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When Hospice Goes Wrong

Nurses Article   (63,053 Views 107 Replies 789 Words)

VivaLasViejas has 20 years experience as a ASN, RN and specializes in LTC, assisted living, med-surg, psych.

8 Followers; 142 Articles; 248,129 Visitors; 9,638 Posts

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Hospice is a wonderful resource in the vast majority of end-of-life situations. They comfort and counsel, provide pain relief, and offer the patient and family both physical and psychosocial care. But every now and again, a patient slips through the cracks in the system and doesn't get the care they need when they need it most. Here's what happened when hospice failed my family. You are reading page 9 of When Hospice Goes Wrong. If you want to start from the beginning Go to First Page.

3,770 Visitors; 233 Posts

I had some bad experiences with hospice too, though. Like the time I called a patient's oncologist when I suspected she was having a GI bleed (she had breast cancer) and he said "What do you want me to do about it? She's a hospice patient. She's a DNR!" As if DNR meant "do not treat anything"! Or later on, when my father-in-law was admitted to hospice with his lung cancer and the nurse did such a terrible job of med teaching that his wife was basically overdosing him with his morphine. When my sister-in-law got a good look at what was going on, she called the agency and the result was a different nurse, better teaching, less morphine, and a wonderful quality of life for him for the remaining months. (The other nurse was shifted to a job not dealing with patients, at least for awhile; Pops was apparently not the only patient who'd nearly OD'd in her care.)

I have a little different perspective here. Regarding the "near OD" on pain meds, this is a huge issue in hospice care. Each pt and family falls somewhere on a spectrum between "no narcotics at all because we are afraid of him being tired or getting addicted" to "comfort by any means necessary even if he is unresponsive" to "just give him the whole bottle and end his pain for good"and there are also laws and standards of care guiding what the hospice can do. Everyone has a different opinion of how much morphine is too much for a terminal pt.

As far as the GI bleed in a cancer pt I'll say it again: DNR does not mean do not treat BUT comfort measures only CAN mean do not treat for a cure. There is a big difference between a pt who is elderly but relatively healthy and just doesn't want CPR, and a hospice pt (remember pts must be terminal with less than 6 months prognosis to go on hospice)

Many times i would hear people say "i know he is dying from dementia but i don't want him to die from pneumonia" or "if she dies from her cancer its okay but i won't have her bleed to death" not realizing that the dementia is causing the pt to aspirate constantly and thus causing the pna, or the cancer is causing low platelets or a tumor is eroding an artery and causing the bleeding. Or staff say "well we can't just watch her suffocate, we have to start bipap!" on a pt with end stage COPD who has expressed they are ready to go, is maybe blue but resting comfortably and had specifically stated they never wanted bipap again.

Not to say the poster i quoted was wrong about the specific situations mentioned. But it is so easy for people emotions and opinions to cause major bitterness about end of life care. Carefully assessing each person's beliefs and priorities along with extensive education about disease processes is absolutely critical when dealing with end of life. If time was taken to do this it could prevent so much suffering.

Edited by jdub6
Grammar

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KJoRN81 has 5 years experience as a ADN, RN and specializes in Med Psych; hospice & tele previously.

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I am so very sorry for your loss.

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Here.I.Stand has 16 years experience as a BSN, RN and specializes in SICU, trauma, neuro.

1 Follower; 42,215 Visitors; 4,883 Posts

I like to think of three other possibilities for the on call nurse, 'clearly uninterested' may draw out to be much different in her shoes,l. She could have been much further than 25 miles than you think, she could have been with a patient and had another patient who had passed away that she needed to be with first, she could have a car that can't get out of first gear, she could merely be an office nurse handling information from the office only

Bolding/italics corresponding to the statement which I'm responding to:

If she wasn't able to respond to calls, she had no business being on call. I have been put on call for my ICU job during low staffing, and I always make sure the charge nurse knows it takes me 40 minutes to get in (even with sleeping in scrubs with a lunch pre-packed) from the time they call. Or once when I was a CNA, an RN made a mistake and didn't realize she was on the schedule...when the charge nurse called her, she had to be honest and say she had just taken a sleeping pill and had a glass of wine and was unfit for duty.

 

If an on call nurse was 50 miles away, she still had the responsiblity to get there asap. That's assuming she didn't have any rules about how quickly she needed to be able to respond. If she didn't have transportation, if she was being paid to be on call she needed to call a cab or Uber so that she could arrive at the client's home promptly.

 

This could have been a real possiblity, that she was with another client who had died moments before Viva's call. However it would have been reasonable to tell Viva "I'm terribly sorry, but I am unable to leave this client's side right at this moment. I will try to reach a colleague or my supervisor, OR if I am unable I will be there as soon as I physically can, and I will get your husband's pain under control." Not to simply refuse to come, refuse to treat his pain, and give him no advice other than "Don't call 911 or he'll lose hospice services."

 

Any way you slice it, her conduct and professionalism was unacceptable.

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Here.I.Stand has 16 years experience as a BSN, RN and specializes in SICU, trauma, neuro.

1 Follower; 42,215 Visitors; 4,883 Posts

I have seen hospices put one nurse on call for a 500 mile region and insist the pts be told they are within the same county, and I've seen managers tell nurses to tell their pts the exact things you were told.

:eek: That is...disgusting. That's also a horrible position to put a nurse in... I still think the nurse as a professional, should not agree to be in that position. "It takes 8 hours to respond to a call 500 miles away. 1) that math doesn't work for the length of my on-call shift, and 2) no I will not lie to a client about my ability to respond. My professional code of ethics forbids it."

I get that people need to work, but at what point do we NEED to do what's right and not whatever unethical practice an agency insists upon? What if they were instructing the nurse to give placebos to save money? Instructing nurses to falsify documentation to increase payments?

