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APN Frequently Asked Questions Question DNR ORDERS 1. Does any one have something in writing or can you just let me know if you can legally write DNR orders as an APN in your state? [Submitted on: 1/15/2006 by: (not provided)] Answers DNR ORDERS In New Jersey there is no legal restriction on APN writing DNR orders. [Submitted on: 1/17/2006 by: chrisclub@aol.com]

DNR ORDERS Also, recall that the Medicare Modernization Act states that an NP may act as the attending Physician. Attending physicians may write DNR's. [Submitted on: 1/17/2006 by: rghuscrn@aol.com]

DNR ORDERS ARNPs in WA state are allowed to write DNAR orders, including completion of Provider Orders for Life Sustaining Treatment (POLST) our statewide out of hospital DNAR orders. They can also write them at the UW Medical Center.


[Submitted on: 1/17/2006 by: Darrell Owens,Ph.D., ACHPN, CNS VM:206-341-4636 Fax:206731-2363 Pager:206-541-0776 Email: owensd@u.washington.edu]

DNR ORDERS WV specifically in state law restricts to physician writing DNR orders. [Submitted on: 1/17/2006 by: Barb Mulich]

DNR ORDERS I suggest your refer to the manual for the modernization act. The language is on page 4, and may also be found elsewhere in the document if you have the time to look it over. [Submitted on: 1/17/2006 by: rghuscrn@aol.com]

DNR ORDERS In Oregon NP's can write orders addressing resuscitation status. We also use the POLST form which includes other life sustaining measures i.e. use of antibiotics and artificially administered fluids and nutrition. [Submitted on: 1/17/2006 by: Rick Warren]

DNR ORDERS It is within the scope of practice for nurse practitioners to write DNAR/DNR orders in North Carolina. [Submitted on: 1/17/2006 by: Susan Redding, MSN 252-847-0868 252-816-6585 FAX]

DNR ORDERS NY requires a physician for DNR orders. [Submitted on: 1/18/2006 by: Maryanne Kehoe]

DNR ORDERS WI requires a MD to write DNR orders. [Submitted on: 1/18/2006 by: Laurie Good]


DNR ORDERS NPs can write DNR orders in Ohio. [Submitted on: 1/18/2006 by: Robin Vachon-Kraut]

DNR ORDERS NP's can write DNR orders also in NC. [Submitted on: 1/18/2006 by: Sue Koesters, FNP Tel: 828 255-0231 Fax: 828 255-2880]

Question PAIN AND SYMPTOM MANAGEMENT POCKET REFERENCE GUIDES 2. Does anyone know of other pain and symptom management pocket reference guides that are available other than from Florida Suncoast or Southern California Cancer Pain Initiative? [Submitted on: 1/16/2006 by: (not provided)] Answers PAIN AND SYMPTOM MANAGEMENT POCKET REFERENCE GUIDES Pocket Guide to Hospice/Palliative Medicine by AAHPM and the Symptom Management Algorithms: Handbook for Palliative Care by Wrede-Seaman MD (available through HPNA National Office) [Submitted on: 1/17/2006 by: Cheryl Vahl]

PAIN AND SYMPTOM MANAGEMENT POCKET REFERENCE GUIDES Evidence Based Symptom Control in Palliative Care Arthur G. Lipman, PharmD, FASHP Kenneth C. Jackson II, PharmD Linda S. Tyler, PharmD, FASHP It contains Clinical Practice Guidelines and Algorithms and is found on Amazon. [Submitted on: 1/17/2006 by: Rebecca Gagne Henderson, RN, BSN, CHPN]

Question PATIENT AND FAMILY SATISFACTION SURVEY 3. Does anyone have a patient and family satisfaction survey that they are willing to share? [Submitted on: 1/18/2006 by: (not provided)]


Answers PATIENT AND FAMILY SATISFACTION SURVEY We developed a survey for families of pts who died based on focus groups. It appears on p. 814-15 in new edition Ferrell and Coyle palliative care text. The info about developing it appears in the chapter (it was also in the previous edition). We used it several yrs ago on a small # of families but then ran out of funding and have not used since. If any of you choose to use or if you look it over.. Let me know what you think. It was designed primarily for family feedback/satisfaction of hospital death. PS. Do any of you use or have access to family satis questions on the Press-Ganey survey that many hospitals use. I understood that they are finally looking at this issue but have been unable to access the questions. Much appreciated. [Submitted on: 1/18/2006 by: Susan Redding, MSN 252-847-0868 252-816-6585 FAX ]

PATIENT AND FAMILY SATISFACTION SURVEY For those who already send these surveys out, are you sending them to the families of all consults and how soon after the intervention are you sending? [Submitted on: 1/18/2006 by: Susan Redding, MSN 252-847-0868 252-816-6585 FAX]

PATIENT AND FAMILY SATISFACTION SURVEY We use the press ganey bereavement survey which we adapted for our use. Results have provided some useful information and will allow us to bench mark. [Submitted on: 1/18/2006 by: Jennifer H. Gentry RN MSN ANP APRN BC PCM Office 6607564/Fax 919-684-8569 Pgr: 970-4816/970-CARE]

PATIENT AND FAMILY SATISFACTION SURVEY We use the Press Ganey Hospice Satisfaction Survey. [Submitted on: 1/18/2006 by: Marilyn Graves, MSN, RN, CHPN Office: 443-849-8224]

PATIENT AND FAMILY SATISFACTION SURVEY We talked to Press Ganey about their Bereavement survey this past fall. They have no reliability/validity on it and they don't compare institutions like their other surveys. I was hoping they did, because we use their other surveys here, and I thought that would help convince our institution to do this. So,


Press Ganey has a tool, but they say that users often "tweek" it to meet their own needs so it's not "standard". It is on the CAPC site, under Tools, noted to be that of UCSF. The person at Press Ganey we talked to was: Dawn Wilkerson TEL:(888) 773-7742 [Submitted on: 1/18/2006 by: dwilkerson@pressganey.com]

PATIENT AND FAMILY SATISFACTION SURVEY The theme of the questions is very similar to the tool of Marie Bakitas in Ferrell & Coyle. We tried the Teno After Death Bereavement Phone survey and found the phone calls difficult to do. Dr. Teno had said call at 36months...but usually had to call when 'we had time', hard to find people at home, and hard to keep them on track with the survey questions...they'd want to talk about other stuff...which was interesting too. It seems there isn’t a lot out there for hospital death. [Submitted on: 1/18/2006 by: Cheryl Vahl RN, MSN, AOCN, ACHPN Tel: (319) 356-1616, pager #5200 FAX: 319-353-8988 Email: cheryl-vahl@uiowa.edu]

Question CONSULTING AND BILLING 4. A question keeps coming up from administration regarding consulting and billing. Currently, this is our process. We have a consultation service, no inpatient units. A referral can come from many sources, but the healthcare provider must write the order for a consult for me to become involved. On many occasions I am asked to see patients without a consult from the provider. I ask nursing to obtain a consult. Can a nurse generate a consult if the provider doesn't? Is that appropriate? I feel I can be a resource to nursing and offer suggestions, or I will speak to patients about living wills if asked, but I don't feel comfortable soliciting my own consults. Any Suggestions? What is everyone's practice? [Submitted on: 1/22/2006 by: (not provided)] Answers CONSULTING AND BILLING It sounds as if many of us operate the same way. We are a consult service only as well. Many curbsides to a variety of folks, nurses, housestaff, etc. We only see the patient or family if the primary team writes an order. If a nurse calls regarding an identified need, we curbside, and then based on if believe might be of help, we ask the nurse if he or she is comfortable talking to the primary team about a consult, and if they are not we contact the resident on the team (we are a teaching hospital) to explore the possibility of a consult. This has been a wonderful teaching tool for the residents, and almost results in us being involved (unless the patient is neurosurgery and that is a different story unique to our hospital). In my consult (for which we bill) I always list the referring


team and attending. [Submitted on: 1/23/2006 by: Darrell Owens, PhD, ACHPN Clinical Assistant Professor and Director Palliative Care Consult Service University of Washington at Harborview]

CONSULTING AND BILLING I do not work in a hospital setting, and am currently an NP student. My understanding is that if the NP is a hospital employee the NP is unable to bill for consultations. Is this true? [Submitted on: 1/23/2006 by: rghuscrn@aol.com (Rebecca)]

CONSULTING AND BILLING That is not true, but a common myth. The same myth has been circulating for years that a CNS cannot bill either. Who pays your salary is less important than what you are paid to do. General staff education, and other non-specific duties are not billable. Services provided in the role of an NP or CNS, that would otherwise be provided by a physician, and require assessment, etc. (see CMS site) are indeed billable. The problem is that most hospitals don't have a history of billing for APNs, and Nursing Services are generally not set up to generate a bill, that does not mean they cannot. If you are going to the conference in Nashville , the Pre-Conference Novice to Expert might cover some of these issues. [Submitted on: 1/23/2006 by: Darrell Owens, PhD, ACHPN Clinical Assistant Professor and Director Palliative Care Consult Service University of Washington at Harborview]

CONSULTING AND BILLING Just an FYI if this has not already been discussed. The key components of a consult are listed below in order to bill for consultation as an APN or MD. Even if we get a request from another team member (other than MD), we still discuss it with the attending and ensure we have his/her by-in. 1. Request (who is asking)-Do NOT state referred by. 2. Reason (why are they asking for a consult) e.g. " I am seeing Mrs. Black in consultation at the request of Dr. xx Physician for xx." Document the HPI, ROS, Past Family Social History (PFSH), your examination and your assessment and plan. 3. Reply (your advice and report back to requester). This requirement is met by documenting in the joint medical record. 4. Time- Sum times spent in these activities. 5. Avoid stating there will be continued involvement with the pt. 6. A consultation is a single event unless the pt's physician makes another request. Documentation requirements in terms of history, ROS, etc. are the same at each level for consultation [Submitted on: 1/23/2006 by: Lisa Szczepaniak, MSN, ARNP Phone: 603-650-4563 Fax: 603650-8699]


CONSULTING AND BILLING Our hospital employs a company that defends us in cases of billing errors. I do not charge for consults, as the advisor of this company says by definition, a consult is a physician requesting a physician see a patient. I charge for inpatient visits and follow-ups since I'm not a physician. This is a view most NP's I know disagree with. My reasoning is if I'm ever in the hot seat defending myself to medicare (or whomever) for a charge, I've followed the direction of the guy the hospital pays loads of money to keep us in order. [Submitted on: 1/23/2006 by: Diane Ranna]

CONSULTING AND BILLING Since medicare's own wording states that an NP may act as an attending physician (medicare modernization act pdf page 4 just sent a couple of days ago.) then they cannot question the consultation. You may want to pass the document on to the "expert" and advocate for your ability to practice to the whole scope of your discipline. [Submitted on: 1/23/2006 by: rghuscrn@aol.com (Rebecca)]

CONSULTING AND BILLING At our facility, the ordering physician requests consultation of the "team". Order typically reads, "Consult Palliative Care Team". If, however, the ordering physician specifically writes an order for our Palliative Care physician, we clarify the order in hopes of utilization of the team as a whole. Our billing company does bill for NP consults and follow up visits. Our palliative care physician is not always in house. [Submitted on: 1/24/2006 by: LaRonda Beam, APRN (865) 981-2598]

CONSULTING AND BILLING Does anyone feel comfortable speaking to billing issues and "Safe Harbor Law" and "Stark Law"? These laws are always bantered about when hospital APNs want to bill and they are employed by the hospital. I have always been told that they may not bill by the atty. [Submitted on: 1/24/2006 by: Patti Murray ND,ANP Murraypt@alexian.net]

CONSULTING AND BILLING Just a point of clarification, an APN cannot bill Medicare or


Medicaid if they are under the Dept of Nursing or are considered part of the per diem rate the hospital is already getting. To bill would be double dipping. Also, if an APN works in a setting that is a hospital owned outpatient practice, an APN could not bill Medicare and Medicaid as the hospital is already getting and outpatient DRG particularly in oncology. So it is very important to know one source of salary. [Submitted on: 1/25/2006 by: Constance Dahlin, APRN, BC, PCM Tel 617.724.8659 Fax 617.724.8693]

Question 5. Can you please let me know the rational behind placing a lidocaine patch for 12 hours and then removing it for 12 hours? have a MD who would like to keep it on for 24hrs, has anyone done this? [Submitted on: 2/13/2006 by: (not provided)] Answers Package inserts or the company site explain this.. I'm not sure my memory is right, but i think it is to "rest" receptors.. and/ or duration of action of lidocaine so once at steady state only needs to be used q 12. [Submitted on: 2/15/2006 by: Marie Bakitas, ARNP, MS, FAAN]

According to text I received from a presentation by M. McCaffery at a City of Hope Pain Resource Course I have taken, it states that new research shows that up to 4 patches may be applied for up to 72 hours (changing every 12-24 hours) without increasing plasma lidocaine concentration to toxic levels. [Submitted on: 2/15/2006 by: Rebecca Gagne Henderson RN, BSN, CHPN]

[Submitted on: 2/15/2006 by: Corrine Anderson, MSN, RN, GNP, APRN-BC-PCM]

I will reply first with the product information from the manufacturer (Endo Pharmaceuticals) Excessive Dosing Excessive dosing by applying LIDODERM to larger areas or for longer than the recommended wearing time could result in increased absorption of lidocaine and high


blood concentrations, leading to serious adverse effects (see ADVERSE REACTIONS, Systemic Reactions). Lidocaine toxicity could be expected at lidocaine blood concentrations above 5 µg/mL. The blood concentration of lidocaine is determined by the rate of systemic absorption and elimination. Longer duration of application, application of more than the recommended number of patches, smaller patients, or impaired elimination may all contribute to increasing the blood concentration of lidocaine. With recommended dosing of LIDODERM, the average peak blood concentration is about 0.13 µg/mL, but concentrations higher than 0.25 µg/mL have been observed in some individuals. And then I will add-frequently find the Lidoderm patch effective in situations where the pain is localized. Our pharmacy (in the hospital setting) will not allow anything other than what dosing is allowed in the researched literature (usually limited to the product trials that are reflected in the product inserts). There have been situations where nurses failed to remove the patch as ordered, and there have been no adverse reactions but we are limited to 12 hours on, 12 hours off. As another responder suggested, I have heard the theory proposed of losing effect by constant exposure to receptors. That makes sense to me, but I can't find a reference as I looked earlier when that idea was proposed. Sort of seems like a research project, if Endo would fund it!! (would need to measure blood levels, as well as measure effect over the extended hours and record any adverse effects. Probably more than most of us have time to do along with program issues and patient care needs! [Submitted on: 2/15/2006 by: Corrine Anderson, MSN, RN, GNP, APRN-BC-PCM]

Question 6. Do any of you have criteria(triggers) for automatic palliative care consults in your hospitals? I am thinking of things like so many days in ICU, multiorgan failure, post CPR. [Submitted on: 2/20/2006 by: (not provided)] Answers My team presented in Nashville , our data, were earlier Palliative Care referrals in the MICU. We did a nine month trial looking at "automatic" palliative care referrals for essentially 5 triggers. We developed these collaboratively with the intensivists and collected LOS data (amongst other things) both pre-trial and during. Our five triggers (if I remember correctly) were 1) anybody admitted to the MICU with a ST IV malignancy 2) anyone older than 80 years of age with 2 or more life-threatening co-morbidities 3) anyone who sustained an MI while hospitalized 4)anyone who ended up in the MICU after being in the hospital for >10d 5) anyone who sustained a stroke requiring a ventilator We then made the commitment to see these folks within 24-48h of their MICU admit. While we're not able to demonstrate an overall hospital LOS decrease, we did demonstrate a 7 DAY LOS decrease in the MICU which was statistically sig!!! It was very cool. [Submitted on: 2/20/2006 by: Marcia Buckley RN,MS]


Elizabeth Pitorak, Director of the Learning Institute at Hospice of the Western Reserve, has been involved in a Safe Conduct project at University Hospitals, in which palliative care is integrated into Oncology. I believe all stage !!!B & !V cancer patients are automatically referred to Palliative Care - & business is booming. You can reach her through 216-3832222. Or contact polly.mazanec@uhhs.com. She is the APN who is providing Palliative Care consultation at the hospital. [Submitted on: 2/21/2006 by: Molly Loney, RN, MSN, AOCN mloney@cchseast.org 440312-6636]

This is in response to Molly's response. The Safe Conduct Team(SCT) is an integrative model of palliative care at the Ireland Cancer Center(ICC) at University Hospitals in Cleveland, OH. This team has been in existance since 1998. From 1998-2001 it was a demonstration project. Since that time, the SCT members composed of an APN, SW/Counselor and spiritual care coordinator have been employees of ICC. The SCT sees specific populations which are automatically referred to the SCT. They are Stage IIIB and IV Lung; advanced GI - colon, pancreatic and some esophageal. Patients with other diagnoses are only seen by special request due to the heavy caseload of the team. Elizabeth Pitorak from Hospice of the Western Reserve is the teamleader and can be contacted by phone: 216-383-3740 or pager: 216-840-2046. Polly Mazanec, APN on the SCT can be contacted by email polly.mazanec@uhhs.com [Submitted on: 2/21/2006 by: Elizabeth Pitorak]

While our team has been successful in the MICU arena we are now reaching out in the Burn/Trauma ICU so anyone out there doing work in that environment...I would appreciate any info you have (please e-mail me directly:marcia_buckley@urmc.rochester.edu ) [Submitted on: 2/21/2006 by: Marcia Buckley]

Question 7. Is anyone doing staff bereavement? We are putting together this portion of our program and have hit a snag. The HIPAA officers are saying we cannot use pt names. So, my questions are: 1. How then do you all f/u with staff/referral sources, etc. to let them know patients have died? 2. What type of staff bereavement do you do -- what is involved & how often? 3.


Are others experiencing the same barriers as far as HIPAA is concerned? [Submitted on: 2/28/2006 by: (not provided)] Answers Not sure about this, but when someone has died, it generally is public information. My sources have told me that HIPAA then does not apply. Wish I could remember who my source was who told me this! [Submitted on: 2/28/2006 by: Shari Froelich RN, MSN, MSBA (517) 780-7289 Fax: (517) 7966498 Shari.Froelich@wafoote.org]

This is my understanding as well. My husband is a healthcare law attorney and I asked him this very question as we wanted to have a memorial service where read the names aloud. He says that as death certificates are public record that the details of their illness are still protected by HIPAA, but not the fact that they have died. [Submitted on: 2/28/2006 by: Rebecca Gagne Henderson]

One of the units where I work does do a bereavement service for staff yearly where the staff receive a program with each pts name written. The names are all read aloud by various staff and then the staff are able to cite a particular memory and light a candle in a pts honor. The pts death is a matter of public record and this bereavement service is only open to the staff who provided daily care. As far as letting referral services know of the deaths...I guess I don't understand the question. Certainly any service actively involved in the pt would know? You should re-check with your HIPPA person. The Oncology Nurses Society (ons.org) might also be a resource. [Submitted on: 3/1/2006 by: Marcia Buckley]

ANSR [Submitted on: 3/1/2006 by: Joan T. Panke, APRN, BC-PCM Tel: 202.715.4337 Fax: 202.715.5334 Pager: 1-877-311-9873]]

The info provided earlier is from NHPCO Policy section and I had an opportunity to speak


with an 2 attys as well about this and both agreed. I was floored myself, but these are the times we live in!!! So it might be wise to just double check with your HIPAA officers. If it is considered a violation, it could be a problem, if not a fine! While I personally find this frustrating (I'm being kind), it seems that despite deaths being in the public record, the actual printing of names raised a flag here. Apparently, names can be spoken, but it is considered protected information if written, and the risk of the names being discarded improperly is at the heart of the problem. We are beginning the process of creating other ways of communicating information regarding deaths as well as ways/rituals for staff to acknowledge specific individuals without writing down names (writing on a slate w/water that disappears was one suggestion, lighting candles and speaking the name was another). Feel free to share other ideas. While deaths may be a matter of public record, the place of treatment prior to death would be protected health information. Also, in hospice the patient and family are the unit of care, so disclosing patient deaths publicly identifies the family as bereaved. Hospices have stopped publishing a list of deaths for these reasons. Some of the ways hospices have communicated patient outcomes include: A "disposition" voicemail. Deaths are left on a password protected voicemail, allowing clinicians to learn of patient deaths in real time. This prevents phone calls and visits to patients who are no longer living, and allows for a rapid response to the bereavement needs of the family. Time in weekly care planning meetings to acknowledge recent deaths and identify ways the team might have done better in the patients care. It's important to determine the reason for communicating such information (is it patient/family centered or employee centered?) and proceed from there.' [Submitted on: 3/1/2006 by: Joan T. Panke, APRN, BC-PCM Tel: 202.715.4337 Fax: 202.715.5334 Pager: 1-877-311-9873]

Question 8. Are there any NPs out there whom are actual hospice medical directors? I am presently the medical "advisor" in our volunteer county hospice program. We are a frontier county. ( I also run a small, rural clinic here and wear many hats.) Presently, I am the most qualified provider here in the field of hospice and palliative care. The Hospice Board is now looking for a physician to be medical director...am I legally able to be medical director? We do not bill our patients. In Montana, NP's are independent and not needing a collaborative physician. We have our own DEA #, prescriptive authority, etc. [Submitted on: 3/1/2006 by: (not provided)] Answers Federal guidelines specfically state that APNs CANNOT serve as medical director. They can only serve in an emergency 1 time basis. not ongoing.. Look at Transmittal 315 and 205. [Submitted on: 3/1/2006 by: Connie Dahlin]


Are there any NPs out there whom are actual hospice medical directors? I am presently the medical "advisor" in our volunteer county hospice program. We are a frontier county. ( I also run a small, rural clinic here and ar many hats.) Presently, I am the most qualified provider here in the field of hospice and palliative care. The Hospice Board is now looking for a physician to be medical director...am I legally able to be medical director? We do not bill our patients. In Montana, NP's are independent and not needing a collaborative physician. have our own DEA #, prescriptive authority, etc. [Submitted on: 3/5/2006 by: Margaret Bortko FNP (406) 682-5000 bortkonp@3rivers.net]

Question 9. Can anyone share with me a tool used for auditing charts? I am in the planning stages of starting up a new Palliative Care program (consulting service only) for my community hospital. I would like to collect some data now before the program is launched. Any suggestions would be appreciated. [Submitted on: 3/2/2006 by: (not provided)] Answers I would encourage you to check out the CAPC site. It is a wealth of information including quality & quantitative data to document & track. We have a tool adapted for initiating palliative Care Rounds in our ICUs...using the form recommended by Mt. Carmel's program (as one of the 6 national leadership development sites through CAPC). [Submitted on: 3/2/2006 by: Molly Loney, RN, MSN, AOCN mloney@cchseast.org]

Question 10. We have seen several ALS patients recently and issues have come up around the long term implications for treatment decisions such as trach, peg, vents, finances, caregiving etc. Does anyone have any protocols or involvement with ALS patients early in their care when all of these issues could and probably should be addressed. Any resources appreciated. [Submitted on: 3/6/2006 by: (not provided)] Answers ANSR


[Submitted on: 3/7/2006 by: Meg Campbell]

I have a very unique ALS patient in my home based Palliative Care program. Through him I am learning a great deal. Not just about the disease but the decision-making process as the disease progresses. We discuss the changes in his condition and plan for his future needs. I have been seeing him for about 8 months. We have discussed his wishes re mechanical ventilation and he is not sure what he will decide when that time comes. I have to admit that at first I was not sure how much our PC program had to offer him. He has a wonderful family and support system of friends and church. He is treated at a major university for his ALS and I don't think he could get better care. I've come to realize that over time we have been able to help problem solve, plan age and provide practical advice. Because of our palliative care role he talks w/ us about EOL issues. When he travels to the ALS clinic the focus is on function only and the current trials. [Submitted on: 3/7/2006 by: (unknown)]

I have spoken to his ALS support group. Only one other patient has sought our service. I think these patients could be better served by palliative care. [Submitted on: 3/8/2006 by: Nanci Tansey, MS, GNP]

ANSR [Submitted on: 3/8/2006 by: Linda Blum, MS, GNP, APRN-BC]

We work closely with neurology on ALS patients within a short time of their diagnosis. We help out with advanced care planning and then symptom management. We collaborate closely as we have different thoughts on g-tubes and tracs. We then become the primary when they go on hospice. [Submitted on: 3/11/2006 by: Connie Dahlin]

The Promoting Excellence site has a nicely done guidelines section specifically about ALS. I have personal experience with this horrific illness, my Mom died at age 60 after 2.5 years


with the bulbar form. For what its worth this is one of the most challenging palliative care diagnoses, on a par with head and neck cancers. Bulbar presentation is the most difficult and patient progression varies. Swallowing and speech losses are often early before respiratory challenges leading to early decisions (6 months to a year before death) when PEG is useful, contrary to other diagnoses when PEG is generally not useful. BIPAP, especially at night, is often useful with the patient who does not want long-term ventilation. Individually tailored decisions are best, ALS patients remain cognitively intact and interactive with their environment and families until the end. Thus, while ventilation is not recommended, an individual patient may choose this intervention for a time-limited trial and opt for vent withdrawal later, etc. Lastly, early communication while the patient can still speak about the hypothetical, yet real natural history of the disease, is important, especially about ventilator treatment preferences. However, most palliative care clinicians dont get involved with these patients until late-stage disease. [Submitted on: 3/7/2006 by: Meg Campbell]

We work closely with the ALS program at my institution. The ALS program at my hospital sees patients from a wide catchment area. I have been working closely with the nurse case manager and the neurologists at the Forbes Norris Center. They refer a significant number of patients to us for symptom management and to our acute palliative care unit for ventilator withdrawal and end-of-life care. Their nurse starts counseling patients and families about the dire nature ALS at diagnosis. She works closely with the social worker to make sure that advance directives are completed and that discussions about enteral feeding and trach/vent/bipap/cpap occur early in the relationship with the clinic. I was always impressed with their approach (when I worked in home hospice) and now that I collaborate closely with them, I am even more impressed with the thoughtful nature of their care. A good review article (dated but useful) is Borasio GD, Voltz R, Miller RG.Palliative care in amyotrophic lateral sclerosis. Neurol Clin2001 Nov;19(4):829-47. [Submitted on: 3/8/2006 by: Linda Blum, MS, GNP, APRN-BC]

Question 11. I do home palliative care visits, and usually bill by time spent. I am currently precepting another NP in PC. In her class work, she needs to determine billing for a complex visit to a sickle cell pt. Can the APN group advise on billing for time, co-morbidities, use of EM codes for most correct coding/reimbursement? -- This is the second time I have heard someone refer to "home palliative visits." Can someone educate me as to who pays for palliative care in the home? Do the same rules apply to home palliative care as they do to home health as far as home bound status is concerned?


[Submitted on: 3/19/2006 by: (not provided)] Answers Our Palliative Care Team is actually a physician specialty practice with 2 MDs, 2 NPs, and 1 MSW (we also "borrow" chaplains and volunteers from hospice for certain situations).We make visits in the home mainly because it is a hardship for most of our patients to make it into the office.We bill under Medicare B and other commercial insurances. There is no restrictions such as homebound status etc. [Submitted on: 3/20/2006 by: Gretchen Fitzgerald, CRNP 610-969-0310]

Medicare covers “palliative� care under the home care benefit, which requires meeting the home bound status and skilled care requirement. We plan to IDT these patients and follow them through with the same staff to Hospice. [Submitted on: 3/20/2006 by: Judith Hemke BC-HPM]

You can also do home palliative care consultation visits which are covered under Medicare part B and some commercial insurances. These visits do not follow under home health or hospice, but are viewed as a specialty physician or np visit. [Submitted on: 3/20/2006 by: Julie Isaacson]

During my employment at Hospice & Palliative Care Charlotte Region, I was seeing patients in the acute care setting, extended care setting and at home (have since relocated to Utah and a inpatient palliative care program). Home palliative care is a great service for patients who have a life threatening illness but who may not meet hospice criteria or who for personal reasons are not receptive to the idea of hospice. It can act as a great bridge to hospice. Will be happy to discuss with you more if you want to contact me via e-mail. [Submitted on: 3/21/2006 by: Ginger Marshall, MS, APRN, ACHPN office (801) 213-2922 fax (801) 585-3884]

I have an outpatient Palliative Care program, home based. Currently the only reimbursement comes from my billing for home visits. It definitely provides a service to the patients and families. We are not a home health agency so can not use our hospice nurses


for routine home visits to these patients. are currently using registry nurses and it is working very well. [Submitted on: 3/21/2006 by: Nanci Tansey, APRN, GNP tanseyprn@yahoo.com]

My concern is that hospice will be swallowed up by palliative care, and the patient population will suffer. As patients are referred to hospice later, and later, the possibility to be a financially solvent hospice will diminish. It is already a dismal affair. In order for a hospice to break even financially for an admit to hospice the patient must remain on service for 15 days. That is just to recoup what was spent on the admission. If hospice disappears the beauty of the IDT will be lost, and that is the aspect that makes hospice so special. If Medicare figures out how to maintain the integrity of the program while caring for those folks that fall between the cracks, more power to them. In the end, I just hope that the baby won't be thrown out with the bath water. [Submitted on: 3/23/2006 by: Rebecca]

Palliative care does not mean losing the IDT team at all. I work in an acute care facility in a palliative care department and have IDT meetings twice a week with the entire team and daily with MD, APN, RN, and counselor. I am not aware of any studies that show with using palliative care the hospice length of stay has decreased. If they are out there please let me know. In fact I think it would be interesting to look to see if palliative care actually increases hospice referrals and time on hospice. I know at my institution the amount of hospice referrals has increased over the 7 years we have been established. My personal feeling is that we are all practicing palliative care just in different settings and under different reimbursement structures. If we can find a way to work together more and create a comprehensive care program that would help patients with symptoms from life threatening illness the care would be better all around. [Submitted on: 3/23/2006 by: Kelli]

I assume that your palliative care program is hospital based? I am speaking of home care. If you are home care how is your funding met for the remainder of the IDT? Too many of us depend on the kindness of strangers (grant money) which disappears at the whim of the grantor. We need real reimbursement for the service provided to patients. It is obvious that there needs to be a bridge between home health and hospice, and someone just wrote me to say they have numbers that show an increase in referrals to hospice. An increase in referrals does not necessarily equate to an increase of quality hospice care or LOS. We have


a referral source that sends us patients from their palliative care that are so near death sometimes we don't get through the admissions process. (By the way, did I mention that the cost of the admission process in Los Angeles is about $2K. That means in order to break even the patient needs to be on svc about 2 weeks) What does need to be done is 2 things: we need to have an open discussion about these issues, and we need to have more studies about such things. Something needs to change and is going to change. If it is that palliative care and hospice become one in the same, so be it. The discussion must begin somewhere. I have no trouble reinventing myself or my organization. Nothing stays the same. In the end I just pray that our patients receive better care. [Submitted on: 3/23/2006 by: Rebecca]

My experience is similar to Kelli's. Our hospice referrals have only increased over the last 6 years. What has possibly contributed to that is, because of the emphasis we've placed on identifying patients earlier in the trajectory for palliative care referrals, we are tending to see more patients with a longer survival. Then, our palliative consult service makes the referral to hospice in a more timely fashion. Overall, we've tried to disabuse physicians of the idea that patients need to be imminently dying before they can be referred either to palliative care or to hospice. Lots of one-on-one education, but it's paid off. [Submitted on: 3/23/2006 by: Rita]

Our Palliative Care Consult service (hospital and clinic based) has also demonstrated increase referrals to hospice. Across the country it seems we have experienced late hospice referrals (with or without Palliative Care involvement). Part of this is the strict enforcement by Medicare payors of criteria for admission and to remain in hospice. Part of this is due to having more palliative interventions to prolong life so referring physicians hold off. Part of this is the skill level of primary care and specialty providers in palliative symptom management. We are all in the middle of change- shifting from the way it has been (eol care) to the way people need it to be. How it all shakes out remains to be seen. Staying grounded in what brings us all to this work is one way of maintaining a calm assurance that if we continue to collaborate and advocate as nurses who believe in the importance of this work we will undoubtedly figure it out. Isn't it great to have the opportunity to pave the way for the future of this important work? [Submitted on: 3/23/2006 by: Jane McCabe]

It has been my experience that PC in the hospital and/or home can get patients into home


hospice sooner rather than later, thus improving the hospice ability to impact patients and families during this time (and the bottom line). [Submitted on: 3/24/2006 by: Shari Froelich RN, MSN, MSBA (517) 780-7289 Fax: (517) 7966498 Shari.Froelich@wafoote.org]

I agree with this. Also, in response to the comment about being afraid that PC in the home will take away patients from hospice, I found that home PC will be able to follow patients that hospice will not because their care is too expensive. I think this and the comments made below identifies the need for home palliative care and how home palliative care and hospice will work together and benefit each other. [Submitted on: 3/24/2006 by: Robert Smeltz, RN MA PNP ACHPN Office: 718-206-6919 Fax: 718-206-8716 Pager: x16869]

Though our home palliative program (which is modeled after a physician practice with MDs, NPs, and MSW)we have actually seen an increase not only in our hospice census but also in LOS. Last fiscal year our average Hospice LOS for patients who were previously on palliative care was 64 days and our median LOS was 42. This is especially true for non-cancer diagnoses due to the difficulty regarding prognosis in these patients. We are the ones who introduce hospice early on in the illness so when it actually comes time for hospice we find that the patients and families agree almost immediately. Our palliative care service and our hospice work closely together and we take on the patients who are discharged from hospice to create a continuity of care. I believe with this collaboration, palliative care is only adding on to the success of hospice. [Submitted on: 3/25/2006 by: Gretchen Fitzgerald, CRNP]

Question 12. I'm wondering if there are any institutions out there that have a policy for "clinician controlled analgesia". Specifically, I am looking at a way to get my institution's buy in to use the PCA technology to deliver clinician administered bolus doses for patients who can no longer push the PCA button and who need breakthrough doses as they are actively dying. Would like to avoid extra needle-sticks if possible. [Submitted on: 4/3/2006 by: (not provided)] Answers


Our nurses will use the PCA pump to bolus pts, not by hitting the "button" that the pts would ordinarily press but by resetting the pump temporarily to deliver the bolus (we just write a cont infusion order with a prn~ usually q20min). It is quite effective, is safe and user friendly for the nurse. [Submitted on: 4/4/2006 by: Marcia Buckley]

At our institution, we call this "PCA by Proxy". We have a policy indicating that only patients on 'comfort care' or hospice can utilize PCA by Proxy protocol allowing for caregiver/nursing staff to use the PCA button to deliver bolus dosing for patients who are unable to do so themselves. It is our policy that the physician must write an order stating that PCA by Proxy is okay. Then the nursing staff is responsible to provide and document both written and verbal instruction to the caregiver on the appropriate use of PCA by Proxy. We have an educational hand out that we give to caregivers that are utilizing PCA by Proxy. Having said this, we also provide an additional order for clinician dosing via sq injection for symptoms not controlled by the PCA or if there is no bedside caregiver to administer PCA by Proxy. [Submitted on: 4/4/2006 by: LaRonda Beam, APRN lbeam@bmnet.com (865) 981-2598]

We are working on a CCA (caregiver controlled analgesia) policy, and we got an example of of a site which I will check with my colleague who did the search and give to the group about. There are some issues in risk managemnet with the policy so we're still working on getting it in place. Until then order prn dosing to be given by the nurse for breakthrough as we would order as a prn on the pump itself if the pt could push. Many of the nurses open the pump and give the bolus does thru the pump [Submitted on: 4/4/2006 by: Jane Owen]

Question 13. I am a recent APN graduate. I have 10 years of experience in hospice care. Our home hospice program is health system based. I have met with the director of nursing to establish the APN role in hospice. She is open to the role and the inclusion of the role of attending to those patients without a physician who elect hospice. She is also open to our program expanding to include palliative care consults. The director asked if I could give her some estimated annual projected revenue for these two services. Our average daily census is 48 and those patients coming in without a physician is approximately 1-2 per quarter. [Submitted on: 4/6/2006 by: (not provided)]


Answers Our field is young and the changing billing requirements and provisions are new and not well tested. Consider offering your boss the revenue earned by a doc for the same # of patients at 85%, or consider offering your boss a time-trial and re-evaluation of your value in "x" months. Look at your value creatively: # of new referrals, patient/family satisfaction, $ generated when there was no doc, etc. Answer this question: "What would be happening with patient if you weren't there?" From that question look at what you can measure. [Submitted on: 4/11/2006 by: Meg Campbell]

Regarding the potential for Palliative Care consults: If you are going to be starting an inpatient consulting service your may want to check out the CAPC site. For example they have a formula for estimating potential referrals (based on hospital's death rate with the assumption that every patient who dies in the hospital would have been a potential palliative care consult and CAPC estimates that 50% of Palliative care patients die in the hospital then of course the other 50% being discharge...so basically you would double the rate of the hospital's death rate). Then as a conservative estimate you could set a goal for 20% of that number for your first year. With that information you can estimate your cost savings for the hospital by plugging that number into their formula. This will take a little homework as you need to know the top DRGs resulting in death, their length of stay, etc.. The QI department should be able to help you get this info. Sounds confusing but a lot of info on this on the CAPC site. www.capc.org Click onto tools, then onto tools to conduct financial analysis. I am at Univ of Utah and we started a palliative care / hospice care consult service here in Nov 2005. It took us about 2 months to work on the infrastructure before we started to see patients in Jan. Given our estimates our goal was 120 patients our first year, after 3 months we are up to 85 patients. I would be happy to share the specifics of our program, estimates of cost savings, plans for growth, etc... Just email me directly or give me a call. [Submitted on: 4/12/2006 by: Ginger Marshall, MS, APRN, ACHPN office (801) 213-2922 pager (801) 339-6684 ginger.marshall@hsc.utah.edu]

Just last week, an ESRD patient died with this complication after several weeks of lingering in ICU and hospitalization. The calciphylaxis was intra-abdominal, but worse, there were calcium deposits on the leaflets of her heart valves which proved to be the final blow. She did have several deep skin lesions of the non-healing variety, which seems to be characteristic as the tissues are prevented from recovery. It's a miserable thing to see. The above patient probably makes the 4th one I have seen die at our hospital in the renal area.


