melsch

You are in Canada, get your union rep involved right away. They are your best protection. Don't worry about losing your job, labour laws will protect you, but document everything and try not to go to a meeting with management without your Union rep. Remember the doctor is an employee of the hospital/health authority and has no say in your employment no matter how long he has been around. His behaviour is deplorable and he needs to be called on it.

I am not sure what you mean by intellectual disabled, but I work in a palliative inpatient unit and from 7 am to 11 pm we have 1 RN, 1 LPN, and 1 Care Aide for 12 patients. From11 pm to 7 am we have 1 RN and 1 LPN for the same patients. This is very doable, and safe. Rarely have we had to have extra staff for 1:1 etc. We are not overstuffed, but I feel it is just about the right ratios.

Often patients wait until they are alone to die. I have even encouraged family to leave for an hour or so if a patient seems to be hanging on for some reason to see if possibly it is just that they want to be alone, with the reassurance that I will call if there is a drastic change, or the patient passes. Families who are ready and wishing for peace for their loved ones are usually open to the suggestion. Families also know their loved one and if it is their personality that they might want to be alone they sometimes come up with the idea on their own.

I work in hospice and I think your perspective changes when you deal with death on a regular basis. I don't see death as a bad or awful thing for the patient, I see death as something normal that everyone must go through, and my job is to make it as comfortable and dignified as possible. I am rarely sad when a patient dies, but if it is my family member or a friend it is totally different. I am sad because I will miss them, or if their death was caused by an accident or crime, I might be angry or devastated by what the person might have experienced, but my patients are expected to die so there is different feelings when they pass. I am sorry your Mom's death was not as nice as you were hoping, my patients whose lungs fill up at end of life like that are the hardest on everyone as you feel so helpless. Be assured that your Mom probably wasn't aware of the fluid by that point and it is harder for you to watch, than for her to experience.

We used to do that, but now we get paid for the hours worked. It is much better and no one gets short changed as it never worked out fairly.

The pt was probably dying anyway, and didn't die from an allergic reaction, but we always use a lower dose of dilaudid rather than morphine if they say they have an allergy to morphine. If the patient is still able to take meds orally we sometimes get them on oxycodone, but usually it is just a direct switch to dilaudid. We find lots of people say they are allergic but when asked what their reaction is they say it makes them nauseous or sleepy, which are expected side effects and not allergies, but if the pt can't say we would err on the side if caution and use something else.

My employer mandated we get the shot this year, or wear a mask at all times from December until march. I figured it would be easier to get the shot than have a mask on at all times. I got the shot yesterday and thankfully I have sick time because I had to call in for last night and tonight so far, we will see about tomorrow. Within a couple of hours I started feeling hot then cold, then just really tired. Really I feel like I have the flu, and I am guessing that my body figures that I do and is trying to fight it. I am feeling so lousy right now I am wondering if wearing a mask would be easier. It has reminded me why I haven't had the shot for about ten years.

This is our protocol: Has there been a BM within the last 48 hours? If yes give two sennosides 8.5mg at hs. If NO, give two sennosides 8.5mg twice a day. If BM within 24 hours continue and monitor if no advance to: Increase sennosides 8.5 mg tid and add lactulose 15-30 ml BID for more rapid effect. If BM within 24 hours contiune or lower sennoside dose. If no BM advance to: Nurse to assess for impaction - if no impaction give bisacodyl supp or fleet enema. If BM within 24 hours return to previous dosing, in order to aim for BMs q 3 days. Of course nursing judgment re individual patients, PPS level, and intake, come into play as to how aggressive we are with using the bowel protocol.

Where I live nurses are considered an essential service which means we are not allowed to reduce our numbers below what is considered enough staff to look after the patients. What we have done is work to rule, which means we only do essential jobs - no extra paperwork, no house keeping jobs, no overtime etc. Management can do those jobs until our contract is settled. If another union goes on strike we still have to show up to work, but anyone who is not considered essential (as determined by our union) doesn't cross the picket line, and everyone who is at work refuses to do the work that would be done by the other union.

We do this as well. And if a patient has a gown on we sometimes place the top sheet under the gown, next to the patient. Don't tie it or it could be a restraint. It doesn't always keep them from taking off their pad - but it slows them down a bit.

I am in a stand alone inpatient hospice. We have a mix of end of life, respite, and symptom management patients. We have two 12 bed units. Day and evening shifts have an RN, LPN, and a care aide, for each side and on nights there is an RN for each side and a LPN on one side and a care aide on the other.

