tag:blogger.com,1999:blog-29595741510794511172024-02-20T03:47:32.525-08:00HospiceNPHospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.comBlogger21125tag:blogger.com,1999:blog-2959574151079451117.post-73015042417058274882010-04-19T11:16:00.000-07:002010-04-19T11:30:00.913-07:00Who is your health care proxy?Last Thursday was National Health Care Decisions Day. As I sat around a conference table, I asked a group of colleagues how many had completed advance directives. Only about one third raised their hands! This is astonishing to me, because we are all hospice workers, we all know what we are supposed to do. And the next question: do you know where it is? brought fewer responses.<br /><br />It's sad when we don't practice what we preach. It's bad enough when we are overweight and smoke, drink too much and drive too fast. But we of all people should be the poster children for having Living Wills and Medical Powers of Attorney completed. Is this like the shoemaker whose children went barefoot? Or the carpenter without a roof?<br /><br />I especially like the Five Wishes forms. These are easily obtained on the website, and completed at leisure. There is no need to pay money for an attorney. I like them for their detail, which of course you can complete as much or as little as you desire. They incorporate the Living Will and the Health Care Proxy in the same form, then go on to planning your funeral. It should be noted here that I have no ties to the Five Wishes or the Aging With Dignity organization. But I applaud them for the work they have done to improve access to advance directives and increase education about them.<br /><br />So how about it? Do you have yours completed? What about your family? Do you know where it is? Does your health care provider know? If the answers to any of these questions is no, you have work to do.HospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.com0tag:blogger.com,1999:blog-2959574151079451117.post-79438901562014353272010-04-01T12:00:00.000-07:002010-04-01T12:12:32.611-07:00Wrongful death in HospiceHospice patients are supposed to die of their disease, right? At least that's what I've always thought. This week I had the shock of learning that one of my patients had been found at home dead, likely due to foul play. It's not clear exactly what happened. Another family member was with him, also dead. There was talk of murder/suicide.<br /><br />Processing this event has not been easy. This patient had been in and out of the inpatient facility, most recently discharged home a couple of weeks ago. At that time, he was doing fairly well with his symptoms and disease progression. He was still ambulatory, his pain was well controlled, and he was eating to his satisfaction. He knew that when his time came to die, he could return to the inpatient facility and the nursing staff he trusted would care for him. That had been his wish, to be cared for by these nurses in his final hours. His life, and his wishes, have been taken from him.<br /><br />This sort of thing has never happened to me before. I don't have statistics on untimely deaths in hospice. I know that suicide occurs, but this was so obviously not suicide, at least not on the part of the patient. Are there statistics on murders of hospice patients? Has anyone else had a similar experience? I'd like to hear about it, and how you worked through it.HospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.com0tag:blogger.com,1999:blog-2959574151079451117.post-18435836329272951502010-03-24T06:08:00.000-07:002010-03-24T06:28:12.987-07:00The Rally in TallyWhat I'm missing by going to Kansas City today is the Nurse Practitioner Rally in Tally. Nurse Practitioners from all over Florida are convening on Tallahassee as I write this to gather in Waller Park to Rally regarding our bills regarding prescriptive authority.<br /><br />This is the 16<span id="SPELLING_ERROR_0" class="blsp-spelling-error">th</span> year we have filed bills to release the strangle hold on our practice. We can write for all medications except controlled substances. Florida is one of the last two states (Alabama is the other) denying <span id="SPELLING_ERROR_1" class="blsp-spelling-error">NPs</span> the legal authority to write for schedule 2-5 medications. This causes unnecessary delays in care, many times outright denial of care, and increase in cost of care. We have had study after study that show the safety of nurse practitioners' prescribing patterns. We put together a White Paper as well as a Senate Report, both of which concluded that there was no good reason to deny controlled substance authority to <span id="SPELLING_ERROR_2" class="blsp-spelling-error">NPs</span>.<br /><br />The problem in Florida is that the Florida Medical Association funds many key legislators. The chair of the Senate Health Regulations Committee, who determines which bills get on the agenda, has been heavily supported by <span id="SPELLING_ERROR_3" class="blsp-spelling-error">FMA</span>, as has his son in his first bid this year to a legislative seat. The Senator stated publicly that he has no intention of putting our bill on the agenda, end of story. He will not do it. He said this last week at a Florida Nurses' Association Lobby Day event to a group of <span id="SPELLING_ERROR_4" class="blsp-spelling-error">NPs</span>. If the bill is not on the committee agenda, it dies. If it isn't heard in the Senate committee, it won't be heard in the House committee either. The House is looking to the Senate for leadership on this issue. So it's done.