But I did see one who has done well after having had a parathyroidectomy to correct the calcium problem Her skin lesions seemed to be the only location at the time the parathyroid was removed, so in essence, they "got it early." After the surgery her lesions began to granulate and she did recover and now 3 years later is still living without pain and going on with her life. I know she was the exception and it was a thrill to see it, even if just for once. I would say pain is the biggy. And the open wounds, which won't heal make sepsis the likely reality. Prognosis depends on the innate immunity as well as pouring in the right antbx. I don't think there are too many stats on this, but I will be interested to see if anyone can point us in the direction of more concrete information. [Submitted on: 4/21/2006 by: Corrine Anderson, MSN, RN, APRN,BC-PCM 817-820-4929 corrineanderson@texashealth.org]

Question 14. Today I saw a lady with ESRD on HD, who has extensive calciphylaxis. Her HPI includes the following: Pt is a 50 y/o female with non-healing abdominal soft tissue wound with calciphylaxis, pelvic abscess, skin breakdown over backside and buttocks with calciphylaxis present, ESRD on HD, and DM. HD#4 at Harborview (HD#19 including prior hospital). The patient is A and O and participates in all decisions, along with her husband and sister. My questions are: 1. Has anyone cared for a patient with calciphylaxis in a palliative care setting, if so what were the issues (other than pain)? and 2. Does anyone have any prognosis information specific to calciphylaxis, the data I reviweed did not cover this area very well. If she stops dialysis prognosis will not be an issue, but she and her family would like some prognosis information prior to making this decision. [Submitted on: 4/8/2006 by: (not provided)] Answers Had one patient about 2 years ago. She was in horrendous pain and would beg to die but when she was medicated she would want to continue with treatment. Her family was fearful of opioids of course. We put her on Dilaudid PCA (with continuous infusion too) and she did fairly well. She was being taken to surgery frequently for debridement as I remember for the skin lesions from the calcium deposits. She wanted to continue this. She was eventually discharged home to continue dialysis and the wounds were moderately healed. She came in about 3-4 months later in acute distress and died in that admission 窶的 believe she was septic at that time. Calciphylaxis is a fairly rare complication for dialysis patients. The family told me this patient had some good quality of life for some weeks after leaving the hospital the first time before symptoms and pain started again. Hope that helps. [Submitted on: 4/21/2006 by: Linda Gorman]


We have had 3 patients with this.. Pain is a huge issue. But with proper gudiance, can be managed. [Submitted on: 4/21/2006 by: Constance Dahlin, APRN, BC, PCM Tel 617.724.8659 Fax 617.724.8693]

Our Nephrologists generally estimate about 3 months with patients with calciphylaxis given the infection/sepsis rate. I've seen patients live longer than that, a few shorter. Pain is usually the biggest issue. We often use opioids and Lidoderm patches - cut the patches to make "picture frames" with them around the sores that hurt the worst. We only use 3 patches at a time. We make certain not to get the patches on open skin and we have the patches on for 12 hours and off for 12 hours - depending on which time of day the sores hurt the worst. Most of the time, 3 patches can make frames for several sores, depending on their sizes. [Submitted on: 4/24/2006 by: Elaine Glass, APRN, BC-PCM 614-566-PALL (7255) B# 614842-1209]

I, too, have had a patient with calciphylaxis - it was very sad and he did not live more than a week due to the extensive open areas from his feet up to his abdomen. We mainly provided pain management. [Submitted on: 4/24/2006 by: Debbie Gunter RN,MN,FNP,ACHPN]

An excellent article which covers basic reveiw of calciphylaxis is titled “Calciphylaxis” by Kirt Beus, MD and Brendan C. Stack, Jr, MD, FACS and is printed in the Otolaryngology Clinics of North America, 37 (2004) p. 941-948. [Submitted on: 4/24/2006 by: Ginger Marshall, MS, APRN, ACHPN office (801) 213-2922 pager (801) 339-6684]

Question 15. I had a patient die yesterday….He was young, 48 years old. Died of colon cancer. What I, and some of the RN Case Managers noticed was that many of our younger patients when they die experience a rougher death. More agitation, difficulty getting symptoms under control, more delirium. Any ideas? Comments?


[Submitted on: 5/1/2006 by: (not provided)] Answers I dare to say that the consensus (anecdotally) amongst hospice nurses is that this is seen in patients experiencing untimely deaths with young, strong bodies (heart and lungs). They are physically and emotionally unready to go. I don't think that this is something we will see measured and quantified in the literature anytime soon. We have had good outcomes in hospice with intense spiritual and emotional support. In my opinion, the key is helping the young dying person to find meaning and purpose in their death. Unfortunately, we are not always successful. Within the last 6 months we have been successful with a 22 yo female with rectal ca and most recently with a 23 yo male dying with AIDS. They both found peace in the end. (let's hear it for interdisciplinary work) [Submitted on: 5/10/2006 by: Rebecca Gagne Henderson]

I have had the same experience and seem to use a lot more ativan with these type patients. Letting go can be a lot more difficult at this age as they are often leaving wives and children behind. If we get involved early enough we try to orchestrate a special family day such as Disneyland with a nurse attending if able, as well as have our MSW's and Chaplain work closely with these clients. It can also be difficult for staff as well.Seems like we are looking closely at our own mortality? I don't like the term terminal sedation but some sedation for our younger patients towards the last few days makes a huge difference in their ability to pass peacefully. [Submitted on: 5/10/2006 by: Lois M. Elston R.N.CHPN]

It is also harder for us as health care providers to come to grips with deaths of younger patients. It hits closer to home. We need to continually look inside ourselves to know what are the triggers to our own grief. What gives meaning and purpose of our own lives? We can unintentionally pass our distress on to the patient and family. The wonderful interdisciplinary work that is done in hospice and palliative care is a great support for the people we serve and the health care providers that work in this area. I know that our staff does a wonderful job with all patients we serve, but overall they struggle with the deaths of the younger patients much more than with those who are elderly. [Submitted on: 5/11/2006 by: Robin Anderson]


Question 16. I am most interested in learning more about Methadone. Can you suggest any resources? Any evidence based studies? [Submitted on: 5/5/2006 by: (not provided)] Answers Our hospice physician have recently introduced methadone into our clinical practice although I personally have used it for many years with great success for end of life pain management. Outcome Resource at 1-866 877-2053 has some great guidelines and information regarding dosing, usage and protocols. [Submitted on: 5/8/2006 by: Lois M. Elston R.N. CHPN]

We just published this, it might help as a resource Griffie, J., Coyne, P., Coyle, N., "Difficult Cases in Pain Management: Use of Methadone in a Multifactorial Approach." Clinical Journal of Oncology Nursing, Vol. 10, No.1, 2006, pp.45-49 [Submitted on: 5/10/2006 by: Patrick Coyne]

Question 17. I have a question perhaps someone can help with. I have a patient who has terminal cancer and wants to go back to the Dominican Republic to die. He is able to sit in a wheelchair, but he is weak and has a partial small bowel obstruction (he is NPO and has NGT suctioning, which could likely be stopped for several hours if need be). The family wants to book an airline ticket for him to get him back to the DR. Has anyone had experience with this so I could give the family some direction and answer some of their questions regarding making flight arrangements. [Submitted on: 6/26/2006 by: (not provided)] Answers The medical team needs to help out with this as family cannot do it alone. Usually social work helps us contact the airlines which fly there and get the patient cleared from their medical director. This takes getting the NP and MD to talk with airlines. Once that is done, they can arrange flight and transportation to airport and help family arrange transport at other end. So ask which airlines go there and then call for guidelines. [Submitted on: 6/29/2006 by: Constance Dahlin, APRN, BC, PCM]


I have sent patients out of the country and home to die. You will need to contact the airline and complete a medical clearance form that attests to the patient's ability to fly. My team sent a 27 yo woman with end-stage HCC and spinal cord compression home to Ethiopia to die. [Submitted on: 6/29/2006 by: Linda S. Blum, MS,GNP,APRN-BC]

The biggest problem I have found with airlines is regarding oxygen requirements. Many will not allow passengers with O2 or it has to be below a certain L flow. If this is not an issue, family should regular purchase ticket asap, before patient is too ill to travel. It may be helpful if the NG could be pulled for the flight. You and/or the family will probably want to make sure there are arrangements made in Puerto Rico when he arrives, hospice etc. [Submitted on: 6/29/2006 by: M. Anastasia Driscoll CRNP, CHPN]

We have also assisted patients to get home. The Salvation Army (if available) was a big help for our agency and the family. We had to make sure he had enough pain meds as his country did not have proper access to them. Good luck. [Submitted on: 6/29/2006 by: Helen Martin, APRN]

Another option to look at is an air ambulance. They can be costly but I have had patients pay for the trip on a credit card and then use the patient's estate to pay the bill when it comes in. I use to not offer this option because of cost, but do now just so my patients know all the options. It is best to call 3 to 4 companies to get estimates and sometimes they will make you a deal. [Submitted on: 6/29/2006 by: Kelli Gershon]

Have you heard of Angel Flights? These are volunteer pilots who transport patients free of charge. Note the address below. 1515 East 71st Street, Ste. 312 Tulsa, OK 74136 Phone: 918.749.8992 Fax: 918.745.0879 Email: angel@angelflight.com : www.angelflight.com [Submitted on: 6/29/2006 by: unknown]


Patients, hospital social service workers, or friends, who desire to arrange transportation for a patient should contact the Angel Flight office to obtain required documents necessary for qualification [Submitted on: 6/29/2006 by: Bonnie Morgan]

Question 18. I will soon be entering graduate school and am interested in any and all advice from APNs regarding which route I should pursue. Have any of you APN's attended University of Alabama at Birmingham's Palliative Care NP program? If so, any thoughts or feedback? What about George Washington University's online End of life MSN program? I am looking for an online program and need direction. [Submitted on: 7/2/2006 by: (not provided)] Answers I am a Clinical Nurse Specialist with an emphasis in Integrated Health Practice (Dominican University of California), I am also a current “on-line” student @ The Ursuline College Breen School of Nursing. The programs offered are a MSN with tracks of Management, Palliative Care, Adult Nurse Practitioner, and Family Nurse Practitioner. I am enrolled in the post master’s certificate program in Palliative Care. site: www.ursuline.edu/acaff/breen/gr [Submitted on: 7/2/2006 by: Sally Lippitt-Houston]

You have already taken your first step, which is asking for input. Based on personal experience and much dialogue on this site, you should be careful in your selection process. First and foremost, what are you hoping to accomplish with your MSN? Education, clinician, advanced practice clinician, etc. If you wish to practice as an ARNP you should be familiar with your state law, scope of practice for ARNPs, and recognition of palliative care as a specialty or subspecialty. Until the majority of states catch up with the importance of palliative care as a specialty, you should consider an ARNP program that allows you to board in something in addition to palliative care (assuming you want to pursue and ARNP tract). I know UABs program allows for this, but you would best be served by speaking directly to them. If you wish to pursue a palliative care CNS, the same issues apply. Check to see if your state even recognizes CNS as advanced practice, if there is title protection, and any limitations in scope of practice. Again depending on your path there are many good


programs that offer an MSN with a focus in education, administration, etc. It will really depend on your desired practice area and career goals upon graduation. [Submitted on: 7/2/2006 by: Darrell Owens,Ph.D.,ACHPN,APRN VM:206-341-4636 Fax:206731-2363 Pager:206-541-0776 Email: owensd@u.washington.edu]]

It is exciting to hear you looking at graduate schools and focusing on palliative care. I would suggest when looking at schools, also look at the professors, their profiles on the page for the school of nursing, look at their publications, look up some articles and read their work. You have the opportunity to look around, critically check out programs--and depending how much mobility you have--go for it! Apply for several programs, so that when you are accepted you have options. It is an exciting time. First I was a CNS, now I am an NP. I would not suggest that way around the bend to your goal. [Submitted on: 7/3/2006 by: Cathleen Crafton NP-C voicemail 612-863-4818 office phone 612-654-0462 cathleen.crafton@allina.com]

Question 19. What are some important questions to ask regarding taking a position as a manager of a Home Hospice Team? [Submitted on: 5/30/2006 by: (not provided)] Answers RN:Pt ratio, stability of current team, skillbase of interdisciplinary team, make sure you meet the medical director, who would be your supports? what type of support staff, after hours coverage, who will guide you through your state regs. [Submitted on: 5/31/2006 by: unknown]

I would add questions about financial management and expectations, staffing ratios for other disciplines (social work, chaplaincy, home health aide, therapies), contracts in place for general inpatient care, respite care, continuous care in the home, current productivity expectations and reality. [Submitted on: 5/31/2006 by: Linda]


I would add-Is this hospital, home care based or free standing? If free standing what is the revenue base? What personnel are already in place and what are their experience base in end of life care? [Submitted on: 5/31/2006 by: Cindy Stafford CRNP Clinical Coordinator Western Maryland Health System Home Hospice]

Question 20. Does anyone have info on validated scales for adults? I'm not looking for the FLACC, but for any others that have been validated for adults. [Submitted on: 6/2/2006 by: (not provided)] Answers PAIN- is pretty good. 1: J Am Med Dir Assoc. 2003 Jan-Feb;4(1):9-15. Related Articles, Links Comment in: J Am Med Dir Assoc. 2003 Jan-Feb;4(1):50-1. Development and psychometric evaluation of the Pain Assessment in advanced Dementia (PAIN) scale. Warden V, Hurley AC, Volicer L. Geriatric Research Education Clinical Center, Edith Nourse Rogers Memorial Veterans Medical Center, Bedford, Massachusetts 01730, USA. Victoria.Warden@med.va.gov OBJECTIVES: To develop a clinically relevant and easy to use pain assessment tool for individuals with advanced dementia that has adequate psychometric properties. DESIGN: Instrument development study using expert clinicians and behavioral observation methods. Measurement of sensitivity of the instrument to detect the effects of analgesic medications in a quality improvement activity. SETTING: Inpatient dementia special care units in a Veterans Administration Medical Center. Participants: Nineteen residents with advanced dementia who were aphasic or lacked the ability to report their degree of pain and six professional staff members. Additionally, data from medical records of 25 residents who were receiving pain medications as required (PRN) were collected. Measurements: Based on the literature review, related assessment tools and consultation with expert clinicians, a five-item observational tool with a range of 0 to 10 was developed. The tool, Pain Assessment in Advanced Dementia (PAIN), was compared with the Discomfort Scale and two visual analog scales (discomfort and pain) by trained raters/expert clinicians in the development study, and used for detection of analgesic efficacy in a quality improvement activity. RESULTS: adequate levels of interrater reliability were achieved between dyads of the principal investigator with each clinical research rater and between two raters. PAIN had satisfactory reliability by internal consistency with a one factor solution. PAINthe Discomfort Scale-Dementia of Alzheimer Type (DS-DAT) were significantly correlated, providing evidence of construct validity. PAIN detected statistically significant difference between scores obtained before and after receiving a pain medication. CONCLUSIONS: The PAIN is a simple, valid, and reliable instrument for


measurement of pain in noncommunicative patients. Since the patient population used for its development and testing was limited to a relatively small number of males, further research is needed before it can be universally recommended. [Submitted on: 6/2/2006 by: Debbie Onken]

PAIN validated for patients with Alzheimer's disease and we have validated here at Hospice of the Western Reserve for patients who can not self report [Submitted on: 6/2/2006 by: Judy Bartel]

Question 21. We finally convinced our hospital to invest some resources into building a division of palliative care. I am curious about others experiences - 1. What is your staff to patient ratio (outpt and inpt)? 2. How often, on average, do you see the patient - both on the outpatient side and inpatient side? 3. Who is mainly involved with the patient (MD vs NP)? 4. Is your practice mainly made up of End-of-Life Care/?should be hospice? patients or more of the chronic illness spectrum? (Our goal is the latter). My one fear is that we will be working with a part time MD director with occasional assistance from other interested MDs, so once again this is going to be very NP based. From conversations with other programs, it appears that the successful programs have a full time MD standing behind them - does anyone have a different experience? [Submitted on: 6/3/2006 by: (not provided)] Answers We have had an inpatient PC service for 6yrs. We are a large 600+ , not for profit, private Baptist hospital. We have had a part time medical director, since its inception. He is an oncologist with a heart for PC-but way too busy to be too active with us, so it is basically a nurse managed service. I am an NP, and the other 2 coordiantors are, BSN, . We have no outptatient service, and don't plan on one. We're a scatter bed service with MD generated consults. We (nurses) evaluated the patients, made recommendations for sx control and if they needed DC planning would help with that process. eventually got a PC unit where the patients had a place to go with specially educated nurses on EOL and sx control. We recently closed that and now have a hospice unit. The big advantages in that change for the patient and family are the added resources that hospice provides that we couldn't give on the acute care side in PC-like bereavement, volunteers, social services solely dedicated for counselling etc. For the hospital the HUGE< and I mean HUGE, advantage is that the LOS and the mortality rate goes way down, which makes the hospital report card look really


good! Now I'm trying to figure out if we need a medical director at all. In the beginning, we had to show the MD's and nurses how much time we saved them dealing with issues of the patient and family and that we could control symptoms. Once the nurses learned what we did they started asking MD's to make referrals to us. We always bounce the plan of care off the attending or the consulting MD before we write orders and take them as verbal orders from him/her. Of course you will have MDs that will never understand or buy into PC, but by far and away are up to 60-70 consults/month. We opened the the hospice unit April 24 and have DC'd about 50 pts out of the hospital into the unit (which is physically in the hospital proper) and that has decreased the the hospital mortality rate for i month by 50 deaths-which is approximately 50%....hope this helps. [Submitted on: 6/3/2006 by: Jane Owen, Baptist Memorial Hospital Memphis, Tn.]

We have an inpatient APN consultative program.We saw over 500 patients in 2004 and 2005. There are two of us...Oncology CNS and Geriatric N.P. collaborate with all the attending physicians and it works extremely well. As far as the program, there might be less barriers with this type of collaboration. It is not threatening and extends the PC philosophy to many different physician specialties. We have observed a culture change in the organization. We each carry a caseload of 12 to 15 patients. We see end-of-life and patients with chronic progressive disease. We do much pain and symptom management, lead family conferences and work with the multidisciplinary team to help coordinate the plan of care. I see the advanced practice nurse as able to do the consults without a problem. The problem with not having a strong physician champion is you are not well represented on the administrative level. Politically this has potential problems in that the administration might not value the work you do. Even if you collect data and present it.... you never know. The physician voice can be powerful in the organization and is helpful when you want to further develop physicians (i.e.. the hospitalists). [Submitted on: 6/3/2006 by: Judy Passaglia RN,MS Mills Peninsula Health Services Oncology Clinical Nurse Specialist Palliative Care Services 650-696-5011]]

We also have a very strong NP led program that sees inpts, outpts via a clinic and case management program and also has worked to support staff to care for the dying and improve pain management. We see pain and palliative patients. We have a part-time medical director - who is head of rehab and spends a few hours per week and we split the patients between myself, him and another NP - see about 800 inpatients per year and our daily list is 12-20 patients. I also would be happy to discuss with you privately more comments. I don't think a full time medical director is necessary. I have multiple docs that back me up if my medical director is out of town. I think there are many ways to do


palliative services. We also have seen a culture shift here and work with many other community hospitals to start programs. email me directly if you want further info or assistance. [Submitted on: 6/6/2006 by: Peg Nelson nelsonp@trinity-health.org]

Question 22. My questions are-Do other teams have a physician see all palliative care consults in the hospital? Are the MDâ&#x20AC;&#x2122;s board-certified in palliative care? Do other NPâ&#x20AC;&#x2122;s find their practice limited by hospital bylaws such as progress notes requiring an MD signature in 24 hours? Any input/advice would be appreciated. [Submitted on: 6/15/2006 by: (not provided)] Answers I am an FNP practicing in a trauma center. Our consult service consists of me full time and 2 MD's(each only is .25, so there a here a limited no. of hours weekly or not at all if on vacation) one PC-BC. I see the majority of the cases by myself, make recommendations and write orders if the team agrees. My orders or notes are not co-signed. I have a collaborative agreement that states a review of my records should be done at least quarterly. I am nationally board certified by NBCHPN/ANCC in Palliative Care Management, but this was how I have always practiced even before my certification. [Submitted on: 6/16/2006 by: Patricia Lippincott Knox MSN,FNP,APRN,BC,PCM Clinical Coordinator Palliative Care Service Clinical Assistant Professor / Department of Medicine Clinical Assistant Professor /College of Nursing Center for Bioethics and Humanities Upstate Medical University Room 1111 750 E.Adams St. Syracuse,NY 13210 315-464-6098 Fax 315464-4761 knoxp@upstate.edu]

I am an acute care NP also now certified in palliative care who works full time on our hospital's palliative care consult team. I work with a part time physician who is board certified in palliative medicine and geriatrics (our program is sponsored by the geriatric department). Both of us see new pts and then I do all of the follow-ups. I do not need to have anyone cosign my notes. There is no such requirement in my state, Maryland. When the physician is on vacation, she is covered by our geriatric faculty, none of whom are palliative certified. Looking to the future, we have the goal of using only board certified physicians in recognition of the fact that that way we can more guarantee their expertise in palliative care. However, this is not a requirement of the hospital. [Submitted on: 6/16/2006 by: Marian Grant CRNP Palliative Care Service Johns Hopkins


Bayview Medical Center 410-550-1145 phone 410-283-5720 pager]

I am an Acute Care NP (and an OCNS) in Rochester NY and am one of two NP's on our University Hospital's Palliative Care Consultation Service. Both NP's are boarded in Pall Care. We have a number of Board Certified Palliative Care MD's rotate through the service, usually in two week blocks and they work full time on the service for those two weeks (one full time doc on service day to day). Medical residents etc rotate through. All new consults are first usually seen by an NP or resident. We then present them to the attending who will also see them that day for initial evaluation. Follow-ups~ most of our pts are seen in followup daily. Certainly, complex pts are always seen with the attending but many follow-ups can be seen by the NP~ write notes, make recommendations and sometimes will write orders. We can bill under most insurances. The resident's patients must be seen by the attending but only for billing purposes. I find it interesting that a physician is having trouble with your set up. Our docs do all have to be boarded in order to bill. Prior to insurances requesting this credential, our team all sat for their specialty boards because it was the right thing to do and does acknowledge a certain core competence and commitment to the specialty. [Submitted on: 6/16/2006 by: Marcia Buckley University of Rochester, Strong Memorial Hospital Rochester, NY]

It might be useful to identify what OH requires if anything, about APN notes and orders being co-signed.. Sometimes hospitals apply rules that are not based on statute. Demand for board-certified practitioners (medicine and nursing) exceeds supply. Thus, your physician colleague who is seeking board certified practitioners may have demands that cannot be met, immediately. It might be satisfactory to that doc if a palliative-care board certified APN saw all the patients. This is a common practice in most states. I have a concern if the RNs who are ELNEC-trained are not APNs because seeing patients and offering consultation is not in the scope of an RN who is not an APN. [Submitted on: 6/16/2006 by: Meg Campbell]

In our APN consultative practice model, a palliative care physician never sees the patient. The APN does the consult and collaborates with the attending physician and or inpatient physician. Our notes do not have to be co-signed. [Submitted on: 6/16/2006 by: Judy Passaglia RN MS Mills Peninsula Health Services Oncology Clinical Nurse Specialist Palliative Care Services 650-696-5011]


I am a board certified palliative care APN, and the director of the palliative care service for the University of Washington at Harborview Medical Center. We are a county-owned, academic medical center where trauma and neuroscience are the primary specialties. Our service consists of me full time, one part-time 0.2 FTE MD (not boarded in PC), and two per diem MDs, also not boarded in PC. We see approximately 400 new consults per year, perform just over 1,000 follow-up visits, and as of March have an outpatient palliative care clinic 1/2 day per week to see ESLD patients not eligible for transplant, and oncology patients, most of whom are stage IV. Each month have an internal medicine resident completing an elective, a medical student completing a required rotation, and occasionally a PharmD student. As a consulting service we do not write orders (nor does any consulting service in this hospital), only recommendations. My notes are not co-signed, but I must cosign all medical students and resident notes to reflect supervision and teaching. The parttime physicians cover in my absence, but do not "cover" me or see the patients I have seen unless they come on service as the attending provider when I am off. It is important to note that their lack of board certification is reflected in the complaints I receive from other providers when they cover. There is clearly a difference in skill when a non-palliative care provider does a palliative care consult. I also hold a clinical faculty appointment to reflect the clinical teaching I do. It just so happens this is how our institution operates, and I agree with Meg, some institutions have policies that may not be state law. For example in WA an ARNP can sign a DNAR with no co-signature, but our medical bylaws do not allow that within the hospital. I also share concerns with Meg regarding non-APNs conducting palliative care assessments, regardless of ELNEC training, as that is clearly within the scope of practice of an APN. [Submitted on: 6/16/2006 by: Darrell Owens, Ph.D., APRN, ACHPN Clinical Assistant Professor and Director Palliative Care Consult Service Harborview Medical Center 325 9th Ave, Box 359806 Seattle, WA 98104 Voicemail 206-341-4636 Pager 206-541-0776 owensd@u.washington.edu]

I am the other NP working with Marcia at the U or Rochester. The other reason that the MD sees all consult, is the way our billing is set up. The NPs can not bill for the inital consult, but can bill for follow up visits. [Submitted on: 6/19/2006 by: Laura Hogan]

In our program our medical director hears about all patients and gets involved if needed. He is board certified in hospice and palliative medicine, he contacts patient's attending MD


before seeing the patient. Our NP does work within the confines of the hospital bylaws which requires MD signature to progress notes and orders within 24 hours. Our philosophy has been that MD must be board eligible, if not certified, to serve as medical director. [Submitted on: 6/19/2006 by: Cornelia Scibetta Asheville,NC]

Our program is APN-based. Myself, a CNS, and my partner, Linda, an NP, see all the patients ourselves. I'm board certified in PC, but Linda just got out of grad school and has not sat for the exam yet. Our medical directors are both oncologists and neither are board certified in PC, although one is interested in doing so. We meet to discuss pts once a week in team APNs, doc, SW and chaplain. The docs do not see the pts unless we ask them to or call them for advice. They only cosign our orders for opioids or other scheduled meds, which to my knowledge are the only legal requirements in Ohio. I have my CTP and Linda is working on hers (thus, the docs are currently signing all her orders). We work as consultants only, so the patients are still cared for by their primary physician and other consulting physicians. [Submitted on: 6/19/2006 by: Elaine Glass, APRN, BC-PCM Clinical Nurse Specialist Palliative Care at Grant Medical Center 340 East Town Street Suite 10-330 Columbus OH 43215-4639 614-566-PALL (7255) B# 614-842-1209 Fax = 614-566-8009]

Question 23. 1) Is there any published data on appropriate outcome measures for an outpatient palliative care service? 2) UHC published a 2004 Benchmarking Report on inpatient palliative care. Is there anything similar for outpatients? 3) What data does your organization collect to measure the performance of your outpatient palliative care service? [Submitted on: 6/28/2006 by: (not provided)] Answers Our program sees outpatients one half day a week in the outpt setting. Our Cancer Center I think actually gives us some support but not every pt seen in OPD is an Onc pt. One attending and a NP share this part of the practice. We do not have any formal outcome data collection procedures in place. [Submitted on: 6/28/2006 by: Marcia Buckley NP U of Rochester, Strong Mem Hospital Rochester, NY]

Question


24. Does anyone have experience with Rettâ&#x20AC;&#x2122;s syndrome? I have a fifteen year old girl who is now having nearly constant seizuring and pain/distress such that she is only at peace when medicated. Her mother has decided to stop tube-feedings and this has been upheld by an ethics consult. When we started her morphine gtt, we began to see itching and benryl doesnâ&#x20AC;&#x2122;t seem to be covering it entirely. Since a switch in opioid is logical, I am thinking about an infusion of methadone (with its propensity to cover neurological pain better than the others. I have never done methadone with a child (this girl is 68# and has been nonambulatory most of her life with a developmental level of 3-4 months). With methadoneâ&#x20AC;&#x2122;s unique properties, (dosing and such I am very familiar with), are there any specific concerns re: its use in this situation? [Submitted on: 7/30/2006 by: (not provided)] Answers My question/comment has to do with her ability to experience pain or discomfort. Does she have cognitive function at baseline (not seizing)? Does she display signs of distress (ouch face, moaning, crying, legs kicking, etc.) when she is not seizing? Would it be useful to aggressively suppress the seizures rather than use opioids if the signs of distress are seizurerelated? Perhaps she would be well served by a benzodiazepine infusion to suppress seizures with an opioid as an adjunct if there are signs of distress when she is not seizing. [Submitted on: 8/1/2006 by: Margaret L. Campbell PhD,RN,FAAN Nurse Practitioner Palliative Care and Clinical Ethics Detroit Receiving Hospital 4201 St. Antoine Detroit, MI 48201 Associate Director of Research Center to Advance Palliative-Care Excellence Wayne State University 313 745-3271 313 745-3637 fax mcampbe3@dmc.org]

We had a case of a woman who was found down in her apartment, was resuscitated (unfortunately) and had anoxic encephalopathy with constant seizures. The only thing that controlled the seizures was propofol. We initially tried to switch from propofol to a benzo drip but very quickly had to go back to the propofol. [Submitted on: 8/1/2006 by: Kerstin]

I'm sorry for the delay in responding, I have been on vacation. I forwarded your e-mail to a friend and his response follows. Hope it helps! Christy Thanks for forwarding me the email. A couple of thoughts. IV methadone can prolong the QTc interval? Cardiac arrhythmias are not mentioned to occur commonly in Rett's syndrome just glancing over the latest of edition of Rudolph's pediatrics. Oral methadone does not increase the risk for cardiac arrhythmias. IV or po methadone has a lot of interactions with cytochrome P450.


Depending on the anti-epileptics and other drugs the patient is on, this should be looked at ahead of time. Harriet Lane has nice summary charts of the possible interactions with cytochrome P450. If the provider is interested in running an IV methadone PCA, I would recommend emailing Nessa Coyle or Lauren Shaiova. I have only used a methadone PCA once and both Nessa and Lauren were very helpful in figuring out infusion rates, and boluses. coylen@MSKCC.ORG lshaiova@bethisraelny.org (this email is probably out of date as Lauren left BI and is now back at Memorial) Take care, John John is Dr. John Saroyen, pediatric palliative/pain specialist at Columbia in New York. There will be an article on methadone written by John in the next ChiPPs Newsletter which is the Pediatric Palliative Care newsletter sponsored by NHPCO. Also HPNA has pain and symptom algorithms for pediatrics as an aid as well. [Submitted on: 8/4/2006 by: Christy Torkildson, RN, PHN, MSN National Director for Professional Relations and Research George Mark Children's House 2121 George Mark Lane San Leandro, CA 94578 510.346.4624 office 510.346.4620 fax http://www.georgemark.org]

Question 25. We are nearing the completion of our first year that our inpatient palliative care consult team has been operating. Of course, we are going to need to show financial data among other kinds of data. My question is with the financial data. We are collecting financial data of the patients that we see with the help of our decision support team within the hospital. The problem we are having is creating a meaningful control group of patients (retrospectively) to compare financial data between the two groups, with the hopes that we demonstrate a financial impact or reduction in length of stay. Has anybody created such a control group, and can you share with me how you went about it. [Submitted on: 8/1/2006 by: (not provided)] Answers The data we use for the control group is from death data. Costs of care (in-patient and outpatient) for the 6 months preceding death for all in-patient deaths. Then compare difference between the people who had some involvement with palliative care. This is easy to do with our electronic medical record. You could pull by mission diagnosis code as well for your control group. If you do a lot of pain management referrals- compare pain scores/assessment information. Also recommend using other folks data as well. CAPC, Dartmouth Study, etc. [Submitted on: 8/4/2006 by: Jane McCabe Palliative Care CNS Denver VA]


There was a randomized control trial of palliative care/non palliative care done by Kaiser Permanente in one of the Denver, Colorado Kaisers. Appropriate patients were put in palliative care group or in control group without palliative care and outcomes were compared. I attended a session on this at Annual Assembly in the last couple of years. I can't remember the names of the participants but I believe the data has been published. Does anyone remember more details? Otherwise we have done what was previously mentioned: from hospital deaths we matched discharge DRGs (what hospital actually billed for) for palliative care patients and compared financial data with nonpalliative care patients who died with same DRG. That has been helpful. What we have found most useful though is obtaining cost per day data from finance- pre palliative care and then cost per day while on palliative care. [Submitted on: 8/7/2006 by: Linda Gorman, RN, MN Cedars-Sinai Medical Center Palliative Care program Los Angeles, CA]

The CAPC (Center to Advance Palliative Care) site has all sorts of tools/spreadsheets for your financial folks to do analysis to prove your (or the program's) impact. [Submitted on: 8/7/2006 by: Cheryl Vahl RN, MSN, AOCN, ACHPN Advanced Practice Nurse Palliative Care Coordinator Holden Comprehensive Cancer Center University of Iowa Healthcare 200 Hawkins Drive 5970 Z JPP Iowa City, IA 52242 Tel: (319) 356-1616 pager #5200 FAX: 319-353-8988 Email: cheryl-vahl@uiowa.edu]

I remember hearing this at the HPNA/AAHPM conference in Arizona and I thought it was a study done by Kaiser in California. I too was impressed. [Submitted on: 8/7/2006 by: Karen Gilbert, ARNP North Puget Oncology Anacortes, WA 98221 360 472-1095]

Question 26. We need a policy for SQ Butterfly needle insertion and med instillation in our Acute Palliative Care Unit. Would anyone be willing to share? [Submitted on: 8/10/2006 by: (not provided)] Answers I am willing to share our procedure. I do not use the fine, right angled SQ needles that most home hospices use. Here in the acute setting I only have to place a SQ less then 5 x's in the


last year and our CS will not carry them with such low volume. That is the reason the procedure I sent refers to the 25 ga. butterfly needle. [Submitted on: 8/11/2006 by: Donna Willoughby Palliative Care Nurse Coordinator CoxHealth 269-6147]

Our policy is currently under review for acceptance and is different in the following details: 1)we like a product put out by B-D called an Intima IV set which has a 4 inch Y on it. I am not sure if the pediatric butterfly is a metal needle like the regular butterflies; this is a nylon cath which is inserted with a removable metal needle (it has a needle protector sheath already attached). We use the 24G for morphine and dilaudid, but there is also a 22G which must be used for thicker solutions like lorazepam. 2) we have lorazepam and phenobarb on our list of acceptable infusions. 3)we used the sites for both intermittent injections and infusions (as it appears Donna does as well). We prime the tubing/site with the solution that we plan to infuse through it or inject intermittently. For example, if a patient is going to be getting 5mg morphine every 2-4 hr prn and we decide not to infuse it at first, we might prime the site with 10 mg/ml Morphine and give 0.5ml injections. If their need warrants infusion, say starting at 3mg/hr, we would have pharmacy mix the solution at 10 mg/ml (what is already in the tubing). 4) I didn't see whether Donna's policy refers to the max infusion rate--it is generally considered that SQ tissue can withstand up to 3ml/hr. We try to stay way under that, as little as 0.1 ml/hr will work (there is no concern about keeping a line open). We try to make sure the cont rate does not exceed 1ml/hr, leaving room for bolusing, making sure the boluses are less than 0.5 ml each. I am so glad to see this conversation here. I have used SQ infusions in the home for years but am working inpatient now in a new area where they have not previously had this option. [Submitted on: 8/11/2006 by: Sharmon Figenshaw ARNP Providence Hospice /PEMC Inpatient Hospice Everett, WA 98201 425-261-4777/ 425-210-1627]

We've been doing SQ since the mid-1980's. Have only seen one infected site in all that time. 1) The diabetic folks wanted site & tubing changes more often than the general population. In homecare they change things weekly. We chose to keep SQ at the same frequency as Periph IV...for the sanity of the STN's. 2)We use a Baxter SQ needle; but also can use an IV cannula inserted at 45 degree w/ extension tube ...and that works. 3) the med list is an evolving thing; I just check with pharmacy about pH on any new med we are considering...we've also done Ketorolac and fosphenytoin in addition to those already mentioned. 4)we try to keep max volume to 3-5cc/hr but I've seen 10ml in the Lit also...just have pharmacy concentrate the soln'. 5) we've also done hypodermoclysis for hydration...it's a VERY OLD thing that has come full circle...any RN grads from the late 60's


might remember it. There's a new company promoting synthetic hyaluronidase, but 've never used it and the Lit doesn't recommend either way. [Submitted on: 8/12/2006 by: Cheryl Vahl RN, MSN, AOCN, ACHPN Advanced Practice Nurse Palliative Care Coordinator Holden Comprehensive Cancer Center University of Iowa Healthcare 200 Hawkins Drive, 5970 Z JPP Iowa City, IA 52242 Tel: (319) 356-1616, pager #5200 FAX: 319-353-8988 Email: cheryl-vahl@uiowa.edu]]

