Hello! I am having issues caring for a patient who is in an LTC facility. Daughter wants no prolonging of life for patient and just wants him to be comfortable. Pt is on 15 litres/minute oxygen via non-rebreather mask. Mask is tearing up the poor guy's face, in spite of being padded with foam, etc. Doctor orders read "Keep sats in high 80s" I want him to go on a high flow nasal cannula for comfort. Yes, he will desat, but he will be comfortable. He has IV fluids running because doc told daughter that death from dehydration is painful and a 'bad' way to go. Facility also does not want to give him PRN morphine as they are afraid it will 'depress' his breathing. He's breathing 28-32/minute. Also the dose is only 2 mg IV q 8 hours prn. Again, orders read "Morphine for pain" not morphine for breathlessness, so DON won't let nurses give it if he 'looks' comfortable. He's gasping at times for air, (I call it 'fish' breathing) but they don't consider that 'pain'. BP is also higher than expected for his condition (125/68) so I wonder if that is an indication that he's uncomfortable as he is very weak. Patient is mostly not responsive to questioning. I cannot get the flippin' doctor to call me back (very common problem in my job when the doc is not our hospice doc), and our hospice doc doesn't have priviledges in the facility. I am at a loss as to what to do from here. Patient cannot swallow. Roxanol is available as alternative to PRN IV morphine. What I WANT to do is 1. Get order for less O2, and switch to high flow cannula 2. Get the intervals for the morphine increased to q 4 hours PRN and add breathlessness to the indications for use. 3. If patient lungs begin to sound wet, have order to discontinue IV fluids. Am I missing anything? Am I on target here or completely off base?
A good time to make attempts to manage this problem is to make sure you are at the care plan meeting at the facility. If possible, invite the facility social worker to come to your IDG meeting. This establishes a relationship between the facility and the hospice agency. People are more in tune to working as a team when they are made to feel included in the task. While this may not work for some facilities and agencies, the effort is worth allot. Also, when going into the facility, the best way to get them on your side, is to get on their side. Establish a close working relationship with a nurse who frequently cares for the patient and the patient's CNA. I promise you, the lines of communication will improve and soon you will have the DON, ADM and others on your side. Establish a bond through Continuous Care services with the facility and more or less be there with the family during visits. Make your visits last longer than an hour. Let your face be seen more often than not. Best wishes to you in your hospice career. Coralyn.
From Hospice you can expect the Hospice team to provide one on one direct care to the patient and your family. When hospice care is provided, we encircle the family in the plan of care. All care is directed by the RN case manager from the Physician who will receive reports from the RN regarding pain management, comfort measure and desires and wishes of the patient and his family. The Chaplain, who is an important part of the IDG team will support the patient and his family's spiritual needs. The Social Worker is very important on the IDG team because of the support given to the patient and family for such things as getting affairs in order. The CNA will assist the patient with one on one daily care when the patient is too weak or no longer able to care for himself. The whole team works together to make the journey from life to death as painless for the patient as possible. They will help you recognize the signs and symptoms of pending death and may even support you with continuous care regimen when the patient is 24-48 hours into his imminent death. I pray for your comfort and the comfort of your uncle.
Facility also does not want to give him PRN morphine as they are afraid it will 'depress' his breathing. He's breathing 28-32/minute. Also the dose is only 2 mg IV q 8 hours prn. Again, orders read "Morphine for pain" not morphine for breathlessness, so DON won't let nurses give it if he 'looks' comfortable. He's gasping at times for air, (I call it 'fish' breathing) but they don't consider that 'pain'. BP is also higher than expected for his condition (125/68) so I wonder if that is an indication that he's uncomfortable as he is very weak. Patient is mostly not responsive to questioning. I cannot get the flippin' doctor to call me back (very common problem in my job when the doc is not our hospice doc), and our hospice doc doesn't have priviledges in the facility. I am at a loss as to what to do from here. Patient cannot swallow. Roxanol is available as alternative to PRN IV morphine. What I WANT to do is 1. Get order for less O2, and switch to high flow cannula 2. Get the intervals for the morphine increased to q 4 hours PRN and add breathlessness to the indications for use. 3. If patient lungs begin to sound wet, have order to discontinue IV fluids. Am I missing anything? Am I on target here or completely off base?
coralynwoodson
23 Posts
A good time to make attempts to manage this problem is to make sure you are at the care plan meeting at the facility. If possible, invite the facility social worker to come to your IDG meeting. This establishes a relationship between the facility and the hospice agency. People are more in tune to working as a team when they are made to feel included in the task. While this may not work for some facilities and agencies, the effort is worth allot. Also, when going into the facility, the best way to get them on your side, is to get on their side. Establish a close working relationship with a nurse who frequently cares for the patient and the patient's CNA. I promise you, the lines of communication will improve and soon you will have the DON, ADM and others on your side. Establish a bond through Continuous Care services with the facility and more or less be there with the family during visits. Make your visits last longer than an hour. Let your face be seen more often than not. Best wishes to you in your hospice career. Coralyn.