TLDey

Thank you for your support! Yes, there's two staff present (a nurse and an aide) 24/7. I did address it with the Business Manager for the agency (whose daughter actually owns the company), and she assured me she'd hold the "managing" nurse accountable to count the controlled substances just as the rest of us were doing. The Business Manager offered to put a lockbox in the home if needed. The managing nurse spoke with the patient's husband, who preferred to hold onto the backup meds himself (keeping them on a different level of the home that we don't have access to), vs. resorting to a lock-box, and she also made arrangement with him, that when she worked once a week, he would give her enough to refill the small bottles to get us through the week. I felt like this was a satisfactory solution, and no longer feel the need to investigate whether she's diverting meds or not, as long as the rest of us are above question. I didn't mean to make it sound like an "RN vs. LPN" issue, but this girl's been a bully and a thorn in my side, and I suppose it made me feel a little better to throw some credentials around, tho' I'm not so proud of it now.

Hi, I've been working on a private duty case for the past several months. There are several nurses in the home. When I first started on the case, the nurse I took over for full-time, an LPN, advanced to become the clinical nursing supervisor for the agency. (She still staffs in the patient's home one day per week, and designates herself as the "Casemanager" and the "only one qualified" to direct the patient's care, in addition to her new supervisory duties with the company). This nurse asked me to take over the monthly med ordering when I first started. The patient was on Ativan and Percodan at that time, and they were keeping big bottles (up to #120 count) in a non-locked, fully-accessible-to staff-and-family, and non-counted backup cabinet. We used the backup meds to restock smaller (#25 count) bottles which were kept in the main med cabinet. These bottles we counted every shift, keeping a sign-out sheet for them. (The sign-out sheets get turned into the company, where they are filed in the patient's medical record; no one tracks anything from them). I asked her why we weren't counting the big bottles in the backup cabinet, and she said it was because it would take too long, and there'd "never been a problem" (how she knew that, I don't know). I've been an RN for 26 years, including 14 in the Emergency Department, and I've had several coworkers get mandated to treatment for addictions and diverting meds, so I was leery, but I went along with what she said. The patient had been with the company 6 months, by then. After I was 6 months into the case (so the patient had been with the company for a year, without having her backup meds counted) , the doctor started ordering larger refills (#180 count) of the back-up Ativan. We had d/c'd the patient's Percodan because of med reactions, and I signed over the remaining Percodans to the patient's spouse, so we wouldn't be responsible for them. The doctor ordered (#180 count) bottles of Ultrams instead. The nursing supervisor, still working the home, said we didn't need to count the Ultrams, giving the reason that "it's not addictive, they count it in nursing homes, but we don't need to count it in home care". (I don't know what resource she was quoting). I started to feel funny about not counting the backup Ativan, and not counting the Ultrams at all. So I personally started counting them both, whenever I was working. I found 3 Ativan tablets missing within a 2 week time period. (At the same time I discovered this, one of the nurses, admitted to me just before she quit, that she was doubling up the patient's ordered phenergan dose occasionally, and occasionally giving 1-1/2 times the ordered Ultram dose, as we weren't counting these, so she likely had been doing this with the Ativans also). I let the clinical nursing supervisor know about the discrepancy, and I told her I initiated sign-out sheets for both big and small bottles of Ativan's and Ultrams. This was just two weeks ago. This supervisor has since staffed in the home two shifts, and while most of the rest of us have been counting the backup pills and signing the narc sheets, she herself has NOT been counting them, and she also has NOT communicated anything to the staff regarding counting pills. Now I'm wondering if maybe SHE is having a problem. She has access to other patient's homes/meds, with her supervisory visits, and it doesn't look like she's interested in changing the counting policy! How could a nursing supervisor of an agency, after having been reported a problem, not be interested in an effective resolution to the problem? Would like suggestions please, as to how to proceed, or a written resource that might impact company policy for counting controlled substances. The easiest thing I could do for this case would be to ask her to have the doctor write for only small refills so we don't have a backup supply to count, or to see if we could get them bubble-packed, but it wouldn't satisfy my need for investigating this nursing supervisor. Thank you, Terry, RN