The challenge is finding safe needles per JCAHO guidelines. Metal ones are easier. SQ pumps used at home long before PICC lines. You can go up to 10 mls/hr depending on the solution so wouldn't limit yourself to 3 mls. in case you need to go up that high.. [Submitted on: 8/12/2006 by: Constance Dahlin, APRN, BC, PCM Palliative Care Nurse Practitioner MGH Palliative Care Service Boston, MA 02114 Tel 617.724.8659 Fax 617.724.8693]

Does anyone have a policy that specifically addresses hypodermoclysis. Also are there any specific studies or resources that address sites for sc meds. (our medical director thinks only the abdomen should be used for medications) [Submitted on: 8/22/2006 by: Sue Koesters, FNP Carepartners Mountain Area Hospice Asheville, NC 28802 Tel: 828 255-0231 Fax: 828 255-2880]

Off the top of my head, the only studies I've read were in the mid '90's regarding sq absorption of insulin. According to the study the abdomen is the best place for administration of insulin. Sorry, I don't recall the citation. [Submitted on: 8/22/2006 by: Rebecca Gagne Henderson RN, BSN, CHPN Director of Education Directives Palliative & Hospice Consultative Services]

Question 27. Does anybody use Actiq? Ideas on cost and how long it lasts. I have a patient aspirating and NPO…poor pain control. Policies on its use? [Submitted on: 8/14/2006 by: (not provided)] Answers


The few patients I have had who were using this from before they went on hospice did not do so well with it and ended up needing roxanol or sq/iv dilaudid or morphine. Supposedly it is the only opioid with a molecule small enough to be truly absorbed in the oral mucosa. I haven't seen it prescribed when a person is in hospice because of the cost issue but maybe it is because it is also because it doesn't seem very effective. If your patient is aspirating, could they be on a sq infusion of morphine? Or even if you use roxanol sl and release the drops very slowly, would it then be effective? is the pt npo and dying? you could use a fentanyl patch with roxanol but it takes about 12 hours at least to get a therapeutic level with the fentanyl, and then not predictably so, depending on the pt subcutaneous tissue, body temperature, etc. [Submitted on: 8/15/2006 by: Cindy Brown]

We have used Actiq quite often for patients who are obstructed or cannot tolerate po. It is very effective and easy to trial. It comes in 200, 400, 800 mcq per sucker. We often order a few as a trial for a pt to see if it will work before ordering many. The cost varies - but it can be up to 10-12 dollars per sucker. But its been around for quite a while now and the cost should be less. Many insurances cover it if you can show they cannot tolerate po. It is important to instruct the patient to not suck on it like a sucker but to take the med and rub inside the cheek until they feel relief - usually only 1-5 minutes and then stop and take out sucker - usually there is med left and it can be reused. many times we use it with a patch also. We also use sc opiates in the situation you are describing. [Submitted on: 8/15/2006 by: Peg Nelson]

We have had similar experiences. Have used the Actiq in nonsurgical bowel obstructions. Some patients get good relief; some say the raspberry flavor makes them nauseated; and I've had local hospices refuse because of the cost, "get them on something cheaper". Check Micromedex or the APS Principles of Analgesia 5th Ed for administration guidelines. If they don't tolerate it, we too have gone to SQ int/cont delivery of opioids. [Submitted on: 8/15/2006 by: Cheryl Vahl RN, MSN, AOCN, ACHPN Advanced Practice Nurse Palliative Care Coordinator Holden Comprehensive Cancer Center University of Iowa Healthcare 200 Hawkins Drive, 5970 Z JPP Iowa City, IA 52242 Tel: (319) 356-1616, pager #5200 FAX: 319-353-8988 Email: cheryl-vahl@uiowa.edu]

I remember hearing, at a presentation on Actiq, that the condition of the oral mucosa is of


importance as well. The main concern was production of saliva and a moist mucosa, that dry mucosa impaired absorption. The first 25% of Actiq is absorbed via the buccal space, the remaining 75% is absorbed via swallowing with saliva. I steer away from using it because I haven't seen good effects in the final hours of life. [Submitted on: 8/16/2006 by: Diane Ranna]

I have seen actiq work well for patients. It's effectiveness can be limited by how well it is administered. If it is used the way somebody would a lollipop, then a lot of it gets swallod, and fentanyl has a very low bio-availability. It is intended to be dissolved by rubbing it along the buccal mucosa, with the intent more will get absorbed via sublingual mucosa. Still, they have found that even when used properly a large portion of it is absorbed through the gut, which could be why they are given at high dosages (200mcg actiq is starting dose compared to the 25mcg patch). It has a short half life as well and the cost is high. I think in hospice, for these reasons, it is a good medication of last resort (IV/SQ is not an option, roxanol not effective, pt can't take PO). [Submitted on: 8/16/2006 by: Robert Smeltz, RN MA PNP ACHPN Nurse Practitioner/Clinical Coordinator Palliative Care Service Jamaica Hospital Medical Center Office: 718-206-6919 Fax: 718-206-8716 Pager: x16869]

Question 28. I am caring for a patient that is currently in the ICU on dopamine. The family has chosen comfort measures only for the patient and wish for her dopamine to be d/c'd. I am workig with an ICU nurse that is supportive of the family's decision, however, is interpreting her dopamine as a life support measure, and following the policy and procedure for termination of life support. This will necessitate the pt waiting for two non-involved physicians concurring on d/c of dopamine. This is what our policy defines: Life Sustaining Procedure: Any medical procedure or intervention, which when applied to a patient in a terminal condition or in a coma or persistent vegetative state with no reasonable cognitive function, would serve only to prolong the dying process and where, in the judgement of the attending physician and a concurring physician, death will occur without such procedures or interventions. The term 'life sustaining procedure' may include the provisions of nourishment and hydration (please note, nourishment and hydration may not be discontinued without the known wish of the patient) but shall not include the administration of medication to alleviate pain or the performance of any medical procedure deemed necessary to alleviate pain. I believe applying this to dopamine is excessive, but I'm working with ICU nurses here. I am most eager to educate them in the legality of differentiating treatments considered life sustaining, and encourage them to think differently, but will have little voice without data, literature, and what others are doing to back me up. Any suggestions would be helpful. It was at 5 mcg, and


had not been titrated...was not affecting renal output, either. [Submitted on: 8/23/2006 by: Diane E. Ranna, MN, FNP-C, ACHPN Palliative Care Coordinator Piedmont Fayette Hospital 1255 Highway 54 st Fayetteville, GA 30214 Cell: (770) 833 - 6770 ] Answers Dopamine is a life-sustaining therapy. But, a lot of hospital interventions can fall into that broad category: fluid resuscitation, pacemakers, inotropes, pressors, ventilators, dialysis, etc. The problem may be the very conservative process and language in the policy not in the ICU nurse's correct interpretation of Dopamine as life support. I would suggest that a group of stakeholders, ICU and palliative care, sit down and draft a policy revision. [Submitted on: 8/23/2006 by: Margaret L. Campbell PhD,RN,FAAN Nurse Practitioner Palliative Care and Clinical Ethics Detroit Receiving Hospital 4201 St. Antoine Detroit, MI 48201 Associate Director of Research Center to Advance Palliative-Care Excellence Wayne State University 313 745-3271 313 745-3637 fax mcampbe3@dmc.org]

That was my feeling also - that the issue is the policy. For now, it would seem that you would have to go by the confines of the policy. I am curious as to the statement you made about about ANH not being able to be stopped without the "known" wish of the patient - I hope this does not mean it has to have been written down and isn't it s that many still believe that this is different than any other "medical interventions." Certainly, one of the issues with such a narrow policy is the delay in being able to act on the family's decisions, as we all know how hard it can be to get a family there only to have to slow the process and give them time to question their already tough decisions. Is there any difference in the policy application if the patient/family elects their hospice benefit and either stays in the hospital or moves to an in-patient hospice unit? [Submitted on: 8/23/2006 by: Debbie A. Gunter APRN,FNP-BC,ACHPN Director of Clinical Services VistaCare Hospice - Atlanta 678-457-1391]

Agree that the policy needs to be addressed. Out of curiosity what is the rate of the dopamine and has it been titrated recently? [Submitted on: 8/23/2006 by: Ginger Marshall, MS, APRN, ACHPN Nurse Practitioner Palliative Care Services office (801) 587-5202 pager (801) 339-6684 fax (801) 5859166]


In my practice we treat dopamine as a life-sustaining therapy (in the same way we do norepi, levo, and other pressor agents). I believe you have a policy issue based on very strict wording. This is a great opportunity to work with the ICU nurses, critical care docs, and other interested parties to revise the policy. Was this policy written to adhere to some state law, or just hospital policy? [Submitted on: 8/23/2006 by: Darrell Owens,Ph.D.,ACHPN,APRN Clinical Assistant Professor and Director Palliative Care Consult Service Harborview Medical Center Box 359806 325 Ninth Ave Seattle, WA 98103 VM:206-341-4636 Fax:206-731-2363 Pager:206-541-0776 Email: owensd@u.washington.edu]

Prior to meeting with your focus group you may want to look at the concept of an Allow a Natural Death (AND) document. Many believe that this is just a "kinder-gentler" name for a DNR, but it goes much further and takes into consideration the many other scenarios other than cardiac or respiratory arrest. If done correctly it covers this type of situation. It offers a planned and designated time for discussion and education for the family to hear the hard news, and it alleviates the MD and hospital of the dreaded cloud of litigation. Once consent is obtained the family and healthcare providers can let all the aggressive interventions fall away and the patient can die as naturally and comfortably as possible in the hospital setting. The document is placed in the chart just as a DNR. If you want more info just google "Allow a Natural Death" or Chuck Meyer. [Submitted on: 8/24/2006 by: Rebecca Gagne Henderson RN,BSN,CHPN Director of Education Directives Palliative & Hospice Consultative SVCS]

As I read all the responses and questions, I am concerned that there is a confusion about #1. futility and the need to stop treatment based on the futility of it (which is a medical decision that 2 doctors may need to concur[if that is your policy] and is decided without input of family and only based on the medical condition of the patient) with #2 the stopping of a treatment based on patient and/or family wishes which is the right of all patients and families. #1 most hospitals have policies to support the stopping of treatment usually when family wants to continue treatment and the patient is dying usually in multiorgan failure and it would be futile to go on. #2 is the basic right of all patients to stop or not pursue treatment based on his personal goals. there does not need to be physician concurrence with the wishes of patients and families, obviously if the doc does not concur with family wishes, he can sign off the case after finding a doc to take over. I would be happy to personally talk with you about this if you wish. I have been involved in ethics and the drafting of futility policies if it would be helpful. Certainly if a patient or family based on patient wishes wishes to pursue a comfort goal, that is the right of the patient and family


and we stop treatment all the time in palliative care and hospice without 2 physician approval or going through the futility policy. [Submitted on: 8/27/2006 by: Peg Nelson, APRN, BC-PCM 248.858.6818 St. Joseph Mercy Oakland Pontiac, MI]

Question 29. I am fairly new to palliative care and I am looking at ways to reach out to the community and do some community education. I am struggling with what and how best to present. I would appreciate any helpful hints from colleagues more seasoned in this area. [Submitted on: 8/25/2006 by: (not provided)] Answers There are a number of ways. One way is to reach out to your hospice and their "bridge" program, if they have one. Senior groups in the community are great opportunities to discuss what PC is, resuscitation, power of attorney etc. Faith communities sometimes offer educational programs. Any cancer network organizations that do community outreach in your area would be open to adding palliative care to the list of classes they offer. Your local ONS chapter meets regularly and has a speaker at every meeting. Nursing programs, undergraduate and graduate level. Also, you can create a PC seminar for the nursing staff at the hospital you are associated with. If you do that I suggest a multidisciplinary approach. These are some of the programs I have been involved with. I generally get great participation. People find they are really interested in these topics. It is often the first time that PC has been presented. Usually, I am invited back to do a repeat presentation. [Submitted on: 8/25/2006 by: Judy Passaglia RN,MS Mills Peninsula Health Services Oncology Clinical Nurse Specialist Palliative Care Services 650-696-5011]

I stumbled on a way to reach out to the community a couple of ways. Out-patient clinics near our program treat patients with COPD, CHF, and various cancers, and they run support groups for these patients. Meeting with these types of support groups is a good way to reach out. Also, most hospitals and hospices have community boards that meet usually quarterly. Meeting with them has been a great way for us to reach out to the community. [Submitted on: 8/25/2006 by: Robert Smeltz, RN MA PNP ACHPN Nurse Practitioner/Clinical Coordinator Palliative Care Service Jamaica Hospital Medical Center Office: 718-206-6919 Fax: 718-206-8716 Pager: x16869]


In addition, you don't say if you are affiliated with an inpt setting but certainly offering to go to staff meetings, service meetings etc and just do a basic presentation on what Pall Care even is. I have a stock talk that I give called "Palliative Care: It's Not Hospice" as I find alot of confusion on that. It can be a barrier to getting Pall Care involved initially because so many people aren't hearing that they are ready for hospice or primary docs (regardless of specialty) have difficulty with it as well. I am also involved in teaching at the University a course and Pall Care and Hospice. Pound the pavement. Offer to do talks on Pall Care topics (feeding tubes in end stage dementia, dialysis stuff, hoping for the best and planning for the worst, advance directives etc) [Submitted on: 8/25/2006 by: Marcia Buckley OCNS, NP Pall Care Consult Service U of Rochester Rochester, NY]

In 1997,we formed a community task force on care of the dying. As a result of the task force work, our community formed the "Community Alliance for Compassionate Care at End-ofLife." www.missouriendoflife.org Mission statement: "The Community Alliance for Compassionate Care at End-of-Life is a not-for-profit organization dedicated to enhancing community awareness of end-of-life issues and promoting quality care for individuals at life's end. Our members are an alliance of healthcare professionals, educators and members of religious, business and civic communities throughout the Ozarks region. Together, we strive to improve the quality of life for dying persons and to support healthy bereavement for families and friends." THIS ALLIANCE has many working groups within it. Education of healthcare providers Advanced Directive Circles of Care training Multicultural education Story Keeping Workplace Initiative Regional coordination of the National Pain Initiative education programs As a community, we have been able to accomplish a great deal more than any one person. Palliative care is the standard in all of the Regional Hospitals and most of the LTC facilities. [Submitted on: 8/25/2006 by: Donna Willoughby Palliative Care Nurse Coordinator CoxHealth 269-6147]

I have found the community appreciates information on Advance Directives. Marketing it can be tricky. Another, surprisingly successful program was on grief. I'd be happy to discuss these options, or other options any time. [Submitted on: 8/26/2006 by: Lori Hedges W - 773 296-5837 Page: 773 713-5078 Home 773 338-8664]


Question 30. I am looking for one of you methadone experts out there to point me in the direction of a helping with a tough pain mngt situation. I am working with a 52 yr old man, previously incarcerated with a history of opioid abuse, who came into the hospital on his normal dose of methadone at 150mg TID last week in a pain crisis. He has horrific mets to bone from lung cancer. He is very thrombocytopenic (plt <10,000) and his oncologist feels he cannot tolerate any more radiation or chemo because of this. He is still eating/drinking well, but is bedbound due to the pain. The oncologist increased his methadone to 200 q 8hr and started him on a dilaudid infusion. We recommended an increase in his decadron from 4 to 16 mg bid which started last Thursday night--he improved significantly in those first 24 hours (his pain went from a steady 9-10 down to 4-6). The pt was able to state clearly that he would prefer sedation with comfort to get his pain down to 4 or below. His brother, who has been adamantly supporting his brother in his hope for cure, now supports this comfort goal. He is currently on a regular acute care patient in the hospital receiving The goal is to find a less acute setting to manage him in which will probably mean SNF with hospice (he could go on a waiting list for a bed in the inpatient hospice which is in the next county, but weâ&#x20AC;&#x2122;d need to move Since then his pain has re-escalated over the weekend. His dilaudid infusion was has gone from 4 to 8 last Thursday, 8 to 15 on Friday, 15 to 25 to 40 over the weekend. I had written to make sure his bolusing stayed at 100% given the fact that this is only a portion of his total opioid picture, given the methadone which continues. (I have just learned that was not done, with some bolousing of only 8 mg in the last 24 hours, perhaps accounting for his current pain crisis. That is being corrected. We have now also ordered a pain consult to see if an epidural will help. I do not have him on an NSAID because of concern about bleeding given his thrombocytopenia. Here are my questions: 1) If we try to at least approximate some equivalency to the methadone and dilaudid, either with the intention of moving him to 100% of one or the other, what dose conversion do we use? My information on methadone conversion states using a 20:1 conversion for doses over 1000mg morphine equivalence, but at this calculation, the methadone alone would be at 12,000 mg oral morphine/day! (and now figure in the 40 mg/hr of dilaudid!). Does the dose conversion continue to change? Would this be 40:1 or 100:1?? Any suggestions? Who would you recommend I talk to? 2) Would an NSAID be worth trying? Should the thrombocytopenia be a reason not to do that? He has no history of NSAID use or of GI bleed in any setting. 3) Would you keep going up on the decadron dose? Are there any other adjuvants you might try? There are probably more questions but these are the big ones right now. We will probably opt to just keep him on his current methadone and dilaudid, titrating just the dilaudid just to be safe. Still I wish I knew how to figure what proportion of his total opioid the dilaudid represents. [Submitted on: 8/28/2006 by: Sharmon Figenshaw MN, ARNP Providence Hospice/ Inpatient Care Everett WA, 98225 Cell-pager 425-210-1626 / office 425-261-4777] Answers Although this will not help the acute pain but if you believe he will live awhile, which if you


are looking at SNF placement might be what you are thinking Zometa has good data in decreasing pain from bone mets. This is a bisphosphonate but would not be helpful unless the patient has months to live. You might be familiar but if not it is a 15 min infusion and have to be done at a center. [Submitted on: 8/28/2006 by: Becca Hawkins, MSN, ANP Nurse Practitioner Palliative Medicine St Mary Medical Center Walla Walla, WA]

Our team has had success in these cases with 2-3 doses of Torol at app. 60 mg IVP. Your pharmacist will call you because this is a high dose and because of the renal impact. But depending on the goal of the patient and only a few doses, that should not matter. It has worked in several patients with bone mets who were no longer responding to Dexamethasone. [Submitted on: 8/28/2006 by: Niki Koesel, ANP, ACHPN Hospice and Palliative Care Charlotte Region]

Some general recommendations and questions â&#x20AC;&#x201C; - It sounds like the methadone is oral while the hydromorphone is IV; consider changing the methadone to IV and discontinue hydromorphone - Trial of adding benzodiazepine - You donâ&#x20AC;&#x2122;t describe his pain; could he have become neurotoxic from the hydromorphone at rapidly increasing doses? - Since he is willing to accept sedation, consider adding ketamine and decreasing opioids - Consider total sedation with barbiturate if none of the above effective of desired. [Submitted on: 8/28/2006 by: David Hall FNP Willamette Valley Hospice Salem, OR]

I've heard of decadron doses up to 100 mg/day. Also consider po Ketamine 50 tid for start. Consider opioid rotation to fentanyl gtt at 50% of equian. dose. Let us know what you do and how it works. [Submitted on: 8/28/2006 by: Terry Thompson]

Question 31. I am filling a pilot role as a Palliative Care Nurse Specialist in two of our health care system hospitals in Sonoma County. One hospital is large ( 325 beds, Trauma Center, Comprehensive Cancer Center) and the other hospital is smaller (about 88 beds ) in a smaller/more rural community neighboring the larger facility. My challenge is that I am


having difficulty advancing the concepts of palliative care in this smaller facility. Case Managers and Social Work feel I am duplicating their roles. I have done numerous presentations to these two groups, nursing supervisors, staff meetings, physiciansâ&#x20AC;Śbut the idea seems to just melt away. There are many patients who could benefit from palliative support in the hospital; my initial assessment indicated almost 30% of the ER patients had 2 or more prior admissions, multiple co morbiditiesâ&#x20AC;Śetc. Does anywon have any experience in introducing Palliative Care to a small facility? Any research anyone can recommend? I would appreciate any practical suggestions. I might also add that the nursing staff itself has told me more than once how badly they need a role such as mine, yet CM and SW seem to feel the nurses are not consistent enough to be fully informed of medical/psych/social situation & needs. [Submitted on: 9/28/2006 by: Sally Lippitt-Houston] Answers I can sympathize as well, but my situation has been somewhat of a cure for your problem. I am physically located in the same department with Case Management and Social Work, and therefore part of their team. Because work for the same boss, we all get along pretty well, and she directs them to use Palliative Care. Donâ&#x20AC;&#x2122;t know if this could be managed in your area, but it does work. Good luck! [Submitted on: 9/29/2006 by: Nancy Cato Grabb, RN,C, BSN, MBA, CHPN Manager Palliative Care Methodist Dallas Medical Center 1441 N. Beckley Dallas, Texas 75203 214-947-2526 office and voicemail pager 972-451-2453 - pager 214-947-2499 - fax nancygrabb@mhd.com ]

First, I think the big challenge was getting to be there. It is going to take some time but your availability will win them over. The first time they have a very difficult case where you are able to demonstrate the value of a palliative care consultant in helping the patient and family and bringing about a decent resolution I think you will be "in." I think you have to win the approval of the gatekeepers and once there, you will be able to meet their needs. [Submitted on: 9/29/2006 by: Cindy Brown ]

Maybe you could promote your expertise in pain/symptom management. That is usually not a specialty of case managers and social workers. I have done chart reviews of patients who die in the hospital- look at pain scores in last 3 days of life or use of restraints. That could be something you could impact from a clinical perspective. [Submitted on: 9/29/2006 by: Linda Gorman Cedars-Sinai Medical Center Los Angeles ]


Oh, do I understand your plight! I work in a small hospital 45 miles outside Atlanta Ga. 100 beds, but growing, resistant case managers/social workers, nonplussed physicians, no interdisciplinary team, fun, fun, fun! You're on the right track with your inservices. I have found that time has been my best ally. I also attended every board meeting of every kind that I could stand. Cancer committee, med, pulm, ER. I now have a very supportive CM in the ER that helps me identify cases that certainly will be hospice appropriate if the pt makes it out. Then I try to sell the doc on how I can help. I always end with, "And if the patient improves and never comes back to the hospital, the pt and family got great symptom mgmt/emotional/spiritual support this go around." Unfortunately, this is sometimes the only way I can get in the door. Then I rely on showing (repeated contact with admitting providers and consulting providers) how palliative care is appropriate. Sometimes it sinks in. I still, however, get hospitalists that will say, in regards to the liver failure patient with agonal breathing and a bp of 60 syst, "weeeeeellll, if the lactulose doesn't work by tomorrow, I'll call you." Yeesh. There's a fine line beten good marketing and clocking them over the head with the patient's chart. Press on. I also am only at this hospital for 20 hours a week, so my services are far from readily available. I've left that battlefield for the time being. However, it's served me in that now I have to structure my time there, as I am working another palliative care job the other 20 hours a week (huge teaching hospital, full PC team with board cert MD - love it!). So, now my approach includes, "I'm only here x time this week, if I start early with cases, I can help the case managers figure out a discharge plan when the pt does go home." and I'm a little more likely to get the referral. [Submitted on: 9/29/2006 by: Diane Ranna (404) 840 7931 ]

Diana, let me be the devil's advocate here. Although this is a way to get referral, I also think it is a slippery slope, because one is more likely to be associated with case management than palliative medicine/palliative care. In the position I recently took, I am struggling with a common misconception that I am part of case management and my role is to help LOS. My attitude is – through my clinical skills I will enable patients to be discharged sooner. Although one may argue it is case management, I disagree– it is the clinical approach. And ultimately ask – aren’t all of us who direct patient care case managers? I don’t like the term “case manager” to begin with, it sounds too much like “medical police”, I think the term discharge planners would be a more appropriate term for what these people do. [Submitted on: 9/29/2006 by: Jan Frandsen MSN NP-C]


Sally is right on ~ your presence and getting there is the first half of the battle! Once you have the opportunity to consult and assist with their most difficult and complex case, you’re sure to win them all over. I believe the keys to success in the hospital setting are competence, consistency and responsiveness. Being able to support the primary care staff in the aftermath is also huge. I too have found the social workers the most difficult to “win” over here at Methodist Charlton in Dallas. You’re on the right track. Keep up the good work, as persistence will pay off in the end! [Submitted on: 10/2/2006 by: Kristi M. Griffith, RN, BSN, CHPN Manager Palliative Care Methodist Charlton Medical Center 3500 W. Wheatland Rd. Dallas, TX 75237 Office 214/947-7656 Direct 214/947-7677Pager 972/336-9974 Fax 214/947-7657 kristigriffith@mhd.com ]

Question 32. Does anyone have P&P re: combination infusions aimed at palliative or total sedation; we are trying to develop policies for our inpatient hospice and palliative cases in the hospital. Prior to this, any combination of opioid and benzodiazepine infusions has been considered conscious sedation and has needed to be done in one of the intensive units where full monitoring is available. Obviously, this is counter to the goals of most of our patients receiving sedation for intractable symptoms at the end of life. We have been OK with morphine and lorazepam with our oncology floor, where most of our inpatient care is done, but there has been increased anxiety with the nursing staff when we are using combinations of fentanyl or dilaudid and versed, and especially when we need to add phenobarb to this mix, not to mention the rare incident where ketamine has been called for. The nurses very much want to have these cases and be able to do it well, safely, to be properly trained etc. I would appreciate any examples any of you can offer of policies that involve the management of this process. Feel free to email to me here or at sharmon.figenshaw@providence.org or to fax these directly to me at the hospital : [Submitted on: 10/4/2006 by: Sharmon Figenshaw ARNP Providence Everett Medical Center Unit 7A phone 425-210-1627 / fax on the unit 425-261-3575] Answers I have been putting together a guideline for palliative sedation at my hospital and share the same concerns you have expressed. I also would be interested in any feedback anyone is willing to share. [Submitted on: 10/4/2006 by: Laurie De Lalio MS, APRN, BC, CT Palliative Care Clinical Nurse Specialist Baylor University Medical Center Dallas, TX 214-820-6851 lauriede@baylorhealth.edu ]


The VA National Center for Ethics in Health Care just released their report on Palliative Sedation and it has a nice overview of issues as well as recommendations for practice within the VA. It seems important as we discuss this important topic that we are clear about the definition of palliative sedation. There is growing consensus that it is not sedation caused from symptom management side effects of sedation. Clear definition, intent and indication is important. The VA report recommends written informed signed consent just like pre-op anesthesia. Sounds as though people are lifting the sedation intermittently to check in with the patient and give them the opportunity to "be awake" for awhile. Also helps with the documentation. If they don't wake up you may be able to discontinue it as it is no longer indicated. Our VA report defines it as the administration of non-opioid drugs to sedate a terminally ill patient to unconsciousness as an intervention of last resort to treat severe, refractory pain or other clinical symptoms that have not been relieved by aggressive, symptom-specific palliation. [Submitted on: 10/4/2006 by: Jane McCabe MS, RN Palliative Care CNS VA Eastern Colorado: Denver ]

Here is our policy. It's been several years since it has been updated. And by far, our physicians prefer to use Nembutal as patients may ask to have the drug backed off at times such as a visit from children. I will be open to any suggestions for improvement. [Submitted on: 10/4/2006 by: Donna Willoughby Palliative Care Nurse Coordinator CoxHealth 269-6147 ]

Question 33. We have had our palliative program for 1 1/2 years, currently we offer pet therapy and music. I would like to incorporate other therapies such as Reiki. We have staff trained in different therapies. How can I utilize their expertise and start up a program? Does anyone have policies/guidelines to share? [Submitted on: 10/20/2006 by: Marianne Herman, RN, MSN, APN,C Palliative Care Coordinator/Nurse Practitioner AtlantiCare Regional Medical Center 609-652-3480- office, 609-525-2679, pager marianne.herman@atlanticare.org] Answers We too are in the process of developing our complementary therapies offerings. I have been a Therapeutic Touch practitioner for decades and consider it just another aspect of my comprehensive approach to patient care. We have a few Reiki practitioners and they will


treat patients at their request and will also offer the treatment, get verbal consent, and incorporate it into their treatment plan and chart it as they would any other modality. I also include guided imagery, progressive relaxation, and hand and foot massage in the care of my patients. We have taught hand and foot massage to our LPNs and HHA and some of them use this. We contract with a few massage therapist and this has been very well accepted. [Submitted on: 10/23/2006 by: Maryanne Kehoe ]

We are an out patient hospice service. We do a lot of complementary therapies, too. We have a fabulous music therapist and all our nurses and one of our HHAs are Reiki certified at this time and we have two Massage Therapists. We are writing routine orders for the Music Therapist for all patients in RCFEs (board & cares). We write orders for massage. It gets murky sometimes when the nurses want to, for instance, practice Reiki during a visit - do they need to get an order for it? We do not have any formal policies and procedures for our complementary therapies and yet clearly need to do so. Other instances: aromatherapy and Breema bodywork. Would love to hear how others are formalizing policies, procedures and documentation to meet licensure and JCAHO issues and establishing job descriptions/competencies. [Submitted on: 10/23/2006 by: Debi Onken, MSN GNP CHPN Buena Vista Hospice Care, Inc. ]

May I ask if this is part of the services the hospice/hospital services or if you bill insurance or if patients pay out of pocket? [Submitted on: 10/24/2006 by: Cheryl Vahl RN, MSN, AOCN, ACHPN vanced Practice Nurse Palliative Care Coordinator Holden Comprehensive Cancer Center University of Iowa Healthcare 200 Hawkins Drive, 5970 Z JPP Iowa City, IA 52242 Tel: (319) 356-1616, pager #5200 FAX: 319-353-8988 Email: cheryl-vahl@uiowa.edu ]

All the complementary services we offer (Therapeutic Touch, Reiki, Pet Therapy, Music Therapy, Massage, Progressive Relaxation, Guided Imagery, Hand/foot massage) are included in the per diem. The only thing so far that has been a significant cost is the massage therapy. We hope to add Aromatherapy soon and the essential oils are costly so we are hoping to find a grant or other funding source. We also have at least one RN who hopes that will be able to support her position with a primary focus on energy work but that is in the future for us.


[Submitted on: 10/24/2006 by: Maryanne Kehoe ]

We pay for these services out of the hospice benefit. [Submitted on: 10/24/2006 by: Debi Onken, MSN APRN CHPN Buena Vista Hospice Care, Inc. ]

Question 34. I am trying to improve end of life care for patients at 300 bed community hospital. Several staff members suggested to me that an order set for the CMO patient might be helpful to the ordering clinicians as they all come from such varied educational and professional backgrounds. Some symptoms are not anticipated and thus not addressed until the patient/family are quite distressed about them. Does any one have a form or an order set they use for inpatients who are not under hospice care and which you would not mind if I adapted for my facility? Thank you! [Submitted on: 11/13/2006 by: Jennifer Bobolia,RN,FNP-C,CHPN Palliative Care Service Old Colony Hospice 1 Credit Union Way Randolph, MA 02368 Phone 781-341-4145 Fax 781-2977345 jbobolia@oldcolonyhospice.com ] Answers You may want to research 'Allow a Natural Death'. This is a movement begun by Rev. Chuck Meyer. Essentially it will allow for a CMO, but I personally believe that AND is a more accurate and emotionally comforting term. If you use google as the search engine the information is easily located. [Submitted on: 11/13/2006 by: Rebecca Gagne Henderson RN BSN CHPN Directives Palliative and Hospice Consultative Services ]

Our comfort measures sheet is published in Ferrell and Coyle, Textbook of Palliative Nursing, p. 798 in our chapter on Quality Improvement of Hospital Care. You may find some helpful suggestions about related issues to improve pall care in hospitals there as well. [Submitted on: 11/14/2006 by: Marie Bakitas, DNSc, ARNP, FAAN Post Doctoral Fellow Yale University School of Nursing Assistant Professor Adult Nurse Practitioner Section of Palliative Medicine Dartmouth-Hitchcock Medical Center 1 Medical Center Dr. Lebanon, NH 03756 Palliative Care Office 603-650-5402 Fax 603-650-8699 VM 603-653-3524 pager 603650-5000 pager #7030 ]


I had a very similar situation. I am in a major military medical center and we instituted palliative care approximately 3 years ago. I really believe your best approach is to educate the nurses, ELNEC is preferable, but if time/staffing does not allow providing inservices for the nurses would be very effective. This is what we did and the nurses and APNs (CNSs and NPs) really drive the program. We have a very basic order set we use when a patient/family arrives at the decision to be "comfort care" and then I made laminated forms (that end up all over the hospital) with "Comfort care order suggestions" Because are a teaching hospital, the MDs did not like the "check box" approach, and this format actually has the MD write out the orders based on symptoms/or symptoms the nurse anticipates. What we have found in the last 2 years, is that we have dramatically increased the number of comfort care patients, hospice referrals and decreased the amount of deaths in the ICU. have multiple physician specialties, and now our medicine teams are actually very good at writing comfort care orders. I still have occasional issues when a surgery or cardiology patient becomes comfort care, but with each patient it gets better. If the nurses are armed with the knowledge, they will be the best vocates for the patients, on the floors and in the ICU. ditionally, it is helpful if you can get a hospice MD to speak to the hospital MDs. also used a "gift fund" to create 2 "comfort care suites" on our Oncology floor. [Submitted on: 11/23/2006 by: Carma Erickson Hurt, APRN BC PCM Clinical Nurse Specialist ]

Question 35. I know this is an age old question but how are people receiving referrals? We started out with a bang and seem to be experiencing a low. We have major resistance from the oncology group so any thoughts there? Seems like people only think of us as terminal care as well, so sometimes we are not accepted because we are only for the dying! Also do you have any tips for keeping "in the face" of the referring staff? [Submitted on: 11/28/2006 by: Becca Hawkins, MSN, ANP Nurse Practitioner Palliative Medicine St Mary Medical Center Walla Walla, WA] Answers We experience seasonal and holiday highs and lows. We are slower in the summer and before major holidays and busy from January through April and right after major holidays. With our MICU, the highest referring service, I make daily screening rounds to stay visible. Likewise, on the geriatrics unit. [Submitted on: 11/28/2006 by: Margaret L. Campbell, PhD, RN, FAAN Palliative Care Nurse


Practitioner Detroit Receiving Hospital 4201 St. Antoine Detroit, MI 48201 313 745-3271 mcampbe3@dmc.org Research Associate Center for Health Research Wayne State University 313 577-1847 m.campbell@wayne.edu ]

Our Palliative Care Service has been in existence for 5 yrs now and we are usually swamped with an average daily census (as people we are consulting on, not necessarily the primary on) of 20-25 pts (700 bed university affiliated hospital, Level 1 Trauma, solid organ transplants etc). We still have lulls but they are short lived. When first started up, we clearly defined ourselves as different from hospice. People still get that confused but more often than not, people are getting it. It is a continuous education process. While work quite closely with the hospice programs in town, we do distinguish our goals from those of hospice. When first started, it was small. I would get nervous about lulls. I have learned to just get through them. We have established contacts and relationships now on most of the units including the onc unit, rehab, MICU, Burn-Trauma ICU, BMT, cardiology (CHF unit, cardiac transplant ICU), neurosurg, general neuro~ it has been slow in the making but it continues to grow. We do symptom mgt inservices according to unit need, on a real slow day I may drop onto a unit just to say hi and offer to do inservicing etc. When are slow I contact some of my contacts and offer our music therapist or massage therapist to pts not followed by us. Services generally start out slowly as people figure you out, then do pretty well...then hit a dip before taking off. As we have increased our visibility the percent of onc pts has declined as other services increase. Our onc population now comprises 40-45% of our overall numbers. [Submitted on: 11/28/2006 by: Marcia Buckley RN,MS Palliative Care Consultation Service U of Rochester, Strong Mem Hosp Rochester, NY ]

I agree with Marcia, hang in there! Palliative programs have a life of their own and it can take time (years--but don't let that be a discouragement!) before the service comes into its own. Every service has lulls and that's OK. Keep putting the service out there, round on the units, do unit-based inservices so the nursing staff gets to know you. Educating the nursing staff to ask questions about the goals of care when the team is rounding can also be helpful. Oncology has been tricky here, as well. I suspect there are a number of reasons for that but again, hang in there and keep being present. Offering to do a grand rounds for various services as well as for nursing can also be helpful. We also offer a palliative care all-day seminar (mostly based on ELNEC) as a core course once or twice a year out of our nursing education department. [Submitted on: 11/29/2006 by: Rita Mastroianni Johns Hopkins Hospital ]


We have a scattered bed pain and palliative service called supportive care in a 300 bed hospital and see 16-25 patients per day - very busy that has grown over the last 7 years, I think being seen sometimes as only the pain service gets us in the door earlier in sicker patients as we are not seen solely as end of life people. We also have developed an outpt clinic and case management program so that we can follow people over time. With Oncology - helping with pain is often also seen easier than palliative and obviously we can then develop a relationship with the patient and assist as needed. Access is really important. [Submitted on: 11/29/2006 by: Peg Nelson St Joes Pontiac Mi ]

