What To Do When Family and LTC Facility NOT On Same Page.....

SuesquatchRN, BSN, RN · Jan 1, 2009

From my limited experience you sound right on target.

lesrn2005 · Jan 1, 2009

Sounds as if daughter needs education! Very touchy situation but you need to educate her to the dying process and IVF's are a stressor for the body to deal with when shutting down. She can refuse these even as next-of-kin and request comfort care only. How about that social services person and the DON? Are they on board with Hospice? Enlist their services to speak with the doctor directly about giving appropriate orders to make this man comfortable. I dealt with a similar situation and the DON (very pro-Hospice) and I had an arrangement that if a Hospice nurse needed orders from the difficult doctor, the DON would call and get the orders for the Hospice nurses. Took the heat off of Hospice. The NC sounds like appropriate idea.

tencat · Jan 2, 2009

Thanks for the responses. The problem is that the DON is NOT pro-hospice, in fact has told her nurses NOT to give the morphine unless there are very 'obvious' signs of pain only. He hasn't had a dose since he left the hospital two days ago. In fact, I tried to give some today and the facility told me they didn't have any IV or oral on property though they had 'ordered' it (told us they had it when we admitted patient)......today he was breathing 32/minutes, HR 104, BP 130/60 (high considering he's bedbound and semi-conscious), fever of 102, gasping, sat at 85%, and the Assistant DON decides that a tylenol suppository should be enough because the fever was probably the cause of all the issues (maybe so, partly anyhow) and he didn't need the morphine because it would depress his respirations (2 mg)....URGH! I'm about ready to suggest to the daughter (who WANTS the morphine, WANTS the IV discontinued, and WANTS him comfortable with a nasal cannula until someone says to her "all that MAY accelerate the dying process", then she kind of gets gun-shy) to take him home to die as he will not get what he needs here. I want to support the facility, but I think they are not allowing me to do my job at the patient's expense because they don't 'like' hospice in the facility. I'm trying not to get my knickers in a knot in front of the family, but they know that we are not all agreeing. I don't want to drag the daughter into our disagreement, but I don't know what else to do. The daughter agrees with me about care when I present my ideas to her (I've not told her that the LTC DON does not). The DON and her assitant paint me as wanting things that are not necessary and will cause way more problems for the patient, and they are telling the family this.

SuesquatchRN, BSN, RN · Jan 2, 2009

I worked in a place that discouraged pain meds even in the actively dying.

Tell the daughter to take him home.

leslie :-D · Jan 2, 2009

this is sooooo barbaric and cruel.

the med'l dir of the hospice, needs to call the treating physician and have a little chat.

most times, md's will listen to ea other.

dc all ivf's...it is creating many unneeded stressors on pt's body, including breathing.

agree about nc, and changing indications and parameters for morphine use.

2 mg??

it should be minimum of 5 mg q2h, pain/sob.

if no one listens, then yes, bring him home (if time allows).

tencat, if you really believe pt is being neglected (and it sounds like he is), get ombudsman involved stat.

make a stink.

this is truly cruel behavior.

leslie

Laurell28 · Jan 3, 2009

I think it would helpful to request a meeting with the DON and hospice team members to air concerns on this man and his comfort (or lack thereof). This facility is in desparate need of education.

rngolfer53 · Jan 3, 2009

this is sooooo barbaric and cruel.
the med'l dir of the hospice, needs to call the treating physician and have a little chat.
most times, md's will listen to ea other.
dc all ivf's...it is creating many unneeded stressors on pt's body, including breathing.
agree about nc, and changing indications and parameters for morphine use.
2 mg??
it should be minimum of 5 mg q2h, pain/sob.
if no one listens, then yes, bring him home (if time allows).
tencat, if you really believe pt is being neglected (and it sounds like he is), get ombudsman involved stat.
make a stink.
this is truly cruel behavior.
leslie

Fully agree with Leslie (from whom I learn a lot as a new hospice nurse. Thanks Leslie). If the family is unable to care for the Pt at home, is there another nursing facility in the area that has a better attitude toward unnecessary suffering?

Jost930 · Jan 3, 2009

Tencat, you should check your facility contract, the new CoPs clearly designate that Hospice maintains 'professional management' and that should be included in your contract with SNF. You should have your Plan of Care in pts chart and that would include the comfort measures you mentioned. The CoPs also dictate that the hospice is responsible for education of hospice philosophy and services to nursing home staff - use this opportunity to educate. In my experience our medical director prefers not to confront or direct another PMD, we find calling 'team meeting' with DON, primary nurse and her hospice supervisor seems to be effective most times. Good luck!

tencat · Jan 3, 2009

Thanks for all of your replies. I live in a small town, and the medical community here is REALLY anti-hospice. They are afraid of morphine. They are still in the 'save them at all costs' mentality. I don't fault them for their ignorance. However, I DO get my knickers in a wad because NO one, the doctors or the nurses in the LTC or the hospital, even CARE to know why we do what we do. We have tried as a company to have our director talk with the doctors during their monthly meeting they have with the hospital. They basically told him he had five minutes, and he was wasting their time because they already knew what hospice was all about. Obviously they don't with orders such as those I mentioned above (2 mg Morphine q 8 hours). I talked to the LTC DON about setting up an inservice for staff. She said "We do the same things hospice does. We don't need an inservice". It is so disheartening. At least we have our med directors who will give us any orders we feel are appropriate as long as we can justify them. This applies to the people in their own homes, not the LTC where our docs have no priviledges to write orders, and the in-house doc is on the same page as all the other docs in town.

Ombudsman sounds like a good idea. The staff finally got smart and DID remove the mask and put on nasal cannula, and patient was way less agitated, vital signs came down. I pray he passes soon, for his sake. My hands are tied as far as doctor orders go because I called his attending yesterday and she said "you can only use the morphine for very obvious signs of pain, not for breathlessness." Sigh......

dmdrn73 · Jan 3, 2009

Is it feasable for the daughter to take him home? Are there any Hospice Comfort Care homes in the area that he could be transferred to or is his condition not good for transport?I agree with a PP who said that your Hospice Med director needs to have a chat with the pt's doc or LTC doc.

Hospice_Heather · Jan 4, 2009

My heart goes out to everyone who tries to manage a pt hospice care while they are in a facility. I can relate to all these post and have come to hate it when my pt has to be in a facility. If there is ANY way for social services to help the pt be at home that is what I would do. I have moved from being worried about the facility to only being worried about MY pt, they are my priority.