<br /><br />The <span id="SPELLING_ERROR_5" class="blsp-spelling-error">NPs</span> will gather anyway, knowing this. There are many legislators who still don't know these details, and if they do, they may put pressure on their fellow legislators. There will be a lot of energy there, and at least one group, a group from <span id="SPELLING_ERROR_6" class="blsp-spelling-error">Volusia</span> County, is being introduced in the House.<br /><br />I'm looking forward to hearing all about it. Wish I could be there.HospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.com0tag:blogger.com,1999:blog-2959574151079451117.post-12200798810075357012010-03-24T05:50:00.000-07:002010-03-24T06:08:36.918-07:00Going to Kansas CityI think there's a song in there some where isn't there. It's running through my head as I pack my suitcase for a couple of days of learning and mental gymnastics.<br /><br />I have the honor of being chosen to sit on the Exam Development Committee for <span id="SPELLING_ERROR_0" class="blsp-spelling-error">APNs</span> for certification in hospice and palliative care. The exam is given by the National Board of Certification in Hospice and Palliative care Nursing, <span id="SPELLING_ERROR_1" class="blsp-spelling-error">NBCHPN</span>. After taking a course in writing test questions, now I will go to this meeting and for two days we will review and create questions for the certification exam. There is actually more than one exam but they are created to be, from a test point of view, equivalent.<br /><br />The process of creating good test questions has always interested me. When I found that in the early days, a non-nurse could take the certification exam and pass, I was not surprised. Some people are good at taking tests, and can figure out from the question and the answers what is considered the "right" answer. The challenge is not only making a question with a good right answer, but making good wrong answers. Not tricks, but good. Add in that it all has to be evidence or literature based, and it's clear why it takes a long time to create even one question.<br /><br />I'm not sure why they chose me. They need people from various parts of the country, and I come from a region where they had an opening, that much I know. But am I really qualified? I did <span id="SPELLING_ERROR_2" class="blsp-spelling-error">ok</span> in the course, but that was rather compressed. The next couple of days in Kansas City will tell the story. One thing is clear: it's hard to be a novice again. And that's what's really going on in my head right now, this fear of maybe not measuring up to expectations. Having identified that, I feel better already.<br /><br />I'll just keep singing my song; <span id="SPELLING_ERROR_3" class="blsp-spelling-error">goin</span> to Kansas City, Kansas City, here I come....HospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.com0tag:blogger.com,1999:blog-2959574151079451117.post-72925398946201075372010-03-21T07:00:00.000-07:002010-03-21T07:24:13.041-07:00On CallOh the wonder of being on call. At my agency, <span id="SPELLING_ERROR_0" class="blsp-spelling-error">NPs</span> are on call Monday through Thursday 5P-8A, or Friday through Sunday from 5P Friday until 8A Monday. The latter is my job this weekend. It's grueling at times, because the phone rings day and night. There are stretches when it doesn't ring at all. Then suddenly there is a deluge of calls at the same time. Afternoons and evenings are usually busy. But I've had nights where the phone never stopped and I never slept.<br /><br />What I've learned from this experience is that my first customer is the nurse at the end of the phone line. Yes, it's about the patient, but my relationship with the calling nurse makes all the difference. I had a call yesterday from a newly hired nurse, still in orientation. He was so afraid of saying the wrong thing, of not saying the right thing, and generally of offending me. He kept calling me "ma'am". I may not be "one of the gang", but I don't want to be seen as an ogre either. I finally told him, listen, these are the things I need to know up front on a call, and I don't bite. He sort of laughed at that, and I reminded him that I'm a nurse too, but with maybe another degree and more experience. He seemed to relax a bit. Hopefully as time goes by he will get comfortable, but right now I'm hearing someone overwhelmed with everything he has to learn.<br /><br />I've been doing this for several years with the same agency and many of the nurses are like phone friends. When Maggie calls, I know her distinctive voice. I know also that I'm going to get a complete description of the situation in the home, and her experience will help me understand what steps to take. I can trust her, I've learned that. I've actually met Sabrina, and she's as vivacious as her voice sounds. She brings her positive attitude to everything she does, whether a class on documentation or attending a death. The whole team of weekend nursing staff, about 15 of them, are excellent, caring nurses who understand hospice and can communicate that on the phone.