I have posted on here many times and answered questions every now and then. Dad passed away Oct 7th 2013 from Liver Cancer . He was in a hospice facility for 11 days until he died. The day before he was admitted he was in the hospital and was talking,eating and very clear headed but his ammonia levels were high and he had been very combative, not eating and wouldn't take his meds for 4 days at his nursing home. ( He was in for a Psych Evaluation.) The hospice worker talked to me about admitting him instead of returning to the nursing home. I agreed to this and arrangements were made. He was transferred later that day and was alert and in good spirits. The next morning he was unresponsive and stayed that way until he passed. They gave him morphine and ativan around the clock. He never got any water but they did cleanse his mouth and moisten it with swabs. It seemed like he could hear me the first few days because I would shake his shoulder and say "dad". His eyes seemed to be moving under his eyelids and his mouth would move slightly. I did ask about them lowering his dosages so he could wake up a little. The nurse said he was getting a very small dosage already. I just wonder if the drugs made him unresponsive and if less was used he could have ate and drank and lived longer. I know it was time for him to go but I'm kinda puzzled about his going from complete alertness and straight into unresponsiveness so quick. The nurses did a Great job. I myself don't know how they do it. They treated dad like he was their baby. So gentle and compassionate. I was just wondering if anyone else had the feeling that death felt a little rushed once their loved one was placed in Hospice.
Please acknowledge in return that not only are these individuals not the norm, but they are also actively pursued and weeded out by their supervisory bodies. Regulation is not as effective as anyone would like it to be; but then neither is law enforcement.
We still need to find ways to care for and comfort the dying, and it isn't like we have the luxury of waiting for improvements in practice before we decide which route to pick. The hospice movement is the state of the art as far as it has been possible to develop it thus far. It's better than hospital. It's better than families having no support. But no, it can't stop death often being a terrible event; and no, it can't give us the comfort of certainty in every decision that we make for our loved ones.
Well, some very smart and compassionate folks, many of them quite religious started thinking " what does it matter if dying folks are given levels of pain control that might be addictive? These folks are Dying and don't deserve to die in agony.
Thus, the Hospice movement began. Yes, sometimes there are Hospice facilities, but those are few and far between. Most folks who go on Hospice remain in their homes, or in the nursing homes or Assisted Living places that are their residences. Hospice folks are trained medical professionals.
Honestly, a lot of times it seems like 2 different groups talking at each at each other. Some of the grief I see on here is overwhelming. I also get the feeling there is a unspoken political agenda with the one hit posters
"Here are the FACTS. Hopefully, this information will settle the subject that hospice nurses DON'T kill their patients by giving Morphine.
According to Wikipedia; A large overdose (of Morphine) can cause asphyxia and death by respiratory depression if the person does not receive medical attention immediately. The MINIMUM lethal dose is 200 mg. TWO HUNDRED MILLIGRAMS!!
We [Hospice Nurses] start the patient on 5 (FIVE) mg. every 4 hours. More Morphine can be added for "breakthrough" pain (pain not received with the 5 mg. routine dose). The breakthrough pain dosage can be 5 mg., 10 mg., or 15 mg. every hour. So, for every 4 HOUR period, IF you give the maximum dose, the patient could receive a maximum of 65 mg., a far cry from the 200 mg. minimum lethal dose.
So, for the accusers, do the math. We hospice nurses deserve an apology."
I rest my case.
The hospice RN will still visit the patient as she would in the home and the 24 hour service is still available to the facilities nurses patient and family. Hospice is informed of any changes in condition and the need to change medications. The hospice nurse does not however have any control of medications as she would in the home and has to rely on facility Drs for changes in medication needed which is very frustrating for the hospice nurses when their orders for home care are written with discretion to increases doses.
The hospice also has to have a contract with a facility before they can be part of the care team for a resident.This means a patient on hospice at home may have to give up that service if no contact is in existence. They can of course still go ahead with their admission and if discharged continue with hospice at home.
Terminal sedation while often requested by the patient or family is a really hot button and very difficult to arrange. The patient must be an inpatient and be constantly monitored as the dosing is very sensitive for each person. Most Drs are very reluctant to authorize it.
Another issue is the so called "comfort kits" If the policy of the individual hospice is to provide these kits on admission they will consist of very small doses of medications that can be used in an emergency and will include such things as morphine, anti nausea medication and other commonly used end of life medications. The hospice will have standing orders that allow a RN to administer these drugs without contacting a Dr. I must stress that the amount available is only sufficient to keep the patient comfortable for a reasonable number of hours till a Dr can be contacted and a pharmacy is open. In many rural areas 24 hour pharmacies are a wishful dream.
Some families are very upset by the provision of these kits when the patient is admitted because it perpetrates the myth that hospices kill patients. I can not tell you how many times as a hospice RN in the middle of the night I wished we had them. We did have a couple of Pharmacists who were kind enough to open their stores in the middle of the night. However it usually took at least an hour before the patient could receive their medication.
Not for profit hospices are run by an Executive Director who reports to an Executive committee of lay people from the community. I don't need to describe the frustration this causes. One example was that we wanted laptop computers.
