to much responsiblilty & allow the patient or families to become co-dependent (old word) on us personally. They (patients & families) are still responsible for their decisions & family for most of the care once they have all the facts & as we teach them. And we aren't the only persons that can give them service that is what I love about having the whole IDG team especially the CNA's, MSW's, & Chaplains. Shari

What a great idea! Recently I had an ES Alz patient that had a lot of oral secrections at times (not able to control with scop patches or atropine gtts) so our pharm crushed MS IR tabs & put them in capsules for PR adm, they didn't think just putting the tab in would work as well. Possibly this could be done with higher doses also.

Thank you to all who replied. I appreciated your input. It really makes a difference if you know the whole story & that story varies from patient to patient, family to family. Just in the last 2 weeks, I had a family decide not to treat an aspiration pneumonia because there was no way to keep the patient from aspirating, he even aspirated on his own saliva. Another family chose not to tx an URI, but the MD chose to ignore their request & treated a non-exisistant UTI with Levaquin. Another family was told by the patients MD that pneumonia "Was the old-man's best friend". The other family I had made mention of took my advise not to treat a low-grade temp & cough with an antibiotic & the following Monday the patient was fine (no cough or temp). All "in the life of a Hospice Nurse". On a personal note, I'm off for the next 5 weeks for a much needed vacation. Thanks Again for your input. ShariWN

How do you all feel about antibiotics for URI? All of my case load is in either Long Term Care facilities or Alz Units. I am questioning the need for antibiotics for these patients. Is the antibiotic for comfort (as it would be for a symptomatic UTI)? The patients may certainly die from the URI & they do have uncomfortable symptoms. How do we rate the need for antibiotic use? Sometimes it feels like the family & CG's are really wanting to extend the patients life. So are these patients really hospice appropriate? Thanks for your feedback, Shariwn

Personally I think you & the PM nurse did a great job meeting the needs of your resident at the EOL. I'm a hospice case manager for our SNF's & Alz units in our area, one of the big issues for me is to educate the staff including MD's & Managers as to when it is appropriate to call in hospice. I have one facility that just loves us & wants to put their residents on service way before it is appropriate, so I do a lot of evals there.:)

Our nurses work 10 hr days, if fulltime 4 days Mon thru Fri. We are blessed right now with nurses that want to just do call & weekends. I job share a case manager position, so I work a week on then a week off.

Also the ability to work autonomously & be a good team member at the same time.

Marachne I also thank you for those links. I agree with Leslie, it does depend on the amounts given. Also I would think it would be difficult on the staff to be giving the Roxanol every hr. If the doses were small I would probably try to change the scheduled times to every 2hrs or 4hrs & see how the patient tolerates it. In the 4 yrs I've been doing hospice in facilities with just ES Alz or dementia as a DX, I've never had to schedule the Roxanol every hr at the EOL. Misterose do you have any say in the scheduling or are these standard orders from the physicians?

I have struggled with this issue as well. When I first started as a hospice case manager in SNF & Alz units 4 yrs ago the majority of med issue was on both ends of the extreme. Either the residents weren't getting anything or Roxanol 1ml every time a med was given. So I either had lots of behavior problems to deal with or gorked pts. It has taken a lot of education with the med giving staff of the facilities (ongoing), very specific (narrow) orders & lots of patience. If I have a patient that is ES ALZ or Dementia with behaviors, pain assessment is the 1st thing I do. Are they on any pain meds now? Non-opiates to narcotics. If the patient is able to swallow & isn't on a narcotic I will try a non-opiate scheduled 1st. This often is enough to start with. If staff have a problem getting the patient to take meds, even crushed in food, I'll try scheduling the smallest amount of Roxanol a couple of times a day, especially before hands on care. 1st thing in the morning & just before going to bed at night. As I evaluate the effects I'll either increase the dose or the times or both. I use Fent Patchs only if getting any kind of oral med into the patient is difficult. There is a low dose 12mcg patch now that really works for the general ache of old age. Even with all that I still question at times whether or not I'm giving the patient enough or to much. I love what I do & I love the caregivers because they really care about their residents & they want what is best for them.