Acute care?

I was a hospice nurse for 15 years.

Acute care is in a hospital.  This is where they continue doing aggressive treatment.  Chemo, radiation, further surgery, etc.
Hospice is where the doctor certifies, if your disease process (not necessarily cancer ) continues on the normal course, you have 6 months or less to live.  You can have IV's with medication.  You can have g-tubes with tube feeding.  But they are not encouraged.  When a persons end is near, they lose their appetite so using a g-tube to forcefully feed them makes them very uncomfortable.  Hospice is for comfort. 

We use all means and methods to keep a patient comfortable. Most of the RN's know more about pain management than doctors do  cause we have constant classes in it.  I have had my patients change doctors when one would not keep my patient comfortable.
For instance:  I had a pt with facial cancer.  Half of her face was eaten away.  The doctor would only give her extra strength tylenol!!!!!  Can you imagine!!!    So I had the hospice doctor come in and we got her some morphine and got her comfortable.

If you have any questions on hospice, give me a jingle.

bette m

Thanks Bette.  That all makes sense except for the fact that they have given her 2-3 months to live and that was about 2 months ago.  She got a lot better last week and is now spiraling downhill.  She is in a lot of pain, which they try to manage with IV pain meds.  She has the TPN for her food since she doesn't eat.  The NG tube is the thing that goes into her stomach and sucks all the juices out.  She doesn't eat anything, but her digestive system isn't working right and hasn't been for about 2 months.  So, the bile and other stuff builds up and has to be sucked out.  Any thoughts?

I would call hospice and have them come out to sign her on.  Sometimes doctors are very reluctant to call in hospice until the last few days.  A tragic mistake.  Usually these are the older docs.  Her doc has to refer her to hospice but there are ways of getting around that and the hospice admit nurse will help you.

The TPN should be stopped.  Her body does not want, or need it.  That is evident from the digestive system not working.  IV's hurt to start, hurt to have in and hurt to restart.  We prefer to use patches or medicine under the tongue.  If she is in pain, she needs stronger meds and that is all there is to it!!!!!   I get very angry when docs won't increase the meds cause "she might become addicted"   HUH???
Or any other dumb reason.  The normal dosage of morphine is usually 2-8 mg every few hours for someone that just had surgery.   I had one patient that was taking 64,000  YEP, sixty-four thousand, every 12 hours and 20,000 every 2 hours as needed.   The doc went silent when I requested this amt.  But he had been worked up to it and it was what he needed to keep comfortable.  In fact,  he was running his construction business using his computer in his bed.  Ask any hospice nurse that has been in for a while and they will all nod their head yes.  That is an unusual amt but certainly not unhead of.

Hospice needs to get her home where she can die with her family and loved ones around and not in a cold sterile hospital.  She will have nurses, nurse aides, social workers, chaplains and a doctor always on call if her doc is unavailable,   I used to wait 25 min for a call back from the pts doc and then would call my hospice doc.  I saw no reason to make my pt suffer cause a doc is on the golf course or whatever.

Yep.  I loved hospice.  Am retired now.

bette m

Now-a-days, most insurance companies pay for hospice.  They also pay for the hospital bed and the chux and the medication and the oxygen and thealmost everything.   We can usually get all this out to the home on the day of admit, before the pt is discharged from the hospital so everything is ready and waiting for her.

comfort - comfort - comfort.

My prayers are with you girlfriend

bette 

But if they stop the TPN she will starve to death, correct?  She can't eat anything without throwing up.  She had a port but it stopped working so now she has that other thing (I forget what it's called) oh wait, picc line?  Something like that.  So they don't have to keep starting the IV's.  Which is good because she has tiny crappy veins.  She isn't on morphine, she's on diloudid (sp).  The only reason her pain isn't controlled is because she's a stubborn ass and refuses to admit that she hurts until she's crying and then give it to her anyway.  I will talk to her case manager at the hospital and see what she has to say.  Thanks so much for the advice.

Oh sweetie.  Your case is exactly why hospice was started and why they reccommend you go on it as soon as you are told you are terminal.

yes, she is starving to death right now.  What I used to tell my pts is this:
   When you get ready for bed at night, the first thing you so is turn off your light or lock you door.  Taking away the appitite is Gods way of getting you ready for that final sleep.  It is natural.  Making a person suffer with the tummy pains and the nausea is not.

Yes, she needs a DNR.  But the hospice people are very good at talking to pts and explaining why it is necessary,  without really coming out and telling them that they are dying.

She should be on  routine Morphine (the hospice drug of choice).  It is given every 12 hours and it can be given inbetween time if she asks for it or if her caregiver thinks she is in pain.  Think of a mountain and a valley.  The mountain is pain and the valley is sleep.  We work very hard to keep the pain control somewhere between the two.  We want you awake but out of pain.  The inbetween pain goes under the tongue and starts working in just a minute or two.  The every 12 hour is a long acting agent that releases a little at a time.
There are also the patches.  One every 72 hours. 

I am sorry you have to go thru this.  but that is Gods way and I have yet to win an arguement with him

God Bless

bette

Hi,
 The hospital should have a nurse who is a discharge planner. Hopefully he or she can give you some info too.
  Rough time for you and your family, you are in my thoughts.
  Dee

Hi Buhbahlah, I have no idea, I just wanted to tell you I love you too and that my heart and prayers are your way.  Muah, Gina 

Thanks, Gina.  You're always there for my *****ing but you never complain...why is that??!!  LOL

Cathie, sweetie,

My father-in-law was in hospice a few years back; and if I remember correctly, hospice is specifically for the terminally ill with a life expectancy of weeks or months. Usually, hospice is offered in the community (not a hospital facility). I think the patient has to have a DNR order, too. And my understanding is that acute care centers continue to treat the patient and can provide life-saving measures and other procedures (even though the person may be near death). 

I'm definitely not an expert in this area, so you might want to do a quick Google search.

Needless to say, I'm definitely thinking of you and sending my prayers. I know this is not an easy time for you or your family.