Vent: dealing with nursing home nurses who refuse to provide comfort medication to patient

[stacyRN11]

I work PRN for a local hospice. Recently I had a actively dying patient in a nursing home that was having terminal agitation. I increased his ativan and his agitation decreased. the chaplain stayed with the family to comfort them. I went to another call, the chaplain called stating he was now having pain but the nurse refused to give medication because he was having apnea and she wasn't going to kill him with morphine. When I arrived she told me that giving morphine with a patient respiration rate below 12 is assisted suicide. I calmly tried to explain how patients with pain, the morphine will decrease pain and not decrease respirations. She started telling me that she has been a nurse for 35 years and she knows the patient better than I do. I told her I have been a nurse for 8 years, and board certified in geriatrics and hospice, so I am qualified and understand how the dying process works. I stayed for a couple house to give the morphine. The next day that nurse complained that I belittled her. The family was satisfied with my care, i was just advocating for my patient. Have anyone dealt with nursing home nurses like this and would you handle it differently? Any advice is appreciated.

[MunoRN, RN]

I think there are some misconceptions about the effects of medications like morphine that get promoted when trying to argue for adequate comfort measures in a dying patient. To tell someone with any knowledge about morphine that it cannot decrease respiratory drive means you've lost credibility right off the bat.

One of the main reasons we use morphine at the end of life is to decrease respiratory drive, that's it's main benefit in treating air hunger. To a certain point, morphine does provide some improved physiological function, but it's also not unusual for a dying patient's pain, air hunger, and discomfort to require an amount of morphine that exceeds physiological benefit.

I don't think there's anything wrong with the honest argument, which is that in a patient who is in the process of dying either way, prioritizing comfort is the better ethical choice, as opposed to inaction in the face of treatable suffering.

[stacyRN11]

I didn't say morphine can't decrease respiration, because it does. I told her when a patient is in pain and shows physiological symptoms of pain that the morphine's would decrease pain level. She kept saying that it is state law in OK that giving morphine when respiration is below 12 is assisted suicide.

[nutella, MSN, RN]

Yes, this happens sometimes in facilities because a PRN order obviously can be interpreted differently.

Whenever I feel that a patient needs around the clock medication to be comfortable I discuss it with the medical director and recommend it as such for the facility. Most facility MDs will implement the recommendations and that will ask the nurse to give the medication as ordered.

But the second part is to educate as you go along. The only way other nurses (no matter which education level) will be able to hear you is if they feel you accept that you are only a guest in their facility and that you respect their efforts and give them credit for all they do. And second if you are non confrontational. Sometimes hospice nurses can come across as "strong" or facility nurses feel that they are being "checked upon" by hospice nurses. When you develop a good relationship and report with facility nurses it becomes much easier to also get across some education.

I found that in facilities most nurses (LPN and RN) are truly interested in providing great care and some of them feel drawn to end of life care. It is important to realize and tell other nurses when they are doing a good job and to be collaborative. It is the little things that will matter like asking the nurse who is taking care of the patient how things are going, how can I help her / him to take care of the patient, are there any recommendations from them they would like me to consider. Be non judgmental - one of the most important things! Facility nurses can be very protective of their patients.

I remember that when I started in facilities as a hospice nurse some nurses were really very nervous when they had to tell me about a new pressure ulcer and felt judged. By being non judgmental and focus on how to ensure the care plan meets the patient needs things changed and we sit together now and discuss and tackle problems together. It has to be collaborative. Also, when there are problems because the family is unsatisfied or very critical I talk to the family and bring more hospice resources in like volunteer, chaplain, SW. Do not tell the family when you are not satisfied of unhappy with the facility staff as things can escalate quickly that way.

[nutella, MSN, RN]

I didn't say morphine can't decrease respiration, because it does. I told her when a patient is in pain and shows physiological symptoms of pain that the morphine's would decrease pain level. She kept saying that it is state law in OK that giving morphine when respiration is below 12 is assisted suicide.

Some nurses have strong feelings about this topic and sometimes a patient needs to be re-assigned to a different nurse.

[heron, ASN, RN]

Yes, this happens sometimes in facilities because a PRN order obviously can be interpreted differently.

Whenever I feel that a patient needs around the clock medication to be comfortable I discuss it with the medical director and recommend it as such for the facility. Most facility MDs will implement the recommendations and that will ask the nurse to give the medication as ordered.

But the second part is to educate as you go along. The only way other nurses (no matter which education level) will be able to hear you is if they feel you accept that you are only a guest in their facility and that you respect their efforts and give them credit for all they do. And second if you are non confrontational. Sometimes hospice nurses can come across as "strong" or facility nurses feel that they are being "checked upon" by hospice nurses. When you develop a good relationship and report with facility nurses it becomes much easier to also get across some education.

I found that in facilities most nurses (LPN and RN) are truly interested in providing great care and some of them feel drawn to end of life care. It is important to realize and tell other nurses when they are doing a good job and to be collaborative. It is the little things that will matter like asking the nurse who is taking care of the patient how things are going, how can I help her / him to take care of the patient, are there any recommendations from them they would like me to consider. Be non judgmental - one of the most important things! Facility nurses can be very protective of their patients.

