Thoughts on Hospice Care w/ non-terminally ill patients

[simplyme06]

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?

[nurseprnRN, BSN, RN]

hospice is incredibly regulated and audited constantly. these are the criteria for ...

dementia

inability to ambulate or dress without assistance

urinary and fecal incontinence, intermittent or constant

no consistent meaningful verbal communication

one of the following within the last 12 months:

aspiration pneumonia

pyelonephritis or other uti

septicemia

decubitus ulcers, multiple stage 3-4

inability to maintain sufficient fluid and calorie intake

fever, recurrent after antibiotics

perhaps he meets criteria after all?

[leslie :-D]

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.

often, pall and hospice care overlap.

lots of full codes on palliative care, not so much in hospice.

lots of gray areas to contend with...

even with dnr's, people.

advanced directives are often not compatible with human emotion...

really.

leslie

[leslie :-D]

hospice is incredibly regulated and audited constantly. these are the criteria for ...

dementia

inability to ambulate or dress without assistance

urinary and fecal incontinence, intermittent or constant

no consistent meaningful verbal communication

one of the following within the last 12 months:

aspiration pneumonia

pyelonephritis or other uti

septicemia

decubitus ulcers, multiple stage 3-4

inability to maintain sufficient fluid and calorie intake

fever, recurrent after antibiotics

perhaps he meets criteria after all?

that's the very problem with this criteria.

it can be twisted to suit another's agenda.

for examples, inability to maintain sufficient caloric/fluid intake, results in notable wt loss.

if you lose x amt of wt within a certain time frame, you are hospice eligible.

and dr's ok that, disregarding that many of these pts can easily live at least another year or two.

i've seen things that make my skin crawl.

but i do pray that this pt is much sicker than op presents.

it would justify the presence of hospice.

leslie

[Nascar nurse, ASN, RN]

Gee, aren't I living in a nice sheltered little world. I have never seen this down side of hospice. You are making me all even more happy that I have the crew that I have.

OP, good luck with your resident and good for you for being willing to stick up for them. I hope you have a DON that will listen to your concerns.

[nurseprnRN, BSN, RN]

"that's the very problem with this criteria.

it can be twisted to suit another's agenda.

for examples, inability to maintain sufficient caloric/fluid intake, results in notable wt loss.

if you lose x amt of wt within a certain time frame, you are hospice eligible.

and dr's ok that, disregarding that many of these pts can easily live at least another year or two."

some can, and they will, most will not. did you know you don't get fired from hospice if you still meet criteria? yes, unintended weight loss of 10% of body mass in previous 6 months is a criterion for hospice. why do you think that is? hint: it's not because hospice wants more work. it's because weight loss is a very common part of the dying process, regardless of diagnosis.

see, that "6 months" thing is not a mandate. people can be on hospice service as long as they meet criteria. the six months, though, comes from extensive research on the dying process. most people don't know that natural death is a prolonged process, and looking backwards from date of death, the beginnings of this process in most people can often be identified in that time frame (absent trauma, surgery, acute events). part of that process usually includes decreased oral intake, and does result in wt loss. this is not evil, this is biology. that's why it is included in the admission criteria. but nobody, least of all hospice, believes it's a mandate or a (you should excuse the expression) a deadline.

your post feels to me like you think hospice care automatically means accelerated death, and that has never been my experience at all. if i were you i'd spend some time c the literature on hospice, hospice regulations, and hospice protocols. i think you would be surprised. i once had a hospice patient who met criteria but who was still working, and lived for two years. but he had considerable comfort from the symptom management, counseling, and support from his hospice team. if your only experience c hospice is those late referrals where people are gone in hours or days or even weeks, i can see as you might think that's the way it always is, and then generalize to "they all die faster on hospice even though they could have lived for years." understandable, but just not factually- based.

[leslie :-D]

your post feels to me like you think hospice care automatically means accelerated death, and that has never been my experience at all. if i were you i'd spend some time c the literature on hospice, hospice regulations, and hospice protocols. i think you would be surprised. i once had a hospice patient who met criteria but who was still working, and lived for two years. but he had considerable comfort from the symptom management, counseling, and support from his hospice team. if your only experience c hospice is those late referrals where people are gone in hours or days or even weeks, i can see as you might think that's the way it always is, and then generalize to "they all die faster on hospice even though they could have lived for years." understandable, but just not factually- based.[/size]

grntea, i was a hospice nurse for over 12 yrs, and am fully aware of the regs, lit, protocols.

i understand pts are recertified all the time.

and the majority of my experience, has been positive.

but i honestly don't believe by trying to negate or minimize my experience, is doing anyone any favors.

did you read the post by kwyattmd? (i think that's her username, i apologize if i'm wrong.)

it doesn't happen a lot, but it happens enough...

to the point that it makes my hair curl...even if it was one bad experience i witnessed, is one too much.

but it happened to be more than one time, and no more than ten. ten!!

i was invited to be on a committee for a start-up hospice.

as i sat there in the first meeting, folks (don's, dr's) screening pts through their charts...

i was flabbergasted at what took place at that meeting.

i walked out and never returned.

so yes, it is very factually based, and not talked about often enough.

it's not the norm, and i'd like to see this brought to light, so that it never does become the norm.

leslie

[nurseprnRN, BSN, RN]

i guess i'm the naive one, although you know as well as anyone how the idea of hospice is so often distorted among lay people and even many nurses and physicians. i have never seen this kind of behavior in the local hospices with which i've been involved. thanks for shining the light, and i apologize for misreading your intent.

[leslie :-D]

i guess i'm the naive one, although you know as well as anyone how the idea of hospice is so often distorted among lay people and even many nurses and physicians. i have never seen this kind of behavior in the local hospices with which i've been involved. thanks for shining the light, and i apologize for misreading your intent.

you're very gracious grntea, and thank you.

i'll tell a story that i've never shared before...and it's a difficult one to share.

my mil died in 9/10.

my fil, who was placed in a ltc facility (), was heartbroken and his depression lingered.

he still came home on weekends after being placed, and continued to do so for only a few wks after mom died. (:mad:)

the first time he got bronchitis, he was treated w/abx.

but he continued to lose wt, r/t depression (he was an obese man.).

the 2nd time he got bronchitis, my sil (whose friend heads a hospice agcy) who was poa, decided to put dad on hospice!!

she felt dad wanted to die, to be with mom.

and so, while we were having a party at the facility on his birthday, sil announces he is now hospice care.

he was dead 9 days later.

why??????

i told my husband, i told my sil, i told the hospice nurse - "you people are killing him!!!"

none of the siblings fought for him, just stood there silent as i was crying and pleading.

they too believed that dad wanted to be with mom.

this happens frequently as well.

to this day, i have nothing to do with most of my husband's family.

my point being, people do not think clearly when under duress...

and it is up to us, the medical profession , to guide these people objectively, sensitively, but with integrity.

but hey...anything to build the census, right?

we need patients, we need $$...let's take mr jones - we'll make him hospice too.

yes, i remain profoundly misguided at this point.

i'm so disappointed in man...who is often guided by corrupt inspiration.

these are peoples lives we're talking about and somehow, a handful of greedy people are making a profit in killing people.

that's exactly what it is - killing people who are not ready to die.

12 yrs i spent in an acute, inpatient hospice unit.

i've seen and tended to hundreds and hundreds of deaths...

and i can go to my grave knowing i gave them my personal and professional best.

i also am very grateful that there are millions like myself.

i have to hang onto that.

but please....keep your eyes and ears open.

speak up if someone is not hospice appropriate.

it truly is a matter of life or death.

leslie