Question 36. We have been recommending Tenkoff catheters in select pts for management of their malignant recurrent ascites. Our hospital however has no policy. I was wondering if anyone has a policy/procedure on them? [Submitted on: 1/15/2007 by: Marcia Buckley NP Palliative Care Service URMC Rochester, NY ] Answers Our interventional radiology inserts a catheter similar to a tenckhoff but more like the small chest tubes to drain bag for malignant pleural effusions. they don't have a policy on it but they write orders for its care and drainage. [Submitted on: 1/15/2007 by: Jane Owen]

The physician that I work with and one of our liver service hospitalists have been inserting pigtail urological catheters made by Cook and then using the included adapter to connect to a foley bag. Excellent for drainage of ascites in the home setting for patients who require frequent paracentesis for comfort and whose health is rapidly declining. We have sent about 5 people home with this setup and they are easier to manage than either the Tenkoff or Pleurex catheters and are significantly less costly for the hospice to manage. They can be inserted at the bedside and my collaborating physician has inserted them in the home setting. [Submitted on: 1/15/2007 by: Linda Blum, MS, GNP, APRN-BC]


I was discussing the use of continuous drainage with one of my oncologists, after reading this e-mail. His questions were related to risk of infection and patient complaints of pain from the catheter. Is there anyone that can address his concern. Are the abdominal catheters tunneled in? My patients with long term chest tubes do complain of often severe pain from the tube. [Submitted on: 1/16/2007 by: Donna Willoughby]

We suggest them in a very select group of individuals; usually people we feel have more than days to live and for whom their recurring ascites has significant impact on their quality of life and for whom a home plan is feasible. It is usually a younger population. We take infection risk into account and really try to carefully weigh the benefits of the catheter with the risks. To be honest, the majority of folks I have had experience with do not complain of pain at the site~ I think I have seen more discomfort with PEGS and yes, pleurex catheters. I have to check to see if they are tunneled. [Submitted on: 1/18/2007 by: Marcia Buckley]

Question 37. Will you all be willing to share what you in PC or your hospital is doing for bereavement? Do you have follow-up or just acknowledgment of the death. If routine follow-up, who does it, how often, etc. [Submitted on: 1/16/2007 by: Becca Hawkins, MSN, ANP Nurse Practitioner Palliative Medicine St Mary Medical Center Walla Walla, WA ] Answers We recently initiated a bereavement program at our hospital in Santa Maria California. We, the Palliative Care RN's, send a condolence card to families of anyone who dies in our facility as well as to those patient families who have been on our program and have left us for SNF or Hospice Placement. We do the cards with the assistance of a volunteer who tracks patients (newspaper obituary's etc), addresses cards etc for us. Our cards are generic but if have had significant interactions with the family we like to personalize a bit. We have made arrangements with our facilities hospice to utilize their bereavement counselor and classes. An insert announcing that a bereavement counselor will be calling is included in the condolence card. The bereavement counselor makes one phone call to check on family and offers classes. Occasionally the bereaved wants additional information and the counselor will send out a packet of information. We do not do anniversary cards etc. This alone is a


huge task and could not be done without our volunteer and utilization of hospice bereavement counselor. [Submitted on: 1/16/2007 by: Bonnie McGowan RN, MA, PNP-ACHPN Manager Palliative Care Services Marian Medical Center Santa Maria, CA 93454 ]

We send a sympathy card either from just our service, or there are times when I take a card and have the primary team sign it as well. It is labor intensive, but the teams really appreciate, I find the surgeons appreciates it the most (we are a teaching hospital). For bereavement I use our local hospice program. For children's grief, we are fortunate enough to have a local children's bereavement program, and at times they have come to the hospital to provide support to kids. [Submitted on: 1/17/2007 by: Darrell Owens,Ph.D.,ACHPN,APRN Clinical Assistant Professor and Director Palliative Care Consult Service Harborview Medical Center Box 359806 325 Ninth Ave Seattle, WA 98103 VM:206-341-4636 Fax:206-731-2363 Pager:206-541-0776 Email: owensd@u.washington.edu ]

Our hospice has a palliative care program in contract with Kaiser Permanente. When we were asked to bid for the contract they did not request bereavement. We included it at no extra cost as we see it as part of our mission. We have not done a study on it, but I think we probably see more complicated grieving from survivors of those who die on our palliative care service - not all patients choose to transition to hospice for differing reasons. [Submitted on: 1/17/2007 by: David Hall FNP Willamette Valley Hospice 1015 3rd St NW Salem, OR 97304 503 588 3600 x313 Fax 503 363 3891 davidh@wvh.org ]

I'm not sure about the literature but at our hospice we have monthly rememberance services led by the chaplain. Our home teams and the agency as a whole have quarterly memorial services for staff and families. We also sign and send condolence cards. Somehow it isn't always enough though. [Submitted on: 1/17/2007 by: Jessica Weinberger APN Alive Hospice, Inc. Nashville TN 37205 ]

For our hospital Palliative Care Program, I was hired almost one year ago to develop the


bereavement program. I am shared with the service so I see PC patients as well. I send out sympathy cards to families of any patient who has died on our service. I find these deaths through the local paper and various facilities we refer to such as hospice and LTAC. These cards are mailed out approx. 2 weeks after finding out about the death and are signed by all PC staff who were involved with pt and family. 90 days after the death, I contact each family and offer free bereavement phone support. I began calling families last June and have called 5 months of deaths and we are following 60 families each month for family care bereavement support. I am in the process of seeking volunteers to assist me in making the follow up calls for families who are not in the complicated stage of grief. I have 3 volunteers on board who follow 15 of my 60 families. We call each family once a month. Sometimes we speak to families more than once a month when they are having a bad time. I receive approx. 3 calls/month from families who are having a bad day and just needing to talk. I have uploaded all the local grief counselors and support groups up on our Palliative Care site for the families to access and hand out to other family members. I am in the process of developing an annual Palliative Care Memorial Service hopefully that will be held late this summer. There are so many things to be done that even if your program comes up with the funds to hire someone to work directly or somewhat directly on bereavement, there is still a major need for volunteers. I am more than happy to answer any questions anyone may have. [Submitted on: 1/18/2007 by: Diana L. Ruffin, LCSW St. Luke Episcopal Hospital Palliative Care Services 832.355.3976 druffin@sleh.com ]

Have you tried incorporating the nurses into the MD Death Rounds to facilitate interdisciplinary dialogue? Submitted on 1/17/07 by: Martha Henderson Actually, yes we did attempt to do interdisciplinary death rounds and it did not work. The residents were uncomfortable with other than their peers seeing the degree of vulnerability that can occur with death rounds, and thus reported it was less meaningful to them, as they were more "on guard." The nurses did not feel like they could share openly if they needed to share experiences regarding the MDs. We then went back to rounds by discipline, which has worked well for the MDs. I then tried unit based rounds for the RNs, but staffing (actually getting coverage for their patients) became an issue, and for the most part, many of the RNs decided they did not need them, that they were "just fine." I am concerned about the inability to get death rounds off the ground for the nurses, and see the problem as multifactorial. It would help if nursing administration committed to coverage time, so that nurses could come without worrying about their patients or burdening their co-workers. I also feel that by not making it part of the ICU or unit routine, people have the opportunity to opt out and not address or process the issues around death. I believe MD turnout is good because the attending physicians make it a priority, make the residents attend, and stress the importance of processing. I would love to hear anyone elses ideas of how to make the process work better for our own colleagues.


[Submitted on: 1/17/2007 by: Darrell Owens,Ph.D.,ACHPN,APRN Clinical Assistant Professor and Director Palliative Care Consult Service Harborview Medical Center Box 359806 325 Ninth Ave Seattle, WA 98103 VM:206-341-4636 Fax:206-731-2363 Pager:206-541-0776 Email: owensd@u.washington.edu ]

I have found (after 30 years) of working with ICU staff that they do not do well with group "share" experiences. Our staff does very well with one on one time. They know what they need. [Submitted on: 1/18/2007 by: Pat Murphy ]

I agree with Pat. "Support Group" types of interventions work well for some people however in my experience as a CNS, as a NM, as an APN in hospice and now working in a large academic med ctr as a Pall Care NP, I find nurses respond better one on one, with privacy. Often we develop contacts with whom we feel safe/comfortable venting or sharing very personal feelings with. I think group things should be more focused on coping skills workshops, care for the caregiver type workshops rather than support group type things. Nurses will display great variability with what pts/families they get close to and their personal baggage will affect their response to each individual patient situation. I would put energies into helping nurses identify stressors, self-awareness, communication skill, coping skills type workshops. [Submitted on: 1/18/2007 by: Marcia Buckley URMC Rochester, NY ]

Agreed. We tried to do a monthly Support group for Nurses called "reflection & remembering" ...first Tuesday of every month, led by a chaplain...didn't work...you just can't schedule grief; nurses were off; couldn't get away from the floor; forgot, etc etc. So we encourage staff to contact SW or chaplain to deal with specific issues at the time. We hope to build our chaplain role and have staff view her as someone easily accessible for these concerns/issues. [Submitted on: 1/19/2007 by: Cheryl Vahl University of Iowa ]

As several others have mentioned, I send bereavement cards to families of patients (seen by our service) who die in the hospital. If we find out that someone that we had significant


interaction with dies after discharge, we may also send a card. Our hospital employs a full time bereavement services director and has a department of decedent care. Through our bereavement services program, families receive a total of 4 cards at different intervals through out the year. There is general information about bereavement as well as phone numbers and sites. Many of our patients are from outside of the local area and would not be able to access bereavement services through our local hospice so we tell them how to find help in their area. Our bereavement department also provides loss specific packets and counseling as needed/requested. We have a bereavement advisory council which is made up of about 20 people from various disciplines. The "BAC" plans and puts on our biannual service of remembrance and works on many other grief-related projects for the hospital and its staff. We sponsor grief-awareness week every Nov 1-7 as well as programs and forums for staff throughout the year. I am curious to know if others have a decedent care program? We have a 7 person department and they attend every death in our hospital. They insure that proper paperwork is done, screen for ME cases, assist families with arrangements, and do post mortem care. [Submitted on: 1/19/2007 by: Jennifer Gentry ANP APRN BC PCM Duke Hospital Palliative Care Service DUMC Box 3003 Durham, NC 27710 919-660-7564 Fax 919-684-8569 ]

Thanks for all the interesting ideas you are generating with this topic. I have a question related to hospital deaths. On average what percentage of total hospital deaths are patients on palliative care services? We run about 30%. I havenâ&#x20AC;&#x2122;t seen a benchmark on that data. Submitted on 1/19/07 by: Linda Gorman I would like to find out from the group if any palliative care programs are providing. No One Dies Alone volunteer program? We received the template from Oregon's program and our local ministrator would like to know if other's have this also. We have special trained Palliative care volunteers and then started our End of Life Companion program in Dec. We use staff and medical students, nursing students and any other health profession students from our colleges. [Submitted on: 1/20/2007 by: Patricia Lippincott Knox MSN, FNP, APRN,BC-PCM Clinical Coordinator Palliative Care Service Clinical Assistant Professor Department of Medicine Clinical Assistant Professor College of Nursing, Lecturer Center for Bioethics and Humanities Upstate Medical University, Room 1111 750 E.Adams St., Syracuse,NY 13210 315-464-6098 Fax 315-464-4761 knoxp@upstate.edu ]

Question 38. On an average what percentage of total hospital deaths are patients on palliative care services? We run about 30%. I haven't seen a benchmark on that data. Thanks in advance. [Submitted on: 1/20/2007 by: Linda Gorman]


Answers We have run 40% and 42% for 2005 and 2006. [Submitted on: 1/20/2007 by: Darrell Owens,Ph.D.,ACHPN,APRN Clinical Assistant Professor and Director Palliative Care Consult Service Harborview Medical Center Box 359806 325 Ninth Ave Seattle, WA 98103 VM:206-341-4636 Fax:206-731-2363 Pager:206-541-0776 Email: owensd@u.washington.edu ]

Our 20 year old program sees 60% of all patients who die who have been in the hospital >24 hours. By unit, MICU =80%, medicine or medicine hospitalist >85%, neuro-icu = 60%, surgery and surgical ICU = 40%. We don't have oncology or peds. [Submitted on: 1/20/2007 by: Meg Campbell]

I am so impressed with these stats!! We are a young program (hospital wide program just 1 year old, unit is 6 years old), but I meet regular resistance to the presence of Palliative Care in our ICU !!! I am frequently called in to speak with the patient/ family AFTER the patient has left the ICU and is under the care of the hospitalist service, or I receive a referral from Social Work! [Submitted on: 1/20/2007 by: Sally Lippitt-Houston, MSN, RN, CNS Palliative Care Consult Santa Rosa Memorial Hospital Santa Rosa, California ]

We are running 40% deaths for palliative care patients over the last two years, but 25% of those deaths occurred on inpatient hospice. If you take out the GIP deaths, the palliative care % of deaths in hospital is 32%. [Submitted on: 1/20/2007 by: Nancy Cato Grabb, RN,BC, BSN, MBA, CHPN Manager Palliative Care Methodist Dallas Medical Center 1441 N. Beckley Dallas, Texas 75203 214947-2526 - office and voicemail pager 972-451-2453 - pager 214-947-2499 - fax nancygrabb@mhd.com ]

We try to make sure all those who are dying in our facility are referred to Palliative Care for pain and symptom management. When a patient is eminently dying or made '"comfort care" our Palliative Care Team receives and automatic referral. Don't know stats but with


exception of weekends when we have no coverage I believe we see (admit to service) around 85-90% of those who die in our facility. [Submitted on: 1/22/2007 by: Bonnie McGowan RN, MA, PNP-ACHPN Manager Palliative Care Services Marian Medical Center Santa Maria, CA ]

I practice in a 600+ bed tertiary care center. The hospital averages about 550 deaths per year and our Palliative Care service was involved with 45% of patients who ended up dying in the hospital. [Submitted on: 1/23/2007 by: Kerstin McSteen, RN, CNS Palliative Care Service Abbott Northstern Hospital Minneapolis, MN (Office) 612-863-6539 ]

We try to make sure all those who are dying in our facility are referred to Palliative Care for pain and symptom management. When a patient is eminently dying or made '"comfort care" our Palliative Care Team receives and automatic referral. Don't know stats but with exception of weekends when we have no coverage I believe we see (admit to service) around 85-90% of those who die in our facility. [Submitted on: 1/23/2007 by: Bonnie McGowan RN, MA, PNP-ACHPN Manager Palliative Care Services Marian Medical Center Santa Maria, CA ]

Question 39. Do any Palliative Care Programs work closely with heart failure services with patients who have ventric-assist devices? If you do, what is your role? [Submitted on: 1/24/2007 by: Marcia Buckley URMC Rochester, NY ] Answers We have a Heart Center as part of our hospital. We are seeing more and more ICDs. When our PC team discusses goals of care with the family, we include discussion of the ICD - its purpose at the time of placement and its likely outcomes now. Generally, if the patient's disease is advanced, whether it be CHF or some other disease with underlying cardiac condition for which an ICD was placed, the patient and family decide to disable the ICD. Then, we consult cardiology. They contact the ICD company rep -- in our area it is generally Medtronic. The Medtronic tech promptly comes to turn off the device -- that is done externally without any discomfort to the patient. It can be done without disrupting the function of an accompanying pacer. Sometimes, patients and families are panicky that the


ICD will fire and do not want to wait. For those cases, the Medtronic rep has given me the magnetic devices that can be taped over the ICD to disable - the are heavy and cumbersome, but they are better than a jolt. I still notify the cardiologist. Medtronic follows up. [Submitted on: 1/24/2007 by: Robin Vachon-Kraut Mt. Carmel Health Systems Columbus, OH ]

Do you mean the external assist devices while patients waiting for heart transplant? We have these at our facility and have talked with transplant team who manages them about including palliative care. If a patient is going to come off device without getting a transplant, they want us to be involved. Havenâ&#x20AC;&#x2122;t had any patients yet but I see this as a small volume but high impact role for palliative care. [Submitted on: 1/24/2007 by: Linda Gorman, APRN, BC, MN, CHPN Palliative Care Program Cedars-Sinai Medical Center Los Angeles, CA ]

Our palliative care team has a close relationship with the NP for EP Cardiology. she is very supportive of palliative care and hospice; we call her to disable ICD's either inpatient or she will go to the home. It is her understanding that the company personnel are not allowed to go into the home to disable the device; not sure if that is correct? She does contact us as well with cardiology patients that are having the device disabled or they are not going to put a device into. [Submitted on: 1/24/2007 by: Anastasia Driscoll CRNP, ACHPN Nurse Practitioner, Palliative Care MetroHealth Medical Ctr Cleveland, OH 44109 216-778-7271 riscoll@metrohealth.org ]

When appropriate, after explaining the reasons why, we ask pts and families if they want the AICD turned off. If yes, our Perfusion Team does this for us in the hospital and they are a 24/7 service. They usually respond in less than 30 minutes. If there is some delay or an immediate need to have it off sooner, the CCU has the large magnets to place over the devices. We record the date and time the device was turned off on the DNRCC form. For patients who do not want the device turned off until they get home, we have contacted the companies and as long as a hospice or home care RN is present in the home with an order from a physician, they have been willing to turn off the devices in the home. [Submitted on: 1/26/2007 by: Elaine Glass, APRN, BC-PCM Clinical Nurse Specialist Palliative Care at Grant Medical Center 340 East Town Street, Suite 10-330 Columbus OH 43215-4639


614-566-PALL (7255) B# 614-842-1209 Fax = 614-566-8009 ]

Question 40. Does anyone have documentation of the use of nebulized morphine for cough. I am particularly interested in some research or citation in the literature. [Submitted on: 5/1/2006 by: Becca Hawkins, ANP Palliative Medicine St Mary Medical Center Walla Walla, WA ] Answers Here are two sources, one quite recent and one older: In the journal Chest, Feb 2004, editorial (Baydur, Ahmet) and several good research pieces, especially the article by Foral, et al. For the 1998 source go to address: www.hospice.xtn.nte/dyspnea [Submitted on: 5/2/2006 by: Dorothy Lippman Salovesh, GNP, FNP Palliative Care Nurse Practitioner St. Jude Medical Center, Fullerton CA ]

Via Christi Regional Medical Center in Wichita, Kansas is a multiple campus tertiary care center. Nebulized morphine has not been widely used in our community. I am looking for institutions that may have policies on it's use. Our morphine sulfate is kept in the Omnicells which required nursing to check out the drug (respiratory care currently does not have access to the Omnicell's) then work with respiratory in giving the treatment. Any suggestions would be welcome. [Submitted on: 12/14/2006 by: Alice Thornton Bell, ARNP, ACHPN Service Line Director, Emergency and Trauma Services Via Christi Regional Medical Center 929 North St. Francis Wichita, Kansas 67214 316-268-8677 alice_bell@via-christi.org ]

There is ample evidence, including a Cochrane review, which demonstrates nexbulized morphine is ineffective. In addition, there are case reports of nebulized morphine creating laryngospasms. [Submitted on: 12/15/2006 by: Jan Frandsen MSN CNP ]

Here is our procedure for nebulized morphine. We rarely use it, as most patients in acute


care receive IV, sub-q or SL morphine. The 2 patients that I've had this year were hospice patient that had required a brief inpatient admission and we chose not to alter something that seemed to be working for them. The issue of obtaining the morphine is addressed in the procedure. [Submitted on: 12/15/2006 by: Donna Willoughby Palliative Care Nurse Coordinator CoxHealth 269-6147 ]

We've used it in our Residence mixed with Decadron (Dexamethasone) with varied results. Yes, the data isn't there but as previously stated, it works for some patients. [Submitted on: 12/16/2006 by: Jessica Weinberger APRN Alive Hospice, Inc Nashville, TN 37203 ]

We have stopped using nebulized morphine in our hospice and palliative care program as our extremely well-informed pharmD consultant has updated us that the most recent literature does not show any consistent improvement over sublingual or other routes when used for dyspnea. [Submitted on: 1/25/2007 by: Yonit Yogev, RN, MN, CHPN Group Health Cooperative Home and Community Services Everett, WA ]

We do not routinely use neb MSO4 as there is no evidence that it is effective~ we did continue its' usage on a pt who was already on it when we got involved because she thought it helped but our standard is more of a sublingual route of ministration or just po. [Submitted on: 1/25/2007 by: Marcia Buckley URMC Rochester, NY ]

In the practices I have worked for we used nebulized MS for those who were already on it or the physician had good results in other patients (usually COPD). It either worked or it did not. Since the concentrated MS has proved such good efficiency either SL or PO the nebulized MS is not used much. I think it was a good try at an alternative route for those patients that had failed other treatment efforts. [Submitted on: 1/25/2007 by: Helen Martin, FNP Wrightsville Beach, NC ]


I am concerned that people are still using nebulized morphine. There are a number of well designed papers which outline the lack of efficacy and the problems associated with the use of this route. I donâ&#x20AC;&#x2122;t know if Pat Coyne is on this list, but he certainly has some experience he would be willing to share (I am sure there are others as well). [Submitted on: 1/25/2007 by: Jan Frandsen MSN CNP ]

The cite for the review of studies about efficacy of nebulized morphine is : Jennings AL, Davies AN, Higgins JP, Gibbs JS, Broley KE. A systematic review of the use of opioids in the management of dyspnoea. Thorax. 2002;57:922-923 [Submitted on: 1/25/2007 by: Meg Campbell ]

The research for nebulized MS04 shows no benefit, 2 reported deaths were to bronchospasms, our phase 2 research on nebulized fentanyl did show benefit. [Submitted on: 1/25/2007 by: Patrick Coyne, MSN,APRN, FAAN ]

Is it possible to see the dosages/data etc on the Ph II fentanyl trial? [Submitted on: 1/25/2007 by: Marcia Buckley URMC, Rochester NY ]

AS REQUESTED, DOSE in this study the dose was 25MCG of fentanyl in 2 ml of saline, please see Coyne, P., J., Viswanathan, R., and Smith, T., "Nebulized Fentanyl Citrate Improves Patients Perception of Breathing, Respiratory Rate, and Oxygen Saturation in Dyspnea." Journal of Pain and Symptom Management. February, 23 (2), 2002, pp. 157-160. French, W., Coyne, P., and Smith, T., "Peer Viewpoint: Management of Dyspnea." Journal of Supportive Oncology. Vol. 1 No. 1, May/June 2003 pp. 28-29. Coyne,P., J., "The Use of Nebulized Fentanyl for the Management of Dyspnea." Clinical Journal of Oncology Nursing, Vol. 7 No. 3 May/June 2003 pp.334-335. [Submitted on: 1/25/2007 by: Pat Coyne ]

Question


41. I have been newly hired by a home care/hospice agency in Pa. as a Hospice/palliative care NP. It is a newly created position and the first NP position within the agency, so a learning experience for both myself & the agency. I will be initially based in the local acute care facility, with plans to expand the role to palliative care in both the home & long term care facilities. They are very focused right now on GIP missions at the hospital because the hospital just rolled out a new standard of care policy that provides for a palliative care referral for all patients with an order of comfort measures. The palliative care consult determines if the patient should be converted to GIP status and offers the choice of one of 2 hospices who have a contract with the facility. In most cases all goes well, but I am wondering about those who are terminal weans from the ventilator and live only hours.... Is that really a legitimate hospice referral? I am interested to know what is being done in other areas re: who is converted to GIP status & who is not. Submitted on 1/27/07 by: [Submitted on: 1/27/2007 by: Cindy Drenning, CRNP] Answers I am often called to assist in decision making around terminal weans. If believe the patient will likely survive only a matter of hours, the decision whether or not to use hospice depends on the needs of the family, especially with regard to bereavement. Our palliative care service does not provide that level of follow-up. [Submitted on: 1/27/2007 by: Lori Hedges, APRN, BC-PCM]

I am often called to assist in decision making around terminal weans. If we believe the patient will likely survive only a matter of hours, the decision whether or not to use hospice depends on the needs of the family, especially with regard to bereavement. Our palliative care service does not provide that level of follow-up. [Submitted on: 1/27/2007 by: Lori Hedges, APRN, BC-PCM Advocate Illinois Masonic Medical Center Chicago 773 296-5837 ]

Question 42. I have had a few pts/families ask me lately about info on body/organ donation for medical science/research? Does any one have info on this they can share with me? i.e. a list of where info is found and how to contact [Submitted on: 1/31/2007 by: Jane Pelosi-Kelly, RN, APN Palliative Care Nurse Practitioner Alexian Brothers Hospital Network Office: 847-981-6035 Fax: 847-472-1668 Pager: 847-4797142; In-house: 15101 Cell: 847-875-8796 ]


Answers At the 2005 HPNA conference, I spoke with reps from SCIENCE CARE â&#x20AC;&#x201C; a Medical Research & Education willed body donor program. I have not had any experience with the company, but their printed material sounds like it would be a good resource. contact info from 2005: Science Care 1-800-417-3747 www.sciencecare.com [Submitted on: 1/25/2007 by: Gail Morfit, RN, OCN, CHPN Resource Nurse Capital Hospice Falls Church, VA phone 703-538-2065 fax 703-538-2165 GMorfit@capitalhospice ]

I can speak to our local area. This is usually something that has to be set up months ahead of time, not something that can happen at the end. The organizations that we use are our local Medical Schools and Teaching Hospitals. Hopefully, this can help some. [Submitted on: 1/31/2007 by: Kelli Gershon, MSN, APRN, BC-PM APN Palliative Care The University of Texas MD Anderson Cancer Center (O) 713-792-5935 (P) 713-404-1141 (F) 713792-6092 ]

If you are at a University, your College of Medicine might have a Deeded Body Program [Submitted on: 1/31/2007 by: Cheryl Vahl RN, MSN, AOCN, ACHPN vanced Practice Nurse Palliative Care Coordinator Holden Comprehensive Cancer Center University of Iowa Healthcare 200 Hawkins Drive, 5970 Z JPP Iowa City, IA 52242 Tel: (319) 356-1616, pager #5200 FAX: 319-353-8988 Email: cheryl-vahl@uiowa.edu ]

In addition to the other advice already given, contact a medical school. Bodies that are not obese, or with open wounds, unhealed incisions, or decubiti are not eligible because the bodies must be embalmed and open lesions prevent complete embalment. [Submitted on: 1/31/2007 by: Meg Campbell]

Here in Georgia people can make arrangements ahead of time with a nearby medical school and they will accept the body after death as long as certain criteria are met. We also have a relationship with a local eye bank for eye donation which can be an option for many patients. [Submitted on: 1/31/2007 by: Jennifer Fournier, RN, MSN, AOCN, CHPN Clinical Nurse


Specialist Hospice Savannah, Inc. 1352 Eisenhower Dr. Savannah, GA 31406 912-629-1072 ]

Check out this site: http://www.anatomicgift.com/ [Submitted on: 1/31/2007 by: Robert Smeltz, RN MA PNP ACHPN Nurse Practitioner/Clinical Coordinator Palliative Care Service Jamaica Hospital Medical Center Office: 718-206-6919 Fax: 718-206-8716 Pager: x16869 ]

The place to call in Illinois is the Anatomical Gift Association. Their web site is www.agaillinois.org/ . Other contact info is: 1540 S. Ashland Ave., Suite 104 Chicago, IL 60608 800-734-5283 agonate1@aol.com [Submitted on: 1/31/2007 by: unknown]

Potential donors just need to sign a form and they will get a card back in the mail. Once the medical school is finished with the body they arrange for cremation. The cremains can be returned to the family, but that request has to be made in advance. [Submitted on: 1/31/2007 by: Evelyn Bollinger, RN ]

Many universities, with medical school programs have whole body donation programs. In Memphis we have a group called; MERI -Medical Education and Research Insitute-that take whole body donation with some exclusion criteria (obesity, very aged, and communicable disease). The body is treated with great care and respect and is used to train surgeons from around the world to do difficult, or new surgeries. The body is treated like a live pt, from room thru holding, to OR and PACU. All surgeries are closed with the same techniques and procedures as a patient would be treated in the hospial. The drawback is they keep the body for about 6 months, and then it is cremated, and the ashes returned to the family. The group gives the family $500. they are called the Genesis program I believe. I don't have that exact cntact info with me at home - I will get and send to group on Monday. The site for the whole body program I was referring to is: genesislegacy.org I found a brochure and an added benefit is that MERI will pay for the transportation of the body from anywhere in the continental US, file and pay for death certificates. exclusion criteria are HIV, hepatitis, active syphilis, active TB, less than 18 and and "excessive obesity". Toll free # for information: 877288-4483.


[Submitted on: 2/4/2007 by: Jane Owen ]

Question 43. We have been asked to sporically consult on NICU and peds patients, but want to implement a more formal program. We are working on criteria/screening tool for referral to palliative care specific to the NICU and peds for the nurses and other providers to use. Does anyone have any they are currently using and would consider sharing? We also want to come up with another name for our program. We discussed the Compassionate Care Team, but would also like to hear what others are using. [Submitted on: 2/6/2007 by: Helen Martin, FNP Lower Cape Fear Hospice and Life Care Center Wilmington, NC ] Answers We see pediatric patients in both our hospice and palliative care program. Our pediatric hospice team is called the “Butterfly Team”. We have had more pediatric hospice patients recently and are offering Pediatric ELNEC to our staff and the local medical community as a way to provide education. [Submitted on: 2/7/2007 by: Jennifer Fournier, RN, MSN, AOCN, CHPN Clinical Nurse Specialist Hospice Savannah, Inc. 1352 Eisenhower Dr. Savannah, GA 31406 912-629-1072 ]

Question 44. I have a young woman with ovarian ca, s/p xrt and now having a month long hx of severe tenesmus. Does anyone have an experience with this? I would appreciate any help! [Submitted on: 2/21/2007 by: Karen Overmeyer, ANP Richmond, VA ] Answers I haven’t had to deal with tenesmus but there has been good information posted on www.palliativedrugs.com bulletin board. I have found this a very useful listserv and site for pain and symptom management. [Submitted on: 2/21/2007 by: Barb Mulich, APRN Morgantown, WV ]

Years ago during my MSKCC days I had a gentleman with terrible tenesmus (he had a resected rectal cancer). The only thing that worked for him (and it was quite effective) was


Tincture of Opium, in modest amounts. [Submitted on: 2/22/2007 by: Marcia Buckley NP Palliative Care Consultation Service URMC Rochester NY ]

Sublingual hyoscyamine 0.125 to 0.25 mg scheduled ac and HS or even prn has been effective in my patients. Off course they will need frequent mouth care for dry mouth. [Submitted on: 2/22/2007 by: Donna Willoughby Palliative Care Nurse Coordinator CoxHealth 269-6147 ]

I would try B&O suppositories. I would also try some decadron if she isn't already on a steroid. [Submitted on: 2/22/2007 by: Robin Vachon-Kraut CNP Palliative Care Mt.Carmel Health Systems Columbus, Ohio ]

I have found that low dose tricyclics work for tenesmus. The pain seems to be neuropathic in nature. [Submitted on: 2/23/2007 by: Hallie Mason MSN CRNP Palliative Care Consult Service Summa Health System Akron, OH ]

Question 45. I would like to survey our nursing staff to ask what they consider to be quality end of life care for pts that are actively dying. I'm doing this as a first step to develop a series of inservices and eventually a "caremap" or "comfort care protocol" for this population of patients. I'm finding that the care for patients is substandard at best. The previous place I worked had a palliative care/hospice unit and the care was specialized and met the physical and psycho-emotive needs of the of the pt/family for the dying pt. Now i have a scatter-bed approach and it has been discouraging to see these pts/families unsupported. Any thoughts or ideas in this area would be appreciated. You may email me at owenj@methodisthealth.org. [Submitted on: 3/6/2007 by: Jane Owen ] Answers


Perhaps using the "Gone From My Sight" booklet as a starting point with pre- and postbooklet testing will help. Also, AJN had a series of 6 or so articles a few years ago on End-oflife care which focussed on in hosptial care and they were CEU's so there were tests already done in the journal, if LWW would allow you to use them. If you need the exact dates I might be able to find them if you can't get them through Medline. [Submitted on: 3/7/2007 by: Jessica Weinberger, APRN Alive Hospice, Inc. 615-963-4783 ]

Have you seen the new National Quality Forum Preferred Practices for Palliative Care? If not, take this link: http://www.qualityforum.org/publications/reports/palliative.asp Download the Executive Summary pdf, and see a list of 38 preferred practices on pp 8-9. P.S. I plan to pull this out the next time I encounter a nursing facility that says they are "already doing palliative care" without benefit of hospice or a PC nurse practitioner's services. Also, I find it interesting that palliative care services and hospices are being held to identical standards by the NQF. [Submitted on: 3/7/2007 by: Mary Zuccaro ]

Try the City of Hope Pain and Palliative Care resource Center site. They have a number of survey instruments related to end of life care. site is prc.coh.org [Submitted on: 3/7/2007 by: Linda Gorman, APRN, BC, CHPN Palliative Care Cedars-Sinai Medical Center ]

City of Hope Palliative Care Resource Center has very good surveys designed for use by RNs to determine their ATTITUDES and KNOWLEDGE related to end of life care. I have used them in the past. Here's the link: http://www.cityofhope.org/prc/pdf/Instruments.pdf [Submitted on: 3/7/2007 by: Kerstin McSteen, RN, CNS Palliative Care Service Abbott Northstern Hospital Minneapolis, MN (Office) 612-863-6539 ]

We are interested in creating a Palliative Care Caremap/Pathway at our institution. Does anyone have a sample they would be willing to share? Or share your experiences (good/bad) in trying to establish one? Would greatly appreciate your help...thanks in advance. You can send to me directly at: cheryl-vahl@uiowa.edu


[Submitted on: 3/7/2007 by: Cheryl Vahl RN, MSN, AOCN, ACHPN Advanced Practice Nurse Palliative Care Coordinator Holden Comprehensive Cancer Center University of Iowa Healthcare 200 Hawkins Drive, 5970 Z JPP Iowa City, IA 52242 Tel: (319) 356-1616, pager #5200 FAX: 319-353-8988 Email: cheryl-vahl@uiowa.edu ]

a good resource is the ELNEC curriculum- http://www.aacn.nche.edu/elnec [Submitted on: 3/7/2007 by: Marilyn Graves, MSN, RN, CHPN Clinical Nurse Specialist Hospice of Baltimore 555 W. Towsontown Blvd. Towson, MD 21204 Office: 443-849-8224 ]

Question 46. Does anyone have a policy on family controlled analgesia (hospital based policy) whereas a pt has a PCA but the family is allowed to push the button for the pt? We are hoping to develop such a policy! Thanks! [Submitted on: 3/9/2007 by: Marcia Buckley NP~ Palliative Care Consult Service URMC Rochester NY ] Answers We have hit nothing but roadblocks from pharmacy (citing JCAHO) on this oneâ&#x20AC;&#x201D;would love to hear of anyone gaining ground on this for hospital settings. [Submitted on: 3/9/2007 by: Sharmon Figenshaw ARNP ]

We just created such a policy called CCA "Caregiver Controlled Analgesia"; ASPMN came out with a position paper on the topic. We had rewritten our PCA policy in light of recent warnings and advisory bulletins; but felt we needed this to address what was actually going on in the building. The elements of the CCA policy are: -the LIP must complete a competency training (like conscious sedation) -the LIP designates selected persons to administer CCA -there is a consent form to sign -a document for education of the designee order sheet -bedside log for the designee -wrist bracelets to identify persons consented & educated expected populations: pediatrics; neuro; end of life there are 'general population" and "palliative care/end of life" versions of the consent & education forms It has passed P&T subcommittee and we are wrestling with rollout. [Submitted on: 3/9/2007 by: Cheryl Vahl RN, MSN, AOCN, ACHPN Advanced Practice Nurse Palliative Care Coordinator Holden Comprehensive Cancer Center University of Iowa Healthcare 200 Hawkins Drive, 5970 Z JPP Iowa City, IA 52242 Tel: (319) 356-1616, pager


#5200 FAX: 319-353-8988 Email: cheryl-vahl@uiowa.edu ]

Just came across this article on same topic. http://www.medscape.com/viewarticle/551082 [Submitted on: 3/9/2007 by: Shari Froelich RN, MSN, MSBA Palliative Care Foote Hospital 205 N. East Ave. Jackson, MI 49201 (517) 780-7289 Fax: (517) 780-7251 Shari.Froelich@wafoote.org ]

Question 47. I have a difficult symptom management problem and would appreciate advice from the group: 8 month infant with intractable itching. This child has developed liver problems related to TPN dependence from a non-functioning bowel. Questran was not helpful and topical steroids have had limited success. [Submitted on: 3/19/2007 by: Jennifer Gentry ANP APRN BC PCM Duke Hospital Palliative Care Service DUMC Box 3003 Durham, NC 27710 919-660-7564 Fax 919-684-8569 ] Answers I have never tried this on non-adults, but it works well on adults with itching from endstage liver and kidney disease: Nivea lotion (236 ml bottle) + 3.7 ml of clove oil, which our pharmacy mixes together in the Nivea bottle and relabels with instructions to shake well before each use. Patients apply it several times a day as needed. Most people like the smell of it, but there are a few folks who do not. I have no idea if it would be toxic to a baby if he or she would lick it off? [Submitted on: 3/19/2007 by: Elaine Glass, APRN, BC-PCM Clinical Nurse Specialist Palliative Care at Grant Medical Center 340 East Town Street, Suite 10-330 Columbus OH 43215-4639 614-566-PALL (7255) B# 614-842-1209 Fax = 614-566-8009 ]

