There is a new nurse at mom's SNF. He seems overly interested in getting morphine on board and Xanax and calls me every time mom is struggling. It's a fairly straightforward matter of draining the fluid off her lung and then she's comfortable and can breath. But each time the fluid builds up, instead of getting it drained he talks about her need for morphine. I thought it was just me that found him overly pressuring about it but when my son met him tonite he said he wanted him off my mom's care. Hes very nice but I feel he's either new or possibly a problem..
We went through this with my mom about a year ago. After her chest had been tapped several times ( including one situation where, as mom's lung reinflated, a pocket of bacteria " bloomed", sending her into septic shock) we sat down with her pulmonologist, who said to me " stop poking holes in your mother. The next time this happens, call in Hospice, get her on morphine and let her down gently".
That is what I'll do.
Your nurse may be new or overly aggressive but he probably knows that once fluid keeps recurring it tends to come back very frequently like daily. Are they giving her strong enough diuretics. I had what is called a pigtail when I was in heart failure for a few days and they drained a great deal of fluid through that. they were going to put in a pleural but said there was too much risk of infection with a permanent drain so they just removed the pigtail and stepped up the Lasix IV which worked pretty well. The nurse wants to give Mom the morphine because it will ease her feeling of breathlessness so she is more comfortable. of course the Zane is for anxiety and everyone is anxious when they can't breath.
If you feel Mom is close to death my decision would be to encourage the morphine and although it won't hasten death will certainly keep her a lot more comfortable. By the way a Pleurex is not difficult to remove and can be done by a Dr in the SNF. Much easier to take out than put in. if you think Mom may have some time left it might be worth replacing the pleurex so the fluid can be drained daily. it is a very simple painless procedure. they just put a vacuum bottle attached to the tube and the fluid runs into that. A lot depends on the reason for the fluid build up and how close to death the family and Drs feel rather than what Mom hopes will happen. Repeated thoracentesis can be distressing and exhausting. Hope this all works out for you. You need to question Mom's Drs and get their honest opinion on Mom's prognosis.
Let us know how the procedure goes tomorrow
If the new nurse is young and enthusiastic that's probably what his problem is - youthful enthusiasm and a gung-ho spirit aren't really what you want in hospice. Maybe suggest he be guided by calmer and more experienced older colleagues? If you think he's jumping the gun, don't hesitate to tell him so frankly but not angrily.
I'm an oddball, but I believe we can rush in fear to adding drugs - one cannot wait forever, but surely one can see through the next procedure, when it sounds as if it may correct an error - and comfort by companionship and minimal sedation and pain meds, keep telling your mom that this next intervention will make things better, whether she looks as if she can hear or not - pray and trust and help her hope through this attempt to rectify, and revisit the issue of drugs another time. Sometimes the drugs can ease anxiety and mask symptoms.
I know how challenging all these choices, conversations can be, when the risks seem so high. I saw morphine help a lady with a severe cancer, and had to be somewhat convinced - yet I've also seen times when compassionate extra company, hand holding, resting together, can help an elder calm down, and if you have the alternative procedure planned, this seems good to try, for when things turn around, small signals grow into recovery, and that's amazing too.
The supervisor of Nursing should also observe this over zealous nurse to see what he is doing both with and away from patients.
My mom had a brain bleed near the end of her life. The neurosurgeon at the hospital told us he could fix the problem with surgery. My moms neurologist heard this conversation and pulled me aside and told me he wanted me to think about what he was going to say. He said to me the surgeons could operate but should they? would this operation really better her quality of life? This was a heart wrenching decision to make but the best advice I was ever given. Good luck and God Bless.
My SIL went and convinced the doctors to drain the fluid and hold the morphine--she lived several more months in relative comfort.
As far as the medications are concerned the side effects of many drugs are totally unpredicable especially in the elderly so it is often necessary to experiment to find what works best.
I hope the Dr that said the tube could be removed meant herself not Mom. it would be dangerous to do that ones self. It is a simple process but should be done with safeguards in place in case it is actually in the lung rather than the two layers of pleura surrounding the lung. Reinsertion has to be done under expert X-ray control so the radiologist can see exactly where it is being placed and there is sufficient fluid in the pleura for the two layers to be separated enough to safely introduce the tube. It is possible that the closest hospital does not have the necessary equipment or trained staff to do the procedure. What you have heard is a refusal to do it but they may mean they can't do it because they lack the equipment and expertise. When you are so stressed it is often confusing to really hear what you are being told especially if it is conveyed through a third party.
Personally, I tend to think that when a person is on hospice, the incentive to treat something is removed because there really is no hope to prolong that person's life. The thinking is that they can just give the person some medications to ease their pain & suffering, and make the road "out" as smooth as possible. Nobody likes to see their loved one having difficulty breathing. In your subsequent posts, you say that your mother is indeed on hospice and 96 years old, routinely draining 1.2 liters of fluid from her chest. Adding that to the equation makes more sense to me for why the hospital is doing what it is doing---your mother is very ill, and a thoracentesis could lead to a hospital admission, which nobody wants to be responsible for primarily due to Medicare rules for reimbursement. The hospital won't get paid for her admission. It is sad, but it's true----admission & re-admission rates are scrutinized by Medicare, and physicians & hospitals don't get paid for them. They don't want to do something, have something go wrong & have to admit a 96 year old woman on hospice that is a SNF resident. So, they figure they'll transfer her to the hospital that misplaced the drain in the first place and let them deal with an admission/re-admission. Have them not get paid for a re-admission of a patient that was previously in their care.
Getting back to the matter at hand----the nurse was probably just trying to make your mother comfortable. And, with orders for morphine & xanax from hospice, that's what he was able to do. Your subsequent posts actually turned into another topic altogether, in which it seems like you are more accepting of your mother's passing rather than torturing her with more thoracenteses, drains, etc.
I think the nurse wants to see the pain controlled and likely feels the continual draining isn't in your mom's best interest. This is neither right nor wrong - it's an opinion that has more than one side. His intentions are good but you may not agree with the approach. Talk with the doctor about how long to keep up the draining.
Consider your mom's wishes. How long does she want to continue this treatment. That should be the main consideration. Some people want everything done and others want to quit fighting and simply control the pain. I hope that she is still able to have input.
Take care of yourself, too, during this tough time.
Carol
One thing I know is this ; you can't pilot a boat from the shore
Mom is at a stellar SNF, but each decision is only as good as the person making it. The overzealous nurse came from radiology and is not young, just I think, very into exploring his new job, and his closest male buddy is a Hospice guy. He is frustrated with me because I don't seem on board with the heavy drugs to comfort Mom.
So she had the fluid removed and she breathes easier. She gets some anxiety and they use Xanax. The Xanax makes her more sedated and vocal. So they give her some more. She is unable to open her eyes or sit up but now she calls out a lot, cries, and says she wants to go home, but can't answer any questions. She can shake her head yes or no when asked if she wants water or is pain. Never in pain. Always a no.
Now I am left with this horrible thing to watch. Either anxious and unable to be calmed without the Xanax, or unconscious and unable to be calmed with the Xanax. WHERE IS THE COMFORT THEY KEEP TALKING ABOUT??
I'm just at the point of screaming. Now they want to add Vicodin. For what? Narcotics wind her up. I think they just need to be clear about their goals! Either help her to the other side or don't, but this no mans land is misery.
Where is her own GP in all this? One person - one medically qualified person, that is - taking ownership of adjusting her px and responsibility for her comfort shouldn't seem too much to ask, is it?
I'm not liking the sound of your nurse any better than I did. As my mother used to say "I'm sure he MEANS well..."