<br /><br />So I've spent some time cultivating a relationship with each of them. They know when they call me we will discuss the problem, and see if together we can find a solution. In turn, I know that they will not hesitate to call me, as they do with others in my group, for fear of getting barked at. In the end, the patient reaps the benefit.HospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.com1tag:blogger.com,1999:blog-2959574151079451117.post-89218304230010295102010-03-17T16:19:00.000-07:002010-03-17T16:36:15.459-07:00Home againHere in Florida, many of our patients are from elsewhere. And when they get sick and dying, they want to go "home". Home to my 93 year old patient this morning was Ohio. Dying of a cancer of unknown primary with metastasis to the liver, she was adamant that she was going to get on a plane and get to Cleveland. So we did what we could to expedite the trip.<br /><br />Her son was her companion and caregiver. He was as invested in getting her to Cleveland as she was. Our social worker called the hospice agency there and faxed information so she could continue services. He took care of the flight arrangements. We made sure her medications were ordered and delivered in time before she left. She was getting <span id="SPELLING_ERROR_0" class="blsp-spelling-error">Lasix</span>, so I had the nursing staff place a Foley catheter early this morning and attach a leg bag. The nurses wrote out a list of her medications and the times she was to take each one. She had long acting medication for pain, as well as some for breakthrough, with explicit instructions for what to take when. Her son was a willing student and seemed to understand everything.<br /><br />My main concern for her has to do with air travel. Most people don't realize that airplane cabins are pressurized to about 7500 feet. If you think that Denver, Colorado, is at 5000 feet, 7500 feet is really high altitude. People with heart and lung disease have no margin for error, and can have symptoms of <span id="SPELLING_ERROR_1" class="blsp-spelling-error">CHF</span> and pulmonary edema within a very short time. This woman is 93, frail, has a history of CAD, <span id="SPELLING_ERROR_2" class="blsp-spelling-error">CHF</span>, <span id="SPELLING_ERROR_3" class="blsp-spelling-error">COPD</span>, and has <span id="SPELLING_ERROR_4" class="blsp-spelling-error">lymphedema</span> of her lower extremities from tumor burden in her abdomen. She had also started to leak from her abdominal incision this morning. The effect of altitude could be most unpleasant. However, all of this was explained to her, and she was adamant. She was going.<br /><br />And go she did. I hope she did <span id="SPELLING_ERROR_5" class="blsp-spelling-error">ok</span>. I hope she is there safe and sound. She and her son were going to be busy the rest of the afternoon and evening getting settled in, so we didn't expect or get a phone call. Whatever happened, it was the way she wanted it. "These bones don't belong in Florida", she said to me.HospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.com0tag:blogger.com,1999:blog-2959574151079451117.post-90490311072625116962010-03-16T16:54:00.000-07:002010-03-17T09:29:08.060-07:00Family MattersToday I was reminded how much of what we do in hospice revolves around the family instead of the patient. It is the family who are left to grieve, and they do so at different times and in different ways. They also come to grips with the impending death of their loved one on differing time lines. This makes for some interesting and challenging dynamics, not to mention conflicts, at end of life.<br /><br />I worked with a son who thinks that if he makes sure that his mother gets all of her medications and food, she really won't have a terminal illness. Forget that she has progressive breast cancer and a growing tumor on her pancreas. Forget that her pain is only barely managed, and just when we think her nausea is controlled, something else tips that balance. From his point of view, she just needs to get up, move around, and be herself. His terror is barely concealed, but he thinks we don't know about it. When he is ready, we will speak of it, and try to help him deal with it.<br /><br />Then there was the daughter who can't accept that her father is dying, even though he has been unresponsive with no intake in several days. After all, only a week ago, he was talking and eating. Some of the nursing staff say she's in denial, and I tell them I agree. Then I go on to explain what a wonderful coping mechanism denial is, how it helps us distance ourselves from a truth we can't accept until the time comes when we can. She will be OK, but in her own time. In the meantime, we have to give her our support too.<br /><br />Finally there was a patient admitted to my inpatient unit this afternoon. The family has a history of conflict among themselves and with hospice staff. The sons who accompanied the patient were not happy about her admission, and directed their hostility to some staff members. It seemed to help to explain that hospice house admission represents loss of control to them, and we can't expect them to be happy about that. We should even expect that there would be some resistance. If we meet their hostility with friendliness and a polite attitude and don't get drawn in to their drama, we will be better able to meet the <span id="SPELLING_ERROR_0" class="blsp-spelling-error">patient's</span> needs. The sons left before I had a chance to speak with them. Hopefully tomorrow I'll be able to meet with them and address some of their issues.