I have to agree with the shaving cream suggestion. It really works. Put some on your cloth and start cleaning. Once the fecesis all soft just wipe it off and give the a rinse with clear water.

I asked myself the same question as I work in hospice and wondered what I would do if he was in our facility. We did have a man who raped and murdered a young girl a while ago and I just looked at it as he was just another body and someone had to look after him. He was mostly unresponsive by the time he was my patient though. I don't know if I could have looked after Olsen though - this man was evil and there is no way anyone in Canada doesn't know who he was or what he did. I would have hoped that they kept him fairly sedated so he couldn't harass the staff and to make it easier to look after him. I don't think I could have done it otherwise.

I work in BC, but it seems our collective agreements are similar. I don't believe you qualify for any health benefits, but you would get paid out your vacation pay. The Royal Alex falls under the provincial collective agreement. http://www.una.ab.ca/collectiveagreements/pdf/UNA%20AHS%202010_2013.pdf Amend Article 17 to read: 17.02 (a) Casual Employees shall be paid, in addition to their Basic Rate of Pay, a sum equal to: (i) 6% of their regular earnings during the 1st employment year; (ii) 8% of their regular earnings during the 2nd to 9th employment years; (iii) 10% of their regular earnings during the 10th to 19th employment years; (iv) 12% of their regular earnings during the 20th to 24th employment years; (v) 12.4% of their regular earnings during the 25th and subsequent employment years; in lieu of vacations with pay; (b) Casual Employees shall receive payment in lieu of vacations with pay to which they are entitled following each pay period.

There is a list of current contracts on the Union website. I think it would be dependant on the contract for the workplace that you were hired at. Look for the information on casual workers. http://www.una.ab.ca/collectiveagreements/

It is a question I seem to get a lot. People think that our job must be really sad. I alway say it is the most rewarding job I have ever had. It is sad for family members, but for me death is a normal process and we all have to die. My job is to make a person's death the best it can be. I allow my patients to die as comfortably and with as much dignity as possible. Death is a sad time for family and friends and for the person who is experiencing it as it is a time of separation from those we love. We will all have to die at sometime and when it is someone I love I am saddened by it, but as a nurse I see death as a transition, just like birth, it is something we all must experience. Just as maternity nurses work to make the happy occasion of birth as good an experience as possible we as palliative/hospice nurses make the sad occasion of death as good an experience as possible.

As Leslie said make sure their basic needs are met -toileting, exercise etc. We have extra low beds that we use and keep them at the lowest level. We also have crash mats that we put on the floor - but in my experience they are just another trip hazard for both the patient and the nurse - yes I can be a klutz too. Make sure walkers, canes, wheelchairs etc and within reach, especially if the patient is used to using them as at least they will have something to hold on to if they are unsteady. We use bed monitors (tabs pinned to the patient, sensors under the mattress, and floor pads so when their feet hit the floor we are alerted -my favorite and seems to work best). We sometimes put our most confused and prone to getting up and falling patients in gerichairs at the nursing station so we can keep and eye on them and prevent them from getting up. You will never prevent all falls even with restraints and it seems that we are supposed to allow people to live and risk, and I even heard one manager say that if they keep landing on the floor they must want to be there. I don't agree with that attitude and think we are doing our very confused patients a disservice to allow them to hurt themselves, but I don't have any other answers either.

I wouldn't put it back on either - I would have wasted it and put a new one on and changed the schedule to reflect this. I would be worried about how well it was being absorbed once it had been removed or fallen off. We would just replace it - but if you need a new Dr's order then that is what should have happened. It is also our policy -from the manufacturer I believe - that we do not put tegaderm over the patches as they warm up from the body heat and it increases the absorbtion rate. We can use tape around the edges to secure it but we are not to completely cover it - even with clear tape. We do use tegaderm underneath it if we are making a 12.5 patch out of a 25mcg patch for example.

I am in an inpatient setting as well, so my experience my differ as well. We use SC morphine or dilaudid for pain and to ease the dyspnea symptoms. We use Atropine SC q1h as well, but find that it only keeps more fluid from being produced and works only minimally for large amounts of fluid. We also give regular sedation SC Nozinan or Ativan especially if the patient is at all responsive. Repositioning and cleaning out the mouth as much as possible, and education of the family is really important. We don't suction our patients as a rule - but this is one time that we sometimes do suction for comfort as the amount of fluid build up in the oral cavity can be quite distressing. These are the worst deaths to witness and if the patient is aware I am sure it is one of the worst to experience as well.

