pmabraham

Consider hospice, where you may not have to lift anyone... and consider you may not need as much as you think to retire.

You did the right thing. Stand strong!

"The directions are to place one drop on a clean or gloved finger and touch it to the roof of the mouth." -- hmmm.... one drop touched to the roof of the mouth... not swallowed or ingested. Like all medications, informed consent is offered, and they have the right to refuse. Stand up to the organization if one feels strongly, but the focus should be on the dying patient and what they deem aids in their comfort.

The FDA did such a wonderful job with experimental injectables released as part of Operation Warp Speed, where the manufacturers are under no legal recourse for death or significant, often life-long, side effects.... NOT! I stand by my point that the focus is THE PATIENT! If the terminally ill patient wants to try something for THEIR comfort, perform informed consent and allow them the freedom!

Why would this be unethical if it can provide comfort? Are you aware all of us are living experiments regarding medications? For example, can you (the reader) guarantee that another human being with no known drug allergies will never have a side effect from an FDA-approved medication the doctor prescribed? Can these holistic measures be considered an experiment? Yes, from a point of view, but then, examine the above question about FDA-approved medications. The goal of hospice is comfort that will hopefully enhance the quality of life for whatever life remains. If the patient is okay with trying this new method, then do not cause them harm by preventing them -- do not be their nanny! By the way, when we talk about ethics, nonmaleficence comes before beneficence in priority because you can have people who think they know better than anyone else. In their opinion, such and such would be beneficial and should be forced or viewed as malicious and then censored or otherwise unavailable. Please don't let your personal opinions get in the way of the patient's comfort.

Question on End Stage Parkinsons Problem Statement: Over the past 4.5 years between two separate hospice agencies there has been a pattern of admitting patients for Parkinsons Disease where the result is frequent discharges for failure to decline. For every four admissions, approximately one patient dies within six to nine months. For those that were hospice appropriate, I've worked with both ends of the spectrum where on one end the patient became so stiff they had trouble breathing, were on oxygen, were only oriented to self and was complete care including feeding to the other end of the spectrum where they would have spells of looking as if they were on a horse trying to throw them off, and when they were not having such severe tremors that medications could no longer manage, they could partially participate in self-care such as feeding themselves. Quick Flips doesn't list specifications for End Stage Parkinsons and from researching Medicare briefly describes the following: · Rapid disease progression · Progression from independent ambulation to wheelchair or bed-bound status · Progression from normal to barely intelligible or unintelligible speech · Progression from normal to pureed diet Yet for the patients I've had that fit, the only thing true as been the wheelchair or bedbound status. All the patients that died within the expected time period went through normal disease progression vs. rapid (it was rapid in the last three months, but not rapid in the preceding three), did have intelligible speech, and only progressed in diet in the last month. Therefore, question: Can any of you provide details as to what your admission team (whether one person or many) look at specifically to ensure that a patient being admitted for End Stage Parkinsons is most likely going to die in at least one year after admission? I.e. how can we all be more accurate in admitting Parkinson patients when they are in the terminal stage? Thank you.

Then there's home health and home hospice where you are not working 12-hour days ?

I went back to school at the age of 50 to become a nurse, got my associate in nursing science, passed my NCLEX-RN boards, then went for my BSN. You can do it if this is your dream.

0.25 ml = 5 mg of morphine. The max daily dose of morphine is 1,600 mg. As a hospice nurse, I've had pancreatic cancer patients on 960 mg morphine daily and still talking. Morphine is not a euthanizing agent.

The 4 drops of clonazepam DID NOT speed up the dying process

As a visiting hospice RN case manager, I don't know how much I would trust cameras in order to be able to properly see the condition of the patient. While vital signs, in my experience, are often not the main factor for me to determine estimated end of life, most family members are not trained on how to properly take vital signs... and while this part can be easier if the patient is at a facility, there is still the issue of not being able to properly see the patient (more often than not, I know if a person has <= one month based on visual presentation).