<br /><br />Challenging, yes. Interesting, always.HospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.com0tag:blogger.com,1999:blog-2959574151079451117.post-32922523343491559512010-03-15T17:03:00.000-07:002010-03-15T17:14:27.867-07:00I'm backHello everyone. I've been away for awhile but I'm going to make an effort to do this again. Sorry to have let it go last year but some things got in the way.<br /><br />The Florida Legislature is back in session and the NP controlled substance prescribing bill is once again languishing in first committee. The committee chairs in both the House and Senate refuse to allow it to be heard. If it isn't heard in committee it has no chance of going forward. If anyone has any pull with Senator <span id="SPELLING_ERROR_0" class="blsp-spelling-error">Gaetz</span> and will put in a good word for us it would be most appreciated.<br /><br />I went to the <span id="SPELLING_ERROR_1" class="blsp-spelling-error">AAHPM</span>/<span id="SPELLING_ERROR_2" class="blsp-spelling-error">HPNA</span> Annual Conference in Boston and had a wonderful time. It was heavy on Pediatrics this year, which I am weak in, so I learned a great deal. I went to a particularly good lecture, Managing <span id="SPELLING_ERROR_3" class="blsp-spelling-error">Neuropathic</span> Pain in the Pediatric Patient, and some of it reinforced what I know and then some was new. I was reminded to try <span id="SPELLING_ERROR_4" class="blsp-spelling-error">Ketamine</span> for <span id="SPELLING_ERROR_5" class="blsp-spelling-error">hyperalgesia</span>, which I've never done. The next time I come across a case, I want to remember and see if I can get the MD I work with to help me with this. I've read of great results but it has to be done correctly. Conference is always stimulating and inspiring, and this was no different.<br /><br />New this year was blogging for <span id="SPELLING_ERROR_6" class="blsp-spelling-error">AAHPM</span>, although it was disappointing to do a blog entry and have no comments. But it's great to have an organization so invested in being part of the technology of the 21st century.<br /><br />I'm planning to submit a proposal for a presentation at next year's Conference. I'll be writing about it here in future entries. Here's hoping it gets accepted.HospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.com5tag:blogger.com,1999:blog-2959574151079451117.post-77346711576448269812009-05-20T06:14:00.000-07:002009-05-20T06:27:42.117-07:00Prescriptive Authority UpdateOnce again, the State of Florida has ignored the facts and listened to the vested interests of the Florida Medical Society in denying Florida <span class="blsp-spelling-error" id="SPELLING_ERROR_0">NPs</span> the authorization to write prescriptions for scheduled drugs. In all fairness, I will say that many <span class="blsp-spelling-error" id="SPELLING_ERROR_1">MDs</span> spoke out on behalf of <span class="blsp-spelling-error" id="SPELLING_ERROR_2">NPs</span>, and the issue came much closer to reality than it ever has. Several <span class="blsp-spelling-error" id="SPELLING_ERROR_3">MDs</span> I've spoken with have been honest about the bottom line, that this is a turf issue, and that it's about power and money. I appreciate their honesty, but would like more that they would set aside their hubris and work for the real loser in this fight: the patient. From my viewpoint, this is about access to care, timely access, not just eventual access. They cloak their objections in talk of increased drug dependency rates, but in no state where <span class="blsp-spelling-error" id="SPELLING_ERROR_4">NPs</span> have this authority does this bear out.<br /><br />However, Florida <span class="blsp-spelling-error" id="SPELLING_ERROR_5">NPs</span> are organized now as they have never been before. We have a plan for the summer while the legislature is out of session. We will bring this back next year, and the next, and the next, until the legislature finally does the right thing.HospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.com5tag:blogger.com,1999:blog-2959574151079451117.post-20378146786141540922009-04-25T13:34:00.000-07:002009-04-25T13:59:27.175-07:00Why I Avoid PropoxypheneMany clinicians use <span class="blsp-spelling-error" id="SPELLING_ERROR_0">propoxyphene</span> and its variants for pain control. I never do. In fact, the agency where I work has declared itself a "<span class="blsp-spelling-error" id="SPELLING_ERROR_1">propoxyphene</span> free zone". Independent studies have shown that it is no more effective than placebo at reducing pain. Any pain relief obtained is due to the <span class="blsp-spelling-error" id="SPELLING_ERROR_2">acetaminaphen</span> in the preparation and/or placebo effect. It is not on the WHO ladder for pain control. There are places in Europe where it is banned. The fact that <span class="blsp-spelling-error" id="SPELLING_ERROR_3">propoxyphene</span> is on the Beers list of drugs to avoid in the elderly is not entirely why I don't use it, because I do use drugs on that list for elders, but in small doses and while closely monitoring their effect. The primary reason is that it is so ineffective, especially for the kind of pain that most of my patients have, and there are so many other alternatives.