Question from new hospice nurse

grbrico · Jun 9, 2009

Where I come from our medical directors are pretty quick to take our judgement when it comes to a patient out of pain control. We would have them on a gtt at home before going inpatient. There have even been times we have done continous care with a pt out of pain control and with terminal agitation issues.

Yes, in some of our patients we do use methadone, some dilaudid, most though and our main pain medication has been morphine. Mainly because its one of the only drugs of its kind that assist the respiratory system rather than to depress it. We use it quite frequently for shortness of air, chest pain and any other pain... its good for agitation as well, however we generally add ativan with it for agitation and with psychosis halodol.

Diana2002 · Jun 9, 2009

Well, I don't think the doctor was being advised of the situation with the patient, but I'm not sure. Not been here long enough to get the lay of the land.

They are big on methadone here -- do use morphine, but not Dilaudid. That I've seen. I'm not liking hospice yet, but I hope I will soon.

grbrico · Jun 10, 2009

Well, what don't you like about it... it does take some getting used to its a different nursing entirely. I mean there is still the bedside but in the field, you are on your own most of the time, that is when your team comes in and you work together. Are you in a hospice facility or out in the field? I am sorta new to hospice as well, I have been here nearly 8.5 months.... Im getting the hang of things, in the field I am alright, it was just learning the medications and the different ways they use them, what is and isn't allowed with medicare/medicaid (insurance stuff I never paid attention to while in the hospital.. we staff nurses didn't get to look over bills and billing....) So that was hard... I still have questions.

I guess you would have to ask yourself.... do you believe in what you are doing... have you helped someone ease into death with their dignity intact, abiding by their wishes, do you feel a sense of peace and accomplishment when you look back at the end of the day, no matter how difficult it has been or how few hairs you have left on your head. Can you look into the mirror and say. "I helped ease someone's pain today. I did a good thing" If you can say, even if the person you helped was a distraught, controlling, manical family member come to peace with their loved one's disease process, then my dear.... you are a hospice nurse.

If you can't accept those things in your heart, and you feel better working with others to fight disease and get better, and you feel the same things that I described above, then maybe you are on the wrong bus... maybe, just maybe you haven't found the exact place you fit yet....

But you know what? Your time isn't wasted in what you are doing... you are learning each day, you are learning a side of nursing that many do not see. Im not going to say that your heart wont ache, and that its hard not to become attached to your patients.... There was a few weeks ago.. I literally was falling apart... there was a lot of stuff going on with our hospice and with our personnel and at home. What it did do for me after I vented here..... number one was bring me back to this forum that I do miss, and I learn quite a bit from lurking.

I was told by a very warm and gracious nurse educator with hospice that it takes a year to finally get it... and maybe even then some. You trip you fall, you get back up and ride that horse again and again. Whether it's with hospice or whatever field that intrigues you and fuels your passion with nursing..explore it, but do give the area you chose some time.

Blessings to you

Diana2002 · Jun 10, 2009

thank you for your thoughtful -- philosophical even -- response. i read it with interest.

i don't dislike hospice, just don't like it yet. have always been more keyed on relieving pain and suffering than on fighting tooth and nail for a cure that doesn't exist or comes with too high a price tag for the patient. i'm sure hospice will prove to be a niche for me. once i've been on the in-patient unit for a while, i am supposed to be cross-trained to do home visits.

my original post stemmed from my dismay that a little old lady was allowed to suffer for so long. as the orientee, i did ask pointed questions, but. . .nothing was done until one really excellent day shift nurse was on again. i still feel vaguely guilty . . .like i was too much of a coward to make waves with my orienting nurse. that i could have been more fierce on the patient's behalf and spared her three days of confusion and pain. know what i mean? :imbar

Irish_Libra · Jun 10, 2009

It seems you've had a bad experience of some form of terminal aggitation. I'm sorry you had to go through that so early in your hospice experience. I've been in hospice for 6+yrs now, & I agree it does take some getting "used" to since the ideology behind it is different then other types of nursing. But remember that most cases pts are able to obtain a level of comfort & alertness that is right for them. Each pt (or pts family) will determine what that is. Sadly you will encounter cases where no matter what you do, which drugs you use, which relaxation techniques etc you use, the pt will still have pain/aggitaion issues.

The ones that bother me the most have always been the pts whose religious beliefs tell them that the amt of suffering they have in life will determine their heavenly rewards. I can respect their wishes/beliefs but to watch them suffer needlessly still bothers me after all these yrs.

Oh BTW my company uses Roxinol frequently & phentyl patches but other than your basic NSAIDS (for minor pain) I haven't heard of us using anything else.

grbrico · Jun 11, 2009

I agree with Irish there.... it does sound like a bad case of terminal agitation... and I had one of those about a three months ago.. it still haunts me... no matter what we did, we could not ease this man's agitation... and pain... no amount of medication, and he was a very good man....

Never be afraid to ask pointed questions that is how you learn... dont ever hold back your questions... they may have been doing all they could.. and didn't have it right yet... I dont know.. I wasn't there.... but if you didn't feel right about something... ask... then ask why they are doing what they are doing and why can't they do more... if a preceptor avoids you or doesn't answer your question.... then ask your supervisor... someone will have an answer for you... or... something will get done.

It comes with time... just never be afraid to ask... that is how you learn....

Hugs

Diana2002 · Jun 11, 2009

Hey, thanks for all the support and reassurance. Things are definitely getting better for me in this new world of hospice nursing. Will be back for more advice!