Why should an agency's money-hunger absolve everyone from professional misconduct?

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I was a Hospice Nurse for 10 &1/2 years. I am appaud and ashamed, of the "on call" Nurse response. He or She should have made a home visit, and given your husband the appropriate medication. A hospice patient should never be out of symptom control. I apologize, to you and your family, for the lack of care you experienced.

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4boysmama has 4 years experience and specializes in Hospice + Palliative.

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I am so sorry for the angst that you went through in such an already difficult time :( As a hospice nurse, I am horrified at this situation. and frankly, confused. I have never experienced an agency that doesn't include pain meds in the comfort kit. That's standard practice; and while it sounds like the on call nurse was not very good, it should never fall on her to deliver meds (in fact, at least in my state, it is illegal for nurses to deliver medications to a pt's home) She very well could have felt helpless because the case manager did not adequately prepare in having the medications available in the home. if it really is agency policy not to order the pain meds until they're needed....that is deplorable.

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3,770 Visitors; 233 Posts

:eek: That is...disgusting. That's also a horrible position to put a nurse in... I still think the nurse as a professional, should not agree to be in that position. "It takes 8 hours to respond to a call 500 miles away. 1) that math doesn't work for the length of my on-call shift, and 2) no I will not lie to a client about my ability to respond. My professional code of ethics forbids it."

I get that people need to work, but at what point do we NEED to do what's right and not whatever unethical practice an agency insists upon? What if they were instructing the nurse to give placebos to save money? Instructing nurses to falsify documentation to increase payments?

Why should an agency's money-hunger absolve everyone from professional misconduct?

Again, I'm not necessarily justifying the conduct of the nurse in the OP because i don't know the circumstances. I have never known a hospice on call nurse to take a job knowing they will be covering a huge region or told to lie about staffing. What happens in my experience is they take the job having been told "we split this region between 4 nurses. " suddenly the nurse finds themselves either placed on the schedule alone or being begged to cover a shift alone- "everyone else quit/didn't show/ is on fmla, we are working on it, if you don't do it we will have no on call staff at all." So, it's either leave the shift totally uncovered or do the best you can to help. And then it's mentioned that "we don't want to alarm the pts so try not to let them realize that we are short staffed."

Many agencies in this area are perpetually hiring for multiple positions at once. The bad conditions lead to high turnover which leads to bad conditions, etc. The nurses don't agree to this when hired, they find it dumped on them at the last minute and it's always "can you just help us get through this rough patch as we hire new staff/ until 3 people come off fmla/etc.?"

And this isn't just one rogue hospice- Google "hospice lawsuit" or "hospice profit" and see what you find. Of course there are also many great agencies out there that do things ethically- although even they may find themselves short staffed as it costs more money to hire sufficient staff and do things right.

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3,770 Visitors; 233 Posts

I am so sorry for the angst that you went through in such an already difficult time :( As a hospice nurse, I am horrified at this situation. and frankly, confused. I have never experienced an agency that doesn't include pain meds in the comfort kit. That's standard practice; and while it sounds like the on call nurse was not very good, it should never fall on her to deliver meds (in fact, at least in my state, it is illegal for nurses to deliver medications to a pt's home) She very well could have felt helpless because the case manager did not adequately prepare in having the medications available in the home. if it really is agency policy not to order the pain meds until they're needed....that is deplorable.

It is illegal in my state for a nurse to deliver controlled meds as well. It is actually an arrestable offense to be found with someone else's narcotics in your car.

What no one has mentioned yet is an agency can have whatever policies they like about pain meds but the pt still needs a prescription. I have seen some attending physicians who are very hesitant to order any pain meds even when someone is beginning to show symptoms- and in advance "just in case? " forget about it. If that doctor refers a lot of their pts to that agency then the agency may not want to go around the doc by having the agency MD prescribe the natcs.

Some families are very resistant to the idea of morphine when the pt is comfortable also. If a nurse pushes too hard to have meds available for emergencies some pts/families will become uncomfortable thinking hospice is just trying to drug people into oblivion. (Not saying that was the case in the PP's). It's a tricky spot for the case manager to advocate without alienating people.

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nursejoy1 has 22 years experience as a ASN, RN and specializes in Geriatrics.

1 Article; 6,228 Visitors; 213 Posts

My dad was on hospice and had oral pain meds that took the edge off. He developed a GI bleed and oral meds weren't working for his excruciating pain. When we called hospice, they actually advocated for taking him to the ER where he could more quickly get IV meds. We did so. They stated that he could easily be readmitted to hospice when he came home. I knew that wasn't going to happen and later that same day, my sweet daddy died. But he died free of pain. That was the important thing. I'm so sorry that you had that one horrible nurse. Unfortunately, there are some, who do this job without the heart for it.

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MickygzRN,BSN has 3 years experience.

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"If a nurse isn't willing to drive 25 miles to ease a patient, she should maybe think of another field where it isn't 24/7."

I couldn't agree with that statement more! That's the whole point of being on call!

Shame on that nurse. The primary nurse may have been wonderful, BUT the patient is on hospice for a reason and everything should have been in place. Even more so, as she knew she was going to be away.

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I work in long term care, and have had the same issue with an unwilling on call nurse. Our providers are sometimes reluctant to give us orders for the morphine and Ativan without a hospice recommendation. I will ask them when we admit the patient to their service to give me the recommendation for those drugs, so I have them just in case. I am so sorry for your loss, and that your husband had to suffer like that. That is the whole reason for hospice, and I am appalled at the treatment (or lack of) by that nurse. Maybe she needs to change professions?

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vetnrse has 30 years experience and specializes in Schoolnurse,homehealth,specialneeds,IHS.

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Well I hope she was fired and complaint put into board of nursing. She doesn't deserve to be a nurse

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