It comes from experience and I'm not trying to be snarky. I've articles on medium dot com that go over how to recognize terminal restlessness, when someone is within two weeks or less (does not include sudden death syndrome), etc. but the last time I tried to post such articles, the post was deleted for the reason of self-promotion even though I'm not trying to promote myself and I don't get any payments from medium.

Cheyene stokes and Kussmaul are among the common end of life breathing patterns, but nothing you wrote came across as excessive. We are called to use critical judgement and you used yours. Morphine and Ativan are not euthanizing agents; you did the right thing.

Let's start off with just a little background of how hospice is supposed to work with families. What I'm sharing is per Medicare guidelines and that means every hospice nurse and provider should be following what I'm about to share but I'll put it out there that there are people who may not keep up with the guidelines or try to remember them etc. with that stated when I first meet a family whether their loved one is at home or in a facility I let the family know hospice is not in charge. Hospice is supportive. The power of attorney is the one who is in charge. We will give recommendations for how to best keep the loved one comfortable, but the power of attorney including any and all doctors were involved in the case can toss those recommendations to the wind without offending anybody. When I assess the patient for the benefit of using something like roxanol which is liquid morphine, Included in the assessment is were they ever on any type of opioid, type, dose m, drug allergies, drug interactions... And if they're what is considered opioid naïve I will start them off on the lowest dose as approved and ordered by the doctor keeping in mind that nurses do not write prescriptions orders. And the one thing that everyone reading this thread must keep in mind it's all orders come from the doctor and not the nurse. And if they're what is considered opioid naïve I will start them off on the lowest dose as approved and ordered by the doctor keeping in mind that nurses do not write prescriptions or orders. And the one thing that everyone reading this thread must keep in mind it's all orders come from the doctor and not the nurse. From there we monitor for side effects and we educate everyone involved in the patient's care as to what side effects to monitor and we keep it simple and smile approach. Four years is not a long time to be involved in a specialty but in those years I've had extreme cases ranging from loss of airway Requiring palliative sedation under the orders of a doctor, extreme terminal agitation requiring temporary palliative sedation under the orders of a doctor and cases where it was a complete when were the oncologist could not manage the pain for the loved one that they were completely bed and chair bound due to the pain or thanks to the expertise involved by hospice got to pain so will manage that the patient was able to have one last vacation to the beach with his wife and his rescue dogs before passing. Requiring palliative sedation under the orders of a doctor, extreme terminal agitation requiring temporary palliative sedation under the orders of a doctor and cases where it was a complete when were the oncologist could not manage the pain for the loved ones that they were completely bed and chair bound due to the pain or thanks to the expertise involved by hospice got the pain so well-managed that the patient was able to have one last vacation to the beach with his wife and his rescue dogs before passing. I will continue to maintain that morphine, methadone and the other medication is used by hospice do not lead to euthanasia under Doctors orders with hospice involved.

It’s frustrating do you have anyone who is a healthcare professional think that hospice uses morphine for euthanasia. Prior to becoming a hospice nurse I worked on the cardiac floor where are they increasingly gave me more and more hospice patients. I still remember the one that was on a morphine drip via IV where the doctors orders or to monitor four respirations above 20 for every 30 minutes and to increase the dose until such a time the respirations were 24 or less. During my eight hour evening shift I remember doing 16 increases where the respirations were in the low 50s upon the start of the shift and we’re in the mid 40s towards the end of the shift. This was my first nursing job no not my first patient. This was my first IV morphine drip. I still remember looking like a deer in the headlights to my fellow workers as I was doing my end of the evening Jordan were they were asking me what was troubling me and I shared with them did over the past eight hours I increase the dose 16 times. They looked at me as if I was a child stating how many licks does it take to get to the end of the tootsie roll. They Said Peter, Night Shift is probably going to increase another 16 times. And when I looked amazed they said if he’s still around come dayshift they said they’re gonna increase get another 16 times and none of that’s going to kill the man! as A hospice nurse I have had cases of severe terminal restlessness and agitation we’re under doctors orders I gave 180 mg of morphine in less than an hour along with 50 mg of haloperidol, 10 mg of lorazepam for a 72 year old town man skinny as a stick it took more meds just have him sedated but not yet euthanized because that wasn’t the goal nets never the goal at least for our state. Let alone my faith. It’s a significant amount of morphine do you have a potential and I used to work potential for a reason to kill somebody. Please do not be among those who continue to believe false things when it comes to morphine.