Thanks to all for the wise words. I have been concerned too, because the client's husband came in to talk to the aide I was working with, and myself, re: another aide that was "let go"... the husband said he didn't understand why my company had gotten rid of the aide. He said he and the client had "loved" her and they were upset that she had been wrongfully fired... then a couple weeks later when he was talking to us, he sort of slipped his tongue and said "we" got rid of her, meaning him AND the company. So I asked the lead nurse on the case, and she said yes, the husband had been part of the decision to get rid of the aide. I can only conclude that the husband was intentionally trying to deceive us for some reason, into thinking he had nothing to do with it (we didn't bring it up- he did). Flippin' bizarre...

I am a Private Duty nurse with a home client who requires both an aide and a nurse 24/7. Both the client and her spouse have mood and temper fluctuations, and they are frequently requesting staff replacements. The company I work for replaces staff as asked, but they will lie to the current staff, saying that the client likes them and things are going well, at the same time they are looking for and training replacements. Once the replacement is ready to be added to the schedule, the current worker is let go. I think the company and the client and spouse are afraid to tell current workers that things aren't working out, for fear that the worker might react negatively towards the client. How do other companies handle replacing staff on a case? (Three people have been fired off the case within the past two months, and the company doesn't feel any responsibility to try to have other work to offer them).

I'm sorry I sound so bitter... the SW I worked with was always accusing that I didn't have the compassion to persevere with the repetitive education approach, despite "umpteen" attempts (and I've been a nurse for 26 years- I don't think I would have lasted this long, if I didn't have compassion) instead of him getting in there and helping me. My nurse manager thought it was an amusing situation (she would chuckle) that he & I had conflicts between us, vs acknowledging the need for team efforts in dealing with denial- there was never a collaborative effort. It was very rough & I felt abused. I never figured out how to have victory in this... I got eliminated for "workforce restructuring". Thank You, Jesus, I guess. Has any ever identified that a lot of family caregivers seem to dissociate under stress... like they might have PTSD that gets triggered as their loved one declines? Nothing you say or write out gets retained. To me, it's this caregiver that I think would have VICTORY, if Continuous Care was readily available.

In this scenario, SC won't step in because family says "no". SW is off doing one informational after another; SW has seen family once and "didn't notice any problems" so, it must be my problem...Home health aide, is as concerned as I am (even more so, suffering stress ulcers)... medical director says we don't have the staff for continuous care, and to quit asking... Anyone else been there? Argghhh... Seriously, you have & are able to get continuous care initiated for education? This would be so healing!! Our agency always scores low on "family evaluation" question asking if family felt secure during the end. I am wondering if agencies that have a dedicated staff for continuous care, score higher on this question. (I think, you can't expect fried casemanagers to "volunteer" for continuous care).

Does anyone work at a hospice that supports the use of continuous care for a family who is in denial, or having ineffective coping that's preventing them from being able to manage symptoms properly? If so, where (& what state)- I want to come work there! LOL.... (or, maybe cry out loud)... OK, seriously, what approaches have you found that WORK? for cracking through denial, because the voice of one nurse, even with daily visits, isn't going to do it... the repetitive education crap doesn't cut it. Does anyone else agree that continuous care might be the most compassionate choice in that situation- you know, hang around long enough for the family to get on board with the idea of what it is they need to be doing?

Dear Steeleworks, have you used these interventions in a hospice setting, and can you get effective relief without narcotics? Is there such a thing as a holistic/naturopathic hospice practitioner? I'm so humbled... TL