<br /><br />When I choose a pain medication, I want something that is not too strong, but not too weak. I usually give <span class="blsp-spelling-error" id="SPELLING_ERROR_4">tramadol</span> or <span class="blsp-spelling-error" id="SPELLING_ERROR_5">hydrocodone</span>, or morphine or <span class="blsp-spelling-error" id="SPELLING_ERROR_6">oxycodone</span> in small doses. I may even start with very low doses of methadone. It depends entirely on the clinical situation: reason for pain, level of pain, age of the patient, renal and liver function. These medications have a more predictable affect and can be adjusted easily one way or the other as needed. <span class="blsp-spelling-error" id="SPELLING_ERROR_7">Oxycodone</span> and morphine have long acting preparations, and methadone itself is long acting.<br /><br />So I don't use this drug. It may have some use for acute <span class="blsp-spelling-error" id="SPELLING_ERROR_8">musculoskeletal</span> pain, in young people under 40. I'll be interested in your feedback.HospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.com3tag:blogger.com,1999:blog-2959574151079451117.post-11757680674205366262009-04-25T13:32:00.000-07:002009-04-25T13:34:40.974-07:00I'm backSorry to have been away from this for a few weeks. Sometimes there is more to do than time to do it in. Between work and family obligations, I've had to take a breather. I hope to be back and posting more frequently.HospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.com0tag:blogger.com,1999:blog-2959574151079451117.post-78449188706061702342009-03-07T07:01:00.000-08:002009-03-07T07:23:45.898-08:00RestraintsThe use of restraints is an issue with large ethical as well as practical considerations. The Joint Commission has strict rules about their use, and in my facility we simply don't use them. The issues surrounding documentation don't exist for us, because we don't even own them. I suppose someone could make something out of rolled gauze, but they would be facing termination if they did.<br /><br />So the question becomes, how do we control people who are out of control? First and foremost, we try to find the reason for the agitation. If this is a dementia patient, we try to meet their needs. If they need to walk, we find a staff member who can walk with them. If there is a toileting need, we help take care of that. We do use medications, from <span class="blsp-spelling-error" id="SPELLING_ERROR_0">benzodiazepines</span> to <span class="blsp-spelling-corrected" id="SPELLING_ERROR_1">anti psychotics</span>, which is a form of chemical restraint. We have also gone so far as to put the mattress on the floor to keep people from falling out of bed.<br /><br />It's clear that tying people down makes the agitation worse, and is cruel and demeaning. Some may say that chemical restraint is just as bad, but I don't think so, because the person is still able to move about and interact. I try to give only as much as is needed for symptom control, not to render them completely helpless.<br /><br />We're fortunate in my facility to have a staff/patient ratio of 3/8, and if the need arises for a 1/1 sitter that can be arranged. We are committed to never needing to restrain our patients, but to maintain their safety in other more creative ways. I'm interested in how others manage this problem.HospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.com1tag:blogger.com,1999:blog-2959574151079451117.post-39098314025133188772009-02-28T05:35:00.000-08:002009-02-28T06:09:55.906-08:00Prescribing controlled drugsOne of the more frustrating aspects of working in Florida is that <span class="blsp-spelling-error" id="SPELLING_ERROR_0">NPs</span> are not allowed to prescribe any controlled drugs. Not just schedule II drugs, as in some states, but all scheduled drugs. The law not only confounds <span class="blsp-spelling-error" id="SPELLING_ERROR_1">NPs</span> in hospice and palliative care, but in nearly every other specialty. Psychiatric <span class="blsp-spelling-error" id="SPELLING_ERROR_2">NPs</span> can't independently prescribe Ritalin, and how often does one suppose there is the need? In my practice, I need to prescribe scheduled drugs every day. Because I work in an inpatient unit with a physician usually nearby, I can get things done fairly efficiently, but there isn't always a physician available.<br /><br />So how do I manage? What I do, is write the orders, which means doing all the medical decision making, then the MD signs the order. All of the <span class="blsp-spelling-error" id="SPELLING_ERROR_3">MDs</span> I work with trust all of the <span class="blsp-spelling-error" id="SPELLING_ERROR_4">NPs</span> in our practice, and they may read the order but rarely question it. The extra step of getting the signature is time consuming and dis<span class="blsp-spelling-error" id="SPELLING_ERROR_5">ruptive</span>, and most importantly adds nothing to the process.