Stressed about a loved patient

[Sophia62]

I work in LTC and have taken care of one resident for a little over five years. She has become a dear friend in this time. She is soft spoken and not understood by other staff members. She has developed an ulcer and is on comfort care. Her Last living will states she doesn't want a feeding tube(which she has) and wants maximum pain relief. I feel much anxierty leaving work because people just don't pay attention to her. Other nurses state that, "She looks comfortable." And I have communicated with them multiple times she may appear comfortable but when she is turned and repositioned(every 2 hours) She cringes her face and her discomfort is obvious. But because there is lack of communication between the aides and nurses, and the nurses don't take the time to pay attention to her needs or communicate with her. She recieves no PRN pain medication for the 16 hours I'm not there. It's heart breaking to watch a loved one suffer, when she has PRN medication she could be receiving!!

[Sophia62]

I hope that in the loss of my family, their wishes are not ignored. I am the biggest advocate my patient has! My patient has stated to me and in her will she does not want a G-tube. Yet her health care proxy doesn't care and recieves g-tube feedings, while she is able to have PO intake(but refuses) and is on comfort care! I care equally about all my resident. But I have never come across a family giving their family member the opposite of what they ask for... and not spending more than 5 mins with her every few days.

[LadyFree28, BSN, LPN, RN]

OP, I understand where you are coming from; I am one of those nurse who abhor chasing pain; I like my patients comfortable any way possible; however, sometimes that is not entirely possible.

The pt you are describing sounds like she is going to be in some type of pain, regardless; this pt is losing wt, has a Star 4 ulcer and her bony prominences vulnerable.

She needs to be turned to prevent more complications; it will be painful for the resident; at least you are able to get some form of ATC medication happening.

Sounds like some nurses may need education of palliative/comfort care; can be daunting in a skilled setting; however, it can be done.

Continue to advocate; just make sure where you stand with the resident and your own feelings of caring for this patient; I understand where many posters are coming from; it would be a good reminder as she advances towards her death, please check in with your feelings and debrief to make sure you don't develop compassion fatigue.

[Penelope_Pitstop, BSN, RN]

I have no advice for you other than to continue to medicate her and do what you can to have her pain medications routine rather than PRN, as suggested.

What I want to say is that this is why I admire LTC nursing so very much. I've only worked acute care and have felt very attached to a patient even after just one shift. I don't think I could keep myself from "crossing the line" with patients if I had them under my care for years! I know I've come home from work and couldn't stop thinking about a patient who had touched me even though I'd just met him or her. So I completely understand!

[VANurse2010]

q1h PRN pain medication is not appropriate in a long term care setting unless a patient is actively dying - because it's ignoring the realities of staffing/ratios in LTC. If the patient is able to take po meds it sounds like she may benefit from some controlled release narcotics. If you feel like your patient's wishes are not being carried out, you can always contact your ombudsman.

[Sophia62]

She is able to take PO but refuses. She is actively dying. Although the 1/21 ratio is difficult to deal with; it doesn't mean ignoring the patient's wishes. Her main concern is pain control while terminal, another request is no feeding tube. While her proxy is ignoring her feeding tube wishes, I want her to to go as comfortably as possible.

[VANurse2010]

By actively dying, I mean death is imminent - patient is becoming unresponsive etc. to point that it's a matter of hours, not days.

You still have the option of contacting the ombudsman. I didn't say it did mean that, but I stand by my statement that an order like that is not appropriate. Another option is, of course, scheduled pain medications.

[morte, LPN, LVN]

were I work, we see that Q1 hour order occasionally, freq. not given around the clock, but sometimes 3-4 times in a row, that gets the pain under control, and certainly if it (pain) is becoming a problem, it affords documentation for bigger patch dose.

By actively dying, I mean death is imminent - patient is becoming unresponsive etc. to point that it's a matter of hours, not days.

You still have the option of contacting the ombudsman. I didn't say it did mean that, but I stand by my statement that an order like that is not appropriate. Another option is, of course, scheduled pain medications.

[Caffeine_IV]

Unfortunately you cannot do much about how other nurses administer medications. Working in LTC in the past, I found some nurses were relunctant to give the liquid morphine for comfort care patients.

Families very often disregard the patient wishes and are nowhere to be found later.

It would seem like her med schedule could be tweaked to providie better pain control with instructions to pre medicate prior to dressing changes.

[nurseprnRN, BSN, RN]

I think the OP is not a nurse, because if she were, she wouldn't be going on about "the nurses" and the patient would not be going 16 hours without pain meds. I think the OP is an aide or tech. I question how she knows what's in the patient's will, too. And end-of-life care wouldn't be in a will, anyway.

Sniff, sniff-- is that something unreal I smell here?

[Been there,done that, ASN, RN]

I appreciate your compassion.

Your patient may just be experiencing discomfort with repositioning. It's common. If she settles back down after the turn within a couple of minutes.. she would not necessarily need prn meds.

However, your concerns need to be addressed by your facility.

Request a care conference (through the social worker if need be) and get your answer.

Good luck, let us know.

[Been there,done that, ASN, RN]

Not the place or the time to correct "terminology"

OP is talking about a relationship. It happens in a one on one situation over years.

Let's focus on the needs of the caregiver .. and .. the resident instead of criticizing/ analyzing the relationship.

She has become a dear friend in this time. She is ... not understood by other staff members. ... It's heart breaking to watch a loved one...

It does sound like you've crossed over the boundary of professional care giver. I'm not particularly critical of this but it can and does create all kinds of problems.

** Regardless, it sounds like this resident needs a REAL CARE PLAN and not those useless forms that have to be filled out, filed, and then typically ignored.