I work in a LTC facility. I have a pt who is 91 and has dementia, but no real terminal illness. He talks w/ the staff and propels himself in his w/c. Very nice man. Obviously confused, but nonetheless, nice and happy. One day, he started coughing and had some SOB, so we did a CXR and slight infiltrates turned up. MD ordered Avelox. Called daughter (DPOA) to let her know what was going on and she became very angry that he was "STILL BEING GIVEN ANTIBIOTICS". She called a hospice center nearby who came out and admitted him right away to hospice care. D/C'd all his meds (including anti-biotics) and started routine Morphine and Ativan to "keep him comfortable". Pt is never in pain, rarely has SOB. IMO, I see no need for Morphine. So he's been on this set up for about 2 weeks now. Whenever the hospice nurses come in, they seem shocked that he's still eating and functioning well. So shocked it seems, that they increased the time intervals for the ATC Morphine and Ativan.
Now, I'm not trying to belittle hospice by any means. I totally appreciate the care they give to our terminal patients and those that are actively dying. I also understand that hospice doesn't only help the actively dying patients, but also those that are coming close to the end.
In this situation, I just feel as if they are facilitating a faster decline in the patient...and for what reason? I just don't understand. I try to advocate for my pt, but the daughter continues to say that she wants him kept comfortable...yet she's not even here to see that he IS comfortable without all the meds. I guess I'm just confused. Maybe I'm missing something? I've only been a nurse for 2 years, but I can't help but feel like there is something wrong with this. Thoughts?
I think its a touchy subject.........we have a couple that i saw that were inappropriate.....one happened to be personal friends of one of the drs. that pt has been coming in for 'respite' for years.......yes the family really needs the support that comes with hospice .....but it doesn't make it not fraud when she clearly isn't declining and will most likely be here 6 months later ect.......
I have also seen full codes who are very medically unstable coming in .......but they have been that way their entire life. yes if you pulled their trach or they got an infection....they would definitely die in six months but they have been that vulnerable since childhood. I think some families sign up for the hospice benfeit for the cna and case mgt with no intention of ever truely getting on the hospice page. those cases are frustrating for everyone.
I am sad to say that you are right to be suspicious. During my years as a hospice physician (I'm now retired) I saw a change occurring in the industry. When our own hospice was taken over by a for-profit company whose CEO was an MBA who knew nothing about medicine or hospice we suddenly started seeing a push to accept more non-terminal patients. After visiting several of the patients and concluding that they were not appropriate for hospice I refused to sign their certification papers. The CEO then decided that face-to-face visits with the physician were not necessary and urged me to sign papers based solely on the recommendations of the new nurse he had hired. Needless to say I did not remain employed by that company! The Medicare per diem is just too tempting for some business-minded CEO's to resist and there are not enough regulators to keep up with all the fraudulent cases. Even some non-profit hospices are now moving in this direction in order to stay competitive. However, that being said, there are still many reputable hospices out there. Watch for the good ones who value patient care over profit and recommend their services to your patients and families.
thank you dr. wyatt, for validating my experiences with some hospices.
peoples lives have been taken prematurely, all in the name of $$$.
inappropriate candidates are taken for hospice services all too frequently...
when these folks can easily live far longer than the 6 month parameter.
but once you start snowing them with morphine...i'm sorry, in that i am an experienced hospice nurse yet it is something that rips at my core to this day.
thankfully most hospices are not this way, but there is an alarming trend amongst those who rule with their wallets.
it is devastating to even post this, but people need to know.
if you think someone may be inappropriate for hospice, please advocate for that pt...
do not hesitate to question and question and question.
families and doctors both often support hospice services for a pt, for their own individual reasons.
there are some, just by virtue of having dementia or mental impairment, or physical debility...
it's a very slippery slope who we can potentially make hospice-eligible.
again, thank you for sharing your experience.
at least you will be able to live and die, knowing you cared for people the right way.
I am sad to say that you are right to be suspicious. During my years as a hospice physician (I'm now retired) I saw a change occurring in the industry. When our own hospice was taken over by a for-profit company whose CEO was an MBA who knew nothing about medicine or hospice we suddenly started seeing a push to accept more non-terminal patients. After visiting several of the patients and concluding that they were not appropriate for hospice I refused to sign their certification papers. The CEO then decided that face-to-face visits with the physician were not necessary and urged me to sign papers based solely on the recommendations of the new nurse he had hired. Needless to say I did not remain employed by that company! The Medicare per diem is just too tempting for some business-minded CEO's to resist and there are not enough regulators to keep up with all the fraudulent cases. Even some non-profit hospices are now moving in this direction in order to stay competitive. However, that being said, there are still many reputable hospices out there. Watch for the good ones who value patient care over profit and recommend their services to your patients and families.
Doc, this sounds like a company I worked for for one month and quit.
I've heard this from only one hospice nurse in my area and it really doesn't make sense. My aunt recently went on hospice and was required to sign DNR papers inorder for her to be qualified. So, why are some (sounds like very few) hospices allowing pts to have a full code status while on hospice?
Onyx, I have no idea. But hospice is not about hurrying death, it is about accepting that certain things cannot be fixed. Now, one admitted for, say, liver failure can't be on a transplant list, but he can certainly get paracentesis for comfort.
Specializes in Oncology; medical specialty website.