<br /><br />When I work on the home teams it's a different story. I carry a small laptop computer, and send the order by email to the team MD for signature. The MD may not be available at the time, or the technology may not be working so the email is slow to arrive. It can be hours by the time the patient finally gets the medication needed for symptom management.<br /><br />For this reason, the NP groups in Florida have worked year in and year out to get legislation passed to reverse the law. The studies clearly show the safety of <span class="blsp-spelling-error" id="SPELLING_ERROR_6">NPs</span> prescribing scheduled drugs. The issue is about power and money. <span class="blsp-spelling-error" id="SPELLING_ERROR_7">NPs</span> in other kinds of practices have to have a "supervising" physician, who does nothing more than review charts on a monthly basis and is available to sign these kinds of prescriptions. The <span class="blsp-spelling-error" id="SPELLING_ERROR_8">NPs</span> have to pay the MD for this service, and in Florida many retired <span class="blsp-spelling-error" id="SPELLING_ERROR_9">MDs</span> use this to supplement their income. The Florida Medical Society supports many of the legislators, so it's difficult to get our bills through.<br /><br />For me, the issue is really about access to care. While everyone is worried about power and money, people are not getting the care they need in a timely manner. To have to wait as much as 8 hours, as one patient I know did, for pain medication to finally be delivered, is criminal. If any one of these legislators had to wait like that, suffering pain and shortness of breath, there would no longer be an argument.<br /><br />There seems to be more support in the Florida legislature this year. I'm hopeful. Stay tuned.HospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.com1tag:blogger.com,1999:blog-2959574151079451117.post-43692259854449704692009-02-15T11:18:00.000-08:002009-02-15T11:45:46.805-08:00The psychiatric conundrumThis week I learned about Lithium toxicity. In the four years I've been practicing, it's just never come up, but I think that like <span class="blsp-spelling-error" id="SPELLING_ERROR_0">Digoxin</span> toxicity, I won't forget it. The hospice diagnosis was lymphoma, with a history of bipolar disease, treated at this point with Lithium. I've learned this week that Lithium is no longer considered the best drug therapy for this disorder, for exactly the reasons I found: levels are difficult to manage and even a bout of the flu affects concentrations.<br /><br /><br /><br />I don't know what started the cascade, but somewhere in the past month the levels became toxic. Toxicity is exhibited by nausea, vomiting, and diarrhea, which lead to dehydration and increased concentration and further toxicity. If the person is unable to take the drug due to vomiting, there is self-weaning, but if they are not well educated about this, they will try to take the drug and keep it down. Double whammy. She was having <span class="blsp-spelling-error" id="SPELLING_ERROR_1">myoclonus</span>, <span class="blsp-spelling-error" id="SPELLING_ERROR_2">fasciculations</span>, and decreased level of consciousness.<br /><br /><br /><br />By the time I discovered what was going on, she had not been able to take her medications for two days, so was self-weaning, but she was also having vomiting and diarrhea so her dehydration was counteracting that. I started an IV and got a blood level. The level was only 3 by this time, and people are only <span class="blsp-spelling-error" id="SPELLING_ERROR_3">dialysed</span> if over at least 4. And what was really going on was she was entering the dying process: remember the lymphoma diagnosis?<br /><br /><br /><br />What this really underscores is the challenge of caring for terminally ill people with psychiatric illness. Psychiatry is not my forte, and I fumble whenever someone with a serious mental illness comes my way. I'm fortunate to have people to consult with, but it's hard to separate out some behaviors like anxiety and agitation at end of life. Which is the mental illness and which is end of life behavior? Are the hallucinations new or part of the schizophrenia? Does the patient understand their physical illness or does their mental illness prevent that?<br /><br /><br /><br />So the next time I see a patient with nausea, vomiting, and diarrhea, and Lithium on the medication list, I'll stop the drug and get a level on the first day rather than the fourth. It may not change the ultimate outcome, but stopping the <span class="blsp-spelling-error" id="SPELLING_ERROR_4">myoclonus</span> and <span class="blsp-spelling-error" id="SPELLING_ERROR_5">fasciculation</span> would be worth it.HospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.com2tag:blogger.com,1999:blog-2959574151079451117.post-24867414914204117412009-02-06T07:17:00.000-08:002009-02-06T07:40:18.232-08:00Friend or patient?This week I took care of my friend's husband. He died yesterday morning when neither of us were there, which was probably the way it should have been, as he was such an independent person. It was a first for me, to be in charge of the care of someone I know.