RN whos Dad was on Hospice

[muffin7]

Hi Everyone,

As an RN whos Dad was on Hospice I would like to share my experience with all of you. My Dad was on Hospice for about three months in his own home for End Stage Alzheimers. I feel that my Dad was well taken care, but that at the end of his life the Hospice Nurse really dropped the ball.

My Dad's caregiver called us the night before he passed and told my husband that my Dad was a little agitated. My husband told him that he needed to call the Hospice nurse who arrived at miy Dad's house about 30 minutes later. By now it is about 10:00pm and the nurse calls and says that my Dad is a little agitated, but is doing fine and is stable. She was rude and very abrupt and sounded like she really didn't want to have to work.

She never told us that she had opened the "comfort kit" and had instructed my Dad's caregiver to give him Morphine q2hrs (for difficulty breathing) and something else for excess secretions. I really wonder if this didn't knock out my Dad's breathing.

I was so upset the next am when I got a call from my husband to come to my Dad's house because he wasn't doing well. In fact my Dad had passed, but my husband didn't want to tell me and he didn't want to leave my Dad alone. I arrived 15 minutes after my Dad had passed and would have liked to have been there when he had passed.

We knew that my Dad would pass soon, but thought he would have been with us through the Holidays. If we had known he was having breathing difficulty and that the RN had gotten an order from the MD to start the administering the Morphine, etc we would have come immediately to his bedside as well as the rest of the family.

As a daughter and a fellow RN, I ask all Hospice RNs to take the time and keep the patient's family informed of there loved one's condition. Don't assume anything!!!! As a new Hospice RN wrote in another post, she was told by her Hospice preceptor "to fake it, until you know it" find another preceptor!!!!!!!!!! That is really bad advice, you have worked too hard for your license!!!!!!!!!!

[SoCalRN1970]

First of all, my condences on your loss. I lost my mom more than 15 years ago, and it's hard to separate being daughter and nurse. I felt with my mom's case that I had to be "ONE" who was involved and made decisions towards the end. ( My mom did not have a DPOA in place as her illness was very unexpected, and due to my own family dynamics, I won the default due to me being a nurse.... nobody could talk to my 3 eldest sisters, one drinking 24/7 one an emotional wreck and the eldest emotionally no there.. so all medical corresposndence went to me, the yougest child, the RN the one who could keep it together. It was a hard job)

Let me say. I hope you took your concerns to the right place and put it in writing to your hospice agency. I have done hospice nursing for 8 years. I personally never initiate medications or get new orders without documenting I spoke to family including their names. It's just good hospice nursing. In some conditions where family are not completely on board with understanding of medications and do not want morphine or ativan given to calm the rapid breaths ( up to 40 is not unusal for the dying ) I ask them to please look at their loved one. The decision is thiers, not mine as the hospice RN.

Most hospice agencies use a "canned" if you will set of orders for a comfort kit. Usually 5mg of Morphine given every 3 hours prn for shortness or breath or pain. Ativan 1 mg po q 4 hours prn agitation and atropine1% 2 gtts po sl q 3 horus prn secretions or congestion. There are some slight variations to these orders from hospice to hospice but they are usually pretty close.

Morphine, 5 mg is NOT enough to "knock" out someone who is having respiratory distress. This morphine or Roxanol as we call it is an immediate acting short half life form of morphine that hospice usese usually at 5 mg ( the the equivilent dosing wise to a routine vicoden according to every pharmacy I have ever used.) It's actions allows the patient to relax enough to take better proper breaths vs. the fish out of water breathing that we see our patients go through for sometimes minutes to hours to days at a time. Morphine on a hospice level is not used nor is it a high enough dose to cause cessation of breathing. Our patients are always initiated on these meds for symptoms out of control... or active transisitoning of patient's life. It sounds as if this was not explained in your situation.

Patients who are started on this med should of had their dpoa contacted or next of kin to alert so THEY could make this choice. As a Hospice RN I suggest it, but in the end. The comfort control and access are up to the family to approve. So do approve and other don't. But it's THEIR decision.

Please, I hope you contacted the hospice of your service. After hours people are not always in best form when being called out. It's not an excuse by any means. THey also should not be a total reflection or the hospice care your dad received. I have had cases that I worked on so hard and diligently..... family patient are happy. One after hours visit could ruin this. I hope it hasn't tainted your vision of what our philosophy and total goals are which is comfort and active treatment of patient symptoms.

[tewdles, RN]

I am sorry for your loss.

Don't assume the oncall nurse who came to care for your father "knew" that he was going to die within 24 hours. She should have notified family of the change in your father's condition, when she learned that he had died she probably felt badly that she hadn't.

The morphine did not kill your dad, nor did it knock out his breathing. I certainly hope it made him more comfortable.

Hospice nurses often work with Standing Medical Orders and do not need to contact the physician to initiate Roxanol...particularly after hours...so she probably didn't "get an order", there was likely an order already in place.

Nurses new to any specialty "fake it" for awhile at least...they fake the confidence so as not to scare their patients, they fake enthusiasm in the face of fatigue when asked to explain this or that (again) at the end of a long visit, they fake calm and control when their patient's die before they could ever get them comfortable.

You are grieving now, this all seems wrong...as if it shouldn't have happened this way. It may have been easier for you if your Dad had lived through the holidays...or if you had been able to sit with him and hold his hand. But honestly, saying goodbye to your loved one is just not easy...no matter what the circumstances. Take time for yourself...talk with the bereavement professionals from the hospice agency. Forgive.

I am sorry for your loss.

[SoCalRN1970]

I should of clarified yes, my original post mentioned a comfort kit. Those are standing orders.

HOWEVER!! Standing or not. When there is a change in condition or a need to start the Roxanil it's better practice to notify the family of this.

I recently had an experience where a family member was upset that she "forgot" grandma had morphine orders. She was upset this medication was going to be given...and asked to be called with each and every dose "to approve" the medication. ( definately a non nurse ) Truth be told. I told her she needs to come and see grandma since she is requesting this. She said she was leaving to see for herself and the pateint died a few minutes later. She never did recieve the dose of morphine as the grandaughter wanted "to see her" first and make sure grandma "really" needed morphine. Grandaughter walked in the snf to be told "your grandmother just passed.."

Grief, anger and denial do bizarre things to people that normally would not act like this. Yet, it's normal for hospice isn't it?

[SilentfadesRPA]

Sincerely sorry for your loss.