I remember that when I started in facilities as a hospice nurse some nurses were really very nervous when they had to tell me about a new pressure ulcer and felt judged. By being non judgmental and focus on how to ensure the care plan meets the patient needs things changed and we sit together now and discuss and tackle problems together. It has to be collaborative. Also, when there are problems because the family is unsatisfied or very critical I talk to the family and bring more hospice resources in like volunteer, chaplain, SW. Do not tell the family when you are not satisfied of unhappy with the facility staff as things can escalate quickly that way.

Everything nutella said and more. My understanding of the CMS conditions of participation is that hospice agencies may contract only with facilities whose staff have been trained in the hospice model of care. If the facility isn't doing that, then it behooves your agency to address it, preferably before the resident starts actively dying.

[ktwlpn, LPN]

It's time for your people to call their people,talk to their administration.Co-ordinate your efforts with their own staff development department and offer some in -services.Look for a few staff members who are passionate about hospice care,maybe they can step up and help co-ordinate end of life care.It's clear the nurse needs education and support.It's sad when one of us puts a coat of shellac on their beliefs and refuses to learn and grow.I would call the supervisor to the unit in the future as well....

[nutella, MSN, RN]

It's time for your people to call their people,talk to their administration.Co-ordinate your efforts with their own staff development department and offer some in -services.Look for a few staff members who are passionate about hospice care,maybe they can step up and help co-ordinate end of life care.It's clear the nurse needs education and support.It's sad when one of us puts a coat of shellac on their beliefs and refuses to learn and grow.I would call the supervisor to the unit in the future as well....

While it is good to talk to the hospice manager about educational needs of the facility I need to say that going past that can potentially lead to end of employment.

The magic word is "collaboration" - you will get better and more long lasting results when you keep educating in facilities as opposed to go the "punishment" route - which won't work.

I have seen the same problem in acute care hospitals when a patient is CMO or on GIP hospice. Some staff feel that it is an ethical problem for them to give medication until the patient is truly comfortable. They may be educated but feel that they are "killing" the patient and do not perceive their action as "hastening death". In those situations it is often the best action to get the patient re-assigned to a nurse who is not conflicted. While I often say that death will come anyways and morphine will not shorten life but relief suffering - it does not automatically mean that the nurse will agree on it and ethical consideration or religious beliefs can play a huge role. It is always better to explore those things in general because another patient may come along and the situation may be the same...

Now comes the reason why pushing everybody is not going to work:

Hospice care is also a business. Every hospice relies on their GOOD relationship with LTC facilities because they will get less or no referral if the agency is known to be "difficult", "uncooperative" or "complicating things". If enough nurses in a facility complain about a hospice nurse, the nurse can lose the job because the loss of business for the hospice can be significant. There is a lot of competition out there and LTC facilities should always recommend more than one hospice agency but fact is that they are very influential. Let's say a facility MD would like a hospice referral - it is more likely that the nurse will not recommend an agency that is giving her "a hard time".

While it is our duty as hospice nurses to ensure the patient is comfortable and appropriate action is taken we need to be very diplomatic in how we educate and present ourselves. Do not rock the boat because you ego is scratched - it will backfire.

Instead ask if the liaison nurse or somebody else from the agency can come out to present some education on pain management and continue to build got relationships with the different nurses and casually educate on symptom management 1:1.

[MunoRN, RN]

I didn't say morphine can't decrease respiration, because it does. I told her when a patient is in pain and shows physiological symptoms of pain that the morphine's would decrease pain level. She kept saying that it is state law in OK that giving morphine when respiration is below 12 is assisted suicide.

I think you may have misspoken in the original post then;

I calmly tried to explain how patients with pain, the morphine will decrease pain and not decrease respirations.

[ktwlpn, LPN]

:

While it is good to talk to the hospice manager about educational needs of the facility I need to say that going past that can potentially lead to end of employment.

The magic word is "collaboration" - you will get better and more long lasting results when you keep educating in facilities as opposed to go the "punishment" route - which won't work.

.

I certainly am not encouraging any kind of confrontation.I think offering to assist the facility with educating the staff and trying to build a partnership WITH them is a viable option.The largest local hospice in this area is affiliated with the largest local hospital.The majority of our residents are treated there and often return to us with recommendations for hospice consults.We play nice....If we don't it's the resident and their family who pays the price.We offer the services of four agencies,it is up to the family.Staff do not attempt to push them in any particular direction.

[NurseSpeedy, ADN, LPN, RN]

I have seen this and it drives me crazy, although it's not just nursing home nurses that are the problem. I began my work as an LPN in a hospital (yeah, a long time ago). I had a CMO patient who some nurses refused to medicate because the 'respirations were too low'...since when did respiratory suppression mean withholding medication if the patient is CMO?

The doctor got so fed up with the situation that they wrote, " give PRNs when necessary. DO NOT hold for decreased respirations"...the family wanted the patient comfortable, yet some would not medicate because it "decreased their respirations"...um, their dying. At least allow them to be somewhat comfortable.

[evolvingrn, BSN, RN]

Frustrating, maybe a copy of the nursing code of ethics would help