What is your typical response?

tewdles, RN · Apr 19, 2012

I ask some more questions and try to deliver some covert education first. Then, dependent upon how that goes, I speak with the lead nurse or supervisor to schedule some symptom management education for the staff.

We hospice nurses have to be very diplomatic in these situations while feverishly advocating for our patients. The facilities are our customers also and we can help them to improve their practices in many instances, IF they believe that we are on the same team. It is just really important that we do not alienate the staff and cause them to think that we are critical and "holier than thou" when it comes to caring for our/their patients.

Good scenario.

Double-Helix, BSN, RN · Apr 19, 2012

I would explain they purpose of the morphine and lorazepam as well as the fact that dying patients are often not able to verbally or physically express signs of anxiety and pain, even though it might be present. The scheduled medications help to keep the patient as comfortable as possible.

westieluv · Apr 20, 2012

I think the OP was referring to PRN meds for symptom management, as opposed to scheduled meds. This seems to be a common problem with hospice patients in facilities. We get phone calls from LTC nurses requesting a PRN nursing visit because the patient is in pain or having terminal restlessness, but when you ask when they last had a dose of Roxanol or Ativan, half the time they will tell you that it was hours earlier.

Symptom management in hospice is a tricky science. Patients and families don't necessarily like the effects of being on ATC scheduled meds, but you can't always depend on the patients' caregivers to give the PRN doses when they should.

Vtachy1 · Apr 20, 2012

This was actually a scheduled dose that the nurse held. I feel like I have educated her about the reason for scheduling it, and why the patient needs it, till I'm blue in the face, but maybe I should just keep on trying. Maybe it will sink in eventually. I just don't want to cause friction and want to do it in a way that won't upset her but yet will help her understand that the morphine is ok to give and its not going to "hurry things".

NotFlo · Apr 20, 2012

I'm a nurse in a facility. I love taking care of hospice patients and I work very well with the hospice nurses that come in.

Anyhow, I have a huge issue with some of the nurses I work with holding doses of scheduled medication for actively dying patients. Working with the hospice nurse some have been educated and seem to understand better now, but there are a couple who absolutely will not provide a patient's scheduled or PRN Roxanol, ativan if the patient isn't writing or groaning or screaming in pain. It's very frustrating.

CapeCodMermaid, RN · Apr 21, 2012

Perhaps part of this problem could be avoided with a well worded PRN order: Roxanol 5 mg every 1 hour sl...hold for respirations less than 8/minute( or something to that effect).In my facility I'd take the assessment/clinical skills of MY nurses over the hospice nurses any day....and I am a huge proponent of hospice care.

MomRN0913 · Apr 21, 2012

Just from my first 2 weeks in hospice, I am noting the nurses AND the doctors have an issue understanding hospice medications.

I won't tell you the horrifying story of what they did to a very young woman dying of metastatic CA last week. but the director of Hospice let the pain management team have it. Somtimes even after all the education in the world, hospice is very difficult to grasp for some medical professionals and people.

Somtimes bluntness works, if general education does not.

These meds are to KEEP them comfortable, not wait until they ARE uncomfortable or in pain. Just like if the BP med is keeping a blood pressure under control with it's scheduled daily does, it doesn't mean we hold it and wait for the patient to become hypertensive and THEN give it.

perhaps wording it in a situation like this will get them to understand better.

curiousauntie · Apr 21, 2012

Just from my first 2 weeks in hospice, I am noting the nurses AND the doctors have an issue understanding hospice medications.
I won't tell you the horrifying story of what they did to a very young woman dying of metastatic CA last week. but the director of Hospice let the pain management team have it. Somtimes even after all the education in the world, hospice is very difficult to grasp for some medical professionals and people.
Somtimes bluntness works, if general education does not.
These meds are to KEEP them comfortable, not wait until they ARE uncomfortable or in pain. Just like if the BP med is keeping a blood pressure under control with it's scheduled daily does, it doesn't mean we hold it and wait for the patient to become hypertensive and THEN give it.
perhaps wording it in a situation like this will get them to understand better.

I like your htn analogy. It might be the thing that works!

(And on a side note, loving the allnurses android app. This is my first post from my phone!)

kids · Apr 21, 2012

There isn't enough info in the op for me to make a judgement.

My reaction would be to question what in the nurse's assessment led her to feel the dose wasn't needed.

My response would be based on the information she provided.

I've had actively dying metastatic ca patients who were comfortable and peaceful with resps at 8 on minimal meds, I've also had people in agonizing pain on a MS drip at more than 500mg/hour.

Vtachy1 · Apr 22, 2012

If they are writhing in pain,squirming all over the bed, moaning and crying, I would hate to have them hold it for resps of 8 for a Hospice patient though.

CapeCodMermaid, RN · Apr 22, 2012

Most people writhing in pain are breathing more rapidly. It's not easy to have a hard and fast rule about an end of life issue.