I work in a LTC facility. I have a pt who is 91 and has dementia, but no real terminal illness. He talks w/ the staff and propels himself in his w/c. Very nice man. Obviously confused, but nonetheless, nice and happy. One day, he started coughing and had some SOB, so we did a CXR and slight infiltrates turned up. MD ordered Avelox. Called daughter (DPOA) to let her know what was going on and she became very angry that he was "STILL BEING GIVEN ANTIBIOTICS". She called a hospice center nearby who came out and admitted him right away to hospice care. D/C'd all his meds (including anti-biotics) and started routine Morphine and Ativan to "keep him comfortable". Pt is never in pain, rarely has SOB. IMO, I see no need for Morphine. So he's been on this set up for about 2 weeks now. Whenever the hospice nurses come in, they seem shocked that he's still eating and functioning well. So shocked it seems, that they increased the time intervals for the ATC Morphine and Ativan.
Now, I'm not trying to belittle hospice by any means. I totally appreciate the care they give to our terminal patients and those that are actively dying. I also understand that hospice doesn't only help the actively dying patients, but also those that are coming close to the end.
In this situation, I just feel as if they are facilitating a faster decline in the patient...and for what reason? I just don't understand. I try to advocate for my pt, but the daughter continues to say that she wants him kept comfortable...yet she's not even here to see that he IS comfortable without all the meds. I guess I'm just confused. Maybe I'm missing something? I've only been a nurse for 2 years, but I can't help but feel like there is something wrong with this. Thoughts?
Why don't you ask the hospice nurse the next time she visits, or read what's being discussed in care planning meetings with your facility and hospice? I don't know what you mean that you are trying to advocate for the pt. " but the daughter continues to say she wants him kept comfortable." Surely, you aren't getting into disagreements with the daughter over his care?
Hospice does not try to hasten death. I think there is key information you are missing in this case.
Specializes in Oncology; medical specialty website.
i hope you're right, that we're missing some critical and relevant info re pt being on hospice.
there have been times that i have absolutely disagreed with family members re poc.
sometimes it really is warranted, to take a stand.
leslie
I may disagree with their choices, but it is not my place to become confrontational with family.
If this nurse is so concerned about what is going on, she should ask to attend the next treatment plan meeting so she can voice her concerns to the team. If you're going to take a stand, you need to be able to back it up, not just post about it on a MB.
I've heard this from only one hospice nurse in my area and it really doesn't make sense. My aunt recently went on hospice and was required to sign DNR papers inorder for her to be qualified. So, why are some (sounds like very few) hospices allowing pts to have a full code status while on hospice?
One of the primary tenants of hospice is an individualized plan of care based on a patient's wishes. Sometimes people have a terminal illness, and need hospice for the comfort aspect, but when it comes right down to it they are not ready to die. My hospice allows patients to be a full code, but it is touchy once someone is actively dying. Luckily it does not happen very often.
I may disagree with their choices, but it is not my place to become confrontational with family.
If this nurse is so concerned about what is going on, she should ask to attend the next treatment plan meeting so she can voice her concerns to the team. If you're going to take a stand, you need to be able to back it up, not just post about it on a MB.
In no way would I become confrontational with the family about their decision. I was simply asking a vast group of knowledgeable peers who may have more experience than I do, about their opinion...hence posting about it on a MB. I'm not sure what you mean by backing up my opinion. Based on the information I gave, It seems like most people understood where I was coming from and understood that the info I gave WAS me being able to back up my stand on the situation. I really appreciate all of the opinions and advice I have received. I do plan on getting in on the next meeting and discussing my concerns and possibly getting a better idea of the reasoning behind admitting this patient to hospice. Thanks.
Specializes in Oncology; medical specialty website.
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In no way would I become confrontational with the family about their decision. I was simply asking a vast group of knowledgeable peers who may have more experience than I do, about their opinion...hence posting about it on a MB. I'm not sure what you mean by backing up my opinion. Based on the information I gave, It seems like most people understood where I was coming from and understood that the info I gave WAS me being able to back up my stand on the situation. I really appreciate all of the opinions and advice I have received. I do plan on getting in on the next meeting and discussing my concerns and possibly getting a better idea of the reasoning behind admitting this patient to hospice. Thanks.
Backing it up, meaning you need to run your concerns up the chain of command. Meaning you need to be willing to put your job on the line if you honestly believe hospice is only there to hasten the patient's death. Not just talk about how unethical you think the situation is...do something.
I was a hospice nurse for years. My colleagues and I took the dignity of our patients and their families seriously. We weren't ghouls who were in the business of "offing" our patients.
evolvingrn, BSN, RN
1,035 Posts
I think its a touchy subject.........we have a couple that i saw that were inappropriate.....one happened to be personal friends of one of the drs. that pt has been coming in for 'respite' for years.......yes the family really needs the support that comes with hospice .....but it doesn't make it not fraud when she clearly isn't declining and will most likely be here 6 months later ect.......
I have also seen full codes who are very medically unstable coming in .......but they have been that way their entire life. yes if you pulled their trach or they got an infection....they would definitely die in six months but they have been that vulnerable since childhood. I think some families sign up for the hospice benfeit for the cna and case mgt with no intention of ever truely getting on the hospice page. those cases are frustrating for everyone.