The other lotion I have just become familiar with is called Sarna lotion. It is over-thecounter. We have had really good luck. I think itâ&#x20AC;&#x2122;s been around for a while, but it is new to me. [Submitted on: 3/19/2007 by: Sandy Muchka ]


Oxford Handbook of Palliative Medicine also suggests steroids,cimetidine, or paroxetine for itching and mentholated aquaphilic ointment. [Submitted on: 3/19/2007 by: Cheryl Vahl RN, MSN, AOCN, ACHPN vanced Practice Nurse Palliative Care Coordinator Holden Comprehensive Cancer Center University of Iowa Healthcare 200 Hawkins Drive, 5970 Z JPP Iowa City, IA 52242 Tel: (319) 356-1616, pager #5200 FAX: 319-353-8988 Email: cheryl-vahl@uiowa.edu ]

In 2003 Mel Davis et al published a case series (n=4) using Mirtazapine (Remeron) for pruritus [Submitted on: 3/19/2007 by: Jan Frandsen MSN CNP ]

See www.palliativedrugs.com for great leads. You have to register, but itâ&#x20AC;&#x2122;s free. Search by symptom, use the drop down menu for pruritus. Good luck. [Submitted on: 3/19/2007 by: Terry Thompson, MS, RN, APRN,BC-PCM Palliative Care Nurse Practitioner Four Seasons Hospice & Palliative Care 571 South Allen Ro Flat Rock, NC 28731 Cell: 828-551-8507 828.692-6178 / Fax 828.233.0355 ]

Question 48. As inpatient hospital Palliative Care Services grow within an institution, more and more referrals are made. We can get up to 15 inpatient referrals a day. I think people value the direct communication with the team and to talk through a referral. Palliative care is based on communication from the start and it is not just starting antibiotics or such. Personal touch has been my focus. Right now we have a clinician on call beeper who may get the bulk of the referrals. Others are called into specific clinicians based on previous relationships. However, there is talk of mechanizing the process, such as having a form filled out on line, faxing a page etc. Then they may talk, fax, e-mail this to a secretary who then pages a palliative care clinician to call back that person. How have other hospital based services handled this, particularly at academic teaching hospitals, the referral process? [Submitted on: 3/23/2007 by: Constance Dahlin, APRN, BC, PCM Palliative Care Nurse Practitioner MGH Palliative Care Service Boston, MA 02114 Tel 617.724.8659 Fax 617.724.8693 ] Answers We have a functional pager (970-CARE) and the bulk of the referrals come through that


pager, usually carried by me. As you mentioned, some referrals come through another clinician because of a prior relationship. In the near future, a palliative care consult may be entered in the computerized order entry system which will automatically send a page and an email notifying the team of the referral. A phone call from the referring team is still required as with any other consult service. [Submitted on: 3/23/2007 by: Jennifer Gentry ANP APRN, BC-PCM Duke Hospital Palliative Care Service DUMC Box 3003 Durham, NC 27710 919-660-7564 Fax 919-684-8569 ]

Brockton Hospital isn't a big institution (250 beds) but as the lone Palliative Care clinician it can be a challenge to see everyone. The Meditech system the hospital uses has an order entry option for palliative care consults. These print out at the main info desk and the secretaries put these in a mail slot marked "palliative care". Some clinicians also call my office at Old Colony Hospice or me directly with the referral. I usually end up calling the ordering clinician to clarify what they would like me to do and to discuss the case before I see the patient/family. I hope this ansrs your question. [Submitted on: 3/23/2007 by: Jen Bobolia,RN,FNP-C,CHPN Palliative Care Service Old Colony Hospice/Brockton Hospital 1 Credit Union Way Randolph, MA 02368 Phone 781-3414145 Fax 781-297-7345 jbobolia@oldcolonyhospice.com ]

We have tried many means to get referrals, i.e., paging, phone calls, computer generated, face to face, but the best one is the computer generated as it comes to the office and any member of the team can pick it up and do the preliminaries. The computer generated also has the capabilities of tracking/counting which none of the others are as easy to do. [Submitted on: 3/23/2007 by: Shari Froelich RN, MSN, MSBA Palliative Care Foote Hospital 205 N. East Ave. Jackson, MI 49201 (517) 780-7289 Fax: (517) 780-7251 Shari.Froelich@wafoote.org ]

Our referrals come to us by computer order entry into a system called Care Manager that prints out on the printer in our office. The computer program also cues the unit secretary to leave us a voice mail and our voice mail is set up to page us since are usually not in our office to see the printer print out. If a doctor or nurse has some special info to tell us about the referral, they contact us with the SCOOP. Otherwise, we see the patient and figure out what we need to do. [Submitted on: 3/23/2007 by: Elaine Glass, APRN, BC-PCM Clinical Nurse Specialist Palliative Care at Grant Medical Center 340 East Town Street, Suite 10-330 Columbus OH 43215-4639


614-566-PALL (7255) B# 614-842-1209 Fax = 614-566-8009 ]

We have both the on-call pager carried by our Palliative Care Coordinator (PCC) and the mechanized system where the resident/attending requesting the Palliative Consult can enter the request via computer into our Patient Information Network. This generates a page to the PCC or the Palliative Care physician/nurse practitioner on consult service. This really seems to work well and our consults are increasing dramatically! [Submitted on: 3/23/2007 by: Pamela N. Fordham, RN, DSN, CRNP Assistant Professor and Chair Family/Child Health and Caregiving Project Director, Palliative Care NP Program University of Alabama School of Nursing, UAB Deputy Director, UAB Center for Palliative Care NB 301A 1530 3rd Avenue South Birmingham, Alabama 35294-1210 (205) 934-6489 FAX: (205) 996-4113 Email: fordhamp@uab.edu ]

I find this discussion very interesting, being relatively new to an institution, and in the process of creating a palliative medicine/care service (FYI I am the only palliative medicine palliative care clinician). This may be a provocative thought, but I see no difference in how a patient is referred to a palliative medicine/care service than to any other service i.e. cardiology, surgery, etc - as you well pointed out palliative medicine/care is not a task, but a clinical service which deserve every bit as much respect as any other clinical service. If all other referrals go via a computer or are a call to a physician's office/department office then I don't have a problem, but if there is a different process then that process should be followed. I believe this is one reason why some acute pain management services have folded, and personally anything less than how other clinical services get their referrals is disrespectful. [Submitted on: 3/23/2007 by: Jan Frandsen MSN CNP ]

Very interesting, we had this discussion 5 days ago about what to do with this issue. We currently follow the same system as you (APN carries consult pager in the day and the oncall fellow covers it at night). We are growing as you and it is becoming very difficult to cover the pager, enter new consults into our database, see patients and work on "projects," so were looking at other means. We are choosing not to use computer based consult system as the rest of the hospital for our inpatients for the reasons you listed below. Our consulting services love to talk to us personally and we get so much more information than you would with just a computer generated consult. One idea we are thinking about for our future is either a coverage APN or a triage RN. This person would handle consult pager,


enter data into the database, cover follow ups if numbers get too large, handle our phone care program and general "quarterback" for our service. We are going to revisit this issue at our next meeting so I will see if more ideas have come up. [Submitted on: 3/23/2007 by: Kelli Gershon, MSN, APRN, BC-PM APN Palliative Care The University of Texas MD Anderson Cancer Center (O) 713-792-5935 (P) 713-404-1141 (F) 713792-6092 ]

We essentially follow the same process you have in place, believing the personal communication is essential, and it ensures the referring house staff that "someone" got their referral. We are a teaching service, which means that there is always an internal medicine resident on the service full time (Monday - Friday). Our policy is that all calls for palliative care (via the paging operator) automatically go to the resident on palliative care. If someone specifically wants to speak with an attending provider, they can request that person be paged. The house staff take the initial consult, and have a discussion with the referring provider about the consult (urgency, goal, history, etc). I have found that in an academic medical center with many house staff, that they are not always able to identify what they need from palliative care, they just know they want a consult. The person to person communication provides a tremendous learning opportunity for both residents. It provides the palliative care resident with the opportunity to discuss palliative care and teach what our service can do, and it allows the referring resident the opportunity to learn the many, many services palliative care has to offer, most of which they did not know. We considered a "referral" line, but then decided against it out of concern for losing the communication. Clearly we are not getting 15 consults per day (we average 3-5), and as we get busier I can see might have a problem. Other very busy consult services such as renal follow the same process, and it seems to work for them. I am not sure a fax information sheet would provide the informal education for which palliative care is so well known. [Submitted on: 3/23/2007 by: Darrell Owens,Ph.D.,ACHPN,APRN Clinical Assistant Professor and Director Palliative Care Consult Service Harborview Medical Center Box 359806 325 Ninth Ave Seattle, WA 98103 VM:206-341-4636 Fax:206-731-2363 Pager:206-541-0776 Email: owensd@u.washington.edu ]

I work in a hospital that has 4 campuses and my team currently sees patients at 3/4 of them. The 4th hospital is being integrated into our system but the medical staff is and will remain separate. There are 2 FT team members with a 3rd coming on board next month. We have students (nursing), residents and an occasional fellow on elective. We currently receive consults via pager and either myself or the physician I work with speaks directly to the referring physician. We do require that all referrals are provider to provider and have


deliberately not activated a computer generated consult request. There is an excellent article in the Feb JPM about consultation etiquette by Diane Meier. As an APN, I was never formally trained in consultation practice; my training focused on obtaining consultations, not the expected norms of providing them. I wish that I had had the Meiere article when I first began this role; I plan to give copies to trainees in the future. The 400 bed adult hospital generated about 25 new consults this week...today it was 12, nearly all of them after 1pm. Monday will be busy. [Submitted on: 3/23/2007 by: Linda S. Blum, MS, GNP, APRN-BC Palliative Medicine Program Coordinator California Pacific Medical Center San Francisco, CA 94120 VM 415600-4576 Pager 415-809-0122 ]

This is interesting to read others' experiences. Referrals to our adult PC service have generally come via pagerbox and sometimes through a voice mail message. But I always call the referring person back to discuss particulars and they appreciate that. We will be generating consults through the computerized order entry system in the next month or so. I totally agree with the importance of clinician-to-clinician communication--there is a LOT of teaching we do there, especially for house staff, which ultimately has an even greater, ripple effect on patient care as these clinicians learn how to think through the issues. I would not want to lose that with a computer-generated referral mechanism. As well, other pertinent patient information gets communicated "live" and order entry systems do not always capture that detail. So thanks to all for sharing--I will be more cognizant about what I want to do when we are in POE. [Submitted on: 3/23/2007 by: Rita Mastroianni, APRN, BC-PCM Johns Hopkins Hospital 1830 E. Monument Street Baltimore MD 21287 410-614-5284 410-955-2076 fax ]

We use an automated system. Providers put an order in that generates a fax that my assistant pages to the service pager. There is room on the order for providers to say why they are putting the consult in but it's not always filled out. I then page the provider for more background and also to acknowledge I've gotten the referral and give them an idea of when I might be able to see the pt. We are only getting a few referrals a day so this is working for us. We also operate only M-F, 8-5. [Submitted on: 3/26/2007 by: Marian Grant CRNP, Palliative Care Service Johns Hopkins Bayview Medical Center 410-550-1145 phone 410-283-5720 pager ]

I have been watching this thread with interest. We converted from paper to computer order


entry 2+ years ago. We have a consultant task list which lists consults as they are ordered for pain, palliative care, ethics and other nursing consults such as wound, CHF nurse, lactation, etc. All these consultants see the same master list. (HIPPA??) I create my own list from this. Unlike computer generated consult requests for a specific physician where there is a prompt to call the individual, these consult orders do not include this reminder. Sometimes I receive a page, or a voice mail message; sometimes not. This works in nonemergency situations assuming I am there. If I am off (nights, weekends, vacation, etc.), it is possible I will miss a consult. Nursing is used to my high visibility, so have said they don't think to call because they know they will see me. I suppose this is flattering, but I worry. When I receive a consult request, I call the referring person to discuss the situation. For any of you planning the change to computerized order entry, I advise building in a prompt reminding the referral source to contact the consultant. To not do so is a breach of consult etiquette, slows things down, etc. Changing the system once it is in place is more difficult. Thanks for this, it reminds me to fight harder to change my system. [Submitted on: 3/27/2007 by: Lori Hedges MS, APRN, BC-PCM Advanced Practice Nurse, Pain Management & Palliative Care Advocate Illinois Masonic Medical Center 836 W. llington Chicago, IL 60657 telephone: (773) 296-5837 pager: (773) 713-5078]

Question 49. Does anyone out there have experience with JCAHO and Emergency Kits in the home? If so, what has JCAHO's response been to your protocols. I do triage for a hospice which refuses to use e-kits in the home which has resulted in hours of suffering for patients as they wait for medications to be delivered. While I understand the philosophy of individualized plans of care, I don't see how having medication on hand in case of a foreseeable common symptom does anything but improve patient care. [Submitted on: 3/21/2007 by: Rebecca Gagne Henderson RN, BSN, CHPN] Answers We have JCAHO accreditation and we use Comfortpaks from Hospice Pharmacia in our patient’s home with an order from the physician. The medication list has “Comfortpak” listed. When any medication is initiated from that comfort pak, that specific order for that medication is also added to the medication list. We just had a survey and there was not an issue with this that I am aware of. [Submitted on: 3/21/2007 by: Jennifer Fournier, RN, MSN, AOCN, CHPN Clinical Nurse Specialist Hospice Savannah, Inc. 1352 Eisenhower Dr. Savannah, GA 31406 912-629-1072 ]


We have a “Comfort Pak” available from Hospice Pharmacia. JCAHO revied us last year and had no problem with it, though I know different surveyors will have different opinions, no matter what JCAHO may say (my bias is showing.) Our admit orders, which may be customized to the patient, include an order that the Pak may be placed in home if the RN feels it is appropriate and (in bold) that medications cannot be used without calling for an order. The medications and doses and number dispensed are then listed. [Submitted on: 3/21/2007 by: David Hall FNP Willamette Valley Hospice 1015 3rd St NW Salem, OR 97304 503 588 3600 x313 Fax 503 363 3891 davidh@wvh.org ]

When I worked in D.C. we had emergency kits. We were also JCAHO certified. Believe it or not our local pharmacy at the time made them for us. Use was similar to what has been described. They can also be very cost effective. Instead of wasting a Roxanol bottle when only 1-2 doses were given. I too have been frustrated because I can't convince my current hospice to investigate their use. [Submitted on: 3/21/2007 by: Nanci Tansey, APRN, GNP Mercy Hospice and Palliative Care Myrtle Beach, SC ]

I have had similar experience as the one listed below. The most important item is that there is an “assessment” for the appropriateness, an order from the physician that allows placement – complete the assessment on admission – and place the documentation in the medical record. If the patient already has appropriate symptom orders and medications that are already covered by the items in the Comfort Pak we don’t order it, we don’t order them at all for Assisted Living and Nursing Homes – ever – Also, unless the home environment has been assessed for safety and potential for drug diversion and someone who can responsibly ensure safety of the kit – it’s not a good idea to order one-additionally, care has to be taken to ensure assessment for potential allergies and previous adverse reactions are noted and any items that might be problematic need to be removed prior to ordering the kit. [Submitted on: 3/21/2007 by: Pamela Lippitt]

Another issue, similar but different. A hospice I worked with which did not send out e-kits to nursing homes. The reasoning was, if a patient did not use it, it would be wasted at the end of the month- and then needed to be reordered the following month. - Thus, when a pt turned on a dime, started actively dying, the pt suffered for hours without medication.Borrowing from others was not available. Any thoughts regarding the regulations of the


medications in nursing homes? [Submitted on: 3/21/2007 by: Jennifer Clark]

In my experience working with a hospice that provided care to patients in nursing homes, we got around the issue of providing medications for urgent symptom relief to nursing home residents by becoming familiar with which medications the nursing kept on hand for such urgencies. We found that they kept injectable morphine, haldol, ativan, and compazine supp on hand. This helped our patients until we were able to get a regular supply of the needed medications into the nursing home. [Submitted on: 3/21/2007 by: Robert Smeltz, RN MA PNP ACHPN Nurse Practitioner/Clinical Coordinator Palliative Care Service Jamaica Hospital Medical Center Office: 718-206-6919 Fax: 718-206-8716 Pager: x16869]

We have found the same thing. Also injectable Atropine which came in very handy on a Friday night. [Submitted on: 3/22/2007 by: Nanci Tansey APRN, GNP Mercy Hospice and Palliative Care Myrtle Beach, SC]

Our admit orders included all the medications provided in the comfort packs, so we didn't have to get an additional order at the time of use. I have found that more hospices don't use the kits than do, but I think it does improve the standard of care. [Submitted on: 3/22/2007 by: Shari Froelich RN, MSN, MSBA Palliative Care Foote Hospital 205 N. East Ave. Jackson, MI 49201 (517) 780-7289 Fax: (517) 780-7251 Shari.Froelich@wafoote.org]

In the situation where a local pharmacy was making up the kits, how did you get them out to the patients' homes? Did the pharmacy deliver? [Submitted on: 3/22/2007 by: Julia Gies, APRN, BC-PC Providence Connections Palliative Care Program 3601 SW Murray Blvd, Suite # 40 Beaverton, OR 97005 (503) 574-9547]


I work for a Hospice in Michigan and I am able to carry an Emergency Drug Box in my car for which is used through standing orders and provides medications for patient's who do not have the needed medication in the home for symptom management. The drug box is refilled by our local pharmacy and our medical director signs the scripts for any medications we may have used for the specific patient. [Submitted on: 4/3/2007 by: Linda M Boeye]

Our hospice uses "comfort kits" that include Roxenol, Haldol liquid, Hyoscyamine, Lorazepam, Compazine (oral and supp) and a great supp (ABHR) that has ativan/benryl, haldol, and Reglan. We have Hospice Pharmacia remove anything not appropriate before overnight delivery. Almost all physician agree to it and our admissions department often orders it so it is in the home on admission. IT IS WONDERFUL!!! Also, switching to Hospice Pharmacia has been very COST EFFECTIVE!!! as well as a gift to our rural population. We do waste lots of drugs as the kits are only for individuals and must be delivered to a patient's home. [Submitted on: 4/3/2007 by: Maryanne Kehoe]

Have you ever felt that carrying the e-box in your car puts you at any kind of safety risk? [Submitted on: 4/4/2007 by: Julia Gies, APRN-BC-PC Providence Connections Program 3601 SW Murray Blvd, #40 Beaverton, OR 97005 (503) 574-9547]

Question 50. Do any of you who work in the hospital setting have any experience or know anything about Perinatal Palliative Care Programs? I was approached by our Ethics Committee due to a recent case that caused moral distress for all involvedâ&#x20AC;Śfamily and professionals. My work email dress is Sarah.Lippitt-Houston@stjoe.org ! Appreciate any guidance I can receive. [Submitted on: 3/21/2007 by: Thankyou! Sally Lippitt-Houston, MSN, RN, CNS Palliative Care Consult Santa Rosa Memorial Hospital Santa Rosa, CA.] Answers Children's Hospital in Minneapolis/St. Paul has a perinatal hospice program called Deeya, which is Sanskrit for "a small light." The director is Jody Chrastek; she can be reached at: Jody.Chrastek@childrensmn.org There was a recent article in the New York Times about this topic and highlights the Deeya program above. You can find it online, date of


publication was March 13th, authored by Neela Banerjee, title "A Place to Turn to When a Baby is Fated to Die." [Submitted on: 4/23/2007 by: Kerstin McSteen Palliative Care Service Abbott Northstern Hospital 800 E. 28th Street Mail Route 14201 Minneapolis, MN 55407-3799]

Advocate Lutheran General Hospital in Park Ridge, IL has such a program. [Submitted on: 4/27/2007 by: Lori Hedges]

Question 51. I am running into more difficulties with nursing homes allowing hospice involvement. One argument I'm hearing is that they can get more reimbursement from Medicare if they are able to skill those pts. (ie after hospital d/c) for 100 days or so. They get paid more for not using hospice, and families don't have to pay room and board during this time. Many patients die during this time, or they get into the cycle of just sending them back and forth to the hospital to waste more Medicare dollars and give patients the care they don't want. In one particular facility, the DON is making a habit of "talking families out of hospice" for these reasons. She also thinks her staff should be able to provide palliative care themselves, but that's another issue. Does anyone know of any efforts to improve palliative care reimbursement in the LTC setting? Or, suggestions for pushing for change on this issue? [Submitted on: 4/25/2007 by: Maria Ferrell, APRN, BC-PCM Clinical Nurse Specialist Kansas City Hospice & Palliative Care 816-363-2600, ext. 2714 mferrell@kchospice.org] Answers In Massachusetts room and board in LTC can be paid by MassHealth (Medicaid) and then hospice can be paid out of Medicare Part A with no out of pocket expense to the patient/family. However, if there isn't a secondary payer like Medicaid to pick up the room and board charges, it would fall on the family to pay them if they also wanted hospice. The alternative is for the family to pay out of pocket for the hospice care and have the patient use their 100 skilled Medicare days. Unfortunately, there isn't any good way around the problem that I know of at present. Are you credentialed as a consulting clinician at any of these facilities? My hospice has an agreement for the hospice nurses to provide "pain consultations" for patients who are in this type of situation. The nurses will leave recommendations for pain/symptom control and follow up for up to 2 additional visits. The SNF is charged a small fee for this--about $100 if I remember correctly. It is not billed to Medicare as it is an RN visit. If you are there as a consulting clinician, you could bill Medicare directly for your visits.


[Submitted on: 4/25/2007 by: Jennifer Bobolia, FNP-C, ACHPN Palliative Care Service Old Colony Hospice/Brockton Hospital 1 Credit Union Way Randolph, MA 02368 Phone 781-3414145 Fax 781-297-7345 jbobolia@oldcolonyhospice.com]

There was a time when I worked with a hospice that had patients on service and actually discharged them at the request of the SNF so the SNF could get the skilled days. (Needless to say, I did not stay with that group long) On the micro level a response is to educate and appeal to their compassionate side. I should mention that I have worked with many SNF's with staff that are wonderful, caring, and compassionate. Personally, I think the real solution would be a DHS or CMS policy passed that if a SNF has a certain percentage of patients die without the benefit of hospice they sould be investigated by DHS (just as pressure ulcers are) The policy should require that hospice information should be provided at the same time they provide advance directive information upon admission, and that prior to death the goal should be that there is an EOB provided and documented in the chart for each patient. You know how those SNF's love to follow those regs. That would fix their little red wagon. [Submitted on: 4/25/2007 by: Rebecca Gagne Henderson RN BSN CHPN Director of Education Directives: Palliative & Hospice Consultative Svcs]

This same thing is happening here as well. Once CMS opened the flood gates to allow payment for "Palliative Care" the nursing homes magically began offering it. I asked one of the SNFs once how they provided their palliative care and what their training was. They told me they provided pain management (Darvocet was their most common) and brought in the hospice chaplains for free spiritual support. I find that downright offensive. Is there something as a group we can do? What is the stance of the NHPCO? I am out of their loop at present in the acute care setting. By the way every patient we send out to nursing homes gets SNF'd whether they want it or not. Even if we have gotten hospice in place for them. I believe this is Medicare abuse and tax dollar abuse. Last but not least, once the nursing home uses up all the Medicare days the patient is out of luck. [Submitted on: 4/25/2007 by: Nancy Cato Grabb, RN-BC, BSN, MBA, CHPN Manager Palliative Care Methodist Dallas Medical Center 1441 N. Beckley Dallas, Texas 75203 214947-2526 - office and voicemail pager 972-451-2453 - pager 214-947-2499 - fax nancygrabb@mhd.com]

Families so frequently are caught in this financial bind wanting hospice, working unable to


provide care and financial assistance . Once again it is the middle class working families that are squeezed the most! I wonder how many peg tube procedures would be avoided if pt didnâ&#x20AC;&#x2122;t qualify based on that alone? [Submitted on: 4/25/2007 by: Rita Hand]

I believe one of the ways through this dichotomy is through legislative efforts. We have plenty of evidence that the right thing for patients and families is hospice support and as all of you have already mentioned is the financial gap between skilled Medicare and hospice care in the nursing home setting. What is lost is focusing on what is right for patients and not what is best for nursing homes ($$). Our strategy would be to come up with something in-between. I don't know what that would be, but maybe something like pilot projects with Medicare to show that less hospitalizations would occur, better patient family outcomes, etc. [Submitted on: 4/25/2007 by: Shari Froelich RN, MSN, MSBA Palliative Care Foote Hospital 205 N. East Ave. Jackson, MI 49201 (517) 780-7289 Fax: (517) 780-7251 Shari.Froelich@wafoote.org]

Another strategy I have seen work is when the attending physician just tells the family they need hospice care in the SNF and it is private pay. No choices provided. This works if the physician understands the regulations rather than offering to keep the patient on IVs to provide a skilled need so family doesn't have to pay. Often healthcare providers just assume the patient can get hospice services in SNF and everything is covered. Then the consent for hospice should be completed in the hospital before the patient gets to SNF. Changes in the Medicare benefit are the only option for real change. My understanding is that Medicare sees paying for the hospice benefit and skilled care in SNF as duplication of services altho I agree I have never seen a SNF that can provide the range or skill set of a hospice agency. So this comes down to Medicare regulations. Obviously data needs to be kept on number of patients on skill days in SNF who end up back in the hospital for their last days. Sounds like a great project for someone with a national focus. Anyone know someone? [Submitted on: 4/25/2007 by: Linda Gorman Cedars Sinai Medical Center Palliative Care program]

I like what Dr. Joanne Lynn says: "What's easy & routine is what happens to patients. If you want to change what happens to patients, you have to change what's easy & routine." I believe she has been involved in some "Medicaring" demonstration projects in the past and


perhaps ongoing... I've used a list of the NQF preferred practices to gently challenge statements in NF's that they don't need hospice because they're already doing it... [Submitted on: 4/25/2007 by: Mary Zuccaro, FNP Palliative Care Consultations A service of Valley Hospice, Inc. Steubenville, OH and Wheeling, WV]

If there is a concern that there are patients who would not survive their skilled medicare benefit in the nursing home, patients close to the EOL are often appropriate for inpatient hospice. You could work with the nursing home to create inpatient hospice beds, and create a win/win/win situation for the facility (get higher reimbursement than they would with medicaid (at least in my state)), patient and family gets the benefit of hospice, and the hospice gets to see the patient and get reimbursed. [Submitted on: 4/26/2007 by: Robert Smeltz, RN MA PNP ACHPN Nurse Practitioner/Clinical Coordinator Palliative Care Service Jamaica Hospital Medical Center Office: 718-206-6919 Fax: 718-206-8716]

We have the same problem in Michigan. Most of our facilities would rather use the skilled days than put a patient on hospice, unfortunately the patient is the one that suffers by not being able to get the benefit of hospice. [Submitted on: 4/29/2007 by: Linda Boeye]

The issue of Medicare reimbursement for appropriate patients in nursing homes. Patients who go out on skilled days, therefore unable to access their hospice benefit, and come right back to acute care facilities, sometimes many times, for symptom control or other issues that could have been handled by the hospice team in the NH. Most of the patients in our area go to the NH because they don't have a dedicated caregiver. There is most often not an option for a free-standing hospice admission. Additionally, in North Carolina, we often have patients discharged from hospital who have several hours of personal care home health aide service under our state Medicaid program. If these patients choose hospice at home, they have to "give up" their personal care aide. Sometimes these aides have been in the picture for years and are necessary to keep the pt in the home setting. Perhaps it would be possible to have two levels of hospice reimbursement - one for those who require a home health aide and one for those who already have an aide under another program. ? Good luck! [Submitted on: 5/8/2007 by: Susan Redding, MSN Pitt County Memorial Hospital Dept of Care Management/End of Life Care PO Box 6028 Greenville, NC 27835-6028 252-847-0868


252-847-7096 FAX]

Question 52. Has anyone found a helpful treatment for severe dyspnea? How far have you gone up on nebulized morphine and has anyone really found that to work. So far the literature is not very hopeful. [Submitted on: 5/1/2007 by: Becca Hawkins, MSN, ANP Nurse Practitioner Palliative Medicine/CME Coordinator St Mary Medical Center Walla Walla, WA 509-522-5514 Ext: 2392 Fax: 509-522-5504] Answers We use IV or oral morphine with success titrating as needed and using steroids, inhalers, lorazepam, oxygen, positioning, pursed-lip breathing, fans, air conditioning, etc as needed in a case-by-case basis. I will ask my colleague to respond who had data on use of nebulized morphine from a yet-unpublished study about use in NJ hospice patients to also respond. In New Orleans at AAHPM/HPNA 2OO5, there was a great review session on Dypsnea - a kind of state of the science. Should make an excellent CD purchase despite being from 2OO5. [Submitted on: 5/1/2007 by: Kathleen McMahon MEd, MA, CHPN Atlantic Home Care and Hospice Milburn, NJ]

Nebulized Fentanyl Citrate Improves Patientsâ&#x20AC;&#x2122; Perception of Breathing, Respiratory Rate,and Oxygen Saturation in Dyspnea Patrick J. Coyne, RN, MSN, CS, CHPN, Ramakrishnan Viswanathan, PhD, and Thomas J. Smith, MD Palliative Care Services (P.J.C., T.J.S.), Department of Biostatistics (R.V.), and Division of Hematology/Oncology (T.J.S.), Massey Cancer Center, Virginia Commonalth University, Richmond, Virginia, USA Abstract Dyspnea, a subjective symptom of impaired breathing, occurs in 70% of terminally ill cancer patients. Current treatments are suboptimal and little is known about the patientâ&#x20AC;&#x2122;s perception of effect. We tested nebulized inhaled fentanyl citrate on patient perceptions, respiratory rate, and oxygen saturation. The study was conducted using a convenience sample of 35 cancer patients on a dedicated oncology unit. We assessed patient perception (did breathing stay the same, worsen, or improve), respiratory rate, and oxygen saturation by pulse oximetry at baseline, 5 minutes, and 60 minutes. Twenty-six of 32 (81%) patients reported improvement in breathing, 3 (9%) were unsure, and 3 (9%) reported no improvement. Oxygen saturation improved from 94.6% at baseline to 96.8% at 5 minutes and 96.7% at 60 minutes (0.0069 compared to baseline). Respiratory rates improved from a baseline of 28.4/min to 25.9/min at 5 minutes and 24.1/min at 60 minutes (0.0251 compared to baseline). No side effects


were observed. Inhaled nebulized fentanyl citrate significantly improved patient perception of breathing, respiratory rate, and oxygen saturation. This inexpensive and readily available treatment may offer substantial relief of end-of-life dyspnea. Randomized trials, dose, and length of effect trials are underway. J Pain Symptom Manage 2002;23:157â&#x20AC;&#x201C;160.Š U.S. Cancer Pain Relief Committee, 2002. [Submitted on: 5/1/2007 by: Patrick Coyne]

I have references from UK that give neb doses of morphine up to 50 mg. Have personally never used more than 10-15. Fentanyl recommended over MSO4--see JPM. Only anecdotal evidence nebs work, ie, no EBM. Consider IV/SQ opiods. Add steroids for stridor. [Submitted on: 5/1/2007 by: Terry Thompson]

In the past at our hospice, we have used the combination of nebulized morphine and dexamethasone with varying degrees of success. As the data has not supported the use of nebulized morphine, we have tended to rely more heavily on po, sq, or IV morphine. We have also used nebulized Lasix and are trying nebulized dexamethasone now as well. I know that one of our NP's did a presentation on the nebulized Lasix so I'm sure there are data available for that treatment. [Submitted on: 5/1/2007 by: Jessica Wenberger APRN Alive Hospice, Inc. 1718 Patterson St. Nashville, TN 37205 615-963-4783]

There is a newsletter on the topic of opioids in the management of dyspnea that I just wrote last month (April, 2007) for our hospice clients. [Submitted on: 5/1/2007 by: Terri L. Maxwell PhD, APRN, BC-PCM Vice President of Research excelleRx, Inc., An Omnicare Company 1601 Cherry St. Suite 1700 Philelphia, PA 19102 tmaxwell@excelleRx.com 215-282-1789 (office) 215-360-2924 (mobile)]

This question comes up fairly regularly, might even be on the FAQ on the HPNA site for APN members. The responses are usually consistent too: not much actual evidence, occasional problems with bronchospasm, even with outcome of death. I had a hospice pharmacist explain to me once that any benefit derived is probably related to the fact that a certain amount of the opioid is being absorbed via the lung tissue. Hence, it seems like a lot of


effort messing with a nebulizer set up, in addition to not really knowing how much is being absorbed. Why wouldn't one just use the usual modes of easy administration: oral, SC, IV, rectal? [Submitted on: 5/1/2007 by: Kerstin McSteen, RN, CNS Palliative Care Service Abbott Northstern Hospital 800 E. 28th Street Mail Route 14201 Minneapolis, MN 55407-3799 (Office) 612-863-6539 (Pager) 612-654-2631]

The thread has moved to nebulized morphine. I want to respond to the original question about how to assist patient with severe dyspnea. First, what is the source and is the source potentially reversible given the patient's terminal illness trajectory. Is the patient volume overloaded, anemic, ascitic, pleural effusions? Is there something to diurese, transfuse, tap? Have the bronchodilators, steroids, and oxygen been maximized if COPD? Has the CHF regimen been optimized if CHF? Would the patient benefit from non-invasive ventilation, e.g. BIPAP as a temporizing strategy until the underlying cause can be reversed? Moving from correcting reversible causes, if any: Is the patient anxious and/or afraid? Would a trial of low dose ATC benzo be a helpful adjunct to morphine or fentanyl? I like 0.5mg lorazepam q6 ATC as an initial dose if patient is benzo na誰ve. A helpful reference re: dyspnea is the 2006 publication by Booth and Dudgeon, Dyspnea in Advanced Disease: A guide to clinical management. http://www.amazon.com/s/ref=nb_ss_gw/104-70317113131912?url=search-alias%3Dstripbooks&field-keywords=Booth+and+Dudgeon. [Submitted on: 5/1/2007 by: Margaret L. Campbell, PhD, RN, FAAN Palliative Care Nurse Practitioner Detroit Receiving Hospital 4201 St. Antoine Detroit, MI 48201 313 745-3271 mcampbe3@dmc.org]

I think Meg Campbell brings up a really important point. Look at the underlying cause for the Dyspnea first or what ever symptom you are treating and manage that (first) as a part of the overall management. [Submitted on: 5/2/2007 by: Jan Frandsen MSN CNP]

Because of the preservative in morphine that might cause bronchospasm, I use to use Fentanyl 50-100 mcg q hr PRN per med neb. For someone in really bad shape, I have used it q hr x 4 to get the dyspnea under control, and then q 4 hrs ATC, WA to keep it under control. I have not used it for a long time because the literature does not support it's use. However, I can remember 2 pts that I used it on and it was a Godsend to them. The literature supports the use of IV morphine, which I give CIV + PCA q 8 minutes, with a fairly


large loading dose (depending on the pt's opioid hx.), which has also been quite successful. For pts with a creatinine over 1.5, I use dilaudid the same way. [Submitted on: 5/2/2007 by: Elaine Glass, APRN, BC-PCM Clinical Nurse Specialist Palliative Care at Grant Medical Center 340 East Town Street, Suite 10-330 Columbus OH 43215-4639 614-566-PALL (7255) B# 614-842-1209 Fax = 614-566-8009]

What about a patient who is opioid tolerant (taking opioids for pain) and becomes severely dyspneic? How much immediate release opioid can be safely given? The patient is taking 10-20% of his 24 hour morphine dose as breakthrough every 1 hr prn and takes beten 4-5 prn doses daily. Assuming he is already tolerant to the respiratory depressive effect of the opioid, how much IR can safely be given for his dyspnea? [Submitted on: 5/2/2007 by: Bonnie Morgan]

I think that it is not really a matter of how much opiate can you give for symptomatic management of dyspnea but figuing out the etiology of the dyspnea and treating the underlying cause if possible. Meg's post on this was quite eloquent and to the point. I would ask myself what have I missed: is this a COPD exacerbation that would respond to steroids? perhaps r/t to a CHF exacerbation and diuresis needed? bronchospasm and needs nebs? Infection? Anxiety? Have you tried nonpharmacologic modalities? The list goes on.... and then whatever opiate dose works, works. [Submitted on: 5/2/2007 by: Linda S. Blum, MS, GNP, APRN-BC Palliative Medicine Program Coordinator California Pacific Medical Center San Francisco, CA 94120 VM 415-600-4576 Pager 415-809-0122]

I agree with Linda on this, especially regarding anxiety and remembering to consider nonpharm interventions. [Submitted on: 5/3/2007 by: Mary Zuccaro, FNP Palliative Care Consultations Steubenville, OH & Wheeling, WV mzuccaro@valleyhospice.org]

