Was so impressed with my patient yesterday and not so impressed with the family

Published

Ok so my little background.....I was taking of a very nice 98 year lady yesterday,had a congestive heart failure and was desaturating to 80s due to the respiratory failure,doc prescribed lasix,other meds and put her on 5 liter oxygen,lady oriented as a almost 100 years old person could be..had an awsome labs for being that age,her own child is pushed for hospice to make her comfortable but she refused,she wanted to be taken to a hospital and be treated,lady was very nice for the whole time I was being there,cracked me up from time to time especially when she requested to sit in the chair for a long time and asked if we have anything to read,I told her that there are some "entertainment" magazines,but she said 'bring it on" Her child though made me so upset for pushing the hospice,just let her be ya know.

Up Vote Up Vote ×

Well heck, I would think if the patient was in her right mind she could make that decision herself. Unless, of course, it was one of those "I dont' want to upset my family" ordeals. You'll experience that more times than you'll care to count, unfortunately.

Up Vote Up Vote ×

Do you have a program for palliative care in your facility? This may be exactly what this family needs and most people are completely unaware of what a palliative care can provide. Please, also consider why this woman's daughter was so interested in hospice? What does her mother need most, palliative care can aid in physical needs, but also consider the psychosocial of the entire situation. If you do not have palliative care options available, what can be done to support this woman and her daughter. Is it pain management that is the greatest concern? Activity tolerance? What support does the daughter have? Is she caring for her mother at home, alone? What resources can you and the social worker use to aid her in coping?

Think about the other side of this. You see this 98-year old woman for one shift, when she is "at her best." No abnormal labs, post-diuresis, on an effective combination of cardiac medications, oxygenating well. What does her daughter see everyday? Is she hypoxic and disoriented, unable to perform basic ADL's because of fluid overload? I would take the time to consider the entirety of the situation and how you can assist your pt best after discharge.

Up Vote Up Vote ×

Did I miss something from your post? 98year old woman with questionable orientation ("oriented as a(n) almost 100 years old person could be") and who would probably reflect some cognitive dysfunction from the saturations in the 80's who has "CHF" and "Respiratory failure" requiring 5L of oxygen.... My best over-the-internet clinical outcome assessment would be that this is not a reversible condition. While she may be an outstanding funny LOL who you have been granted the opportunity to care for I will pose these questions to you... 1) Do you want to code her? Why or why not?

2) How long do you suppose the lasix and other meds are going to keep her dying body functioning? Her normal labs are irrelevant to me I prioritize on ABC's if she can't get enough Oxygen and cant circulate the blood her labs will soon tank as well.

3)How was her pre admission community assessment? Is her daughter her primary caretaker? Does she live alone? Is she safe? Is the family able to realistically provide the care she requires... 98 year old would make her children 60-70's?

I realize we are in a death denying culture and this post is aggressive and will probably result in me being flamed but you appear to view Hospice as a negative. So you are providing her lasix meds and oxygen which all could be used for her comfort in hospice in the setting of her choice (usually more comfortable than a hospital). And hospice would afford her family other resources to assist her to let her live the rest of her life doing what she would like to do.

You interacted with this woman during a chapter in her life... sometimes you need the peices from the whole story before you can interpret a situation.

Something to think about: we live in a society willing to push the medicine even if it is futile and not willing to push for someone to die naturally and comfortably... and we call ourselves advanced...

Up Vote Up Vote ×

98 year old ladies with congestive heart failure are going to die.

I understand the daughter's concern.... maybe hospice is not appropriate yet, but she probably is afraid of what will happen if her mother codes in the hospital. If I were her, I'd be afraid of that, too. Doing a full code on a 98 yo is not fun.

Edit... the post above me said it so much better!

Up Vote Up Vote ×
Specializes in Emergency Dept. Trauma. Pediatrics.

I am still in school,(although I have already experienced patients dying and one lady I got very close to who was the first patient I lost) in our end of life seminar day we had a lot of awesome guest speakers, one lady works in palliative care, she said that something like 98% of people die in a hospital instead of with hospice care, for a number of reasons. Not wanting the family to think they have given up, being scared to give up, being scared to die...etc. etc.

I don't know the patient or their history, but I would think that unless the child is some cold hearted want my folks to die and get their money type of person, which I think is definitely a minority, it's probably more that the dr's and nurses have explained things to them, they have accepted moms fate and would rather live out the rest of her days comfortable and with a semi quality of life, rather then constantly going through all this just to delay things a few more days.