New desktop computers were purchased! A few months later a big local company donated their caste off laptops that all needed new batteries at $1000 a pop. These being purchased it became apparent why the donating company had given away the laptops. Nice tax write off for them. After many months new laptops were provided for the nurses. In the meantime $13000 was found to re-carpet the entire office building. All the while there were still loose electrical cords running across the floor of the nurses' office. So be kind to your hospice nurses they are at the bottom of the food chain!
Sometimes people think that taking morphine or other opioids is akin to giving up or admitting defeat. However, the primary aim should be to make the patient's final days as pain-free as possible. This isn't giving up -- it's giving comfort.
If every attempt to relieve pain fails, a doctor may suggest palliative sedation. A large dose of drugs will put the patient to sleep, with the goal of helping death to come painlessly. This procedure is rare, and it's never done without full permission of the family and, if possible, the patient. Palliative sedation is not euthanasia, and it is not intended to cause death. It is designed to make the patient unaware and unconscious as the disease follows its natural progression to death. The decision to allow palliative sedation is never easy, even when, as Dahl says, "the alternative is unacceptable suffering."
I know when my Mom [98] passed, I was so glad Hospice was there to help her smoothly pass into the next life without any pain. I was there when she passed and it was very peaceful for her. The Staff at long-term-care was wonderful, and later came in to pay their respects.
You do know in some hospitals, depending on the condition of the dying patient, regular nurses would still care for a patient, even in Hospice, don't you?
Thank you for your comments. I'm sorry for the loss of your parents in such a short time. I'm not upset with Hospice at all. They were very nice and caring. I was disappointed of the lack of notification that my mom was on hospice, until a couple days later. Ironically, the NH PCP found the number and even called the police when the Hospital wanted her body removed, but could not do the same when it came to Hospice.
According to Wikipedia;
"A large overdose (of Morphine) can cause asphyxia and death by respiratory depression if the person does not receive medical attention immediately. The MINIMUM lethal dose is 200 mg. TWO HUNDRED MILLIGRAMS!!
We start the patient on 5 (FIVE) mg. every 4 hours. More Morphine can be added for "breakthrough" pain (pain not received with the 5 mg. routine dose). The breakthrough pain dosage can be 5 mg., 10 mg., or 15 mg. every hour. So, for every 4 HOUR period, IF you give the maximum dose, the patient could receive a maximum of 65 mg., a far cry from the 200 mg. minimum lethal dose.
So, for the accusers, do the math. We hospice nurses deserve an apology.
Of course there are bad outcomes and unforeseen events.
Did the mule that kicked your relative in the head, gave her a concussion, that sent her to the hospital where they operated and she never recovered consciousness get paid by the hospital to drum up business and make money?
That is a ridiculous argument and so are some of the recurring comments on this thread.Nurses and Drs are people too some good and some not so but they are not in the business of killing people.
We know we all will die. We can inform ourselves as to what our options are, we can put our wishes in writing and tell our loved ones too. We can designate one person to carry out those wishes. We, however, have no say in what maladies befall us. One gets cancer, another COPD, another Alzheimer's, etc. The "chosen one" (POA) had to navigate through the illness to try to carry out their loved ones wishes. No one wants pain, now or at death. It can be difficult for the family to manage the patient's severe pain at home. Many family members are uncomfortable giving medicines. That's where hospice comes in.
Now the question I have for the "blaming ones" is, Why didn't you do any research into what the POA agreed to with hospice care? You want to blame us for "killing" your loved one but did you ask us for a copy of the admitting contract, what the hospice doctor's orders are? Did you speak to the POA about your concerns? Probably not. It's just easier, in your sorrow, maybe anger, maybe denial, to blame someone for for loss. (Read any writings/books by Elizabeth Kubbler-Ross. A good one is "On Death and Dying"). Have you ever witnessed a painful or struggling death? Probably not. It's heart wrenching.
I'm sorry your family member has to die. Mine have to also. And you'd better know, that when my mom's time comes, I'm NOT having her suffer or struggle as she departs this earth. I hope the same is done for me.
The fact that you weren't there at the time of death, does not mean that you let them down, they may well have preferred to be alone! Your FIL may have been scared to die, and was begging you to Save him, but do you really think that you had that capability? Many people are afraid of dying, bht they are generally in a facility who is carefully monitoring them, and if they slip away quietly when nobody is around, that is often cardiac/respitory failure, and not a painful way to go. I only hope that I can quietly slip away in my sleep, under the comfort of a Morphine haze. What do you people expect for end of life, devine intervention? People die in their own time, not controlled by Drs, Nurses, clergymen, or yoyr brothers and sisters, and certainly not by the title of POA! The dying patients enlisted POA because they trusted that they would abide by their wishes. End of! Tge reason the dying patien didn't choose you as POA, is because perhaps they felt that you might fall apart and make poor choices based off of unrealistic expectations. They are on Hospice because their medical professionals determined that the end of their lives was near, and that comfort care was the very best option! The medical professionals didn't set out to kill them, that's not normal thinking! You can't change the inevitable!