Scenario:What would you do?

pugmum · Jan 15, 2006

i agree that education is paramount in effectively treating hospice pts in acute pain.
what i'm not so sure about is that hospice pts will always end up in the er.
there are reputable hospices and not so reputable.
but if you have a hospice nurse that is astute in pain assessment, pain prevention, sound pharmological knowledge base and a medical director who is receptive to suggestions, is an expert in pain mgmt as well as liberal in their scripts, there is no need for hospitalization.
in my 10 yrs experience, i have never sent anyone out.
but i've worked in in-pt hospices- not home health.
but again, if you know your stuff and have a doc that equally knows their stuff, then i don't know why a hospice pt would need hospitalization.
leslie

Leslie, I apologize, I never meant to suggest that all hospice pts. would end up in the ER. That sounds bad, as if I am expecting that they will all go there. I should have been more explicit in saying some would end up in the ER. Some will. In some areas, hospice care is new or still does not exist apart from a few palliative care beds in hospitals. It really does depend on where you live.

A personal experience, my daughter's friend's father was dying. He was followed at home with a hospice nurse and physician, a home care team, and had the opportunity of going into a hospice, but chose dying at home. Depsite the supports in place, his family became concerned one night when they could not control his pain and he began to hallucinate - they took him to ER by ambulance. The supports were there, but the family chose to use the hospital. He was discharged back home within a day or two, and subsequently died one week later.

I think that even though we have competent, expert hospice/palliative care teams in the community who can offer the support and care that pts. need, those working in the ER have to be prepared that there will always be some pts arriving - and they will continue to need appropriate care.

DaFreak71 · Jan 15, 2006

I was an AFTER HOURS Telephone Triage RN for VITAS, a nationwide hospice. I worked in Houston. Every hospice patient should have an emergency contact number to their hospice; our patients were not allowed to go the ER (and would be discharged from hospice if they did) unless they contacted either their Primary RN on days, or me on nights. If they went to an ER on their own, the ER staff would call us and we would contact the Hospice MD on call who would interact with the ER docs. Hospice patients are cared for under standards that vary considerably in many cases from that which is given in acute care and/or long term care settings.
celeste7767

Hi Celeste,

I'm a new nursing student and i was wondering if you'd answer a question for me. Why would a patient not be "allowed" to go to the ER and why would they be discharged from hospice if they did? Sounds harsh to this new student. I can understand that hospice is end of life care and that the ER isn't the appropriate place for a terminal patient who has accepted hospice care, but maybe the patients get scared when things start happening. Seems like kicking them to the curb is a mean thing to do.

Adri

Bipley · Jan 15, 2006

Hi Celeste,
I'm a new nursing student and i was wondering if you'd answer a question for me. Why would a patient not be "allowed" to go to the ER and why would they be discharged from hospice if they did? Sounds harsh to this new student. I can understand that hospice is end of life care and that the ER isn't the appropriate place for a terminal patient who has accepted hospice care, but maybe the patients get scared when things start happening. Seems like kicking them to the curb is a mean thing to do.
Adri

Adri...

While you are a student I am an experienced nurse and I have the same question. And if the patient wants to sign up again, will they be permitted?

I think back to my Dad and hospice refused further pain management and he was unable to keep po meds down. Vomiting q15 minutes has a way of making the po meds not work. *I* decided to send him to ER, he just thought it was his decision. Try telling ME after declining pain management the hospice won't take him back! I'll bet they would. :angryfire

I have had lots of experience with hospice nurses and I have to say, the only negative experience was with my own Dad. ALL other hospice nurses have been the best of the best. However my Dad lived in a bo-funk town in Iowa where they had little choice in hospice agencies and we got what we got.

