SOB, Hospice, Narcotics Overload

Red Kryptonite · May 8, 2015

Hospice for THREE YEARS?! How has that not been caught by Medicare?

heron, ASN, RN · May 8, 2015

Medicare has a tip line for reporting possible fraud. Something's not adding up.

Just an FYI, the morphine/Ativan routine is gold standard hospice practice for controlling air hunger. Also, end stage lungers have the longest length of stay of all hospice diagnoses. So neither of these is a surprise in the situation described in the OP, if the patient is truly end-stage.

Either there's more to the story or something's fishy with the hospice.

nurseprnRN, BSN, RN · May 8, 2015

Morphine and other opioids are useless for neurogenic pain, which is why the gabapentin works for hers.

Hospice is very regulated; if she's on a hospice service, she has to meet criteria for the benefit to keep paying.

Something is not adding up here.

toomuchbaloney · May 8, 2015

The woman is on hospice because she qualifies and signed the EOB.

It sounds like you are having professional boundary issues.

You should collaborate with the hospice professionals and palliative care experts who are helping the patient and her family to manage her end of life care.

CCRN2BE · May 8, 2015

I am kinda of holding mylself back from FB'ng a family member I'm friend with to tell them what's goin on...

I really want to ....
tell her grandson (who i'm FB friends with) what is going on.

I understand that you're frustruated and feel that you've exhausted all avenues to voice your concerns about this patient. I've also felt this way when trying to help someone, but finally realized that there are times when no matter how much I wanted or needed to help, it was impossible because it wasn't my problem to take on and I had to let it go, for my own sake.

I think you're heart's in the right place, but doing as you mention with contacting family via Facebook might just be job or even career suicide.

Do not take action or make decisions (especially if it may carry heavy consequences) when in a state of anger or exasperation. Do what you have the authority and power to do and then accept that you've done all you can.

Animal House R.N., ADN, CNA, LVN · May 9, 2015

I understand you love this lady. The thing is she is not your family. Sometimes you do everything in your scope and then you have to et go. If you don't your going to burn out and be no good to anyone.

heron, ASN, RN · May 9, 2015

The more I think about this, the fishier it smells. The patient as described in the OP does not meet hospice criteria for COPD: She is apparently well enough to maintain pulse ox in the middle to high 90's on 2L, only uses O2 intermittently and sats in low 90's on room air. Yet, it's mentioned that she is a "frequent re-admit" ... for what? What is the diagnosis under which she was admitted to hospice? The OP mentioned CHF - how severe is it? Are there comorbidities other than DM that aren't mentioned here? Is her "drug seeking" a function of untreated depression? Or a long-standing personality disorder? Has the OP discussed her concerns with the hospice case manager? Nothing in the description of this situation makes any sense.

I agree that there are serious ethical and HIPAA issues involved with "dropping a dime" to family members who are not POA. Don't ... just don't.

I mentioned in the other version of this thread that CMS has an anonymous report line for possible Medicare fraud. If inappropriate admission to hospice is the underlying issue, then that would be the most effective next step, it seems to me.

The tone of the OP, coupled with the dearth of information leads me to believe that the OP might have an issue of her own here - or maybe running into issues belonging to her nursing co-workers and admins (not uncommon). We are not getting the full story. I'm at a loss as to how to help, really.

inaniel88 · Aug 18, 2016

This woman died a few days later after being re-admitted from hospice -house, she was there for awhile, went out for a week or so, then came back to us to die. Getting MS ATC and drowned in her own secretions. Died on my shift in front of me, I was very torn up and affected by this for awhile, seeing her like that.... Commentors said it didn't add up, and it didn't. "Hospice" for years, COPD on RA and 2L PRN, with pulse ox in the 90s still her first day back...Crisis care for some reason, and the nurse asking for MS q2. Readmitted multiple times from hospital for falls at home/UTI, probably on her opioids she didn't (IMO) really need. Multiple narcotics for neuro/DM pain. All communicated to MD/palliative on my part. She was young, early 60s, and fun/young at heart, independent, ambulatory, but narc-seeking unfortunately. I remember a few days before she was sent out she had me cracking up talking about finding a boyfriend and showing me her new Victoria Secret bra she ordered on her laptop.. POA, who never visited/didn't have a relationship with, wanted her medicated, and medicated she was. She went out ok, SOB with anxiety, came back not herself, and overmedicated (IMO) and died a couple days later. She would come, go, come back on medicare for falls at home/UTIs, go hospice, then go home because she missed being independent, then come back and repeat. I don't know if she was a "hospice" patient when she was at home living with family but she was ambulatory and pretty independent whenever I had her as my pt. No edema, not overweight, no circulation problems,.. I don't know what qualified her for hospice exactly and that was my concern in the first place. That's not my expertise, but her only DX was COPD, Afib, DM. Her pain c/o to me were neuro. She had no reason IMO to have dilaudid and MS. She had no ortho DX, she was up and walking around. I feel like if I had more experience at the time I could have advocated for her more.