Of course it is important to find the underlying cause, but so many of our patients who are referred to palliative care have advanced chronic illnesses, and those with lung ca, chf, and copd often will have a component of their shortness of breathe that's cause is not


reversible. When the dyspnea is severe, and the cause requires some degree of work up that takes time, it is important to relieve the patient from their suffering while they await treatment for their cause. Which brings up another point, treatment of their underlying cause my not be consistent with their goals of care. Some patients may not want a tap, IVs, or blood draws which would be part, in some cases, finding a reversible cause. So, what do do if cannot find a reversible cause of severe dyspnea or a reversible cause, treatment of which is not consistent with patients' wishes: maximize use of oxygen (most patients I come across hate BiPAP or need to be restrained to keep it on), diuretic, steroid, bronchodilators, and antispasmodics as indicated, and of course opioids and benzos. I agree that non pharmalogical interventions should not be overlooked. [Submitted on: 5/3/2007 by: Robert Smeltz, RN MA PNP ACHPN Nurse Practitioner/Clinical Coordinator Palliative Care Service Jamaica Hospital Medical Center Office: 718-206-6919 Fax: 718-206-8716 Pager: x16869]

Question 53. At risk of bringing up the dypsnea issue again, I am trying to develop an evidence based practice around the use of Ativan in my palliative care practice. Having worked in nursing homes, I have developed my practice around the notion that as little as possible ativan is a good thing given the increased falls, delirium, and fact that it does not reduce pain or dyspnea, but potentiates opioids.I struggle with the frequent use I see in the hospital and so have tried to get clear about the evidence out there around when and how to use it...Does anyone have good data about it...There was a recent article in the J of Pain and Symptom Management re: versed and morphine in dypsnea. I have always felt that the benzo reduces anxiety because the dyspnea is not well managed...it seems that nurses are more comfortable giving the ativan than the morphine with pain or dyspnea...thanks for your thoughts...and references, if any. [Submitted on: 5/3/2007 by: Laura Lathrop APRN, BC-ANP/PCM Allina Home Care, Hospice and Palliative Care Unity/Mercy Inpatient Consult Service B-612-654-6943 W 763-236-3651 laura.lathrop@allina.com] Answers The geriatrics literature is rife with data about the pitfalls of lorazepam in older adults including as a cause of falls and injury. In the critical care literature, it has been found to be one of the most deliriogenic medications on the formulary. I will get citations for you and email you off line if I can get your email. [Submitted on: 5/3/2007 by: Linda S. Blum, MS,GNP,APRN-BC Nurse Practitioner Palliative Care Service California Pacific Medical Center Telephone: 415-600-4576 Pager: 415-8090122]


Years ago, my mentor passed on a pearl he learned at a palliative care conference regarding lorazepam: "Ativan equals agitation." In my hospice practice, we use it only for anxiety, rarely for agitation. It usually works very well for COPD patients. [Submitted on: 5/3/2007 by: Jessica Weinberger APRN Alive Hospice, Inc. 1718 Patterson St. Nashville, TN 37205 615-963-4783]

Try doing a medline search under the name Eduardo Bruera, MD. He did a presentation on Feb 11, 2006 at the national mtg in Nashville and the his review of the literature indicated that evidence does not support the use of benzos unless the pt wants to sleep. Our pulmonary intensivist says the literature he reads supports opioids over benzos. [Submitted on: 5/3/2007 by: Elaine Glass, APRN, BC-PCM Clinical Nurse Specialist Palliative Care at Grant Medical Center 340 East Town Street, Suite 10-330 Columbus OH 43215-4639 614-566-PALL (7255) B# 614-842-1209 Fax = 614-566-8009]

There is a nice summary regarding the use of opioids for dyspnea in Evidence Matters by Dr.Terri L.Maxwell, Vol.1, No.2, 2007. Hospice Pharmacia, Phila. [Submitted on: 5/8/2007 by: Susan Redding, MSN Pitt County Memorial Hospital Dept of Care Management/End of Life Care PO Box 6028 Greenville, NC 27835-6028 252-847-0868 252-847-7096 FAX]

Question 54. Is anyone familiar with how the Medicare home health regs affect APN practice? I have recently been informed that the Medicare Conditions of Participation for home health agencies states the plan of care must be ordered by a MD, DO, or podiatry. The president of my state nursing organization said that this issue has been on the national agenda and lobbied by ANA for some time to update regs to include APNs. I don't know where this stands, but have attempted to contact ANA for an update. His description of this process is that an APN can "relay" the order, but the agency must record it as a telephone or verbal order which is later then signed by the physician. At first I found this news devastating as our palliative home care program follows home health regs. Then I realized that I think I should still be able to write scripts, etc. as long as the actual order in the chart is recorded as coming from a physician, and he /she signs off on the order. I see this as "relaying" or carrying out the order that the physician has agreed to. I think this makes sense, especially in cases where


the ordering physician is your collaborating physician. This is actually very consistent with what we already do since we consider ourselves more of a consultative service. Does anyone else out there work within similar programs or have thoughts on this issue? Any references are also appreciated. Also, what about billing for APNs for pts. receiving home health services? Anyone know of restrictions here? A question has also come up about if APN visits can count as RN visits. My line of thought is that they cannot if the APN is billing separate for her services and the RN visit is considered part of the total package under home health benefits. Does anyone have more info to share? [Submitted on: 5/8/2007 by: Maria Kirchhoff] Answers it is my understanding that we can bill for home health visits under Medicare B and I believe there is a CPT code for this. I have made a home visit or two for one of our oncology patients. Our billing department handled the billing so I don't know the code. I would think that home health visits by an APN would use the same kind of billing code under part B. There is a little handbook of CPT codes, but I don't have one on me at this clinic site so I cannot presently look it up for you. [Submitted on: 5/9/2007 by: Karen Gilbert, ARNP 1454 Mud Bay Rd Lopez Island, WA 98261 360 468-2406 H 360 472-1095 C karengilbert@rockisland.com]

If you are asking about the initial orders for homecare, they must be done by a physician. NPâ&#x20AC;&#x2122;s can order hospice by the certficate of terminal illness must be done by a physician. Hospice can take NP orders., home care may not.. The NP may give a verbal order that then needs to be written in plan of care by MD. [Submitted on: 5/9/2007 by: Connie Dahlin]

The home care issue comes up in Congress every couple of years or so. What is required is that the sections of the Social Security Act dealing with home care be amended to allow APRN's to sign a plan of care and to certify homebound status and medical necessity. The current efforts are being spearheaded by a coalition of NP groups (including ANA and AANP) and the National Association for Home Care (NAHC). They have identified a sponsor for the legislation, Senator Susan Collins, R-ME, and are soliciting co-sponsors. I don't know how many senators have signed on, nor do I know realistically whether the bill has a good prognosis or not. You can get more information from Erin McKeon at ANA (Erin.Mckeon@ana.org) or from Jan Towers at AANP (202-966-6414). The last I heard, the coalition was considering changes in the home care rules only --- not hospice. Although the


National Association for Home Care has long been an advocate for APRN's, none of the national hospice associations, including NHPCO has ever taken a leadership position on changing the Medicare hospice rules to allow NP's to sign CTI's. [Submitted on: 5/9/2007 by: Julia Gies, APRN, BC-PC Providence Hospice and Palliative Care Portland, OR]

I am not really concerned with the initial order written for home care -- that is already done by the time I am involved. My concern is related to being able to order medications for palliative management of pain and symptoms once they are already on home health care. Often the physician will request that we manage pain / symptoms. Does this make a difference, or does each order for any type of intervention still need to come from the physician (or at least have physician's signature)? [Submitted on: 5/9/2007 by: Maria Kirchhoff]

I work in a free standing hospice that has hospice home health. I have the consult written as evaluate and treat as indicated so that I can initiate the medical orders. When the consult is written for consult for a specific symptom, I will write orders and the last order states "Initiate above orders if verified with Dr..........." I hope these are helpful suggestions. [Submitted on: 5/9/2007 by: Freda Clark Cowan, MSN, FNP-C,CWS Hospice and Palliative Care Center Winston Salem, NC]

Question 55. I am wondering if anyone knows the process necessary for a palliative care APN to bill for services provided in the hospital setting. What needs to be set up prior to actually being able to bill? Is there a reference online that can be referred to? Any help with this would be greatly appreciated!! You can respond directly to me at deathmidwife@yahoo.com. [Submitted on: 4/30/2007 by: Laurie De Lalio MS, APRN, BC, CT, ACHPN Palliative Care CNS Baylor University Medical Center Dallas, Texas 214-820-6851] Answers I am serving as an attending physician for my hospice in Fl. This was a decision by the Medical Director and management prior to my hiring as the first (and only at present) NP at hospice. The decision was made to be able to bill for my services for the organization. As the first NP with the organization (non-profit) and with the culture change of an NP being


designated at the attending physician, we have overcome many glitches in our processes. The success we have achieved is primarily due to the champion effort of our forward thinking Medical Director. I function as the hospice attending physician for our patients in the community as well as patients in our acute inpatient unit when the community physician has requested to transfer care to the Hospice Medical Team (me and the medical director). Internally, we have made it a policy to designate my name as the attending physician and list the medical director as MD #2. This way, either of us can make a visit and bill. Another big culture change has been on signing the certification and initial plan of care which has scheduled medications included. In the state of FL, NPs cannot sign for scheduled medications and in all states (I think) NPs cannot sign hospice certifications. Therefore, the IT department has devised a way on the electronic medical record to have the Medical Director's name and signature as well as my signature/name on the initial POC/ certification. [Submitted on: 5/22/2007 by: Gail MacFarlane, ARNP The Hospice of Volusia/ Flagler 386566-5230]

I work for a hospice and palliative care nonprofit. I work 2 days a week at an inpatient residential hospice facility caring for hospice patients at GIP level of care. I am attending for some of these patients. But on the days I work there, I see all GIP patients. One of the hospice physicians, at end of day, makes brief rounds. I submit my billing in his/her name and dictate the note, making note that I collaborated with Dr. ___. Please send me your email if you’d like to discuss further—don’t want to be online to whole SIG if not of general interest. Thank you. [Submitted on: 5/22/2007 by: Terry Thompson, MS, RN, APRN,BC-PCM Palliative Care Nurse Practitioner Four Seasons Hospice & Palliative Care 571 South Allen Road Flat Rock, NC 28731 Cell: 828-551-8507 828.692-6178 / Fax 828.233.0355]

In my setting, the organization is billing under my NP name at 85%, but are tracking for productivity issues, all visits I do, whether they are billable or not (if I am the attending physician). My visits are done independently of the MD, most home visits, NF visits and some care center visits. I do phone consultations if I have a question about medical management. [Submitted on: 5/22/2007 by: Gail MacFarlane, ARNP The Hospice of Volusia/ Flagler]

Question


56. I would like to develop an order set for comfort measures only to provide continuity of care for patients. Is anyone using order sets and guidelines written for comfort measures only they would like to share. [Submitted on: 5/29/2007 by: Marianne Herman, RN, MSN, APN,C Palliative Care Coordinator/Nurse Practitioner AtlantiCare Regional Medical Center 609-652-3480- office, 609-525-2679, pager marianne.herman@atlanticare.org] Answers I have nearly 20 years of inpatient palliative care experience, and am opposed to order sets or standing orders because patients I see have a range of diagnoses and are at various points on a terminal illness trajectory and I need to individualize the treatment plan. Order sets can probably be useful if you have a homogenous patient cohort. I will be interested in the response from others on the list. [Submitted on: 5/29/2007 by: Margaret L. Campbell, PhD, RN, FAAN Nurse Practitioner, Palliative Care Detroit Receiving Hospital 4201 St. Antoine Detroit, MI 48201 313 745-3271 313 745-3637 fax mcampbe3@dmc.org]

I agree with Meg, each patient scenario is different. At the beginning of our program some of the ICU nurses requested we formulate standing orders. One of the nurses said " That way, you won't even need to come and see the patient, we can just use your order set". This gave me great pause and we have not revisited this issue since then. [Submitted on: 5/29/2007 by: Ginger Marshall, MSN, APRN, ACHPN University of Utah Palliative Care Team]

I would have to agree w/ Ginger and Meg. have some protocols in our hospice program but even these are individualized for each patient. [Submitted on: 5/29/2007 by: Nanci Tansey]

I will present a little different view. I am actually in favor of order sets, as there is evidence out there that has found that standardized order sets in certain situations due improve care. There are no RCT involving the use of standardized order sets in palliative care that I am aware of, which leaves us with lots of anecdotal evidence about what works and what does not. My concern, and the primary reason I support order sets, has nothing to do with


palliative care providers. I feel that myself, and most other palliative care ARNPs can develop an individualized treatment plan for good comfort or inpatient EOL care without an order set. Unfortunately, many institutions still do not have a palliative care service, and even those that do, providers don't consistently consult palliative care when transitioning patients over to comfort care. Now factor in teaching institutions where housestaff are essentially running the show, where there may or may not have a palliative care service, and you have a potential for a disaster. The disaster involves the under (usually the case), and occasionally over use of appropriate medications for pain and symptom management, stopping or continuing appropriate medications, diagnostic testing, and communication with families, just to name a few. I call your attention to the last edition (not the one you received last week)of the Journal of Hospice and Palliative Nursing, where in the Evidence for Practice Section, the issue of standardized order sets in palliative care was the topic. The housestaff and to a lesser extent our attendings, gave the use of standardized order sets high marks. I would agree with Meg and others that everyone needs and deserves an individualized plan, and I would be very concerned about using an order set that did not allow for individualization. That having been said, an order set can be utilized and still tailored to the individual patient and family. On the latest revision of our comfort care set, we added a check box for "palliative care consult." Adding that option has increased our consults, and provided us with many teaching opportunities for housestaff. Before making a decision regarding use of an order set, I would assess where you are with the implementation of your service, the culture of your institution, the types of patients you see, etc. If you consult on the majority of patients who would need an order set, or you have trained the medical staff well, perhaps you don't need them. Our service is less than 5 years old, and our institution is run by housestaff, and thus order sets work well for our patients. [Submitted on: 5/29/2007 by: Darrell Owens,Ph.D.,ACHPN,APRN Clinical Assistant Professor and Director Palliative Care Consult Service Harborview Medical Center Box 359806 325 Ninth Ave Seattle, WA 98103 VM:206-341-4636 Fax:206-731-2363 Pager:206-541-0776 Email: owensd@u.washington.edu]

I agree with Darrell. I am in a teaching hospital. Before comfort care order sets care consisted of a morphine drip and stopping all medications. As not all house staff or attending will agree to consult palliative care the comfort care order sets have helped to some extent mainly because the nurses who are so familiar with what we do will intervene with the house staff. The nurses do their best to get us involved but not always successful. The longer we have been in place the house staff get to thinking they can do it all missing unfortunately the art of palliative care. [Submitted on: 5/30/2007 by: Barb Mulich WV University Hospitals]


We have had a comfort care order set since 1997. It has been revised a few times as we watch how it is carried out. It has actually been quite successful. It does allow for individualization and is an automatic consult to palliative care team. Order sets in general in our acute setting have improved care. [Submitted on: 5/30/2007 by: Cornelia Scibetta Asheville,NC]

I have published our set in Ferrel and Coyle Textbook of palliative nursing care, chapter on Hospital care. [Submitted on: 5/30/2007 by: Marie Bakitas, ARNP, DNSc, FAAN Post-doctoral Fellow Yale University-School of Nursing and Assistant Professor Adult Nurse Practitioner, Palliative Care Section of Palliative Medicine Dartmouth-Hitchcock Medical Center 1 Medical Center Dr. Lebanon, NH 03756 phone 603-653-3524 pall care office 603-650-5402 fax 603-6508699]

I am in a large teaching institution consisting of 2 hospitals and we are in the process of developing comfort care order sets so that there will be a basic framework for all patients. As with all order sets, there has to be room for individualization. We believe that it will also provide guidance for our house staff, especially if we are not there. For those of you who already have these in place, could you post those? [Submitted on: 5/30/2007 by: Debbie Gunter APRN,FNP,ACHPN Palliative Care Service Emory Healthcare Atlanta, Ga. 404-558-7338]

As a teaching hospital, we've wanted our residents to individualize all plans of care. But experience has proven that leads to lots of excess and inconsistency on the part of the residents (and variance from Attending). The usual comment from residents was "the patient is DNR and we stopped everything." We do have a "suggested" end of life order set intended to guide discussion about what is helpful or not, make sure there's a plan for expected symptoms. Very similar to our MI & stroke care maps. The residents find it helpful, as one of them said "we talked about end of life in med school, but no one told me what to write". Clearly he recognized the need and wanted to do the right thing. As a consult service, I hope and usually do get called to see the patient. But one of my goals is to teach and empower others to become better generalists in this area and provide them accessible tools to do what they need for the patient if we aren't here. Yes, and it's handy for the STN to print and hand to the resident!


[Submitted on: 5/30/2007 by: Cheryl Vahl University of Iowa]

I see the benefits and burdens of using an order set, however I think it is very difficult to utilize an order set in palliative care because so much of our work involves appropriate assessment. The assessment involves patient assessment including cognition, "suffering" , and history of "chemically coping." If these assessments are not done you might cause more trouble by chasing a patients complaint of a symptom with potentially harmful medications. The other part of the assessment is trying to reverse process that are contributing to the symptom, which would be difficult to spell out in a pathway. I think the pathway would be so complex therefore being very difficult to follow appropriately. [Submitted on: 5/30/2007 by: Kelli Gershon, MSN, APRN, BC-PM APN Palliative Care The University of Texas MD Anderson Cancer Center (O) 713-792-5935 (P) 713-404-1141 (F) 713792-6092]

We use an "end-of-life order set" for our comfort measures only patients. Our hospice has their own order sets which is almost identical to the EOL set. Obviously it should be used as a starting point and individualized for each patient. Nursing and House staff have also verbalized satisfaction with the order set. It includes "no routine labs or tests", a list of frequently used meds at the EOL, and a consult section for hospice or our palliative consult service. I would be glad to share our EOL order set with anyone. [Submitted on: 5/30/2007 by: Karen Mulvihill APRN,BC-PCM]

We are also a medical center and use a palliative comfort care order set (about 3 years now) for our terminally ill "floor" patients. One component about using palliative care order set not mentioned yet - is that for our staff nurses - they find the order set improves response time for patient symptom management and they love the autonomy it provides to treat symptoms aggressively. It also provides permission to "focus on comfort and relieving suffering rather than focusing on vital signs" without "having to call and fight the intern or attending for every little detail"... The order set legitimizes our patient population medication needs and for our dying patients includes for example, the option that that vital signs are not required but "comfort assessments" are mandatory and includes to notify the primary team or palliative care if patient remains uncomfortable (rather than notifying for a low blood pressure). As with all standardized order sets, we find that the palliative care order set is a good starting framework, helps to transition the primary team "thinking" towards palliation, gives the nursing staff permission to advocate for the art of comfort


care, provides great teaching moments, then is amended/adapted with "regular orders" as the hospitalization/dying process moves on. We use the order set - from our general internal medicine to renal (dialysis OK) to neurology (continue anti-convulsant) to cardiology to trauma patients. We do not have palliative care order set for ICU (but do have ICU order set that guides withdrawal of artificial life support) but do use the palliative care order for patients not expected to survive hospitalization and are transitioning from ICU to the floor when palliation is the goal. In addition - we created an order set for continuous IV end of life analgesia (IV opiates) for dying floor patients (our ICU's in general do not have a problem continuing IV opiates in their dying patients) - as we had experiences where physicians and nurses were fearful (liability) of continuing a "basal" rate IV opiate in the actively dying floor patient (where the IV opiate was used to control pain and/or dyspnea) and we wanted to stop the use of Narcan in our dying patients (respiratory rate less than 8 drives the emergent implementation of a Narcan protocol). [Submitted on: 5/30/2007 by: Winnie Hennessy, PhD, RN, CHPN Palliative Care Medical University of South Carolina 169 Ashley Avenue PO Box 250345 Charleston, SC 29425 hennessw@musc.edu 843-876-1121 (Office) 843-792-2123 (pager #11132) 843-792-9246 (fax)]

I have found Amos Bailey's set to be a good reference: http://www.palliative.uab.edu/response/section1-15.pdf I then customize whatever changes need to be made considering the patient. [Submitted on: 5/30/2007 by: Diane Ranna NP]

This topic is timely for our system in stituations as we are starting to struggle with Caregiver Administered Analgesia, a related issue that I know was discussed in prior months. Is anyone willing to share their policy and/or experience initiating this new policy? Our Ethics committee would also be grateful for anyone willing to share order sets and policy for EOL care. The evidence based literature often does not address the real world of moving a project of this important forward. [Submitted on: 5/30/2007 by: Cheryl Kirchner, RN, MS Bon Secours Richmonda Health System St. Marys Hospital Office: 804.-287-7551 Home: 804.323.9077]

If you are struggling with the use of a comfort pathway versus not, I suggest reviewing the publication in Arch Internal Medicine, 2005, Volume 165, August. Author is Amos Bailey. The article, Improving Processes of Hospital Care During the Last Hours of Life, supports the


use of comfort pathways to improve end-of-life care. [Submitted on: 6/4/2007 by: Judy Passaglia RN,MS, AOCN Palliative Care Program Manager Palliative Care CNS Stanford University Hospital & Clinics (650)-723-3736 Pager ID# 16929]

Unfortunately, we have not been given the resources for 24/7 coverage. Occasionally the housestaff use the orders to get the patient started and then they consult us to fine tune things when we are available. They find the orders very useful (a copy was sent in a previous response) as they do not have a clue where to begin and they often forget to stop things, which we included in the preprinted orders. [Submitted on: 6/6/2007 by: Elaine Glass, APRN, BC-PCM Clinical Nurse Specialist Palliative Care at Grant Medical Center 340 East Town Street, Suite 10-330 Columbus OH 43215-4639 614-566-PALL (7255) B# 614-842-1209 Fax = 614-566-8009]

Question 57. We are struggling with a "moral/ethical vs the law" issue here in South Carolina. A theme that frustrates our team and our hospital based colleagues is when family dynamics interfere with the known preferences of the patient to withhold treatment options when the patient is dying. What is your experience or how do you/your team/hospital "manage" and resolve treatment decisions in dying patients when an advance directive () designates a surrogate decision maker, the is clear that patient prefers no PEG, ICU trips, or CPR, etc, the surrogate is in agreement with the but the "rest of the family" [or even just a single additional family member] wants full support and therefore the surrogate goes with the "family consensus" or is worried about "going against" the one ... struggle with this issue, primarily because SC does not have futility laws, does not recognize non-family as legal surrogate decision makers [another real dilemma], and the surrogate is "legally" allowed to "change their mind" [meaning change from what the pt expressed in the ]. The same scenario holds true if there is not a written - and the legal decision maker is certain additional therapies are not what the patient wants - but goes with the aggressive treatment that general family consensus wants. Our ethics department in these cases will defer to our legal department who then will recommend that we take the position of the surrogate. Our moral conviction says honor the , but reality = often, with regret and frustration, follow the preferences of the surrogate (with family meetings, guidance, try to understand etc...). Wondering if others have this experience and how you manage... [Submitted on: 6/1/2007 by: Winnie Hennessy, PhD, RN, CHPN Palliative Care Medical University of South Carolina 169 Ashley Avenue PO Box 250345 Charleston, SC 29425 hennessw@musc.edu 843-876-1121 (Office) 843-792-2123 (pager #11132) 843-792-9246 (fax)]


Answers We have encountered this situation several times ( as I am sure others have also). It has been my understanding and practice that we are not based entirely in state statute, but rather in federal statute. The supreme court (at least prior to the current more conservative court) has consistently upheld , including the inability to have them changed by others. We are a state institution (a university hospital) and are therefore represented by an assistant attorney general (AG) who tends to be rather conservative in their opinions. That having been said, according to our AG we do not allow family members or surrogates (whoever the identified legal decision maker) to change an AD unless they are the ones who me the initial decision, e.g., they me an incapacitated person DNAR, and then changed their mind. So if a person completed their own AD, and was competent at the time (which has been challenged once), then we require it must be followed. Our AG has always taken this stance, and we have won twice in court on this issue. A LNOK or DPOA-HC can get a temporary stay against us (the burden is on them), but in the two times that has happened, both were for 10 days only, a temporary guardian was assigned, and at the end of the 10 days the courts ruled that the AD must be followed. Our institution always, always works towards consensus, attempts to provide family support and find common ground, and of course tries to avoid adversarial situations, but when all of these measures fail, the AD is honored, otherwise why bother to write one. [Submitted on: 6/1/2007 by: Darrell Owens, Ph.D., APRN, ACHPN Clinical Assistant Professor and Director Palliative Care Consult Service Harborview Medical Center 325 9th Ave, Box 359806 Seattle, WA 98104 Voicemail 206-341-4636 Fax: 206-341-4635 owensd@u.washington.edu]

I would like to comment on our similar experiences here in another part of the deep southMemphis. I suspect that from the response from Darrell that it is to some degree a regional problem as well. West coast, in general I think is generally more progressive than those of us in the the southeast and south. Winnie you brought up the issue of a futility (I prefer medically inappropriate) policy, and that might help. We are currently working on getting that as a community standard and hope to eventually go the the state level to provide some level of legislation to give the concept more legal immunity (at least conceptually for the MD to start applying) as Texas has done ( it has been challenged there). Our state statute does protect the AD as the person's expressed wishes and cannot be superceded by the HCPOA, but in every case don't make waves and follow the HCPOA's dirctives (to keep the peace). I clearly know that this is not only illegal but not in the patient's best interest. I work on our state task force on AD's and helped to re-write the law to make it as it is now, but can't really get the back up of risk management to follow the path that Darrell's hospital allows....Another important piece is the whole issue of how an AD is addressed to begin with. If it is approached by the MD and all, that the plan of care will be based on what the pt


has expressed in the AD, and not make it a choice "what do want us to do for your family member?" I think this would really help steer the ship of patient care. Still much work in teaching the healthcare providers. [Submitted on: 6/1/2007 by: Jane Owen, APN, BC Memphis]

All of us have experience with this. I've found it helpful to explore with the family/PCOA why they want to disregard the patient's expressed wishes. It can be helpful to ask if they think their loved one is suffering. This often has to do with unresolved issues and often is grief-related. If the family remains resolute,we then call an ethics consult which can be very helpful in moving the process along. [Submitted on: 6/4/2007 by: Rita Mastroianni Johns Hopkins]

Linking with what Rita said, it may be helpful to ask the family what they are expecting to happen and explore their response as well as what are they afraid of happening. Most likely they are afraid of the patient dying even when it is clear to us that that is the expected outcome. I had a pt's son who was not financially prepared to pay for his mother's funeral and therefore would not accept our recommendation to allow his demented, bed-bound, chronically aspirating, non-verbal PEG-fed mother to get hospice care at her nursing home. She was admitted monthly for well over 6 months. Once we found out about his fears, we helped him take steps to prepay her funeral and other related expenses and he allowed the addition of hospice in her care plan. Asking the right questions can open dialogue about with families. However, sometimes all the right questions in the world will not change people's minds. [Submitted on: 6/4/2007 by: Sue McHugh-Salera Mt Sinai School of Medicine New York, NY]

I encounter this conflict frequently. Most of the time spending some time educating the family on the prognosis and the purpose of advance directives resolves the conflict and leads to respecting the AD. Sometimes a second opinion on prognosis is helpful, especially if they are struggling with believing prognosis. With time and education most families come around. We have a very active ethics committee which is called to help resolve end-of-life issues. [Submitted on: 6/4/2007 by: Karen Mulvihill APRN, BC-PCM Danbury CT]


I find it very helpful in many -challenging situations to affirm the good intentions of family members. They want what is best for their loved one. Their intent is good. Affirming good intent often helps people drop some of the defensiveness they feel in their "fight" on behalf of their loved one. From there, it is then easier to talk about, "Is this how your Mom would want to live?" and "What did she think about what happens after death?" Sometimes spirituality and religion can be truly instrumental in helping families consider the next steps in letting their dying loved one journey into death. [Submitted on: 6/7/2007 by: Jacqueline Mauk, RN, PhD, CNS, ACHPN Advanced Practice Nurse - Education Team Hospice of the Western Reserve 19201 Villaview Road Cleveland, Ohio 44119 216.486.6701 216.481.4987 fax 216.818.0101 pager 216.469.2325 cell jmauk@hospicewr.org]

One of the strategies that I have used that works in some situations is to inform the surrogate decision-maker about his or her legal and moral duty as the HCPOA - that is to NOT do what they want to do - because who wants to let their Mom (insert other loved one) die? - but to do what the patient has said he or she wants done. Knowing their legal and moral duty as a HCPOA usually gets the monkey off their back - especially with other family members = "I'm not making this decision - Mom made this decision in her AD. I'm just honoring her wishes by making sure what she wanted done gets done - this is what I'm supposed to do as her HCPOA". Acknowledging HCPOAs' feelings and personal wishes often helps open the door to instructing them on their legal and moral obligations - and dealing with pressures from other family members. I once had a husband hide his wife's AD until I talked with one of his daughters who asked him about it. Once he got it out and read it thoroughly, he felt badly about not honoring his wife's wishes. The AD also helped both daughters support him in honoring their mother's wishes in the AD (one daughter wanted everything done previous to seeing the AD). They were able to withdraw life support and she died within a few days. This conversation took place the day before she was to be trached and PEGed. [Submitted on: 6/7/2007 by: Elaine Glass, APRN, BC-PCM Clinical Nurse Specialist Palliative Care at Grant Medical Center 340 East Town Street, Suite 10-330 Columbus OH 43215-4639 614-566-PALL (7255) B# 614-842-1209 Fax = 614-566-8009]

I agree with Elaine. Having done work with "Respecting Choices" that deals with the identification of surrogate decision makers, it is critical to the patient and the decision maker that they understand truly what that patient wants and specifically defines those wants.


[Submitted on: 6/7/2007 by: Susan Kasseroler, RN, MSN, GNP Director, Hospital Elder Life Program CHRISTUS Hospital - St. Elizabeths 2830 Calder Ave. Beaumont, TX 77702 Phone: 409.899.8582 Pager: 409.726.9143]

Question 58. We are a 230 bed hospital with a" few month old" Palliative Care Consultation Service. I am the sole ARNP provider with "consulting MD" for back-up. The spiritual care role for the service is by consult only, ie, when pts/families request a visit we consult the spiritual care department and they will see the pt. We have virtually no dedicated social work provider but rather, use the MSW/Discharge Planner for discharge planning and not much else. I see the need for a team approach using these 2 disciplines and would appreciate hearing how other hospital programs have integrated the Spiritual Care and Social Work providers into their service. [Submitted on: 6/5/2007 by: Judith A. Hill MPH, MS, RN, BC. Palliative Care Nurse Practitioner Virginia Mason Medical Center Mail Stop: H951 Pager: (206) 540-4732 E-mail: judith.hill@vmmc.org 1100 9th Avenue Seattle, WA 98101] Answers I practice under a similar situation. We utilize the various team social workers as their discipline is essential for care. It might be helpful to do some continuing education with the discharge planners/MSWs with specific palliative care content. When I have done this education piece, I have also used this time as an open forum to discuss how we can work together for these patients. We call pastoral care and make a referral to see our patients (or I ask the floor nurses to do so). I do similar palliative education with the pastoral care department (this is every year as these folks rotate through). Having a more educated staff can only enhance the quality of care. [Submitted on: 6/5/2007 by: Rita Mastroianni Johns Hopkins Hospital]

I work at a small community hospital (approx. 100 daily census)as the APN for our palliative care team. When there is a patient requiring a palliative care consult I generally will go will speak to the staff to find out how the team can help (discharge planning, symptom manage, spiritual issues etc.) I then consult with the palliative MD do a complete physical assessement on the pt. and then pull the needed individuals (social sx/discharge planner, pastoral care in for a family/pt. meeting. [Submitted on: 6/5/2007 by: Margaret Ondrey CNS]


Our setting is similar, one 70% dedicated advance practice nurse and MD back up. I create a 'virtual team' in each setting to work with case management and social work. Our chaplains and chaplain residents see every patient within 24 hours of admission - so this factor is different. Spiritual care 'loans' a 50% chaplain to our team. [Submitted on: 6/5/2007 by: Connie Borden St. Marys SF]

I work in a teaching institution comprising 2 large hospitals here in Atlanta. Our palliative care consult service consists of 2 board certified palliative care MDs, myself as the palliative care NP, a full-time chaplain, and an APRN. We have jsut received funding for another NP our hope is to have a complete team at each of the hospitals. We would love to have our own social worker, but so far, this has not been approved. Our other thought was to use the case manager role as another member of the team. We will also be having one of the chaplain "residents" practice with our team for the next year as part of their fellowship. When this program started in the fall of 2005, it was the 2 MDs each practicing half-time with palliative care and the APRN working part-time. They utilized the chaplains and social workers already in house. [Submitted on: 6/5/2007 by: Debbie Gunter APRN,FNP,ACHPN Emory Healthcare, Atlanta, Georgia 404-558-7338]

I have the luxury of having a chaplain and SW on our palliative care team but we have found that the pt's assigned SW and case managers find this kind of work very fulfilling so we try to involve them as much as possible. I agree that with education this could be something your hospital's SWs and Case mgrs might want to do. Good luck! Marian Grant [Submitted on: 6/5/2007 by: Marian Grant CRNP, Palliative Care Service Johns Hopkins Bayview Medical Center 410-550-1145 phone 410-283-5720 pager]

I practice in 3 hospital system as the sole NP. We have a limited staff for Spiritual Care.......1 chaplain per hospital and limited SW/Case Coordinator staff. I do have a 2nd NP position posted to help with the volumes, but working with the Chaplains has been a valuable team approach. Although they are as pulled as I am, they take referrals from me and vice versa and often will see a patient for me on follow-up if I am unable to be there because of the load at one of the other hospitals. The SW or Case Coordinator assigned to the floor are helpful to begin the Hospice referral if appropriate and in assisting with social issues as they


arise. We have each others pager numbers and call back and forth as part of the "team". The "team" is developed case by case. The medical residents are as much a part of the team as the bedside RN. When really busy, the bedside RN will help me arrange appointment times so families have a better idea of when I can be there. [Submitted on: 6/5/2007 by: Kim Ashcraft, APRN, BC Palliative Care Charleston Area Medical Center Charleston, WV]

Three years ago when we started, the directors of both departments in our hospital supported us by designating ~ 50% of a social worker's and chaplain's time that was dedicated to seeing our patients. Our average daily census was about 10. When it got higher than this and there were cutbacks in the SW department, our SWer got cut back to ~ 25% coverage, but she still comes to our weekly team meetings and serves as a resource to the other SWers whom consult on other floors when we need them for specific pts for primarily D/C planning. The psycho-social support from these other SWers is based on their personal skills, preferences and time. [Submitted on: 6/7/2007 by: Elaine Glass, APRN, BC-PCM Clinical Nurse Specialist Palliative Care at Grant Medical Center 340 East Town Street, Suite 10-330 Columbus OH 43215-4639 614-566-PALL (7255) B# 614-842-1209 Fax = 614-566-8009]

Question 59. This is a request specifically to ARNPs who are working with hospice providers. I chair the palliative care workgroup for our county's disaster response here in Seattle. As part of the plan I have written for a palliative care response to pandemic flu, I am incorporating comfort care kits which would be distributed during a pandemic disaster. From my hospice days, I know these kits were often small boxes placed in patients refrigerators that contained a variety of symptom relief medications. There were also called e-kits, symptom relief kits, etc. I am hoping to obtain a copy of the contents of these kits, including dosages. I know that Hospice Pharmacia has a pre-printed order-set that providers sign. If anyone has a copy of the contents, or the order set that could be sent electronically or via fax, I would appreciate it. The HHS Assistant Secretary for Preparedness and Response is accepting grants for funding of these kits during a disaster, and of course the guidelines just arrived with a very short turn around time. We are fortunate that King County Disaster Response Team (which is the Seattle area), now includes palliative care. If anyone is interested in the plan we are creating (it is a year long process), please e-mail me directly, and I will be happy to share any and all information with you. In the mean time, your comfort kit orders would be helpful. If you need to fax your orders, my number is listed below. [Submitted on: 7/5/2007 by: Darrell Owens, Ph.D., APRN, ACHPN, Clinical Assistant Professor


and Director, Palliative Care Consult Service, Harborview Medical Center, Seattle, WA] Answers The ComfortPak contains a 48 hour supply of medications that address the most common end-of-life symptoms (pain, nausea/vomiting, anxiety, agitation, restlessness, fever, air hunger, and excess secretions). The kit contains: ABHR (Ativan/Benryl/Haldol/Reglan) suppositories 0.5/12.5/0.5/10 mg strength and instructions for use are 1 supp pr q4-6 hours prn - 6 are supplied Acetaminophen (6 suppositories supplied) 650 mg - 1 supp pr q 4-6 hour prn Haloperidol 2mg/ml (15 ml supplied) 0.5-1ml (1-2mg) po q 4-6 hour Hyoscyamine 0.125mg (10 tablets supplied) 1 tab sl q4-6 hr prn Lorazepam 1mg (10 tabs supplied) 1 tab po q 6-8 hr prn Morphine Sulfate 20mg/ml (15 ml supplied) 0.25-0.5ml (5-10mg) po, sl q 3-4 hr prn Prochlorperazine 10mg (6 tablets supplied), 1 tab po q6hr prn Prochlorperazine 25 mg (6 suppositories supplied) 1 supp pr q 12 hour prn [Submitted on: 7/6/2007 by: Shari Froelich RN, MSN, MSBA, Palliative Care, Foote Hospital, Jackson, MI]

I am confused. Are all the medications given in suppository form? In reading the message, tablets are given for certain medications AND a suppository. Is the suppository a combination of AHBR? Also, if the medications are only for an emergency there must be much waste and expense. Just curious. [Submitted on: 7/11/2007 by: Judy Passaglia RN, MS, AOCN, Palliative Care Program Manager, Palliative Care CNS, Stanford University Hospital & Clinics]

