Time spent at visits and other things!

[mc3, ASN, RN]

Just wondering...have worked in hospice for 2 years now. I know there is no such thing as an "average" visit time for our patients. But, for the routine full assessments, without problems, how much time do you chart? After playing around with numbers, I figure it takes me about 1 1/2 hrs per patient. That's from start to end, including a phone call or two, conferring with the facility staff, profiling meds, and computer charting. I'm curious to see what other nurses are doing.

Also, I was taught some basic hospice meds guidelines for end of life care at the first hospice I worked at. I know there are many, many different factors to consider, and having a "formula" isn't realistic, but just as a "rule of thumb" they are:

Roxanol 20 mg/1ml 2.5 mg q4h ATC

Roxanol 5 mg q2h PRN moderate BTP pain

Roxanol 5 mg - 10 mg SL q2h PRN severe BTP pain

lorazepam 0.5 mg q2h PRN restlessness/agitation

Tylenol supp 650 mg q4h PRN fever

Scop patch 1 q72h PRN secretions, can go up to 2 or even 3 if need be

I ask because I'm working at a new hospice, and the MD I work with is very, very conservative. (I'm being nice ) Starts patients out c Roxanol 5 mg q6-8 hrs PRN (doesn't make sense to me - peak is 4 hrs..) and lorazepam 0.5 to 1 mg q6h. Doesn't believe in using Scop patches - say it overmedicates the pt. (In that small of a dose??? Not according to HP...) Likes Levsin. I do to but I like to use Scop patches at the first sign of secretions. I should say I work in ALF's, where, basically, Med Techs can't assess pain, so don't use PRN's. Does the above sound realistic? Or was I just taught pain medication at a hospice that is a bit more aggresive? I also find that I have to really "fight" to get even minimal pain relief for most of my patient. It's not pleasant to argue with an MD who is supposed to be a hospice doc. - I always have to psych myself up to do battle. :angryfire But I will continue to do so, because we are the patient's advocate. (Sometimes, the only one)

I was also taught in using methadone. I see so many cases where a pt could benefit, but overall this hospice won't consider using it.

I guess I'm just frustrated..I have the knowledge to give comfort to our patients but I'm not allowed to use it.

Bottom line, is it me, or is it this hospice?

Thanks in advance - this is really bugging me

mc3

[river1951]

Whew! Many teaching needs here. What is your docs' day job? He sounds like he is not a palliative care specialist.

Those doses seem lees than adequate depending of course, on the patient. I'm sure that somewhere there is a patient that the 5 mg roxanol every 6 hours might work for, but I've not seen a hospice patient with pain issues that small.The point is not though, where he starets, but where will he go?

Can you titrate to get comfort or not?

[mc3, ASN, RN]

Not to my satisfaction, no. I've seen several cases where, IMHO, the patient could have been kept much more comfortable alot sooner. He just won't listen.. And yes, he does claim to be a palliative care specialist.....I did hear through the grapevine, though, that there was an issue with a family a few years back that thought he overmedicated their loved one, not sure if it went to an actual court case or not. In any event, if you can't stand the heat, get out of the kitchen. But, the higher-ups think he's the greatest thing...of course, they don't see what the nurses see...I've complained till I'm blue in the face, but the higher ups don't want to hear it. And the families? They just chalk it up to "well, Mom didn't go easy but at least she's at peace now" It's driving me crazy!!! Which is why I posted the original questions..

mc3

[doodlemom]

We try to use levsin or atropine instead of scope patches just because of the cost issue. I don't think they are outrageously expensive but the patches cost a lot more than the drops. If it's a patient that is going to be around for quite a while and needs the convenience of the patch we will then use it. Is your doctor certified in hospice and palliative care? He sure does not sound like he is.

[EmptytheBoat]

I'm with the others, your Doc is slow on the medication.

Roxanol 20mg/ml may give a ml q 1 hour, Roxanol has a much shorter

life than q 4 hours. Ativan 1 mg q 4 hours usually works for me, and

this will usually decrease the need for Roxanol. I like the Atropine gtts

for secretions, will alternate with the Levsin if needed. Scop is good,

but not formulary. Keep advocating!

[nurseangel47]

Your original question being is that too much time? No, not in my opinion and that is having been a hospice nurse for approx. one year. I love the hospice specialty and those nurses (myself included at the time of my practice in the area)...are exceptional people! My hat is off to you!

It takes approx. that long (one to one 1/2 hours per visit) to do a thorough enough assess., check meds, reassure pt./family members, etc. teach, call docs, wait for call backs from same, etc. It is a very intensive and indepth length to get all done that needs to be done! Thanks for being in hospice.

God love you!