A Hospice Nurse Who Cares 021218
I have been told told “your job must be hard,” or “I couldn't do what you do. God bless you,” or you have a special gift.”
My job is sometimes easy and sometimes challenging. What makes my “job” operable, is that it is a gift from God. I can do it, because my focus is to get the patient comfortable, and be an emotional support for the significant others as family and friends, and the patient if s/he is processing through grief.
Grief isn't always, and usually not demonstrated by crying and a sad face, or bursting out in anger by the time I encounter the patient or significant others. Sometimes getting through the grief is just talking about past experiences such as reminiscing, and going through the photo album.
There are a few reasons my job is challenging or difficult about my work. I am a hospice nurse who does crisis care(CC), or what Medicare calls continuous care. Most hospices like to provide crisis care based on Medicare's guidelines for re-imbursements, such as a minimum of eight hours of skilled nursing care to get paid on that flat rate for the day. Medicare doesn't care if there are one, two, or more nurses on that case for the day, but pays a flat rate for that documented care. This means that they do not pay per nurse on the CC case, but just the single rate for the day after eight hours of skiled nursing completion and up to five days. Most hospices try to get the symptoms under control within 72 hours if possible, but it is a day by day re-evaluation for that decision based on the outcome's goal.
I digressed on the Medicare's issue; now, back to challenges. I've gone into a nursing home to see a patient suffering pain. The daughter had medical power of attorney(MPOA), and in denial about her mother's pain and dying, and fear of morphine. Her mother was dying of metastasized cancer. The ADON lied to the daughter that I did not come to her about the need for pain medicine. The first person I approached was the ADON for the patient's complaint of pain by non-verbal cues. The patient could not verbally reply. The morphine was scheduled based on patients pain level. I found out later that the daughter didn't want the patient medicated for pain until she's called first, but initially I was told to medicate patient with morphine if she really needed it( duuuh!). The charge nurse is the one who medicates the patient there post our request. Anyhow, the daughter totally canceled hospice that same day during my shift. I closed out my notes and departed, but reported the lying ADON back to my office.
Another situation was in the home, the patient moaning in pain, but the daughter says she always does that, that's not real pain. However, based on my experience and training, the patient was clearly, about a 5 out of 10 pain level. Tensed, periodic moans, and grimacing. Pain can also be emotional. That daughter was in denial about her mother's pain. Eventually I was able to medicate the patient and get her comfortable, but that's not always the case. Selfishness and ignorance produced continued pain.
The aforenoted two cases are not often that I see. I have those which are so loving and caring which let me do my job, and find the dose which brings comfort to my patients. I also treated increased congestion, terminal fever, anxiety, agitation, restlessness, nausea and vomiting. Since the summer of 1998, I've only directly cared for 2 pediatrics cases, and was difficult for me on the emotional side. I think I will stick to taking care of older adults.
One last challenge I will mention in this article. The doctor. Yes the doctor is responsible for the orders of medical patient care. A good doctor will listen intently to the patient, family, and nurse caring for the patient and weigh in the matter for best practice, best care of the patient. As seasoned practitioners we know when certain medications are effective, partially effective, and ineffective. We use medication books which give guidelines on prescribing and other pertinent information on medications. Sometimes medicating the patient and educating the family is good medicine for the family. For example, a patient has loud gurgling respirations, some refer to as the “death rattle,” and that sound can be disturbing to anyone. I do oral suctioning, and turn the patient(unless morbidly obesed, then used a low air loss alternating mattress or a lateral rotation mattress) approximately every 2 hours. Medications used has been Levsin, Atropine 1% solution, or Robinul. When a doctor doesn't prescribe medication for secretions which is not contraindicated, because “is it for you or the patient?” comment is not thinking about how it is disturbing to the family and not harming the patient. We can treat the patient and educate the family to relieve their fear or anxiety about the patient.
One more challenge? OK. A patient has a history of petite or grand mal seizures and has been on anti-seizure(anti-epilytic) medications for months or years, but your comfort medicine kit orders is to give 05mg Lorazepam, one tablet every six hours for anxiety or restlessness. The patient is experiencing terminal restlessness So far I have never seen such patient's restlessness partially relieved on such dose.
I would always bring this up to a RN Case manager to see if the Doctor would raise the dosage level to at least 1 milligram for Lorazepam and so far they have. Why are we waiting an hour for a pain or anti-anxiety medication to be effective? But, we should get just as fast or near as fast positive effectiveness as one might get in an emergency room. Sure it might take 3 to 4 doses to get the outcome needed, but after the second dose and no partial effect, then it's time for a new or revised plan of care/treatment.
Personally, I'd like to see just the edge of an oral medication kicking in within 15 minutes, mostly relieved by 30-45 minutes, and down to 2 or less out of 10 pain level by an hour. If the doctor has ordered an adjuvant(such as something for anxiety or agitation), I'd like to give that with the pain medicine as well. That anti-anxiety medicine will reduce that person's perception of the pain's intensity while giving the pain medicine to do it pain relieving job, and perhaps helping the effectiveness for pain relief to last long.
There afore-noted was about my experiences working as a hospice palliative care nurse. If you want medical advice this is not it, but you should contact a licensed practicing physician experienced in hospice or palliative care for medical advice. I prefer a physician who's done bedside care of patients of more than 15 minutes a pop, or who's been a med-surg or hospice nurse for several years before becoming a physician.
By the way, I wear more than one hat(non-exhaustive alphabetically listed): Artist, Christian, Entrepreneur, Hospice Nurse, Patriot.
Ron Parcke-Wms