Just reading your post and the history, that was my assumption. I wouldn't be so quick to automatically think that the family must not care. It isn't as if mom is 65. She is almost 100 years old. Yes I know people live longer these days and that's great for some (I am not sure about others though) but it doesn't sound like this lady is in the best of health like some of those cases.

Up Vote Up Vote ×
98 year old ladies with congestive heart failure are going to die.

I understand the daughter's concern.... maybe hospice is not appropriate yet, but she probably is afraid of what will happen if her mother codes in the hospital. If I were her, I'd be afraid of that, too. Doing a full code on a 98 yo is not fun.

Edit... the post above me said it so much better!

She is DNR and does not want to go to Hospice.

Up Vote Up Vote ×

Not to beat a dead horse but I guess what is lacking for me from this clinical situation is the even though the patient "Doesn't want Hospice" per your report. Does she understand her diagnosis and does she really know what she is declining? Most patients especially the older ones do not have a grasp of what hospice is or what services she would be provided... essentially what you are doing for her plus some but instead decline to participate in hospice based on the name or the fear that they would have to pay more etc....

Up Vote Up Vote ×

Originally posted by blackheartednurse

"She is DNR and does not want to go to Hospice."

Interesting that you say "go to Hospice." This may be a great opportunity for you to speak to someone in your facility familiar with hospice, if you educate yourself, you will be better equipped to educate your patients. Hospice is a type of care, given to individuals with a terminal diagnosis who are near the end of life, where the focus is on comfort measures and maintaining the highest quality of life possible for that patient. There are hospice centers, which I gather is what you are referring to, but hospice is a program that can be provided in a person's home - a hospital - or a long-tern care facility. If it is placement that she is concerned about, then hospice care given in her home, should be considered.

Maybe this woman has yet to accept her prognosis and accepting hospice would mean admitting to herself her death is imminent. Still, it is important that she and her daughter receive a hospice consult (if possible where you are employed) or at least an explanation and resources to explore what is available to them. I have seen numerous patients and their families whose fears were that hospice meant an end to medical care. This is simply not true. No one is going to withdraw care or refuse care because she is on hospice, including but certainly not limited to oxygen and medication. I have heard it said - hospice is the move from cure to care.

I don't think anyone who has posted wanted to put you in a position of defense, including myself. It is as difficult sometimes to convey intent as it is to interpret it in these forums. The very nature of your post, in your reaction to this situation shows a genuine caring for your patient. I hope what you read here will give you a different way to look at the situation and hopefully dispel some myths about end-of-life care.

Up Vote Up Vote ×
Specializes in LTC.

I echo the concerns that the patient may not grasp what hospice is and can do for her. So many people see hospice as an imediate death sentence.

From the way it sounds this woman is in end-stage CHF and could really benefit from hospice. Sooner than later she will drastically decompensate and it's better to have hospice already in the picture with standing orders then having to send her back to the hospital or bring in hospice last minute.

Up Vote Up Vote ×
She is DNR and does not want to go to Hospice.

Well, I'm glad at least for that! (The DNR part!)

I think there is a real, real lack of education as to what hospice is all about.

I haven't been a nurse very long, but what I see of hospice is the bad end... usually a family or court-appointed-guardian fighting for "do everything it takes" until the person is so sick that doctors really have to come down hard or get the ethics department involved. When hospice steps in usually the patient dies within the week. How sad, when the person could have been cared for in a much more palliative way, to ease the suffering and help prepare for the inevitable.

I feel so sad every time I care for a terminally ill elderly person who is a full code.

Up Vote Up Vote ×
Specializes in Peds/outpatient FP,derm,allergy/private duty.

Are you saying, blackheartednurse, that the elderly mother lives at home, or with the daughter, and instead of taking her in to the hospital she preferred to allow her mother's desatting and fluid build-up to remain untreated and "let nature take it's course"?

It could be that the older ('cause that daughter can't be a spring chicken either ;) ) lady had the idea, as many people do that hospice means do not treat-- in which case I wouldn't blame the mother, either! She might have thought she wouldn't be given oxygen and diuretics in hospice.

Many times, as others have said, hospice isn't a place you "go to". It doesn't necessarily mean a facility you go to and wait to die. Most hospices have home care services which are actually a godsend to family members. I think oxygen and diuretics would fall under the area of comfort measures, at least I hope so!

Anyway, that lady does sound like a hoot. Not too many almost 100 yr. old ladies say, "bring it on". Hope things are going better with your preceptor, too.

Up Vote Up Vote ×
+ Add a Comment