Our protocol is also to use ativan 1-2mg sl q4h round the clock when our patients are no longer able to take their antiseizure medications orally. Mix it in a little bit (1/2 cc or less) of water in a syringe and dribble it into the corner of their mouth - if they are mouth breathing and their mouth is dry it helps it to absorb quicker.

Actually I think on a 12 hour shift it is two 30 min unpaid meal breaks and 2 15 minute paid coffee breaks and on an 8 hour shift it is 1 30 minute meal break and 2 15 minute coffee breaks - and on nights we do take them together and sleep for 1 1/2 or 2 hours if able and 1 - 1 1/2 on an 8 hour shift. It all depends on your unit and how busy they are if you can sneak in that extra half hour, and how willing your co workers are to cover for you. I think in Canada we have less paper work as well - as we chart by exception usually (tick sheets for normal findings etc) and no extra documentation for billing etc.

I work nights and we nap on our breaks (not when we are supposed to be working) We do always know where each other is and go and get each other if needed. Our manager is aware and doesn't care so long as everything gets done. We also work as a team so on each unit there are two staff and we look after all the patients so we take turns on breaks and if needed we can get someone from another unit to come help as well. Sometimes if I have a patient dying or patients who have lots of needs I don't get a break, but most nights I at least get a few minutes to lay down and close my eyes. I don't work acute care (although when I did we napped on our breaks then as well - same deal teamwork and covering for each other during break time) so we don't disturb our patients during the night if possible -no acuchecks or vitals, and only turning those who really need it and changing those who wake up or are really heavy wetters. We do hourly breathing checks and answer call lights and help those who are awake, and usually there are not many scheduled meds. Our patients need to sleep so that they can have the energy to function during the day when there is things going on and family to visit with, why wake them unnecessarily to do things to them that could be done when they are awake.

I just had to go back to this question - I think we are more secure with our licenses in Canada. I have every right to question and refuse a Dr's order if I am uncomfortable with it. I need to follow up with the Dr and explain why (and usually have a conversation which will change the mind of one of us ) If I am still not comfortable I then document and speak to my supervisor -who can either come in and do it or contact the doctor. Rarely - but it has happened the chief medical doctor could get involved. The doctor could also be requested to come in and complete the order if he really wants it done. None of this would jepordize my license, unless I was being unreasonable about following a routine order - but I think that would end at my supervisor who would do the order and call me in for a talk about it and maybe a note in my file.) We view most doctors as our colleges and everyone is doing their best to care for the patients and we need each other to work in our roles for that to happen. It would take an act of gross negligence to lose my license - or a drug problem that I refused to acknowledge and seek treatment for. Going back to the issue of work and scope of practice - we work to our full scope in every province. I work with LPNs and Care Aides - who all work to their full scope as well. Most places work as teams - I have more responsibilities than the LPNs and CAs but they are all our patients, not my patients and your patients - if a call light is going off we all are able to answer it and whoever is not busy at the time will get it. Yes that means that the LPNs and CAs might get it a few more times than me as I am stuck doing paper work or giving a med (LPNs can give meds but not CAs) but it is expected that I do my share of the floor work as well. In BC we still pay Medical Service Premiums - $60.50 for one person, $109.00 for a family of two and $121.00 for a family of three or more per month. Most employers who offer benefits offer medical and this is covered - so far I have been lucky and never actually had to pay for it as either I was covered by my parents, my husbands job, or my own job. Regular employees get benefits under our union contract - but casual staff would have to buy it themselves. 10 years ago it was $200 a month for a family - including extended medical and dental - but I don't know what the cost is now. Okay enough rambling for now - just a few thoughts that struck me as I was reading this forum.

Hi frozenyogurt, I am not sure what part of the country you are from, but I know that out west there is not much in the way of formal Hospice/Palliative courses. The Victoria Hospice puts on a couple of really great education weeks every year and I highly recommend them if you are working in hospice. Check into your local hospice association and see if they are offering any other courses and take as many as you can. We are also provided with a number of opportunities for education with regular monthly inservices put on by our nurse educator - on various topics and the palliative doctors organize a monthly dinner for updates and education that the open up to the nurses. I am going to be writing my specialty exam this spring and the only requirements are to have enough hours working in hospice, you don't have to take any particular courses - you just have to get experience. I personally had many years experience in LTC and medical/oncology before I moved to hospice, but we do have a few newish grads (1-2 years) who are working with us in inpatient hospice. I have found my previous experiences to be really helpful in my current position, and would recommend at least a year in medical to hone your assessment skills, but if you are willing to listen and learn from you experienced coworkers you should be okay.