JFTR... my Dad had colon CA that spread to his liver. The skin around his liver looked like swiss cheese. He had a colon obstruction, he had fluid on his belly, he wasn't faking. The man was in pain. Each breath ended in a moan. My Dad was one tough man, but his CA pain hurt! Yet further pain management was declined. To be honest I really believe it was because his pain seriously kicked in at 11PM and the nurse didn't want to come out. I don't know, maybe I'm way off, could well be! But the bottom line is that he was hurting in a big way and that was unacceptable. He shouldn't have been left with an RN daughter trying to figure out how to blow Oxy dust up his nose to manage his pain!

Again, I will repeat... I KNOW this is NOT typical of hospice!!! I know that, that was my first negative experience with hospice ever ever ever. They are the cream of the crop as far as I am concerned. I'm an ICU/Trauma/Everything in the hospital nurse and I couldn't even stand next to a hospice nurse and claim to be any good. I'm not knocking hospice nurses, but I am knocking my Dad's nurse.

thatoneguy · Jan 15, 2006

Are you saying that you do not believe in palliative care in the ER? Protocols or no protocols, everything that roles through the door is a different story and not 2 peeps will ever be treated the same. Do you treat all your chest pains the same way no matter what symptoms they present with just because it is "protocol"? Let's hope not as someone might end up dead sometime due to standard protocols.

dont know where you got the idea i dont believe in palliative care in the ER. or changeing the protocals to fit the patient. my posts were not about if i believe it or should it be done, just that it should be done in the right way to CYA. look at this way.

you did what the doc said. you gave the dose. 5 min later, the nurseing director comes in with a person from osha doing a inspection or someone from JCAHO on a up and coming creditation renewal, finds the pt has passed, monitors off, grabs the chart and sees no vital signs taken prior to giveing the dose, no orders saying to remove the patient off the monitor, no orders saying not to do vitals, no order/instructions on how to give the med. just an order verbal order for morphine. what do you think their reaction will be? how would they know if it was not youthanasia, the only thing the doc ordered was morphine till pain relief. this needs clarification.

i think perhaps the doc was upset that the pt was there in the first place. maybe why he/she just pulled the monitor off the pt. was less one monitored bed. the doc was just following the hospice orders and care plan well, that helps cover his butt for the planned care. you go by the oders given by the ER doc. and the in place protocals. all the doc told you was --well, new rules. dont you think those new rules should be clarified and documented before you implement them. even if you think you know what he meant, write it and i will do it

doing palliative care i have no issues with. implamenting palliative care with out orders i have issues with. so will administration and the brn.

should the pt have been in the ER? no.

once the pt was in the ER is it right to provide palliative care? yes

just think wheather you agree with the said planned care or not, if the care goes outside of the "areas" protocals it should be documented first. especially if the treatment is very different from your "normal, if there is such a thing", type treament.

o dont get me wrong, i use to work in a burn unit and i have given huge doses of morphine and although it helped the pain never went away no matter how much or what pain meds we used. so i have no fear in provideing pain meds to a pt who needs it. thats not the issue.

leslie :-D · Jan 15, 2006

bipley,

w/a gi obstxn and profuse vomiting, there's still no reason in this day and age why the vomiting could not be managed! compazine suppositories still work wonders....giving roxanol (20mg/cc) sl is a viable and realistic route of administration.

i had a pt with colon ca w/mets to his liver. the gi obstxn combined w/his ascites notably impaired his breathing. he wouldn't stop vomiting. he did have a g tube and i aspirated 1000 cc of gastric contents/bile. even the golden standard of antiemetics, zofran didn't work. i truly believe that many of the older meds are coming around full circle. once his vomiting was under control, i gave him liberal doses of mso4, for his pain and breathing. but i did notice that he was becoming quite anxious as his family never left his bedside and were there 24/7. many hospice pts prefer to die alone. so i tactfully scooted them out, gave him another dose of mso4 and stayed by his side, w/a hunch he was going soon. i had my hand on his chest w/his hand over mine. within 15 minutes, he passed.