"I will always advocate for bringing families with unrealistic or even inhuman ideals of "comfort care" into the IDT meeting." Hi Tewdles, Do you mean, actually inviting them to come sit in at the meeting to discuss their case with the IDT members? Have you had families actually do that, and was there then some kind of understanding/resolution? Was it originally presented to the family, that the staff were having concerns re: the family not following a recommended plan of care, or re: symptoms not being managed? (Our IDG was not quick to voice a statement of concern to the family- they might have commiserated at the IDG table, but for some reason did not feel it appropriate to put their name to it in confronting the family). It did not really feel the IDG supported the CM's in this sort of conflict (the CM's were out there battling it on their own); the IDG might have sent the MD or another nurse out to visit/talk with the family, or in occasional cases the SW may have arranged for an RN/SW "family meeting", but it NEVER seemed to resolve the conflict/make a difference, and the most common thing I heard in our IDG or from our MD's, was that "there's really nothing we can do" in the situation. I was feeling like people thought I was a thorn in their sides for having my concerns... "Traumatized", TL

I might add too, that the woman who thought we were insane to tell her she needed to turn her husband, also did not believe she needed to manage his pain. He said he wanted narcotic, and she said of course she would give it to him, but she did not. The next RN visit out, the patient thru facial grimacing, gritted teeth and sweaty brow, said he was "okay" with just Tylenol, (apparently changed his mind) and she was smiling triumphantly.

Hi all, I know I read an article, I think from one of the hospice associations, that said caregivers (even though they may have the legal DPOA, which I think some people are power-tripping with), they are still accountable to the society at large within which they live. So if someone's really "out there" with their belief system, it's not just a "me & my values" against "them" thing, but "them" against "society", like whatever the reasonable, rational society member would find prudent. I think theses are "legal barriers", that it's good and right to try to figure out how to overcome in order to help the helpless. I'd love to come across that article again. Why is hospice about the only specialty that can't stand their ground on what would be considered compassionate relief of suffering? If the family member isn't reasonable in negotiating a plan of care, and simply refuses to follow that plan, I don't know why we can't take action... I've seen caregivers get p***ed off when it was pointed out that it was unacceptable e.g. to not turn their loved one but once a day M-F when the hospice aide comes, to the point where they revoked & went to the hospital, thinking to show hospice staff to be ignorami, but it then backfired and the hospital staff were able to get a compassionate plan of care initiated. I don't know why we don't fight for a compassionate plan of care, like as a team approach, instead of sitting in IDG saying, "well, there's really nothing we can do, if the family doesn't want to". Maybe I need a field where right & wrong is a bit more cut & dry... TL:crying2:

Thank you for responding. Did you wonder, with your client who only wanted herbals & adjunctives, whether there was an element of self-abuse involved (psych/emotional problems)? (Or, whether the pt really wanted relief, but was afraid to go against the family)? I have an easier time when the pt is able to express their wishes, but when the family is deciding for suffering for the person who can't express their wishes, that's when I'M at wits' end....

A hospice agency I recently worked for struggled with the idea of holding families accountable for compassionate care. Because I thought we should hold families accountable, I was looked at as narrow-minded. For example, I cared for a dementia patient who was a holocaust survivor, who me, suffered night terrors. Seroquel actually helped, but his family stopped giving it to him, because he was too sedated, and they were not willing to try any other meds as they feared side effects. The social worker on the case identified that this family's preference was lucidity vs comfort. The IDG ssaid we can't impose our values on the families. So his night terrors continued for the couple of months he was in our care, until he developed what appeared to be an acute incarcerated hernia, after which he died 3 days later. With the hernia, he was moaning, and saying "it hurts". The family fought me on medicating him, even after I told them his prognosis if he did indeed have an incarcerated hernia. I finally told the family it wouldn't be right to keep him at home with an incarcerated hernia without medicating him, and they let me give him a dose of Morphine. A nurse went out the next 2 days, to reinforce pain management. My manager called me into her office, wanting to know why I thought I had the right to "impose my own values" on this family. (The family complained to the social worker, and the social worker complained to my nurse manager, again saying this family valued lucidity). The MD thought the patient should be medicated every 4 hours, but says we are powerless to hold families accountable for managing symptoms. It was a difficult work environment, because the same sort of situations came up repeatedly with my 1-1/2 years with this company. There was no team approach to overcoming barriers to symptom management, because the team did not accept as it's responsibility, overcoming barriers to symptom management. I'm afraid to go back into hospice nursing, without knowing what I can do in this kind of a situation? Has anyone had similar experiences, and if so, what can be done about it?