leslie :-D

i love this part of your post... as i find it pertinent for each person to define their version of spirituality. more often than not, religion and spirituality are used interchangeably and for me, they are most certainly not synonymous. as i read elsewhere, religion is an account of someone else's experience whereas spirituality is your own, unique experience. that spirituality is one's personal journey... no teachings, no dogma, no conditions or commands from external sources. it is discovering, acknowledging, and feeling the wonder and perplexity of the universe and all it contains... whether it is nature, music/arts, meditation... or whatever it is that stirs your soul, often sensing phenomena that feels bigger than oneself. you really need to experience it before one can appreciate it, as my words are meaningless until one has experienced and reveled in the awe of "it". :) and so op, in attempting to answer your question, one's personal beliefs have absolutely nothing to do with your role as a nurse. we are trained in treating our pts holistically. whatever the pt's needs are, we refer/consult/deliberate/contemplate accordingly. being a considerably sensitive and intelligent person, i take pride in being able to competently address my pts needs. absolutely nothing to do with religion, spirituality, or otherwise. leslie

seriously, i suspect the opioids are worsening his symptoms, as they further delay gastric emptying, delay gi motility, and can/do induce increased pain, n& v. we've used erythromycin with decent/improved results... along with neurontin and/or ultram and/or nortriptyline. these meds were initiated after dc'ing the narcs and pts reported improved effect. need to avoid or minimize anything narcotic and anticholinergic, as they appear to do more damage than good. IF he needs to stay on narcs, i would try methadone as it is the only narc i know that responds favorably to neuro pain (which the gut is rich with neural networks)... and PREVENT CONSTIPATION...which always, always, always worsens any situation. i hope you are being aggressive with bowel mgmt. gastroparesis IS a tough one. if all his symptoms are refractory, perhaps ketamine may be the way to go... but you need to be inpatient with experienced staff to administer. wishing him and his family, comfort and resolution. leslie

yes, it'd be highly unethical to disregard a pt's wishes, even if the nurse personally/morally disagrees with it. afterall, we ARE supposed to be their advocates. but it becomes much grayer if you know the pt doesn't want to be rescusitated, and a code is called anyways. this happens all too often as well. and so, should the nurse have to participate in a code knowing his/her pt didn't want it? i don't know the answer, and i could see the nurse being terminated because of it. but at the end of the day, i could also see the nurse being vindicated in a court of law... since the nurse was acting beneficently. we need to choose our battles wisely... and be prepared for undesired consequences as well. leslie

thanks for this. i too, have completely disregarded family wishes when i knew the pt's wishes, which were contrary. more often than not however, i have seen pts defer to what their family wants... putting their own personal desires aside. it is at those times that i have been their voice, and have acted accordingly. again, working inpt hospice for many years, i've had palliative care pts who remained full codes because of what family wanted. i have also witnessed head-butting between drs - one who wanted to pursue aggressive (but futile and invasive) tx, vs the other dr who just wanted them to die with dignity. i'm relieved to read that you have seen an improvement, because at the time, i certainly hadn't. and "slow codes" have indeed, been the saving grace for a few of my pts. for that, i and they, are most grateful. leslie

it is evident (to me) that you are struggling... and hope you can forgive yourself, as that is when true healing will begin. in the meantime, i am confident your mom knows how much you loved her... and pray you will find the much-needed peace in acknowledging that. only then, will your burdens be lifted and you can move forward freely and painlessly. leslie

i wish families understood this. that yes, even with a low bed, floor mats, bed alarms and continual supervision... that the self-determined pt IS going to walk, whether s/he is able to or not. and these pts are going to fall, be hospitalized, return only to fall again. personally, i think there are many family members who suffer a lot of guilt after their parent dies... and much of their angst is displaced. yes, there are substandard nursing homes and i wish all families did their research before selecting a ltc facility for their loved one. medicare has the public results of all state surveys that are done at ltc... and one can plainly see the results/standing of any particular facility. still, we nurses are blamed for everything - some, rightly so. as long as each and every one of us can sleep at night, knowing we gave ea pt our personal and professional best, then all is right in the world. i wish healing and peace for all who are grieving a loss of a loved one. leslie

i can assure you there are many pts on fdg tubes who are not eligible to eat foods by mouth... unless one's intent was to cause serious harm or death. also, fdg tubes do not prevent thirst, and so, a fdg tube would not address that particular problem with your pt. continue on giving good mouth care, that is helpful. and there is a reason that only skilled personnel can feed this pt...as it is too easy in causing a pt to aspirate. i appreciate your compassion, but i do believe you will understand so much more when you advance in your studies. good luck to you. leslie

the bottom line is food is still considered a pleasure of life.... and is always preferable to a fdg tube. the pt still gets to satisfy this most basic need by tasting and swallowing her food. you don't get any of those sensations with a fdg tube. speech needs to stay involved, to ensure pt is tolerating these fdgs and isn't microaspirating. fdg tubes should always be a very last resort, and not used as a means of convenience. leslie

