When to start administering "hospice medications."

[LPN9200]

I've been an LPN for roughly a year and a new issue has recently came up for me that I'm unsure of. I work LTC and have several patients on hospice although they are still seemingly a ways away from death which seemed to be the case with one of my patients up until the last few nights where she's experienced a major decline. She's recently contracted Another infection after recovering from a few other major infections. Family is debating on whether or not to proceed with treatment. Recently she's experienced an increase in Dyspnea. Respirations hit the 40+ mark this evening. I am 100% about medicating and treating symptoms. I am comfortable with administering Roxanol, Ativan, etc. But I am still unsure of WHEN to begin it. Although I realize that in that moment, she needed to be medicated. I've struggled with my decision due to the family still wishing to pursue further abx treatment despite the obvious signs that it's nearing the end. One daughter was onboard with my choice, but another voiced her displeasure saying they weren't "ready to give up and give into that." How do I get more comfortable making decisions such as those?

[4boysmama]

rr of 40 is an absolute indicator for use of roxanol (whether or not the person is on hospice) that level of respiratory distres is very unpleasant. I'm sorry your patient passed in less than ideal circumstances.

I do want to follow up on one point - you mentioned that they weren't ready for comfort measures because they wanted to pursue.... they are not mutually exclusive. I've had plenty of hospice folks doing abx, while still utilizing morphine/ativan for dyspnea. sometimes the abx are treating the family who aren't ready to "give up" or don't want to feel like they didn't "do everything" later on, but it's ur job to educate that while the abx might/might not work, we NEED to treat the current symptoms to give the patient comfort right now, while we're giving the abx the chance to work.

[LPN9200]

Grrrr.... This kills me about the way people conceive of death and they want a family member to live at all costs. It's insanity! I'm so sorry they tried to blame her passing on you merely trying to make her comfortable. You did your best.

I'm curious, though, what kind of education was the family given regarding the dying the process? I think sometimes providers aren't very blunt when it comes to describing symptoms or are afraid of saying something that will get them into trouble (i.e. saying to expect certain symptoms when different ones end up manifesting). I have such a hard time with that. The lack of education about end-of-life symptoms really gets in the way of managing suffering.

Sometimes, when family are present and I get certain vital signs or they ask me to check pulses, I will gently explain what my findings mean and try to reassure them as best as I can. A respiratory rate in the 40s is not comfortable for any adult and watching a sternum bounce up and down as the patient struggles for air is frustrating when the family won't do anything about it because they want them present at all times. They are the ones who need to be present instead of thinking about future hopes for the patient's recovery. It drives me up the wall. It happens too frequently.

The hospice agency that they went through is excellent at providing end of life education for both patient and family. Not to mention that this particular patient's Daughter was a former LPN herself and Son in law was a physician. I think to me that was the most frustrating thing.

[LPN9200]

rr of 40 is an absolute indicator for use of roxanol (whether or not the person is on hospice) that level of respiratory distres is very unpleasant. I'm sorry your patient passed in less than ideal circumstances.

I do want to follow up on one point - you mentioned that they weren't ready for comfort measures because they wanted to pursue.... they are not mutually exclusive. I've had plenty of hospice folks doing abx, while still utilizing morphine/ativan for dyspnea. sometimes the abx are treating the family who aren't ready to "give up" or don't want to feel like they didn't "do everything" later on, but it's ur job to educate that while the abx might/might not work, we NEED to treat the current symptoms to give the patient comfort right now, while we're giving the abx the chance to work.

I totally agree with them not being mutually exclusive and I agree with certain treatments during hospice especially if it can keep them comfortable or is unrelated or indirectly related to the condition that warnted hospice. The family just pushed for everything it seemed in a last ditch effort to prolong the inevitable. The decision to start abx for her most recent infection was tabled the night she died and I believe that was for the best. Starting abx for this infection would have qualified her to be discharge from the hospice company d/t it requiring IV abx and her requiring a midline at the least. Hospice was strict in informing them that they would not pay for any of those things. Despite education, family was set in their ways. I guess I'm having a difficult time with being able to respect the families views and wishes while still being a strong advocate for what's best for my patient which is ultimately my priority.

[caliotter3]

Find myself avoiding hospice due to the issues presented here. Could not reconcile the agency telling me to act in accordance with family's requests rather than patient symptoms in this, of all, venues.