there are so many meds out there with unlabeled uses but are still highy effective. i've given compazine to pts with ards when i didn't have immediate access to the proper meds (a very isolated incident) and it worked quite well.

i'm so sorry your dad passed the way he did. please be rest assured he is at a glorious peace now.:kiss

leslie

Bipley · Jan 15, 2006

bipley,
w/a gi obstxn and profuse vomiting, there's still no reason in this day and age why the vomiting could not be managed! compazine suppositories still work wonders

Agreed. Not sure what exactly was in his belly but he died due to bleeding out. Something broke open and he vomited massive amounts of aterial blood in a matter of seconds. That is what eventually killed him. How much was already in his belly? I've wondered that since the day he died.

....giving roxanol (20mg/cc) sl is a viable and realistic route of administration.

And I would have LOVED to have it available to me to administer. No such luck. However, I also know that is not typical.

...but i did notice that he was becoming quite anxious as his family never left his bedside and were there 24/7. many hospice pts prefer to die alone. so i tactfully scooted them out, gave him another dose of mso4 and stayed by his side, w/a hunch he was going soon.

(smile) You describe my Dad. He got me off to the side and asked if I could arrange it that folks left and I stayed. He trusted me. My Dad had this thing about utilizing the skills of those with the skills. He often times liked to be left alone. I gave him his cell phone and told him to call the house phone if he needed anything. He would use the phone! He'd call and request pain meds even though they were sitting right next to him within reach. My sissy would run down to give him what he wanted and he would refuse. He wanted the nurse to give him his meds. That was my "job," per se. I knew about meds thus it was my job to give him HIS meds. He'd refuse the SAME tablet from my sis but when I would hand it to him, he willingly took it. Made me feel very good. Likely that is why he did it. He just didn't realize he was upsetting sissy.

The night he died his skank (my sister's evil stepmother) was with him. I started up the stairs to go to bed, oblivous to what was to happen. He stopped me and asked if I would stick around. I was thrilled, I thought night time meant private time between the skank and my Dad. My sisters wanted to stay too. He told them to go get him a soda. While they were gone he asked if I could arrange it that they would go "away". I understood. They would stand over him and cry. How depressing!

I did as he requested. He asked me (for the 3rd time) if I was okay with his passing. I lied through my teeth, I told him I was more "okay" with it than I realized and if he needed to go, I would deal with it. It was okay. Longer story short, he died three hours later. 12 months sooner than the docs guessed.

I'm droning on. But you know what, Leslie? I've give absolutely anything to have my Dad back. Anything. I'm ANGRY that he died in pain. I don't permit that for my own patients yet my own Dad died in a huge amount of pain. That's just wrong.

I've always had this gut feeling that if I do a REALLY good job, if I take very good care of my patients something like karma will come around and do the same for me and my own. You know what? That's just not true.

i'm so sorry your dad passed the way he did. please be rest assured he is at a glorious peace now.:kiss
leslie

I'm the rare atheist that believes in an afterlife. Seen too much to discount it. Yes, I know without a doubt he is in a fantastic place.

RnRatchet · Jan 15, 2006

We do our best to keep patients at home until they die with our hospice too... BUT there is always the occasional patient that doesn't WANT to die at home. In that situation, when time is getting close(days left), we direct admit to one of our area hospitals, that have a hospice suite. (Private room that is larger for more room of family and close by or attached sitting room) Sometimes we even direct admit for symptom management so we can have IV doses titrated quickly and get them back on a patch, PO, SL, suppository, SQ, whatever is needed so they can go back home. (this is still by pt / family choice if other pain control routes have failed)

The only time we have a pt in the ER is when they have had a fall and obviously broke something.. not too often that happens. OR you have a family that got scared and called 911. In the 911 cases the nurse on call goes to the ER and discusses the pt / family wishes. When they are admitted to hspice care we tell them to use us as their 911.. we can handle things quickly at home and keep the pt from going through the ambulance ride and hospital ordeal. (Anyone know why things that are suppossed to be for transporting sick and injured people are so rough to ride in?? lol)

BUT it's still the pt / family choice. Just because they've gone to ER doesn't mean we discharge them from hospice. In fact.. the family would have to revoke services.. "not be kicked out"

Pallative care and Hospice Care go hand in hand, but are two seperate entities. Pallative care allows for more aggressive things still as the norm since it's the part that is bridging the gap between the curative to comfort care.