i think several posts may be overlapping, because of 2 separate continuums that we're referring to: nsg continuum - when residents refuse care, on one end of the spectrum are nurses who shrug shoulders and say "ok" and chart accordingly...to the other end of the spectrum, with some nurses wracking their brains (after hours) trying to come up with ideas in getting their pts to comply/cooperate. resident continuum - those who are alert & oriented at one end, and those with total cognitive dsyfunction at the other. reading through all these posts, you just don't know what type of nurse is talking about what type of resident. i'm certain there are nurses who chart "refused care" with absolutely no effort on their parts. just as i'm certain there are residents who retain a notable amt of cognizance, yet dementia is prominent in other aspects of brain function. my experience has been that the most resistant of pts, will/do inevitably find that one person (title irrelevant) who they trust won't harm them, or who they trust to make the dreaded experience, as pleasant and timely as possible. it may not be every week, sometimes showering once a month is the best you will get. and finally, to me, honoring one's dignity entails NOT allowing a resident's condition to deterioriate to the point where they languish to the point where their physical and mental health are affected. i have never, ever encountered a pt/resident where they refused care throughout their stay at the ltc facility. eventually there was always at least one person they entrusted enough with care. as nurses, we have to pick our battles wisely. and i'll tell you quite frankly - if i had a resident that was known to refuse any/all care consistently, i for one had no problem dropping some lactulose in their drink and watched them swallow every drop. same concept with mom. again, this isn't for every pt but if it works for that particular pt, i'm good with that. every pt and situation is unique, and you need to customize ea intervention that reflects the pts known strengths and weaknesses. as long as we do everything humanly possible in honoring the pts needs of body, mind, and spirit, i do believe that's what counts. we as nurses walk many fine lines. in the end, it's finding that balance that dictates the desired outcome. leslie

i agree with all that carolinapooh has suggested. the biggest barrier i see however, is getting the parent(s) on board with this. more often than not, the parents themselves are obese and aren't going to be proactive in getting their children to a healthy weight. i reiterate, not all but "more often than not". this really needs to be a family effort as it entails a major lifestyle change. anything less is setting everyone up for failure, imo. leslie

i seriously believe your state of mind is the culmination of nsg school stressors. i felt as you do, right towards the very end when i wanted to walk away from it all. a loved one gave me a dopeslap that knocked me across the room, but also reoriented me back to my good senses. (thanks, i needed that.) you'll feel differently once you're a nurse, i can promise you that. it likely won't happen overnight, but you will grow into your own unique role of the professional nurse. you will exercise your nsg judgment appropriate to ea pt situation... and will apply your 'mature adult' judgment to those who may try and undermine you. in other words, you do not have to take anyone's ****...please always remember that. like the pp who brought in goodies and had a "talk" with his/her instructors... i too, had the same type talk with mine, less the goodies. i totally rejected their attempts in trying to disparage me, and communicated that calmly, articulately, and succinctly. i made myself quite clear and after that discussion, there were no more issues. you (or anyone) do not have to accept victim status, as you are in control. i'm not saying you're feeling victimized; i'm saying that your perceptions of any given event, are what will define its acuity or not. take your power back; give yourself a much-needed dopeslap; and move forward. you can do this...as you've been doing it all along. it's your time to shine. leslie

the above (my meds) is one of the major reasons i haven't returned to nsg... don't trust myself because a lot of my memory is shot and my mind is often discombobulated. be careful, sweetie. leslie

how does anyone live 6+ months without eating and without a feeding tube? leslie

i *think* those well-meaning friends (who suggested ssdi) weren't/aren't aware of your capabilties at the time you spoke about it. that maybe (and only YOU could answer that) you wouldn't be able to return to nursing. speaking for myself, that is the only reason i suggested ssdi...in hopes of its thought bringing you a piece of comfort, knowing that you didn't have to try and return to the very environment that has created incredible stress for you. iow, i suggested it only as a consideration...and not as an absolute and only option. :) leslie

i believe people fear what they don't know or understand. and so, mental illness and death are 2 concepts that remain intimidating to most people. of course there are resultant offsprings of such a basic theory, but at its core, we fear what we do not understand. a lot more education and support would do wonders in ameliorating the stigma that frequently accompanies the aversions that we create in ignorance. leslie

op, i appreciate the angst this situation elicited from you and it sounds like your concerns were plausible. it sounded like a more acute situation, where immediate intervention was warranted. if you don't/didn't feel comfortable suggesting a rr to the nurse, i might consider discussing it (confidentially) with a um/cn/nm... as long as you clarify that you are not trying to criticize the other nurse; only that you are seeking input as to whether there is a protocol in place, or wanting to anticipate prospective actions in the event of a next time. i agree, it is not a matter of receiving "better" care with the rrt; it's a matter of receiving immediate care. to me, you sound rightly concerned... and also respectful of the potential conflict it may cause. it sounds like you're doing well in your new position. keep it going. leslie

it's especially important that all nurses are on the same page re poc, i.e., anticipate attempts of manipulation and/or staff-splitting, or other types of disruptions. bpd IS a tough one to manage...for the pt and caregiver(s). once that truth is acknowledged, it gives more leeway for progress to be made. leslie

yes i did and yes i was eventually terminated and yes it took its emotional and financial toll on me. but i felt compelled to stand behind my truth and even though i would never want to do it again, i probably would... because that is who i am. you find out who will stand behind you, you find out who your true friends are, and you get to see others true colors. lots of betrayal, lots of backstabbing, lots and lots of lies. but i did it because it was the right thing to do. be prepared for the worst and don't lose sight of why you are doing this. i wish you the very best, and thank you. leslie

