johnys

It would depend to a large degree on what, if any, renal function they have left. If zero, then can plan on a short Hospice stay. There is always the unexpected...had one lovely 93 yr old lady come off dialysis, slipped into a coma on day 5, and unfortunately bled out on day 6, from somewhere we will never know. She was comfortable, but it was not what we had hoped for to say the least.

Much thanks for all your insights. Post-script: pt was sent out to local ED, received IV morphine and ativan, and when meds were finally in place at SNF he went back; died next morning, peacefully. Honestly, I was out of my mind with anguish that I, my company, the SNF and the pharm were not able to provide for this guy when he needed it most. Maybe I just need to figure out how to let go in these situations and move on, don't know. But the SNF should have had meds available and they didn't, the (national) pharm did not deliver stat meds for nearly 6 hrs (too late to keep this guy taking a bus ride to the ED) and I am seeing way too much of this...so back to my question...any state regs or laws in your area that require SNF's to have rescue meds in-house? Any regs/laws that dictate the length of time a pharm has to deliver "STAT" meds? Any laws/regs that require a SNF within a certain time frame to open the e-kit after med orders have been verified by the pharm? I am aiming to get legislation enacted in my state to end this needless dying in pain. Looking for other state models...and again, thanks.

FLArn, thanks for your response. Yes, the doc had faxed signed written scripts to the pharmacy. I confimed that from the nursing home. The staff nurse followed up with the pharmacy to see when the meds might be delivered. We had the confirmation we needed. The problem, again, was that this facility did not have an e-kit, no morphine in their pyxis, and the stat delivery from the pharm was anything but stat. Playing nice in the facility is good, but when they are lying to you, saying that they have meds (which they did not) to cover their butt hoping that the pharm delivery would come through, and meanwhile my client (THEIR resident) is dying in mortal pain what do you do. And Tricia, as much as I would love to carry my own narcs around with me that isn't going to happen...there's rules against that. Education is good, but the drugs have to be available in a timely fashion for any education to worthwhile. I am still convinced, now more than ever, that a law with teeth may be the only real solution, but open to other suggestions. TooMuchBaloney - this pt was GIP level of care...for symptom management of pain that we did not manage.

So, this is one part question, one part unloading, and 4 parts heartache. It is long, and I apologize for that. I am an admissions hospice rn. What I experienced with two patients on back-to-back days is making me question what I am doing. Both cases are similar, involve patients in SNF's (two different facilities) and in both situations the patient's were in the active process of dying. Both patients were clearly in distress. The 1st one had a HR in the 130's, temp 104.5, resp rate in the low 50's, PaO2 on 3L of 81%, lungs filled to the brim from aspiration PNA. I evaluated her in les than 5 minutes, got confirmation for admission from our doc, and got orders for roxanol, ativan, atropine and tylenol suppositories faxed to the pharmacy. The order was for a stat delivery. The SNF had a locked e-kit with everything I needed. The delivery from the pharm never came, the SNF refused to open the e-kit (their rational was why bother, the pharm meds would be here anytime...) This pharmacy is notorious for being 4 to 6 hours on a stat delivery. The poor woman died with nothing on board - 4 hours after I arrived, and 3 1/2 hours after I started begging and pleading for the e-kit to be opened. 2nd pt, next day... no e-kit in the facility; pt 63 yr old male actively dying, (DKA and stroke), agitated, clearly in pain, resp 40, HR 115. Facility had a pyxis med admin system...but not a drop of morphine or ativan in the joint. Once again, 4 hours after my arrival and faxed orders received by the pharmacy (same pharm in both cases, but I will leave them nameless) no meds arrived. The family was very upset and so was I. I got called down to the administators office to be chewed out for being "unprofessional" with the staff. (What I said to a staff RN was I thought it was "rediculous" that the facility did not have any rescue meds, that was reported back, and hence the chewing out by the admin. MY bad, sorry, I should have been more attentive to the feelings of the staff and less concerned about "our" patient who was trying to throw himself out of his bed, he was so agitated with pain.) I recommended to the tearful and angry family (reluctantly) that they send the patient out to a nearby hospital for symptom relief, which the did end up doing. I prayed to god the transfer didn't kill him. The pharm delivery of my stat meds came after he left, 6 hours after they were ordered and CONFIRMED. He died the next morning. My question to you all now is this; do any of you have state laws or regulations requiring SNF's to have rescue meds in the facility, and are there any time frames within which they must open them once orders are verified? I am thinking legislative changes need to take place in my state; I am looking for a place to start. What I do know is something has got to change. I know you may be thinking get a different pharm, but the rest of them in this state are worse, believe it or not. I didn't get into hospice to sit by and watch dying people suffer. I am not leaving. I am going to effect change, so God help me. I am angry, hurt, and feeling utterly useless.

"Yes, when I worked in hospice we did use highly concentrated liquid forms of morphine and sublingual ativan on our patients who were actively dying. Most of them did not have veins that could support IV access. Besides, why cause a dying patient more pain with repeated sticks (IV, IM or SC)? Absorption/circulation of the drug may not be as efficient as oral mucosal route. [quote) I know this is a mildly older thread, but I have seen discussion about the absorption of SL/PO morphine and more importantly, WHERE it is absorbed. Much (but probably not enough) research has been done (with healthy subjects - not dying people) on the bio-availibility of nebulaize, PO, SL, IV, SC, PR equianelgesic doses of morphine. Pharmacology: Sublingual administration of morphine is often used to treat breakthrough pain in an attempt to hasten analgesic onset and peak; however, available data do not support more rapid absorption of morphine through the sublingual mucosa when compared with the oral route (1-3). Indeed, a number of clinical studies have found no substantial advantage to the use of SL morphine over oral morphine (4-6). •Mean time to maximum concentration has been shown to be shorter following PO morphine (0.8 + 0.35hr) compared with SL (1.75 + 1.30 hr), indicating that SL morphine is likely swallowed and absorbed gastrointestinally rather than through the oral mucosa. From www.eperc.mcw.edu. (Fast Facts from the EPERC). Morphine placed in the mouth is not well absorbed through the oral mucosa - something about its lipid insolubility and the pH of the mouth....it IS absorbed via the GI tract, but is subject to 1st pass hepatic metabolism. I have not had much sucess with clients who are not able to swallow AND in pain - will go to PR, IV or SC route (preferably not PR but it can be effective) anytime I can. Just my .01 cent. BTW, hospice nurses rock!