Check https://careers-brightspring.icims.com/jobs/intro?hashed=-626002160 as they own Grane for whom I work as an hourly RN Case Manager.

Grane Hospice pays hourly. They are owned by BrightSpring so it is possible other BrightSpring branches for hospice also pay hourly.

"Tuck-ins" are calls or visits to see if the patient is OK, needs supplies, etc. More often they are phone calls but can be a visit if a change in physical location such as nursing home discharged to home or home going to a nursing home (respite or longer).

Hi: Tuck-in calls and visits should be doable by LPN/LVN/RN et al as it is just a routine visit or call to check in on the patient. Pre-admission evals typically require a good understanding of LCD's and what makes a patient terminal from a nursing perspective. I would think the latter would be better done by an RN, but that's just my opinion.

"I have been told that I do not have a set number of patients to see, nor will I have a list of "regulars" or appointments. I was hired to be a go-between for families and patients who already have scheduled visits during the day, but feel/know that the scheduled visit cannot wait, which probably means change in status, death, need for additional comfort/pain measures, guidance/advice on falls, possibly family dynamics becoming confused. " This is a huge plus as this is the best type of on-call. You'll learn over time which types of calls require (sometimes it is more beneficial for the family than the patient) in-person visits vs. handling it over the phone. Usually, I go by pain crisis, respiratory distress, and other changes that may indicate possible end of life (I.e. <= 2 weeks to live) as major reasons to visit in person; and from there, go by the emotions in the voice on the other end. Based on what you've shared you will bloom.

Salary has pros and cons. When I worked for-profit their for-profit took advantage and I worked more hours without the benefit of overtime. On-call can be just phone, phone + PRN visits or phone + PRN visits + scheduled visits. The latter can be horrendous, especially if salary. By the way, I'm not stating or intending to communicate run. I write mainly hospice stories at https://pmabraham.medium.com/ which may be beneficial to you especially admissions, recognizing terminal restlessness, end of lifek, et al.

As a day RN CM, the company policy is that we do supervisor visits every visit when there are CNA's assigned to the case.

Home Hospice (which from a point of view is very close to home health). You drive solo with the only time management is around is for an annual survey of your skills/practice. When you get good at SBAR's, almost all providers accept your recommendation and often time tell you things like "good job" or "good thinking," or "well thought out" offering encouragement. The families and the patient are often very thankful. As long as you chart in the home, there's minimal work activity outside of work except for a few days before IDG.

Margaret Sanger founded Planned Parenthood and has a long history and connection with the KKK, called black people, "weeds," and wanted all blacks wiped off the face of the planet. Bill Gates and his wife support Planned Parenthood and are on record for wanting far less population than we currently have right now.

Minimizing? Misinformation? Oh my, what a malarky. I've taken care as many of 40 sickly, geriatric, COVID-19 positive patients per shift when I worked in long-term care from April 2020 to November 2020 and 98% to 99% recovered. The liberal fake news media will not tell you those statistics, but how many infected, how many died, but no percentages. They don't tell you that JUST after the November election they changed the tests so that there's now a 50% drop of infections. They keep spreading the fear. People are being negatively impacted by the vaccine, both with severe side effects and deaths... and within 24 hours of being listed such as on a local ABC web site they get deleted and we are told "nothing to see here," the CDC has not verified any severe side effects or deaths. Yet, I personally know two nurses and a patient greatly impacted (thankfully getting better). Misinformation, my behind.