I think several of us on here are coming at this issue with the same opinion just from different directions. We all want our patients to be comfortable and for their choices and wishes to be upheld. I just think everyone's background and experience causes them to approach the idea from a different way.

mandana · Jan 15, 2006

I have really learned a great deal from reading this thread. End-of-life care is always something that I've given lots of lip-service to, but the truth is, I know very little about it.

Thanks participants for sharing your knowledge and personal experiences.

Amanda

GLORIAmunchkin72 · Jan 16, 2006

We had a similar situation where I work. We left it up to the family to decide. They wanted the patient to be comfortable-whatever it takes.

This happened to me this week.
A hospice pt. comes in to the ER. He has end-stage renal cancer and is here for a PCA morphine pump and a Kayexalate enema. (good hopice huh). So the guy is pale as a ghost and hallucinating, I can't get an accurate O2 but it's somewhere around 75%. His BP is 82/40 his family is very rude and demanding. The Dr. comes in and tells me to give him 5 mg of morphine, repeat it until pain is under control, then takes him off the monitor. Another nurse tells him we have to take his vitals if giving morphine. Dr. says--well, new rules.
What would you do? I'll tell you later what I did.

felixfelix · Jan 16, 2006

I took my mom home to die last winter. The doc (Res2, a good guy) gave me a bottle of Roxanol and a TB syringe body and said to give her 0.5ml every few hours for pain. I ended up giving her around that much the first day and ending up giving around 1mg every 2 hrs. or so at the end. I am not a nurse and didn't know squat about MS at the time, so of course I felt guilty for quite a while wondering did I give too much, not enough, etc. Mentally reviewing her s/s I know now I did reasonably well.

Hospice finally called me 2 days after she died...I don't blame them, it truly was the system in this case.

I'm quite interested in hospice nursing now.

sphinx, BSN, RN · Jan 16, 2006

dont know where you got the idea i dont believe in palliative care in the ER. or changeing the protocals to fit the patient. my posts were not about if i believe it or should it be done, just that it should be done in the right way to CYA.
i think perhaps the doc was upset that the pt was there in the first place. maybe why he/she just pulled the monitor off the pt. was less one monitored bed.

Maybe one might get the idea you don't believe in palliative care in the ER from this?

sounds to me like the patient should be intubated, dont know his ABG's but O2 sat of 75 and unresponsive to giving O2 not good signs and with that BP. after intubation you can give all the morphine you want with little worries. but still need to take vitals before giving. my thinking is the doc wants to intubate just waiting till his respirations are depressed enough to do so.

Not trying to be a jerk...I mean, the CYA thing makes sense, and the first thing I thought of, reading this thread was is the patient DNR even? There's a lot of issues to consider, no black and white.

Just had to point out that the thought of intubating this patient made my skin crawl!

It's clear that's it's a difficult scenario, and the acute nature of the ER makes it even more muddled. Good to hear everyone's thoughts, even ones that I don't agree with

:wink2:

noc4senuf · Jan 17, 2006

I certainly wouldn't have taken it upon myself to alter the order for MS 5mg to only 2mg. In our facility this would have been a med error and you would have had a lot of explaining to do. I also would have reported something of this nature to the Board of Nsg in our state. In long term care we deal with a lot of dying residents and it is normal to stop taking vitals even when giving MS..... what are they going to do with the vitals?? A mature and seasoned nurse would know approx how long a resident had left by just looking at them. And if they are in respiratory distress or any way uncomfortable... give the MS!!