(((cp))), i am truly sorry for your loss. while our beloveds departure result in profound angst and despair... it is our spirit of love and gratitude that keeps us together and eternal. i seriously don't mean to sound drippy, i fully believe this. heartfelt prayers for healing, faith, and comfort. until you meet again, i know you will nurture his legacy of all he represented here on earth. leslie

i very much agree with tewdles, that you need to contact hospice nurse stat. and to ensure the (new) poc reflects fewer prns and longer acting, more powerful meds. it doesn't matter if he is an addict or not...not in hospice. his pain needs to be addressed. i am hoping this isn't being turned into a power play betw lpn and rn. furthermore, i know plenty of rn's that hesitate in giving mso4. lots and lots of education and inservices needed with nurses in gen'l. this frustrates me to no end, when i see a pt suffer because the nurse doesn't understand pain mgmt. and ftr, if you look at a pt's med'l hx, one should be able to see why narcs are indicated... and waiting for symptoms to appear is one of the worst ways to manage it. we need to anticipate it and treat it accordingly. you DON"T wait until pt is agitated or restless. it is that much harder to try and catch up to it. preventing it is key. again, please talk to hospice nurse. the hospice nurse then needs to have a meeting with the DON or nurses, to ensure this pt is being adequately managed. gah! this stuff really frustrates me. ;p op, thanks for being his advocate. leslie

this is one of those cases where i am amenable to either/or. catheterization is relatively non-invasive, considering the procedure is hopefully done one time only. and even if it happens a couple more times, the benefit could outweigh its hindrance. my only thought is that this pt's sacrum is reddened... and depending on the reason why, a foley could prevent redness from macerating or spreading. if it was me, i'd discuss the daughter's objections with your mgr and ask "what should we do"? this keeps mgr in control and feeling respected. as tewdles stated, you have an ongoing relationship with her. inevitably, it's preferable to stay in an amicable relationship. again, i say this only because i don't feel this is a battle worth fighting. blessings to you and all involved. leslie

i am sitting here with a half-smile, somewhat incredulous that you perceive the above criteria as seemingly peripheral. this is a major consideration as to why many don't embrace Christianity... because it is just so inconceivable and contingent. i think i've said what i needed to. have a great day. leslie

i'm wondering if you recognize how passive-aggressive your post sounds. first you denounce religion, then you "just believe with my heart what Christ did for me". is not Christ a derivative of Christian teachings, making it solely religious? then you emphatically add scripture from Timothy, to ensure your (religious) .02 is heard. and "Just as eternal life is not for everyone". really? did you just ever-so-glibly say that? the least you (or anyone) can do is if you believe in a truth, staunchly stand behind it. otherwise, indirect jabs are disingenuous and derisive. thanks. leslie

oh! i do remember a refusal from a dr, when i was a new nurse in a ltc facility! and i was adamant about it too....not so much some other nurses. lady with gtube, npo (duh) on comfort care. her brother (frequent visitor) wanted to give pt her favorite food, choc chip cookies. i told him his sister wouldn't tolerate this. long story short, dr gives ok and writes order for "pleasure foods po as tolerated". i still refused. other nurse gives her cookies, pt aspirates, and dies from asp pneumonia. this pt suffered much more than she should have. yes i do understand the other side/perspective of the story. obviously pt didn't tolerate, and paid the price for it. was it really a "pleasure food" afterall? leslie

lamazeteacher, i agree it gets esp tricky when a non-medical administrator demands totally unsafe and non-sensical orders... and more than once, i had been threatened with termination if i didn't follow through. my verbal concerns of my licensure limitations (nevermind the lack of ethics) fell on deaf ears. to say the least, it was very frustrating... and i also acknowledged to myself that even if i was terminated, i would one day be vindicated in a court of law. still, who wants to be terminated. fwiw, i didn't follow these orders but that is only because he listened to the protests of the DON. to answer the question, yes, i have refused drs orders. working in inpatient hospice, i have been ordered to administer lethal doses of narcotics. these orders were totally irrelevant to the pt's condition at the time. to me it was clear that i was being ordered to hasten death...to literally kill someone. of COURSE i refused...loudly and veraciously so. in the end, a nurse must always refuse orders they know to endanger pt safety/well being. leslie