<br /><br />I didn't know him well, just through my friend. That helped, in a way, to take the liberties that we must in order to ask the questions and do the exam. It was a little awkward at first, asking all the questions, getting the history, delving so deeply into his personal life. My friend is a nurse, and she understood what I needed and why, and that made it easier. In some ways, she was caring for me. Then the physical exam, which is intrusive at best.<br /><br />In many ways, he was no different from many people I have cared for. The diagnosis was not unusual; the end of life course was typical and predictable. He was happy that it was me and not a stranger managing his care. What a blessing that I could give him the peace of mind that he seemed to need, that he was surrounded by friends, and friends of friends, to his last breath.<br /><br />And people wonder how I can do this work.HospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.com1tag:blogger.com,1999:blog-2959574151079451117.post-68962823960034937202009-01-26T14:38:00.000-08:002009-01-27T14:50:20.203-08:00The Work, or the JobThere is the Work, and there is the Job. The Work is what I do at the bedside, one on one with the patient or the family, or both. The Work is what I love the most, and what stimulates, inspires, and nourishes me.<br /><br />Then there is the Job. The Job is the Monday through Friday going through the day getting it done part. I love this part too, although lately it's been a bit tough. My Job, primarily, is to provide medical care to patients in an inpatient hospice house. These patients are all what's considered acute level of care, meaning that they have uncontrolled symptoms in the context of a terminal and life-limiting illness. About 50% of them leave the hospice house and either return home or go to a nursing home. The other 50% of them die there. I make rounds, examine them, get histories, write orders, and answer questions from the patients and families. Sometimes there are conflicts that need to be resolved among the family members and I help with that. Sometimes they need help figuring out what the goals of treatment should be. Of course there is loads of paperwork associated with all of this, and similar loads of government regulations that must be met.<br /><br />Sometimes I go out and see hospice patients in their homes, which is a completely different experience. The focus at home is usually not on symptom management, although that is part of it, but on disease progression. You also see how people manage their illness, and being chronically ill, and having disabilities. In many ways, it's very inspiring.<br /><br />The last two weeks, I've been really immersed in The Job. It's been busy, and we've been short staffed. The Work is all part of it, interwoven in all I do, but harder to think about and tease out when I'm moving from one task to the next. Have the patients been seen? Do the nurses have the orders they need to give the care? Has the documentation been completed? What about the other paperwork? and the checkout note for the on-call? Oh, this family member wanted a call back, and this one needs FMLA paperwork completed.<br /><br />This is not meant to be a complaint, just the reality of what's been going on. I think this is the way Real Life works: sometimes you just have to live life, and other times you get to think about it. I like to write about what I'm thinking, and I have several upcoming posts in my head. Right now I have to be happy with where I am in the process and know that it is a process.HospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.com3tag:blogger.com,1999:blog-2959574151079451117.post-33402804200539646702009-01-12T16:18:00.000-08:002009-01-12T16:45:35.358-08:00The Little ThingsMany times it's the little things that seem to mean the most. A patient came off of dialysis and we all decided that fluid restriction seemed pretty stupid. Water never tasted so good. Another patient came in wanting a cup of coffee. He had been in a hospital where no one had given him coffee for several days. He had been given iced tea and milk, but no coffee. He enjoyed that cup of java more than anything else we did for him, at least at first.<br /><br />The best thing, is it's so easy to do these things. There was nothing difficult about getting either the water or the coffee. Either would have happened in the usual course of events. But for these patients, these were not ordinary, or usual, they were special occasions. The satisfaction for me is being a small part of making this happen for them.<br /><br />For this reason, I never order special diets for my hospice patients. I do not impose any limits. If the patient wants to impose limits, that's a different matter. But I think that at this time of life, what is the worst that can happen? The person dies sooner? I also never order for a patient to be <span class="blsp-spelling-error" id="SPELLING_ERROR_0">NPO</span>. If a person is unable to eat, we note they are "not eating", which is more a statement of function than a restriction.