Should I be mad at Hospice? My mother...

[Roland]

was admitted to in patient hospice and died about a week later. At the time of her admission her Dr. (and a second opinion) had given her from two to six months to live (she had non small cell lung cancer that had spread to her liver). We decided to take her to Hospice due to the fact we were not able to control her nausea at home, and the hospital could find no physiological cause on a CT scan (such as an impaction). Her pain was under under very good control with BID MS Contin (30mg) and immediate release morphine pid (15mg).

The very minute she was admitted the nurse said that the Dr. had ordered Haldol for her nausea. I had never heard of Haldol being used in this context, but figured that the Dr. must be aware of some "off label" application of which I was not aware. That night (her first) mom became progressively more agitated and suffered from both visual and auditory hallucinations (she had never before experienced anything like this). Finally, after struggleing to keep her in bed (she kept wanting to get up due to various hallucinations) I called the nurses and they gave her a shot of Atavan and she slept. From that point on Mom took a distinct turn for the worse. Furthermore, the nurses continued to give her more Haldol almost everytime she would even sit up. Two days after admission they performed an enema and this seemed to releave much of her nausea, and she experienced no more emesis. However, the nurses continued to give her Haldol although they did at least admit that it was also being used for agitation in addition to nausea. Mom, was extremely weak by this point not even able to hold her head up (although she pleaded that I place her on a bedside commode rather than suffer the indignity of a foley or diaper).

I became more concerned after telling my nursing instructor who reacted with alarm at the use of this drug in this context. He said that to his knowledge Haldol was not used for nausea, and espcially not in elderly women on opiates. I confronted the nurses at hospice, and one admitted that Dr. XXXX used the drug to "keep the patients comfortable because most of them were not so fortunate as my mom to have family there twenty four/seven". What galls me is that this was such a beautiful facility with amenities far in excess of any residential care facility that I had ever visitied before. However, there were few if any patients out of there beds to enjoy the facility. My mom died ten days after admission and I feel that she may have been "cheated" of potential quality time with myself and her two year old grandson.

Is the use of Haldol in this context common at other in patient facilities?

[CRNI-ICU20]

roland, my condolences to you for your mom. The grief must be really tough right now, because you have this question mark in your head. I think the others here have given a good explanation, although, I agree also with you that since your mom seemed to react better to Ativan, the nursing staff could have backed off the Haldol a little...It sounds like your mom had alot of medical issues that could also, in end stages, affected her mentation and her agitation issues.....lungs and liver are two organs that when they are failing due to metastasis, will elevate ammonia levels, increase CO2 levels, etc....all of which can diminish a patient's ability to function well mentally....

I hope in the day's ahead, you are able to find comfort in the arms of family and friends....and that you are able to carry the spirit of your mom with you as you practice....this just may be the experience you need to help another one day. blessings, crni

[wonderbee, BSN, RN]

Roland, I am sorry for your loss. End of life decisions we make with our loved ones and for them can be full of detours along the way. I don't think there is any one perfect decision.

I read your posts with great interest. I understand that you were not ready for hospice. A word on nursing instructors... most of them haven't pounded a floor or given direct patient care on a regular basis for some time. I have had nursing instructors that had it so wrong that I thought it was criminal they should be teaching at all. Your instructor had no business commenting on the palliative use of Haldol for emesis without the experience on palliative care. It has the two-fold action of reducing emesis and reducing terminal agitation in some patients. We use a cocktail of drugs in a gel that's applied inside the wrist called ABHR for nausea. Ativan, Benedryl, Haldol and Roxanol. Yes, it does have a sedative effect in some patients. In others, it can have just the opposite effect.

Doctors also write standard admitting orders for hospice patients which include comfort medications such as Haldol. It would not be unusual to see that. This doctor chose the use of Haldol for emesis. I would rather have seen chlorprazamine personally. But I wasn't there and don't have all the facts.

No one knows for sure what the trigger was that brought the OP's mother to her end. We can only make assumptions. It could just have been her time. I just recently lost a patient to small cell lung CA. When she came onto hospice, her physician gave her three weeks. She lasted five. She had a very difficult time with terminal agitation toward the end and we treated it with increasing doses of Ativan until she could finally rest. It's a very aggressive cancer and very difficult to watch because the family did not want her sedated when it was clearly what she needed. It's a fine line we have to walk sometimes.