The ABHR that comes from Hospice Pharmacia is only in suppository form, while other meds came in dual modality. Yes, there are waste issues as in "theory" the kits are to be thrown out when the patient died. What I found as a manager was that nurses are typically so cost conscious that they would save certain items and use in a setting where the kit was not available. Don't even want to go down the path of legality of that practice, just reporting the reality of the situation. We had to do a periodic trunk check to help them along with the legal process. [Submitted on: 7/11/2007 by: Shari Froelich RN, MSN, MSBA; Palliative Care, Foote Hospital; Jackson, MI]

Agree on the need for more data, especially in the use of ABHR and similar gels / topical forms. I have seen the gel used often for nausea and fail miserably in both home and


inpatient hospice settings. It still is ordered and used routinely. [Submitted on: 7/11/2007 by: Maria Ferrell]

Question 60. I've checked CAPC and a few other sites in hopes of finding out what the average caseload for a hospital-based palliative care nurse is considered to be and have come up with nothing. Do any of you know where I could find this info? What is the standard within your organization? Any input is helpful. [Submitted on: 7/11/2007 by: Kristi M. Griffith, RN, BSN, CHPN, Manager Palliative Care, Methodist Charlton Medical Center, Dallas, TX] Answers For the in-patient academic hospital health care settings I've worked in... I've found the following: 1. Intake work-up and first visit takes around 1 1/2 hours. We do an extensive review of illness trajectory and past treatments, explore family support resources, and do an in depth medical work-up (including H&P) and make recommendations R/T symptom/family distress. 2. Simple follow up visits for symptom distress issues are much shorter (e.g., 5-10 minutes for chart review and 5 - 10 minutes for patient/family interactions for support 3. Family meetings re: Goals and EOL decision-making are another story, they take anywhere from 30 min. to an hour or more. An average APRN patient load might be 2 new patients and 6-7 "olds"; or...1-2 new pts, 2 lengthy family meetings and 4 - 6 "old" follow-up patients, etc. I've been told that this looks a lot like the patient load nurses have in community hospice settings. [Submitted on: 7/11/2007 by: Barbara M. Usher PhD, APRN-BC, BC-PCM, Advanced Practice Nurse, University of Pittsburgh Medical Center, Department of Palliative Care and Medical Ethics, UPMC Montefiore; Pittsburgh, PA]

A couple of clarifying questions might help narrow down responses. First, are you talking about an ARNP on a consulting service, or an admitting service? On a consulting service, these providers perform an initial consultation, and then some, like our service, perform subsequent visits as needed, which can be daily. An admitting service may do consultations, as well as assume total management responsibility for the patient, which creates different work and productivity needs. In the past I have seen the number 200 circulated, meaning 1 provider either ARNP or MD, per 200 consultations per year. This would only apply to a consult service. If you are talking about other than a CNS or ARNP, who does not bill, then I am not sure if I have seen those numbers in the past. I think you really need to be specific


based the type of service, and the services offered, as there appears to be much variability beten services. Our service completes approximately 450 new consultations per year (10% of which are outpatient), and we see each patient an average of 3 times. We only have one attending provider on at a time, plus one senior internal medicine resident (who does not perform consultations alone). We have one full time ARNP attending provider (myself), one 1/2 MD (7 days per month), and two part-time attending MDs who each cover one week (7 days) per quarter. My faculty agreement states that 19 days per month is full time. Of course we are a 24/7 service, which requires call. To compensate for on-call time, actual time on service is 14 days per month. We work in blocks of 7 days (you are on continuously for 7 days). The expectation is that when you are on service you will manage the service appropriately, and cover all the patients that need to be covered, regardless of how much time it takes. Saturdays and Sundays you make rounds on certain patients, and see emergency consults only. Most weekends you are in and out of the building in 3-6 hours, and some weekends you don't come in at all, if there are no pressing issues. My schedule is usually 14 days on service, and 14 days off service. When off service I do see my own patients in palliative care clinic one day per week, and because I am the service director, I may attend some meetings, but am not required to be in the building during my off service time. Although most of the days are very long, the ability to have long periods of time off is how we prefer to work. In the future,we may need to re-visit the issue, but for now, it is working. The key component when I was setting up the service was that the expectations for the ARNP be the same as the MD. In the past ARNPs have been held to a "40 hour" work week, and the MDs to a 19 day faculty agreement and the practice of whenever the work gets done, you are finished. This often meant removing the flexibility of the ARNP schedule. Now, when the work is done I leave, when there is no work, I don't come in to the building. We follow a non-hourly, overtime exempt pay schedule. This would clearly not work in a unionized environment. I believe I am fairly compensated, but it is not an MDs salary, as I did not complete 4 years of medical school, and three years of residency, so I do not believe I should be reimbursed at MD salary rates. I hope this helps, and I would be interested in hearing what others are doing. [Submitted on: 7/11/2007 by: Darrell Owens, Ph.D., APRN, ACHPN, Clinical Assistant Professor and Director, Palliative Care Consult Service, Harborview Medical Center, Seattle, WA]

I agree with Darrell that much depends on the structure of your service, and thus in the expectations of the PC services. In the acute care setting where I practice, we have had many fluctuations in staffing. Currently, we are a Monday-Friday only, no call service. We have no MD attending, so we work with the patient's admitting attending (hospitalist, oncologist, cardiologist, etc). For the last 3 years, we have seen on average 700 patients per year. The length of stay on our service tends to be very short - 1-4 days; or very long - 3 or 4 weeks, (reflecting protracted ICU cases). Our staff includes the following: 1.5 FTE APN; 1 FTE


RN; 2 FTE SW - one of which focuses on bereavement; and 0.75 FTE chaplain. We are consultative only and do not have inpatient hospice beds; we also have no outpatient capabilities. [Submitted on: 7/11/2007 by: Kasia Montgomery, St. Luke s Episcopal Hospital, Houston, TX, kasia@lenio.net]

Question 61. My colleague and I have come face to face with hospice NPs greatest controversy. We have worked as NPs in our agency's in-patient hospice facility for the past 6 years with "shared/split billing" as our model. Recently, we found out that some of our newly hired physicians are questioning the legality of this process and the agency has been "researching" this practice. We're told our regional CMS chief has refused to comment on this. We're also told that "other" medical directors in our region don't use NPs in in-patient facilities for just that reason. What is everyone else's experience? Do you have any suggestions, references, resources, or comments which may help us to keep our beloved positions? Thank you for your input and support. [Submitted on: 7/31/2007 by: Jessica W.] Answers I am employed by a hospice and provide care to patients in a variety of settings, including in-patient hospice facility. As the first NP hired, our organization elected to pursue naming me as the 'attending physician' in following Medicare guidelines for NP billing within hospice. The identification of 'attending physician' is found in the Medicare Claims Processing Manual, Chapter 11, Section 40.1.3. All the billing for my services for the patients of which I am designated at 'attending physician' are billed under Medicare Part A. My Medical Director rounds on the patients in the in patient unit and bills on all the patients patients with my name listed as attending physician and patients with other community MDs designated as 'attending physician'. This whole aspect of NPs billing in hospice care is fairly new and I don't think the 'waters have been tested as of yet'. In our organization, we have the ability to list more than one physician/NP name on the face sheet - therefore I am listed as MD#1 and the Medical Director is listed as MD#2 - as he has to sign the death certificate, certify terminal illness, etc. I have a book by Carolyn Buppert, "Billing Physician Services provided by NPs" and the author states the rules for billing Medicare for hospice services are found in the Code of Federal Regulations (42 C.F.R. 418.54, 418.54, 418.58, 418.304) and Medicare Claims Processing Manual. Hope this helps, good luck. (NPs) know our value, it is frustrating trying to justify to the bean counters! [Submitted on: 7/31/2007 by: Gail McFarlane]


Jessica, maybe you could clarify for the group what you mean by "shared/split billing." [Submitted on: 7/31/2007 by: Julia Gies, APRN, BC-PC, Providence Hospice and Palliative Care, Portland, OR]

"Shared/split billing" means the NP sees the patient and writes the note. The physician follows the NP with his/her own assessment, adding to the note of the NP as needed. This is billed as a physician visit only as the physician co-signs the note. Thanks. [Submitted on: 7/31/2007 by: Jessica]

Is the NP the attending? I think this has to occur for NP to bill inpatient. You don't share/split when this happens. I count the rules of CMS to be amongst the mysteries of the universe. Good luck. [Submitted on: 7/31/2007 by: Cindy Brown]

I too do in-patient hospice rounds and my agency bills for my service. I am listed on most of our patients as the PCP. That I believe is the critical factor. [Submitted on: 7/31/2007 by: Richard Rader, DNP, NP]

Thank you Gail for your eloquent and detailed reply. I work in NC for a hospice. I see primarily IP hospice patients; though have been named "attending" for a few OPs. During the week, when I see patients in our IP hospice facility, my supervising MD rounds with me at the end of the day. Although I dictate, I note that in each note that the patient was "seen by and case discussed with Dr. X". Billing is submitted in her name so we get maximal reimbursement. We do this even if I'm the Attending, as it maximizes reimbursement. On weekends, I'm on my own (but only take call about once every 6 wks). Because I'm on my own, however, I cannot bill for any of the patients for whom I am not the attending. Haven't been challenged by our intermediary, but couldn't claim with 100% certainty that this is an absolutely kosher method for meeting the letter and spirit of the rule. Open to any and all thoughts on the matter. [Submitted on: 7/31/2007 by: Terry Thompson; 828-551-8507]


I'm curious: how do NPs serve as attendings in states where prescriptive authority for controlled substances is extremely limited? I'd love to be able to serve as an attending, or even to share call with our docs on our inpatient unit, but I practice in Ohio and WV... Any suggestions? [Submitted on: 7/31/2007 by: Mary Zuccaro, MSN, APRN-BC, CHPN; Palliative Care Consultations; A Service of Valley Hospice, Inc.; Rayland, Ohio & Wheeling, WV]

Question 62. I am scheduled to take the exam in September. I have been reviewing the core curriculum and outline for the exam and feeling overwhelmed. Recommendations regarding the exam and the best way to approach the curriculum. Thank you, appreciate your suggestions. [Submitted on: 8/21/2007 by: Marianne Herman, RN, MSN, APN,C; Palliative Care Coordinator/Nurse Practitioner; AtlantiCare Regional Medical Center] Answers I used the UNIPAC series from the AAHPM to study for the exam. I also cross referenced with the Oxford textbook of Palliative Medicine. I felt I was very prepared. The outline was helpful in organizing my studying. [Submitted on: 8/21/2007 by: Karen Mulvihill APRN; CARES Program Coordinator; Hospitalist Service; Danbury, CT]

The HPNA APN Core Curriculum for the Advanced Practice Hospice and Palliative Care Nurse came out in February and should be helpful in studying for the exam. In addition, think about looking at texts for nursing such as Textbook of Palliative Nursing and end of Life Clinical Practice Guidelines. [Submitted on: 8/21/2007 by: Constance Dahlin, APRN, BC, PCM; Palliative Care Nurse Practitioner; MGH Palliative Care Service; Boston, MA]

Do you have the study guide and the Scope and Standards? We also use the Peter Kaye (Red Book) Notes on Symptom Control in Hospice and Palliative Care. We also have study groups formed that meet on Th pm or Sat Noon at our office. Our nurses say that it helps to discuss


the questions or topics. Our next session will be on medication conversions and calculations. Some of us have been certified since the mid 90’s. Others are going for initial certification. Review and remember that you are taking care of patients now and you are successful, so you must know something! [Submitted on: 8/21/2007 by: Marlene Foreman, APRN-BC, CHPN; CNS/Education Coordinator; Hospice of Aciana, Inc.; Lafayette, LA 70503]

I appreciated that tip also. I am seeking initial certification as an advance practice hospice and palliative nurse. I have my certification as a generalist since the mid 90’s. I am having trouble organizing my studies also. I am also conducting study groups for our nurse generalists (15 nurses) and teaching my nursing assistants (7 are going for initial certification in Sept). I really need to get serious about my studying. How hard is the APRN exam? What are the major subjects? [Submitted on: 8/21/2007 by: Marlene Foreman, APRN-BC, CHPN; CNS/Education Coordinator; Hospice of Aciana, Inc.; Lafayette, LA]

What does UNIPAC stand for? Thank you! [Submitted on: 8/21/2007 by: Judy Passaglia RN, MS, AOCN; Palliative Care Program Manager; Palliative Care CNS; Stanford University Hospital & Clinics]

Funny you should ask! I am not sure it stands for anything. It is a self-study series of 8 "units" on specific topics in palliative care. It was made for MDs studying for their palliative care boards. But, I found it extremely helpful for the advance practice boards. There is also the Pocket Guide to Hospice and Palliative Medicine which is a condensed version of the series for daily use. It can also be found at the site below. Here is a link to the site.http://www.aahpm.org/education/curriculum.html [Submitted on: 8/22/2007 by: Karen Mulvihill APRN; CARES Program Coordinator; Hospitalist Service; 2 South; Danbury, CT]

Question 63. There is such a need for palliative care in LTC. I did work with a geriatrician who was the medical director of a local hospice. He would not put LTC patients on “palliative care” because he did not want to “confuse the nurses.” Any ideas about getting a program started?


I will not be going to the national conference this year but please feel free to call 409.899.8582 or e-mail: lsluce@yahoo.com [Submitted on: 8/28/2007 by: Susan] Answers I think it would be interesting if all APNs tracked referrals that went to NF and were hospice appropriate but families chose the SNF benefit first...I know that our hospice follows these folks once they are discharged, by phone. Could we track how many die in the SNF (skilled nursing benefit) before hospice is involved? What would be even more important would be to survey the families to see if they felt symptoms were managed well, compared to those who went directly into a hospice benefit. [Submitted on: 8/28/2007 by: Laura]

I have a special place in my heart for nursing facility residents. Dr. Joan Teno lit me on fire with her research published in JAMA ("40% of elderly NF residents have moderate to excruciating daily pain for 2-6 months after they first report it.") She inspired me to go back to school to become a family nurse practitioner. I started a hospice-based palliative care consultation service in March of this year. The pts who have touched me deeply are those skilled NF residents who can't have hospice but desperately need it. Many come to me with less than a week to live. I've heard that about 10% of NF residents are eligible for hospice care on any given day... Also, that a good way to identify residents who are in need of end of life care is to calculate the average length of stay in a NF, then subtract 6 months, and then evaluate every resident who has been there that long... Are you by any chance going to the national conference (HPNA/AAHPM) this year? If so, I'd love to meet up w ith you and compare notes... [Submitted on: 8/27/2007 by: Mary Zuccaro, MSN, APRN-BC, CHPN; Palliative Care Consultations; A Service of Valley Hospice, Inc.; Rayland, OH]

As a Nurse Practitioner and a palliative care consultant, I have been consulting on these SNF patients for 6 years. Many are receiving treatment or not choosing hospice because of real financial concerns. They often have severe pain issues. The SNF staff greatly appreciates the input. I identified this as a great need in 2000 and started the consult service in 2001. Of the patients that are consulted who die about 50% transition to hospice. With the start of GIP hospice in the NF the transition was able to happen sooner. I do not have an IDT but mobilize the NF team to provide needed care. This is not as ideal as hospice care but it does offer improved end of life care and improved pain and symptom management at various


stages of the disease trajectory. We have 2 FTE nurse practitioners and get about 350 new consults each year. The needs in the SNF are many. As nursing homes are more and more becoming the place that people are spending the final days, being innovative in how package palliative care to these NF will improve their final days. [Submitted on: 8/29/2007 by: Terry]

We still come back to the issue of the NF skilling patients who should be on hospice. I can somewhat understand if this is a first time NF patient and the family has the choice of private pay or skilled Medicare days. What I can't understand is the NFs who insist on skilling a patient for "palliative care" because the Medicare reimbursement is higher than the Medicaid reimbursement. When I speak with NF about their "palliative care" programs, I get answers such as, "oh, we give them hydrocodone,â&#x20AC;? or " we call the hospice chaplain in to talk with them". Maybe it's better in other parts of the country, but not here. I think the patients are robbed of their hospice benefit and not assisted with their pain and suffering. [Submitted on: 8/29/2007 by: Nancy Cato Grabb, RN-BC, BSN, MBA, CHPN; Manager Palliative Care; Methodist Dallas Medical Center]

I think we all encounter this problem everyday. Most of the time it is a payment issue, meaning the patients do not have Medicaid to pay for the room and board while on their hospice benefit. I also encounter a problem with patients who do have Medicaid. I try to get Hospice involved prior to discharge to ensure they get placed on the benefit before they get back to the NF. I work with a small hospice and they often do not want to pay for the transfer and wait for the patient to get to the NF. At that point, the MD at the facility has to then agree to hospice, and sometimes they don't! This is a major issue for this needy population and we need to work on solutions. Again, I think it all comes down to education. [Submitted on: 8/29/2007 by: Karen Mulvihill APRN; CARES Program Coordinator Hospitalist Service; Danbury, CT ]

I would say this is a nationwide problem, as I encounter the same issues in WA state. I agree, there are some patients where home hospice is not an option (for a variety of reasons), and families cannot afford to pay privately, so this using Medicare SNF benefit is an option, albeit less than ideal. It is when a patient has lived in a SNF long term, and has Medicare and Medicaid that we run into problems. In these situations, the SNF wants the higher reimbursement, and I have had them talk a family out of hospice after I as the referring ARNP made the referral to hospice from the hospital. SNFs have been known to


say they have "hospice like" services, or "palliative care" services. I have also had hospital social workers send patients who would otherwise receive hospice (they had Medicare and Medicaid) out on their Medicare SNF benefit, because it is easier to place them, and "get them out of the hospital." This is an uphill battle that is reflective of terrible flaws in a reimbursement oriented system. I am not sure how to fix that problem, but believe that palliative care ARNP consultation may assist many patients, as long as it is not seen as a replacement for hospice (which some SNFs may use as a justification for billing Part A SNF). We ran into that problem in a facility that had a palliative medicine physician as a medical director. The SNF, clearly missing the interdisciplinary team concept, routinely billed Part A, and used the MD as justification that patient's needs were met, and therefore hospice was not needed. [Submitted on: 8/29/2007 by: Darrell Owens, Ph.D., ARNP, ACHPN; Clinical Assistant Professor and Director; Palliative Care Consult Service; Harborview Medical Center; Seattle, WA]

Question 64. Good Afternoon, Is there anyone working as a CNS with a Hospice Agency? If so, could you provide information on how you work with the Hospice agency? How do you bill, etc.? Thanks for your help! Sue [Submitted on: 9/18/2007 by: Suzanne R Ruegg, RN, APRN BC; Palliative Care Consult Service; Mayo Medical Center; Rochester, MN] Answers For several years, I functioned as CNS for a hospital based hospice program. I already worked at the hospital as Palliative Care CNS. When we opened the hospice, I helped with a number of start up duties, developed policies, developed orientation tools and materials, performance improvement. I was a resource for the staff on complex patients and developed education programs based on need and identifying ways to improve practice based on evidence and data from our program. I did a little of everything. I made home visits on complex patients, supervisory visits with staff to observe and teach and helped with establishing new policies/approaches to meet the needs of our particular patient population. Our hospital policy does not allow for APN billing. It was a challenging role and I think one that benefited from CNS orientation. [Submitted on: 9/18/2007 by: Linda Gorman, APRN, BC; Palliative Care Clinical Nurse Specialist; Cedars-Sinai Medical Center; Los Angeles]


I'm a CNS employed by a hospice agency. Although I see pts. under home hospice care, the inpatient facility, and our palliative care program, the only ones I can bill for are those who are not hospice -- i.e. on our palliative home care program, or those who are palliative medicine consults outside of either of the above programs. We will soon be opening up a palliative care clinic, where I will likely be able to bill. We really need to find a way to update the system. I don't know why Medicare reimburses for NP visits but not CNS when some of us are functioning in the same capacity. I give orders, dictate my notes, and submit billing for visits in the same manner as my physician colleagues. I think it's silly that Medicare only reimburses NPs when they serve in the attending role. I think all APN visits done for hospice pts. should be reimbursed. Most of these pts. are no longer going in to see their physicians anyway. I know when I do visits, there is nearly always something that can be added or improved upon with the treatment regimen. There is value in us seeing the pts. aside from reimbursement, but frustrating to feel like we are "donating" our time. Where I work, most home visits are done by myself and one other physician. The other physicians are tied up with the inpatient facility and a hospital consult service. If I didn't help see the hospice pts., they simply would not be seen by an advanced practitioner. Some of these pts. have complex issues (pain, wounds, etc.) that staff have difficulty managing without additional support. I also fit into the physician's call schedule and do rounds at our inpt. hospice facility monthly and prn. Although it's a loss of billing revenue, the physicians and management feel it's important I'm included in this both to reduce call workload for the docs, and for staff to see me in a consultative role similar to that of the physicians. It helps build relationships with staff when they realize you can help them get what they need, and you can serve as a resource for them. [Submitted on: 9/18/2007 by: Maria Ferrell]

I am a CNS and Education Coordinator with Hospice of Aciana, Inc. a non-profit organization without a free standing inpatient unit. We see patients at home, nursing homes, and area hospitals. I am salaried part-time (30 hours/wk). I occasionally see patients, but mostly staff and volunteer education, booklets and brochures, and QAPI as well as Quality Council Chair [Submitted on: 9/18/2007 by: Marlene Foreman]

Good Morning All! I am a CNS in a not-for-profit hospice with a 28 bed inpatient unit. GA only recognizes mental health CNS as advanced practice so I do not bill. I am available to consult with staff but generally do not see patients. I work in the education department and help with orientation, staff education, policy and procedures, research, student assignments, and what ever else needs doing. [Submitted on: 9/18/2007 by: Jennifer Fournier, RN, MSN, AOCN, CHPN; Clinical Nurse


Specialist; Hospice Savannah, Inc.; Savannah, GA]

[Submitted on: 9/18/2007 by: ]

Question 65. Hello Colleagues: I currently have a patient who has a medical history of being “found down” and resuscitated. He suffers from considerable hypoxic brain injury which are referring to as “brain injury dementia.” He is very labile. Aggressive physically and verbally (cursing, kicking etc). I referenced the Non Cancer Compendium on Dementia and suggested to the physician that the patient’s amitriptyline be discontinued as it is contraindicated. The physician felt that none of the “described” dementia’s in the compendium dressed brain injury dementia. Can anyone help me with appropriate input (or references) on the best way to control these symptoms? Would a beta blocker to helpful? In the meantime, he is on multiple medications, a chest restraint jacket and mitts. [Submitted on: 9/18/2007 by: Sally Lippitt-Houston, MSN, RN-BC, CNS; Palliative Care Consultation; Santa Rosa Memorial Hospital; Santa Rosa, CA] Answers Sally, you don't say what medication he is currently taking other than the Elavil. I only have anecdotal experience w/ a similar patient in a SNF where I was on-site NP. Many medications were tried but what worked was Depakote. Just a thought. [Submitted on: 9/18/2007 by: Nanci]

I am not sure if it is an option, but in the past, I have found a consult with a psych ARNP or psychiatrist to be helpful in these challenging situations. [Submitted on: 9/18/2007 by: Darrell Owens, Ph.D., ARNP, ACHPN; Clinical Assistant Professor and Director; Palliative Care Consult Service; Harborview Medical Center; Seattle, WA]

I would be more inclined to try a neuroleptic (haloperidol; olanzapine) [Submitted on: 9/18/2007 by: Candace C. Coggins, MS, MA, RN,C, NP, ACHPN]


I often find that a psychiatrist with geriatrics training can be of great assistance in behavior management for patients with an anoxic brain injury and memory loss. I have seen a couple of patients with agitation secondary to delirium (+/- dementia) who responded well to antipsychotics, in particular, Seroquel 25-100mg (titrated carefully). I would also ensure that other problems like pain, constipation, and delirium were correctly identified and treated. Feel free to page me prn. [Submitted on: 9/19/2007 by: Linda S. Blum, MS, GNP, APRN-BC; Palliative Medicine Program Coordinator; California Pacific Medical Center; San Francisco, CA]

We've also had luck with Haldol, Depakote, and Seroquel. In addition, we've used phenobarbital with good results as well. And, ironically, we've once had luck after all medications were stopped. Our patients were hospice patients and we were not able to use physical restraints thus we had to medicate for safety. [Submitted on: 9/19/2007 by: Jessica Weinberger; Alive Hospice, Inc.; Nashville, TN]

We often use Seroquel 25 mg BID for this type of behavior. [Submitted on: 9/19/2007 by: Shari Froelich RN, MSN, MSBA, APRN, BC; Palliative Care Foote Hospital; Jackson, MI ]

Perhaps this has already been discussed or ruled out, but I am wondering about pain and this gentleman. We know that up to 80% of older adults in LTC have pain and he may have something centrally mediated from his past brain insults. Anyway, he may benefit from an analgesic trial. I came upon an article in Journal of Gerontological Nursing (April 2006, pp 18-25) for a course I am teaching by Chris Kovach and colleagues entitled The Serial Trial Intervention: An innovative approach to meeting needs of individuals with dementia. I know Chris's work well and it is a nice approach to looking at symptom distress in persons with dementia. For the reluctant physician colleague, she has also published an article in a dementia care journal. [Submitted on: 9/19/2007 by: Patricia H. Berry, PhD, APRN, BC-PCM; Assistant Professor Co-Director, Geriatric Nursing Leership Program; University of Utah College of Nursing; Salt Lake City, Utah ]


Hello Colleagues, I have received so many supportive/ helpful messages regarding this case that I want to share our successes/failures in this man’s care. Just to repeat his medical history; this is a man in his early 50’s with a history of alcoholism that was “found down” and resuscitated in the field. He came to our Trauma II center and was in ICU for many weeks. He is now (no surprise) on our Palliative Care Unit. He is responsive at times with minimal language skills, largely nonverbal and aggressive. He has injured several staff members by hitting, kicking, or biting. He is also very perceptive and responds aggressively to assertive or loud or confrontive overtures by staff members. He must be confined with chest restraint and mitts. Per suggestion from the listserv, we have consulted with pharmacy and with a neuropsychologist on this case. I mentioned yesterday that we started him on clonidine (Catapres-TTS). He developed increased agitation, moaning, diaphoresis, and as his nurse described “crying to get out of his skin” by this morning. We discontinued the clonidine and started with 10 mg of methylphenidate. (neuropsych suggestion) Mid afternoon, he was able to ambulate in the hallway with two person assist without aggression, but obviously with large neuro neglect. He continues on regular doses of quetiapine (100mg/day with 100mg prn x1 daily), valproic acid (500mg q AM, 250mg q PM); and lorazepam 1-2 mg q 4 hrs prn. I hope this is an appropriate use of our listserv! This is an interesting and challenging case, and I appreciate the feedback I have received. [Submitted on: 9/21/2007 by: Sally Lippitt-Houston, RN, MSN, CNS; Palliative Care Consult; Santa Rosa Memorial Hospital; Santa Rosa, CA]

Question 66. Our organization is considering residential housing for patients whose families are unable to provide 24 hour care and do not wish to go to a nursing home. This would not be an inpatient facility or even a respite facility. I am interested in learning about any rules and regulations regarding this venture. Are there Medicare CoPs regs, federal regulations, etc? Is there anyone out there that has such an endeavor? If so, please help me learn more. THANKS!!! [Submitted on: 9/25/2007 by: Marlene Foreman APRN-BC, CHPN; CNS and Education Coordinator; Lafayette, LA] Answers Do you have licensed adult family or adult foster homes in your state? It may be one of the easier types of facilities to put together in terms of regulatory compliance and can offer some flexibility in the care you offer. Our island community is now building an adult family home which I expect will house not only elders requiring long term care for chronic illness


but also those requiring terminal care which will be supplemented by home hospice services. [Submitted on: 9/25/2007 by: Karen Gilbert, ARNP; Lopez Island, WA]

Yea for your community! A cozy home that is ADA compliant, welcomes families, and respects hospice philosophy is what we need more of. Not everyone wishes, or is able, to die in their home, or their extended family's homes.... but they do need a place for shortterm respite, or long term placement. As Karen mentioned for Washington state, Oregon too has many urban, suburban and rural adult foster care homes, lodging 3-8 residents, usually with chronic or end-of-life issues. Some spouses share a room. They are often owned by the host family/caregivers, and other groups. Payment is acuity-based, appear to take Medicaid, homes generally welcome hospice residents and limited personal stuff (dresser, portraits, TV's, maybe a cat). The caregivers may be delegated by an RN existing medication, suction, catheter, dressing change, etc. Federal and state Department of Health Services, CMS, etc. certify and monitor caregiving and licensure stuff. Daily notes are made by caregiver, and hospice team who visit. End of life residents are physically closer to caregiver’s bedroom or living room, there are a lot of baby monitors used at night, and in general seem top-notch alternative to a SNF. I was happily surprised to visit many, many AFC's upon leaving San Francisco bay area 8 years to work in Portland, Or, the last 5 as a personally and professionally fulfilled hospice RN. Hope any of this might be helpful, [Submitted on: 10/6/2007 by: Dee Santella RN, MSN]

Question 67. I have been asked to find out what reporting relationship advance practice nurses in hospital based palliative care have - more specifically – are you under nursing or are you under the medical staff umbrella? If you are under the medical staff umbrella, is there a certain specialty? If yes, which (oncology, medicine …) – also, are you seeing both inpatients and outpatients? I don’t know how much interest the answers have to the list serv, so please feel free to respond to me directly at jfrandse@cchseast.org [Submitted on: 10/1/2007 by: Jan Frandsen MSN CNP] Answers More specifically - are you under nursing or are you under the medical staff umbrella? Medical staff - if you are under nursing, you cannot bill for your services. If you are under the medical staff umbrella, is there a certain specialty? If yes, which (oncology, medicine ...) - also, are you seeing both inpatients and outpatients? I am part of a consultation service


that is specifically palliative care. My collaborating physician is internal medicine. I only see inpatients but we are working on ways to incorporate outpatient services also. [Submitted on: 10/1/2007 by: Diane E. Ranna, MN, FNP-C, ACHPN; Palliative Care Coordinator Piedmont Fayette Hospital; Fayetteville, GA ]

In our hospital, as well as outpatient palliative care program, our NP's report to our medical director for hospice and palliative care. Our program is a partnership with the hospital. We report thru the adult medicine service line. [Submitted on: 10/1/2007 by: Cornelia Scibetta]

I am under nursing without prescriptive authority. In the event I ever obtain prescriptive authority, I would be credentialed under the medical staffing office even though I report to nursing. [Submitted on: 10/1/2007 by: Jane McCabe RN, MS; Palliative Care CNS; VA Eastern Colorado HCS: Denver]

I have a dual reporting relationship. I am budgeted in Division of Medicine, Department of Geriatrics, and in that area, I report to the Chair of Gerontology. I also report to an assistant administrator of patient care services in Nursing. I like this relationship, as neither completely understand the role of the ARNP, but each does understand important components. I see inpatients and outpatients, as well as manage home hospice patients. We have no collaborative practice requirements, and full Rx authority, including all opioids. [Submitted on: 10/1/2007 by: Darrell Owens, Ph.D., ARNP, ACHPN; Clinical Assistant Professor and Director; Palliative Care Consult Service; Harborview Medical Center; Seattle, WA]

I am the manager and nurse practitioner of an inpatient consultative palliative care service. Our service reports directly to the Chief Medical Officer (medical staff) and I'm credentialed through the hospital to administer and bill for services. Our service has its own cost center and budget. Our medical director is an oncologist with strong palliative interests that has staff privileges and has a private practice in an adjoining building. He receives a stipend for his directorship. This structure has been well accepted in our hospital culture which is


majorly physician driven. Our past medical director was a pulmonologist with strong palliative interests. I have seen some outpatient clients in physician offices that are on campus - close to the hospital. Our service is too small to be effective with outpatients, so we definitely limit that availability. [Submitted on: 10/1/2007 by: Deanna O. Richardson, MN, MPH, APRN-BC; Manager, Palliative Care Program/Family Nurse Practitioner; Piedmont Healthcare; Atlanta, GA]

I am a solo practitioner in a hospital PC consultative service and I report to nursing. I am in the process of (hopefully) moving the service from nursing to medicine as I feel that the work is more consistent with a palliative medicine model as opposed to a palliative nursing model. I have never reported to nursing in any of the roles I have had as an ARNP and feel that the work we do an ARNPs is more medical-model based than nursing model, although nursing is always a component of what we do. I work currently with an oncologist who functions as a consultant but who does not have any direct care responsibilities for PC. If we are able to move the service to medicine, we will be joining the hospitalist group and reporting to the Medical Chief of Staff. We see only inpatients and bill for all visits (reporting to nursing does not impact ability to bill). We would like to add outpatients to the service at some point but will need additional FTE's to do this. [Submitted on: 10/1/2007 by: Judith A. Hill MPH, MS, RN, BC; Palliative Care Nurse Practitioner Virginia Mason Medical Center; Seattle, WA]

I am with the palliative care consult service for Emory Healthcare in Atlanta, Ga. Our service is under Hospital Medicine, Department of Medicine and all the medical practitioners report to the Division chief of Medicine. We are soley an in-patient service going between 2 teaching hospitals - no outpatient as of now, but we would love to with more practitioners. [Submitted on: 10/1/2007 by: Debbie Gunter FNP, ACHPN]

I am under the Department of Advanced Clinical Practice which is ultimately under nursing. This Department supports all advanced practice providers including CNS s, NPs as well as PAs. I am credentialed as the physicians are and report to my collaborating physician as required by the Joint Boards of Medicine and Nursing with full prescriptive authority. I am mainly inpatient (including the ED) but in the future will be seeing patients in hospital-based clinics. [Submitted on: 10/1/2007 by: Jennifer Gentry ANP APRN BC PCM; Duke Hospital Palliative Care Service; Durham, NC]


Our department uses advance practice nurses both inpatient and outpatient. Our hospital is a cancer center and we are under the division of medicine. All of our APNs are credential via medical credentialing committee. Our department used to be housed under anesthesia, but found we were a better fit for the division of medicine. Our APNs have a dual reporting system to our department administrator (non-clinical) and chair of our department (MD.) [Submitted on: 10/2/2007 by: Kelli Gershon, MSN, APRN, BC-PM; APN Palliative Care; The University of Texas MD Anderson Cancer Center]

Our team is a separate department in the hospital, the Palliative Care Department, and all of us in Palliative Care (MDs, me as CNS, and chaplain) report to the director who oversees a collection of departments and clinics under the auspices of the Virginia Piper Cancer Institute. I am credentialed with medical staff as an "allied health professional.â&#x20AC;? I see only inpatients at this time but this structure leaves open the possibility of billing outpatient someday when we establish a clinic. [Submitted on: 10/2/2007 by: Kerstin McSteen, RN, CNS; Palliative Care Service; Abbott Northstern Hospital; Minneapolis, MN]

Question 68. For those of you on teams with Palliative Medicine doctors, how are referrals handled when nurses or social workers think a patient needs palliative care but there is no MD order? We often run in to hearing about patients who would benefit from palliative care but the attending physician has not written an order. Do any of your services see patients without an attending physician order? And if so, how do you relate to the physician. If you need an order, what strategies have you used to obtain one? Thanks in advance. [Submitted on: 10/19/2007 by: Linda Gorman, RN, MN; Palliative Care Clinical Nurse Specialist Cedars-Sinai Medical Center; Los Angeles, CA ] Answers WE have a consultive service and any discipline is able to make a consult for palliative care. Then the chart is reviweed and a palliative care screening tool is used. The primary care physician is called if the patient screens positive. Most of the time, the physicians will agree to the consult using this method. This is a great opportunity to provide information to the physician about the program and palliative care. We always use the phrase, â&#x20AC;&#x153;would you be


surprised if this patient expired in the next year?â&#x20AC;? ( know ideally you should be thinking palliative care at the diagnosis of chronic disease) but you have to start somewhere in the learning process. We also leave information on the chart for the physician such as the EPERC Fast Facts. [Submitted on: 10/19/2007 by: Susan Kasseroler, RN, MSN, GNP]

Our service accepts referrals from all sources. We handle it by meeting with the patient and/or family and explain what our program has to offer. We then write a short note that referral received from whomever and that the program was explained and whether or not the patient or family is interested or if they need to think about it. If they want our service then we call the MD for an order and explain why we saw their patient. [Submitted on: 10/19/2007 by: Jean Endryck, FNP; Family Nurse Practitioner; Director of Palliative Care; Seton Health System; Troy, NY]

We also run into this problem on a fairly regular basis, especially with neurosurgery patients where the nursing staff clearly believe they would benefit from a consultation, and the team does not (for a variety of reasons). We have very good working relationships with most services, and don't want to discourage nurses or social workers from calling. That having been said we do not see any patient or family unless the attending provider (or a resident on their team) orders a consult. First, if you are a billing service, the attending has to order the consult, and there needs to be evidence that the results of the consult were sent to the attending. We meet this obligation by cc'ing our note to them in the electronic medical record. If know the team, sometimes we will call them directly, or we have the nurse call them and say they spoke with us, and a consult sounds like a good idea. Because we have a resident on our team, I almost always have them call the resident on the team, and secure an order. I have to admit there are times when the team outright refuses the consult, again some services more than others. Seeing patients without the primary team ordering a consult would not work in our institution based on our culture. [Submitted on: 10/19/2007 by: Darrell Owens, Ph.D., ARNP, ACHPN; Clinical Assistant Professor and Director; Palliative Care Consult Service; Harborview Medical Center; Seattle, WA]