<br /><br />There are many other "little things" we do that mean so much. The extra blanket, the fan for the <span class="blsp-spelling-error" id="SPELLING_ERROR_1">COPD</span> patient, many things. But taken altogether, they become a large part of what makes hospice care different and special.HospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.com0tag:blogger.com,1999:blog-2959574151079451117.post-80527197337556845572009-01-09T18:11:00.000-08:002009-01-09T18:27:22.695-08:00Time for renewalIt's been a busy week. I worked last weekend, with several new admissions which means new history and physical workups, and then this week the pace never let up. Yesterday was my birthday, and in spite of being so busy with patients, everyone gave me a nice little party with cake and ice cream, flowers and balloons, and cards that everyone signed. It's a measure of the close feeling we have for each other that we get to do this kind of thing. It was nice being on the receiving end.<br /><br />The patient flow was hectic all week though. I don't know all the figures but it was like a revolving door, with admissions, deaths, and a few discharges home. I really felt like I was on a treadmill much of the time just to get the work done. The compensation for working last weekend is that I have a 3 day weekend now, and it's time to rest and recover.<br /><br /><br />Recovery is vital to being able to work in hospice for the long haul. This work is very stressful, even more so to me than critical care was. Burnout is a common occurrence, and you have to make a conscious effort to renew your own spirit. So this weekend I'll be taking walks, reading some fiction (I like mysteries), maybe sitting on a beach somewhere. I'll be spending some quality time with my family. Monday when I return to work, I'll be ready once again for the challenges.HospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.com0tag:blogger.com,1999:blog-2959574151079451117.post-18844891429830822852009-01-07T14:39:00.000-08:002009-01-07T14:49:32.154-08:00Dying badlySome people do not die easy. It's difficult for me to deal with, because I want to "fix" whatever is wrong, whether it's pain or anxiety or shortness of breath or whatever. But sometimes, even with all of that having been looked at and taken care of pretty well, the person is still thrashing around. It's as if they are fighting so hard not to die, they are fighting against the medications I've used to help their symptoms. I try calming words, and presence, and sometimes touch, but sometimes nothing works. It's very frustrating. More than that, it's humbling. After all, I don't have to be perfect do I? Well maybe I think I do. When I have my successes, it's so easy to think it's because I'm so smart and good at what I do, when really the patient had a great deal to do with how they responded. People have to be receptive. I am always amazed when some people fight death to their literal last breath. It doesn't happen often, thank goodness, but it does happen. I leave them feeling totally wrung dry, emotionally drained, always wishing for the happy ending but taking some comfort in knowing that the person did it "their" way.HospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.com0tag:blogger.com,1999:blog-2959574151079451117.post-13244615556943683392009-01-05T12:20:00.000-08:002009-01-05T12:30:55.766-08:00Pain management successOne of the things that I LOVE about my job is the impact I can have on people with pain. Consider this woman: 46 years old, ovarian cancer, metastasis to the bone, pain in her right shoulder, lower back, and right hip. When I first met her she was on very high doses of methadone (good drug but not working for her), and was still doubled up in pain. She had not slept in days, except for naps disturbed by dreams. She had lost 25 pounds in 2 months because she was unable to eat due to the pain. I put her on a Dilaudid infusion at 5 mg per hour with a 3 mg bolus every 10 minutes. She used the bolus very little, because the basal rate turned out to be spot on. The next day after starting this, she told me she had slept all night. She was able to walk standing straight up. She was eating. The next day after that, she was smiling. She had again slept all night, but was not sleepy during the day. She was functional. She is still on her infusion at this dose, but we discussed the probability that at some point her illness will worsen and she may need more. It will be simple to increase the dose, just by adjusting the pump. Her hospice nurse is visiting her frequently and checking for any side effects, changing the tubing and bags as needed, and will let me know of any issues. Seeing her move about, eat normally, and function normally is such a rush for me. I don't know how long this will last, but if she gets even a week (although I think it will be much longer) of pain relief, it will be worth it.HospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.com2tag:blogger.com,1999:blog-2959574151079451117.post-49550564119731384952009-01-05T08:29:00.000-08:002009-01-09T05:59:04.735-08:00IntroductionThis is my first time at this business of blogging. I want to write about the wonderful world of the Hospice NP, the good times and the bad. Some people ask how it is I, and others like me, can do this work, and hopefully this blog will answer that question. In a word, because it's meaningful. I know at the end of the day that I mattered to someone. But it's much more than that. So in the coming days and weeks, I hope to fill the posts with my thoughts and feeling about what's going on in my life as a hospice NP. If it strikes a chord, write a comment. I'd love the feedback.HospiceNPhttp://www.blogger.com/profile/03996822537502970850noreply@blogger.com4