I love working in a profession where our goal is not to extend or shorten the lifespan, but rather to bring comfort thereby increasing quality for the dying and for the family. Are we always successful? Admittedly no. Sometimes despite our best measures, there is that one situation where it didn't turn out exactly the way we all wanted it to. There is no hard and fast science to care of the dying but an informed artful and heartfelt use of the tools at hand and a sincere desire to alleviate pain and suffering. Please do not judge us too harshly. There is no one "right" way to go about this.

[jr4jc]

haldol is often used in small doses for nausea with very good results. and sometimes in conjunction with other meds for nausea. abhr gel works great and rarely causes sedaton

haldol in small doses can cause agitiation and confusion and hallucinations and can cause a pt to look like they have terminal agitation when they don't, and very few dr's and nurses back off the haldol when they see these side effects they decide it's terminal agitation and give more haldol or even stronger sedatives.

haldol should not be used in pt's with low kidney and liver function--which is most hospice pt's

terminal agititation; i have done hospice 10 years and have seen it less than 10 times and when it is seen NO ONE can tell you if it's source is physical or emtional or spiritual---if it is emotional or spiritual then you do the pt a huge injustice by sedating them instead of allowing them to deal with whatever they are NOT at peace with.

if you are seeing it often then i would bet and be right that you also are using haldol

[chihuahuamama]

First I would like to offer my condolences on the loss of your mother.

Several points I would like to make.

As a hospice nurse and a nursing instructor, I am distress that your instructor gave you an answer without researching the questions. Haldol is not only used for nausea in hospice settings, but in some cancer treatment centers. Some researchers have suggested that it is safer in the older population than drugs like compazine and phenergan. We use it in our hospice for both nausea and end of life agitation, but it the compounds such as ABHR troche, topical gels and supp.

What troubles me most is that your mother seemed to not be tolerating the drug evidenced by changes in her perceptions and behavior. It would not have left you with so many questions if the drug had been held to see if those symptoms improved or if the nausea worsened. It does not sound like you were respected as a member of your mother's care team as well as you could have been.

I agree with the other post that this is a part of your grieving process. I had been a hospice nurse 18 years when my own mother died of CHF. The MD had sent her home on BID lasix injections even though she could swallow. After discussion this with Mom (also a nurse), we decided to give her po lasix as long as she could take her meds. It was really her decision. And even though I supported the decision and would have told any other familythat I agreed with it, I felt a little guilt after my mother's death. So questioning ourselves and others is normal.

I hope you can soon find peace with this.

[RNorBust]

Our hospice uses haldol for nausea, but usually only if first line drugs haven't worked. We normally use it in conjunction with other meds. Just like any medication, different people react differently to each med. If that was not the case a Phenergan suppository would stop everybody's nausea. Saying that you heard from the nurses that this doctor uses haldol on everybody, versus the scenario that your mom was having uncontrolled nausea and they started haldol for it, is describing two different situations. I have had some family's give very good reports back on their loved one's being placed on haldol. Other family's were uncomfortable with it, and occasionally it just didn't work..

I'm so sorry for the loss of your mom. I lost my mother last September, and it is so hard to go through. I don't think there is a single nurse here that could give an accurate opinion of your mother's care. None of us could without having been apart of it.

[jr4jc]

i challenge all--medical and not to look up online or in books and see haldols uses, side effects, precautions, overdosing,

PDR or google haldol

there are so many other GOOD choices for nausea and others for sedation

i have seen haldol work well in 5 pt's in 10 years of hospice work, so YES i have seen it work well for psychosis--true psychosis

i have seen it fail in hundreds of pt's and i am not exagerating--hundreds

see what pt's should NOT take it according to the literature

and i have heard a DR use the term medicationg the staff--which means medicating the pt to keep them quite and quit bothering the staff

LOOK it up---LOOK it up

sedation is a sign of overdose in most books

[hospicemom]

Ativan is my first drug of choice. I have also used haldol as a "next step" to control nausea and agitation. Ativan is also used for nausea in some cases however i have not found it to be as effective.