My service requires an order from the attending MD before either the NP or MD for palliative care can see the patient. Many times the floor RN or case manager will call the MD and ask for an order for palliative care consult. This is usually sufficient. At other times, I


have called the physician myself and explained how I could help the patient. I will then write a telephone order from the physician requesting the consult (even though as an NP I could write the order myself, I feel it looks better to have it as a phone order). Please feel free to contact me directly for further info. [Submitted on: 10/19/2007 by: Jennifer Bobolia, FNP-C, ACHPN; Palliative Care Service Old Colony Hospice/Brockton Hospital; Randolph, MA ]

As Darrell commented, it is important to note that if you are billing for your services as a consultant there has to be some type of written order in the patientâ&#x20AC;&#x2122;s chart. [Submitted on: 10/19/2007 by: Joanne M Sigler, MSN, ARNP, BC-PCM; Palliative Care Center of the Bluegrass; Lexington, KY]

Our culture here is that we have a strong advanced practice nursing presence and a strong patient care services. Thus, if it is not a formal palliative care consult for pain and symptom management, we can still do a palliative care nursing consult. I do not bill for this visit. Additionally, the note may be vaguer and not make specific recs but would speak to supporting staff etc. [Submitted on: 10/19/2007 by: Constance Dahlin, APRN, BC-PCM; Palliative Care Nurse Practitioner; MGH Palliative Care Service; Boston, MA]

We take referrals from anyone, we review the chart then call the MD or team let them know we were called prior to seeing the pt. 99% of the time they think it is a great idea. (I would guess that ~ 20-25% of our consults start from non MDâ&#x20AC;&#x2122;s.) If they don't want the consult, we give the caller a curbside consult +/- a note depending on the issue, Best wishes, Ps We are aware that it is not billable without a MD approval, (but we usually don't bill as hospital employees). [Submitted on: 10/19/2007 by: Pat Coyne]

It is really important for us to have the "buy in" of physician staff in terms of our survival and the bigger picture. Even when we get a referral from a house officer, one of our first questions is who is the attending and are they aware of the consult. The last thing we want to do is alienate our physician customers. All that said, I encourage nurses and other


disciplines to call me and I can help them problem solve, give curbside vice and sometimes negotiate with the primary team for an official consult. [Submitted on: 10/19/2007 by: Jennifer Gentry ANP APRN BC-PCM; Duke Hospital Palliative Care Service; DUMC; Durham, NC]

Our service is small, just an APN (me) and a part time MD who is primarily our ethics consultant. I often receive requests from nursing or case management to see patients with no MD order. I will speak to the individual making the referral and strategize the best way to handle the issue. I will often call the MD to discuss the request. It is rare that I do not have cooperation from the MD to proceed. Ours is a consulting, not a managing service. The physician on the team will not see patients without an MD order. [Submitted on: 10/20/2007 by: Lori Hedges MS, APRN, BC-PCM; Advanced Practice Nurse, Pain Management & Palliative Care; Advocate Illinois Masonic Medical Center; Chicago, IL]

Question 69. I recently moved from NY and have encountered some cultural differences impacting our hospice practice. Previously (in NYC), referral sources had three options: 1) Continue being followed by PCP; 2) Collaborative care between PCP and Hospice Medical Director (w/NP); or 3) Transfer of care to Medical Director (w/NP). Choices 2 or 3 required assessment and planned follow up by the MD/NP team which was able to bill Medicare for each visit. (I believe the NP reimbursement was about 80% of the reimbursement for an MD visit but I am not sure). Does anyone know the reimbursement for MD and reimbursement for NP? In NY, were glad when physicians chose numbers two or three because it enabled knowledgeable palliative care to prevail. My dilemma is that in my present locale (SC), turning over the care of your patient to the medical director (and designee) is akin to abandonment. The nurses have great latitude to make suggestions and recommendations; all of which is great if their recommendations are evidence-based rather than forged by tradition only. I was thinking that the referral options (with marketing to promote the "value-added" of choices 2) and 3) might make it easier for our physicians and nurses to enhance the quality of their care and still preserve meaningful relationships between providers and the patients and families they serve. Part of the overall goal is to be able to bill for NP services because our medical director is PT and sees more referrals to him as a hardship. I want to present the idea as a source of additional revenue; opportunity to enhance practice and minimal impact on his load because of NP out making visits and coordinating care. Has anyone (everyone?) out there dealt with similar issues? Do you have recommendations? Information? Any/all ideas are gratefully accepted. Thanks very much. [Submitted on: 10/24/2007 by: Candace C. Coggins, RN,C, ACHPN, APRN, BC; Hospice Care of


the Low Country] Answers In the 3 scenarios that you mention: 1) PCP maintains responsibility for care, 2) Collaborative care between PCP and hospice medical director with NP, and 3) Transfer of care to hospice medical director or NP --- it is my understanding that NP services are billable only under option # 3. CMS allows hospice-employed NP's to bill for services to hospice patients only when the NP is the patient's attending. Hospice-employed MD's can bill for services to hospice patients whether they are acting as a consultant (option # 2), or whether they are acting as the attending physician (option # 3). If the hospice in NY figured out a way around this and was able to bill CMS directly for NP services under option # 2, I would be very interested in hearing how they did it. I have always been told that direct NP billing was not permitted under any scenario except option # 3. I think that in any new community it is a process --- and sometimes a long one --- to build trust among the community physicians. Go out into the community and meet them. Can you and the MD get yourselves on the schedule to give a talk at medical grand rounds at the local hospital? Offer yourselves as resources to call with difficult patient management issues. Make yourselves available. Gradually as community PCP's get to know you see that you can help them, they will start involving you more in their patients' care. [Submitted on: 10/26/2007 by: Julia Gies, APRN, BC-PC; Providence Connections Program; Beaverton, OR]

I am under the impression that as an NP, I can bill for visits as a specialty NP, even if I worked for a hospice agency. I currently bill for patient visits in the oncology specialty and have done a few home visits for oncology patients and billed for them as well. Wouldn't palliative care visits as a specialty work the same way? I am referring to palliative care visits to non-hospice patients. I suppose that for visits to patients in the hospice program I would need to be one of the medical directors for that to work. Do I have this right? [Submitted on: 10/27/2007 by: Karen Gilbert, ARNP; Lopez Island, WA]

If you are seeing non-hospice patients (IE palliative care patients), you can bill Medicare B as Hospice is allowed to do a palliative care consult for non-hospice patients. You do not have to have the medical director do the visit if you have met the billing requirements. [Submitted on: 10/27/2007 by: Connie Dahlin]


Karen, you can bill for your visits to a hospice patient whether you are a specialist (oncology or palliative care), or whether you are the patient's primary care provider. The only time you cannot always bill for your visits to a hospice patient is if you are employed by a hospice agency. In that circumstance, CMS would only allow you to bill for seeing the hospice patient if all of the care had been turned over to the hospice agency and you were the patient's attending. As an employee of a hospice agency, you as an NP cannot bill for specialty visits or consult visits to a hospice patient. Obviously, this does not apply to nonhospice patients. Nor does it apply to visits you make if you are not employed by hospice. [Submitted on: 10/29/2007 by: Julia]

Thanks very much for contributing to the clarification of this thorny problem. I have uncovered many levels of understanding (misunderstanding) held by doctors, nurses, and administrators. Not a very user-friendly process. My question to your post would be: What kind of circumstances would an NP (not employed by the hospice) be making a visit on a hospice patient? Perhaps an NP working with the PCP? Thank you. [Submitted on: 10/29/2007 by: Candace C. Coggins, RN,C, ACHPN, APRN-BC; Hospice Care of the Low Country]

Karen Gilbert's situation is one example: an NP working in an oncology practice making visits to hospice patients. Or any other specialty: palliative care, cardiology, pulmonology, etc. Mostly we see NP's in primary care continuing to care for their own patients after they go on hospice. [Submitted on: 10/29/2007 by: Julia Gies, APRN, BC-PC; Providence Connections Program; Beaverton, OR ]

I continue to see some patients after they are admitted to a hospice program, and I am not the primary provider. This is often after I have done a consultation (inpatient or outpatient), and their PCP ask that I stay involved to consult for symptom management (both physical and emotional). Unfortunately, our local hospice programs are having some issues with staffing and continuity, and have hired many inexperienced RNs. Historically many of our PCPs relied on hospice nurses to provide accurate symptom assessment and recommendations for treatment which is not happening, so they have asked that we stay involved and manage symptoms. We have an electronic medical record, so I cc a copy of my note to the PCP after my visit (which is often a home visit) with any changes I have made, including orders I write for medications. Because we are not the PCP, my bill goes to hospice


as a consulting provider in the same way a cardiologist, oncologist, or other specialist would do. [Submitted on: 10/29/2007 by: Darrell Owens, Ph.D., ARNP, ACHPN; Clinical Assistant Professor and Director; Palliative Care Consult Service; Harborview Medical Center; Seattle, WA]

As I mentioned to Candace, many NP specialists follow patients after they are admitted to hospice. We have a number of NP's in oncology practice doing it in our community. But I think that what you are doing is particularly important. There are some very medically complex patients admitted to hospice, and many PCP's are really asking for help with management. Unless the hospice has an experienced physician with a lot of availability --and many hospices don't --- there will continue to be a need for the kind of specialty service you are providing. Thanks for being there for the patients. [Submitted on: 10/29/2007 by: Julia Gies, APRN, BC-PC; Providence Connections Program; Beaverton, OR ]

Question 70. Has anyone personally developed, or has your institution developed, a policy specific to palliative care or palliative team referral? I am aware there are many guidelines specific to cancer and non-cancer diagnosis that indicate appropriateness of palliative care, but I am wondering if anyone has put these numerous guidelines into a hospital policy form? We have developed a suggested list of criteria but are considering developing a policy. Thank you! [Submitted on: 11/7/2007 by: Sally Lippitt-Houston MSN, RN-BC, ACHPN, CNS; Palliative Medicine Consult Team; St Joseph Health System, Sonoma County; Santa Rosa, CA] Answers We have automatic referral of all pancreatic, stage III/IV lung, and brain tumor pts at the time of dx. They are not in the hospital, so this won't help your specific question. However, our program is very strongly focused on "early detection" of appropriate pts and / Prevention of crises. Our oncologists believe that this has kept folks out of hospital and prevented prolonged/ ineffective hospital tx when our onc pts are admitted. [Submitted on: 11/18/2007 by: Marie Bakitas, ARNP, DNSC, FAAN; Post-doctoral Fellow; Yale University-School of Nursing and Assistant Professor Adult Nurse Practitioner, Palliative Care Section of Palliative Medicine; Dartmouth-Hitchcock Medical Center; Lebanon, NH ]


I have worked in both outpatient palliative care and hospice and currently am setting up an inpatient palliative care service. We have not written a policy yet, but in answer to your question I would check with the CAPC site policy resource and also there is an abundant info in the palliative care literature about referral criteria and process for handling requests for consults. Hope that helps. [Submitted on: 11/8/2007 by: Jan Kimball MSN APRN, BC-PCM; Palliative Care Service; Rex Healthcare; Raleigh, NC]

Question 71. I was wondering if anyone out there has FTE under both the dept of Medicine for billing and under the dept of Nursing. We are looking to hire another APRN and this might be a way that we could get approval for another position. Your help with this as always is very much appreciated. [Submitted on: 11/12/2007 by: Sue Ruegg] Answers I am in such a position. I am housed in the Department of Medicine/Geriatrics, but nursing pays for a large portion of my salary (they somehow transfer $$$ between departments). This means I report to the Chair of Gerontology for clinical issues (ARNPs in WA do not require collaborative practice), and an associate administrator for nursing for administrative issues. I am fortunate because my adwministrative boss in nursing completely gets the ARNP role, and is very supportive. I was originally hired into nursing, but was transferred to medicine for credentialing and billing, with nursing continuing to pay for a portion of my salary. So it is possible with creative thinking. [Submitted on: 11/12/2007 by: Darrell Owens, Ph.D., APRN, ACHPN, Clinical Assistant Professor and Director, Palliative Care Consult Service, Harborview Medical Center, Seattle, WA]

Are you able to bill with most of your salary coming out of Nursing (hospital setting)? My understanding is that it is considered "double-dipping" by CMS to bill when your salary is paid by Nursing because CMS already covers the cost of Nursing. [Submitted on: 11/12/2007 by: Susan Kasseroler, RN, MSN, GNP; Beaumont, TX]


It's not so much who pays your salary, but whether your salary is included in the Nsg cost report. You COULD report to Nsg and bill if your salary isn't included in Medicare cost report--the latter would be double dipping. Anyhow, that's how I understand it. [Submitted on: 11/12/2007 by: Terry Thompson]

This is fine to do. It also makes billing possible... [Submitted on: 11/13/2007 by: Connie Dahlin]

One can do percentages of nursing and medicine.. Look at how much time you are seeing patients and put that percentage under medicine. [Submitted on: 11/13/2007 by: Connie Dahlin]

Question 72. We have a patient that was found down at home by a neighbor. He's intubated now, not weaning, on tube feedings. We had an ethics consultation, and he is now a DNR/AND. He is not brain dead, so we cannot discontinue life support. Certainly, he would benefit from deceleration of care, but we have no family or POA. Has anyone run into this? How did you solve it? I am willing to bet he will not be a candidate for deceleration, as there are no provisions for this with Georgia Law unless there is brain death. [Submitted on: 11/19/2007 by: Diane Ranna, NP; Piedmont Fayette Hospital, GA] Answers I'm not at all familiar with the GA laws, so take this with a grain (or a pound) of salt. When the five TX hospitals got together all those years ago to develop language, we found it most instructive. It was something like, "benefit refers to those therapies that can be appreciated and valued by the patient." When I was chairing a hospital ethics committee, one of the tenets of our consults was that a therapy should never be started that the team (whichever the team is) isn't willing to discontinue. (Think of stopping antibiotics that weren't working to clear an infection. The same principle should apply to vents, dialysis, medications, etc.) I'm not familiar with the concept of deceleration. When there was no next of kin we went through the process of having an advocate assigned for the patient, though not necessarily through the courts. [Submitted on: 11/19/2007 by: Mimi Mahon, PhD, RN, FAAN; Advanced Practice Nurse,


Palliative Care & Ethics; Associate Professor; School of Nursing; George Mason University; Fairfax, VA]

We are an inner-city hospital, and face this issue with some frequency. I can tell you what we are forced to do by hospital policy, and by WA state law. Some decisions can be made based on medical futility when death is an almost certain outcome, e.g., acute decompensation requiring multiple pressors, and MSOF. Absent that, we must file for guardianship, which takes 2-4 weeks, and continue care, including trach and PEG if indicated. This buys the patient a life of care in a SNF, which may or may not have been what he or she wanted. Depending on the judge, and later the guardian, they will consider information provided by people who know the patient, even if they are not legally related. In my experience, these patient cycle in and out of the system (hospital to SNF to hospital) with multiple infections, and either die, or stay in the SNF and loose track of them. While it is not something most of us would elect for ourselves, some people would, and therefore without concrete information about the patient or how they lived their life, have no way of knowing, and our state sides with life, even if vegetative. It is very frustrated for nursing and medical staff. Our state does not allow withdrawal or withholding of medical care without a guardian, or just because someone has neurologic injury. [Submitted on: 11/19/2007 by: Darrell Owens, Ph.D., APRN, ACHPN, Clinical Assistant Professor and Director, Palliative Care Consult Service, Harborview Medical Center, Seattle, WA]

Our state does not allow withdrawal or withholding of medical care without a guardian, or just because someone has neurologic injury. I would venture to guess this will be our state's stance as well. I selfishly, am hoping that the patient will die without further intervention (trach and PEG), but who knows? By the way, AND is Allow Natural Death, the verbiage we use with our patients and families. My phenomenally dedicated and motivated friend and coworker in the system, Deanna Richardson, worked hard to have a shift in the semantics of our state as well as facilities. Kudos! [Submitted on: 11/19/2007 by: Diane Ranna]

An ethics consultation is very beneficial. Sometimes friends and neighbors can shed some light on the patient's values, beliefs, past choices and preferences and the substituted judgement the standard of decision-making may be applied. If there is no information to support this level of decision making, then the standard becomes "best interest.â&#x20AC;? This is a


bit more complex, as one needs to consider "best interest" in a more broad sense. Best interest should consider what is the medically appropriate care based upon the patient's condition. I would seek medical consensus among the PCP and consulting physicians. If there is no chance that this patient has a poor prognosis with death likely to occur within a year, then consider comfort care as medically appropriate in light of prognosis and provide only those therapies for the patient's comfort and safety--tracheostomy, PEG and hospice referral. Would not do lab or diagnostic tests and treat only symptoms for maintenance of patient comfort. We have found that even with a court appointed guardian, making treatment recommendations related to medical prognosis and appropriateness of medical therapy has been acceptable. [Submitted on: 11/20/2007 by: Chris Westphal APRN-BC ACHPN; Director/NP PRISM Palliative Care Services; Oakwood Healthcare System; Dearborn, MI]

This response is from California. Our hospital is a member of Catholic Healthcare syst. The corporate office, with advice from ethics and legal, developed a policy called "health care decisions for unrepresented patients.â&#x20AC;? This policy is not for emergencies and is for when the physician determines the patient does not have capacity. An intensive search is documented to attempt to locate a surrogate decision maker that includes, examining personal effects, contacts known persons (i.e., building managers, friends), contacts the secretary of state to inquire if an advance directive is registered. If the search still shows no surrogate decision maker then, a goals of care can be determined by weighing: relief of suffering, recovery of cognitive functions, preservation of function, quality and extent of life sustain, and cultural/religious beliefs if known. If all members of the multi-disciplinary team agree on the appropriateness of withholding or withdrawing treatment, it can be implemented. If there is disagreement on the care plan, then the ethics committee is consulted. Legal would be consulted for: injuries inflicted by criminal act; condition is result of adverse medical event; patient is pregnant; patient is under 18 years of age; patient is parent with sole custody of a minor child. We are just in the process of approaching this policy, so we have not implemented it yet. [Submitted on: 11/20/2007 by: Connie Borden, Palliative Care Coordinator St. Marys Medical Center â&#x20AC;&#x201C; SF]

We have developed a flow chart to assist staff (which includes an automatic ethics consult). One important starting point is to insure that a diligent search has been done for a surrogate decision maker. We have included in our policy the involvement of our University police department, and social services There are several reports in the literature about this topic, see White, Curtis, et. al. Annals of Internal Medicine Jul 3 2007 147 (1)


[Submitted on: 11/20/2007 by: Jennifer Gentry ANP APRN BC PCM; Duke Hospital Palliative Care Service; Durham, NC]

You also might want to check the "surrogate" law here in Tennessee. This is where a physician is able to "appoint" a surrogate for an incompetent or unconscious patient who does not have a legal durable power of attorney for healthcare. This person may be a family member, a friend, or even the physician if there is absolutely no one else. [Submitted on: 11/20/2007 by: Jessica Weinberger, APRN; Alive Hospice, Inc.; Nashville, TN]

Question 73. At our hospital, a new consultation is requested by the attending MD on the primary team. The patient is first seen by the Palliative Care attending MD (with or without a physician trainee) and the Palliative Care attending MD bills for this initial consultation. On subsequent days, the patient may be seen by either the MD or the NP (in addition to other members of the team as needed). Whoever sees the patient (MD or NP) bills for the followup consultation visit. All of the NPs and MDs are employees of the School of Medicine, not the hospital. There is no precedent in our institution for NPs billing for new inpatient consultations, but we can find no law or policy that prohibits us from doing so. Is anyone out there doing this now? Is it legal? Any actual or potential problems with this model? Can the Palliative Care MD bill for subsequent follow-up consultation visits if the NP billed for the initial consultation? [Submitted on: 12/21/2007 by: Jay Horton, FNP, MPH, BC-PCM, Clinical Coordinator, The Lilian and Benjamin Hertzberg Palliative Care Institute, Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, NY] Answers I am the full time NP on our hospital's consult service. As our physician is only part-time on the team, I see many of the consults and most of the follow ups. I also work for the School of Medicine and so bill for both consults and follow ups. Sometimes I do a follow up on a consult the physician has billed for and vice a versa. We've been doing so for 2 ½ years without a problem. [Submitted on: 12/21/2007 by: Marian Grant CRNP, Palliative Care Service, Johns Hopkins Bayview Medical Center]


In our institution, there is only one attending provider on at a time, and one resident physician. In our hospital, consistent with WA state law, an ARNP can be an attending provider (in our state there is no physician collaboration requirement, and have full Rx authority for all opioids). When I am on, I bill for the initial consultation and subsequent visits, when the MD is on they do the same. We cover in 7 and 14 day blocks, so I when I rotate off service, the MD will continue to bill for any subsequent visits on my initial consults, and vice versa. The important thing to remember is that we are in the same "practice group," which means that we are essentially treated as the same provider. If we had a new consultation last year, and the patient comes back to the hospital a year later, and we see them again, we cannot bill them as a new consultation if someone in our practice group has seen them within the past three years, which includes outpatients. I am also School of Medicine faculty which allows me to supervise and teach the resident and fellows on our service. Charting is different when I am on service, versus when one of my MD colleagues is covering. As an ARNP, our institution will not let me link to the resident's note for billing (like the MD can), even if we did the entire consult together. As an ARNP, I also cannot link to the resident's physical exam (like the MD can). When I am on I have the resident write the note using our template in MS Word, and then have them e-mail to me, where I edit it, add my own physical exam, and my own impressions, I then add it to the medical record. This process is far more time consuming than if I just wrote the note myself, but if I did that it would eliminate the opportunity for resident learning that I believe writing a palliative care note provides. If there is anyone else supervising residents, I would love to know if you do it differently. [Submitted on: 12/21/2007 by: Darrell Owens, Ph.D., APRN, ACHPN, Clinical Assistant Professor and Director, Palliative Care Consult Service, Harborview Medical Center, Seattle, WA]

Very informative, thank you. If I understand, then you are employed by the School of Medicine? what then, if any, are your responsibilities/involvement with the Dept of Nursing? We have residents rotate with us also, and have created with our Informatics Dept, an interdisciplinary electronic note. So we have one document, that any team member can initiate, but the MD is the final reviewer. During the day, the RN, Chaplain, Music therapy, Resident can provide their input. The MD reviews, edits, signs at the end of the day. As an APN, the Compliance office doesn't allow me to chart History of Present Illness, Physical Exam, Impression & Plan. Although we often chart this information in another section and it is cut/pasted into the appropriate header by the MD. If employed as an ARNP, I would be able to chart under those sections. [Submitted on: 12/22/2007 by: Cheryl Vahl RN MSN AOCN ACHPN, University of Iowa]


We are a university hospital, so we are all university faculty, and paid by the university, but I am in the Department of Medicine budget. All of my billings must first go to offset my salary, the rest goes into the large university system black hole, never to be seen again. I also hold a faculty appointment in the School of Nursing and Pharmacy. My relationship with nursing is that I precept ARNP students, but work very closely with nursing staff, never forgetting my roots. I founded the service at Harborview, and am very proud of the fact that it is the only consult service within the university system founded and directed by an ARNP. Although an MD order is required for an official consult, every attending provider on our service knows that any nurse can call at any time with questions, to vent, for support, etc. I think have a great relationship with nursing. [Submitted on: 12/22/2007 by: Darrell Owens, Ph.D., APRN, ACHPN, Clinical Assistant Professor and Director, Palliative Care Consult Service, Harborview Medical Center, Seattle, WA]

Question 74. We are working on a home care program for palliative care. Does anyone have any information about the productivity expectations for APN in home care? Can you please give me an idea of the estimated volume of visits and/or referrals one could anticipate that could be billable to Medicare and/or Medicaid for palliative care consults? Any thoughts appreciated. [Submitted on: 11/6/2008 by: GERALDINE ABBATIELLO, PHD, APRN, BC, RN] Answers Dear Geraldine and Sig colleagues, In my experience doing home care visits in Palliative Care, a big factor may be the time spent traveling depending on your geographic areas. I would also suggest investigation of your reimbursement for visits depending on state regulations to represent the value of the APN visits. In addition when initiating Palliative Care visits consider the assessment tools you will use as well as how you will measure clinical outcomes from your visits to represent quality not just quantity of visits. Check out HPNA and CAPC resources. Best wishes in this endeavor [Submitted on: 11/8/2008 by: Carol R Matthews CNS, ACHPN, Lake/University Ireland Cancer Center, Palliative Care Nurse, Mentor, OH]

At-home palliative care is a very needed and very gratifying experience, comprising visits to our shut-in population, follow-up for inpatient palliative care consults, symptom and disease management for patients with end-stage chronic illness, complex family decision


making, advance care planning, as well as visits to hospice appropriate patients who are not ready for hospice or continuing with therapies not deemed appropriate for hospice. Our experience doing outpatient palliative care home visits as a team of NPs (OACIS Services, Lehigh Valley Hospital, Allentown PA) is that Medicare reimbursement rates for home visits are adjusted to account for the extra time (and most visits are billable at a visit intensity of 4 or 5, but of course at 80% the rate paid to physicians), but in general, it is hard to make a go of it, if productivity is the criteria for success. The NPs travel over a wide area and it is hard to carve out geographic areas with a small team of providers. In addition, it is very difficult for NPs to wade through the social issues that we confront without a staff social worker. Our estimate was that each visit accounts for about 2-3 hours of time (depending on initial versus follow-up, family meetings etc.) if you account for time in the home (60-120 minutes), travel (average of about 20-30 minutes), coordination of care and other follow-up between visits (30 minutes). This makes it possible to do from 3-4 visits a day per provider. At the point when I left the practice in August (I'm now working at Harborview in Seattle), I was carrying about 75 patients, seeing them about once monthly. At Harborview, our model of outpatient care is more diversified comprising outpatient clinic, home visits, hospice, and consults at SNFs and other facilities (e.g., renal dialysis centers). I can't say yet if this model is more sustainable financially. By the way, OACIS is looking for another full time NP to join the team. It's a wonderful opportunity, and very gratifying work. [Submitted on: 11/8/2008 by: Risa Denenberg ARNP, ACHPN]

At my hospice, medical service expectations are to make 4-6 visits per day. There are other hospices in Florida where I know the expectation is 8 visits per day (that is a for profit hospice). Even though Medicare does not mandate frequency of medical service visits, as an agency, our rule is that we see patients with cancer diagnoses once a month and non-cancer diagnoses every two months. If there is a change or an urgent need, a more urgent visit can be arranged. [Submitted on: 11/8/2008 by: Beverly Douglas ARNP ACHPN, LifePath Hospice, Tampa Florida]

Since all hospice is palliative care, from a visit stand point, my experience is with a new admission, I am able to see 3-4 patients a day, and with a follow up 4-6. This is highly dependent on location (the distance I have to drive) as well as complexity of the visit. As for expectations for palliative care service, at this point we are hospital based only. But my expectation is that for field service I would expect the work to be about the same. [Submitted on: 11/9/2008 by: Meg Ramstad MSN ARNP, Hospice of Volusia Flagler, Port Orange FL]


There are some differences to consider for free standing home-based palliative care programs, i.e., if it is not associated with a hospice or home care agency. With hospice there is a team to support the patient. I know the ideal for palliative care programs is interdisciplinary, but for most "free-standing" palliative care home programs, it's only the provider NP, so there is more pressure to manage the entire scope of family needs as well as a broader scope of disease management. So visits may take longer. For example, if the provider wants to start a new medication, but the patient's insurance won't cover it, the NP has to figure out how to get the medication for the patient. Or if there is family conflict over placement versus staying at home, or whether the patient is safe at home, the NP may have to deal with these issues without team support. In addition, without RN visits, NP visits may need to be more frequent. Just some thoughts to consider. [Submitted on: 11/9/2008 by: Risa Denenberg ARNP, ACHPN]

You can also consider contacting the case management dept of the patientâ&#x20AC;&#x2122;s insurance to see if you can find a CM who will be helpful in navigating some of the insurance areas. He/she can be part of the palliative care team. [Submitted on: 11/9/2008 by: Leslie Piet, RN, MA, CCM]

Question 75. Hello everyone, I have something for which I was trying to get some advice. It has been bothering me for a few weeks. A few weeks ago, I went on a visit with a dementia patient that assaulted a resident at a nursing home. I want to be careful what I say due to HIPPA, but the details are irrelevant. In the post days, I was having a hard time and talked with our bereavement coordinator. She brought up an interesting point. Historically, we did not have sex offenders living in our community (most often if they were known they were killed or jailed). However, we now have sex offenders in our community, and as they age and move in to our senior community how much of a risk does this place on our patients or family? They are being placed in close quarters with vulnerable individuals who are too weak or oriented to be able to defend themselves. Maybe even the offender themselves may not understand what they are doing, but the urge is there. How can we as a hospice community help to protect our patients and other patients? Also, when you have to help the one who has attacked it is very difficult. However, when they are our patient that is what must occur, but how can we move past it? Any suggestions? [Submitted on: 10/6/2008 by: Becky]


Answers No specific suggestions, but this article may give you some direction: Harvath TA. Caley J. Wanlass W. Ralls W. Schulling J. Toth S. The nursing home resident with a history of pedophilia: issues and challenges. Journal of the American Medical Directors Association. 2001 Sep-Oct; 2(5): 215-21. ) I've attached the manuscript. [Submitted on: 10/6/2008 by: Miriam A.E. Volpin, BS, RN-CHPN, Doctoral candidate, Hartford Scholar]

Becky, I can't help wondering how you came to view a patient with dementia (many of whom are agitated and combative) as potentially a former a sex offender. Perhaps you left some of the story untold. As palliative care providers, we frequently come into contact with patients who exhibit symptoms such as agitation, combativeness and delirium. We are called upon as experts to offer assistance and support to patients and caregivers to ameliorate these symptoms, which cause suffering to the patient and potential harm to patients and caregivers. As far as "moving past" any qualities of characteristics of our patients that are uncomfortable or distasteful to us, it is our personal and professional responsibility to find ways to do that. Most importantly, keep noticing and talking with colleagues about the feelings that come up for you when you are providing care, and ask for support when these feelings may be interfering in your ability to provide the kind of care you would like to be able to. [Submitted on: 10/6/2008 by: Risa Denenberg APRN, ACHPN]

Hi Becky, I was in a similar situation and agree that it presents a real moral/ethical dilemma. In this case the patient was an elderly gay male who had been accosting other male residents in the facility. (Our assessment was that he was demented and not aware of what he was doing. He scored very low on a mini mental status exam). We tried a number of things: environmental modifications so that the offender could not be alone with other patients. He was placed on an antipsychotic med (can't remember the name!). When theses measures didn't work he was referred to a gero-psychiatric specialist. There was discussion of chemical castration, which of course was a huge deal and would not have been considered a real option until all other measures were exhausted. As far as moving past difficult situations, I don't know that it's possible! In all my years as a hospice nurse I've come to the conclusion that you just have to go "through" the situation, process it and get support along the way. Sounds like you did that by talking w/ the bereavement counselor. [Submitted on: 10/6/2008 by: Mary Knopf]


In the example I discussed earlier the patient was a known sex offender. I agree with Risa though that inappropriate sexual behavior can be a part of dementia. Mary [Submitted on: 10/6/2008 by: Mary Knopf]

If they are known to have these tendencies, they most probably need to be in another environment and not where there are vulnerable elderly. The other option is chemical restraint which I know we have used in those situations until placement can be obtained. Psych is also actively involved. Roz [Submitted on: 10/6/2008 by: Rosalind Slevin]

I guess I should clarify that I am a weekend on call nurse, at at very busy hospice. I am aware that dementia patients do have aggressive tendencies, and behavior issues. I just had never pictured one resident attacking another. I began to wonder how I would feel if that were my family member. I do not have to come in contact with this patient any more, but the situation has weighed heavy on my mind and heart. I do not know if this patient is or is not a known sex offender, but the act was a sexual assault. It was posed to me by my bereavement coordinator about the sex offenders in our community and the potential problem as they age and move into the LTCF's. I was just wondering if others have considered this, or ran across this situation. I have never in my hospice experience prior to this. When I was in the situation, I was focused on caring for my patient, getting him in a safe place for evaluation, and providing support to the facility staff and his family. It was only after I left the situation that I realized how bothered by it, I was. I kept picturing what had occurred, that is why I was asking. Thank you to everyone who wrote with support. I just want to know ways that I can try to recognize this problem in patients, before this happens again. I want to know I have not missed something in patients that I come in contact with, and I want others to be aware of the potential risk. Becky [Submitted on: 10/6/2008 by: Becky]

You have brought to our attention a much needed conversation. Thank you. One area you might want to consider is was this pt a veteran and is he suffering from PTSD. Just a thought. [Submitted on: 10/6/2008 by: Dale Williams, Hospicecare of Kansas]


I agree with Dale that I appreciate your bringing this topic to the attention of the list serve. There are types of dementia that bring about aggressive behaviors that the patient may never have experienced before. So although I understand your thought process of our aging population including sexual predators (something none of us like to think about), we may just see more of this as our dementia units become more populated. I am concerned though with your statement that you want to avoid "missing" something. We, as health care providers, need to recognize is that we are not responsible for our patientâ&#x20AC;&#x2122;s behavior (or for that matter - anyone else). This may not be something that any staff person, including a physician, social worker, or counselor could predict. You cannot blame yourself. You mention a bereavement counselor. I would hope you consider a personal counselor that can help you work through this event. Possibly your institution has employee assistance for this specific type of thing. Don't let this eat away at you...get some professional help that can allow you to process. You may be suffering some PTSD yourself and you need to take care of yourself before you can take care of others. Take Care, Michelle Witkop, FNP-BC Palliative Care [Submitted on: 10/6/2008 by: Michelle Witkop, FNP-BC, Palliative Care]

Regarding the most recent response that you received, I think I may be missing something because I'm not at all concerned with your having asked "am I missing something?" M.A. Heme-Onc NP [Submitted on: 10/6/2008 by: M.A., Heme-Onc NP]

Question 76. Hi all. My hospital is interested in establishing a volunteer program, so that no person dies alone. If your hospital has such a program, I would appreciate any information you are willing to share, especially related to the following areas: recruitment process (and any suggestions or lessons learned), training curriculum and logistics. By this, I mean how do patients get referred, who handles the referrals, how do you schedule people to be with dying patients? Again, thanks for your time and help in this matter. [Submitted on: 11/13/2008 by: Leslie Blatt APRN, Palliative Care Coordinator, Yale New Haven Hospital] Answers


There is actually a very good website and program established in Oregon, http://www.peacehealth.org/Oregon/NoOneDiesAlone.htm. [Submitted on: 11/13/2008 by: Nancy Joyner, RN, MS, APRN-CNS, ACHPN, Clinical Nurse Specialist-Palliative Care Altru Health System- Altru Hospital 1200 So Columbia Road Grand Forks, ND 58201]

Hi Leslie, I actually created a volunteer program at Baylor University Medical Center while I was the Palliative Care APN there. We called our program "Doula for the Dying" and I had the chaplain for palliative care's assistance in recruiting volunteers from various faith organizations around the region. The palliative care team was instrumental in assisting with educational efforts. Initially, we scheduled a 6 week series of classes which were held one evening a week for 2 hours for a total of 12 hours in educational preparation. The volunteers saw patients on the palliative care service and they were screened by myself and the pc chaplain to ensure their appropriateness for the work. I have an entire manual I would be happy to share with you. Please feel free to contact me directly. [Submitted on: 11/13/2008 by: Laurie De Lalio RN, MS, CNS, CT, ACHPN, St. Anthony Central Hospital, Denver, CO]

We also have a well established No One Dies Alone program and have mentored many other programs. We are in our 4th year of the program, and have approximately 100 volunteers. And I think have well over 5000 hours of service. [Submitted on: 11/13/2008 by: Peg Nelson, NP, BC-PCM NP and Director of Palliative and Pain Services, St. Joseph Mercy Oakland, Pontiac, MI 48341 ]

Question 77. I'm wondering if you could give me input from your hospitals on the following regarding terminal weans: a. Can any physician in your hospital write the orders for terminal weans, or is it limited to a certain group(s) of physicians? b. Can you send me a copy of your terminal wean order sets/protocols? Thank you so much! [Submitted on: 9/17/2008 by: Ginny Vravick, Palliative Care Clinical Nurse Specialist, Penrose-St. Francis Health System, Colorado Springs, CO 80907] Answers At my hospital, anyone who has privileges to write treatment orders can order the removal


of life sustaining therapies. [Submitted on: 9/17/2008 by: Crisis Club]

Hi Virginia, Part of your answer will depend if your hospital has open privileges to ICU or has dedicated ICU MD's. In general at our hospital, the ICU director who is a pulmonologist is involved in our patients that are to be come comfort care once extubated. Connie Borden St. Mary's SF [Submitted on: 9/18/2008 by: Connie Borden, St. Mary's SF]

Question 78. Hello members, Being fairly new to hospice, I have a question in regards to measuring arm circumference...: a. In the older population, are you supposed to allow the extra skin to count in your measurement or do you measure taunt? b. I understand the concept of choosing a measuring point on the patient to be consistent (ie. 5cm. above anticubital or 2cm.above anticubital), but what do you do with the "flabby" skin? Thank you, Tara Taylor, RN, CHPN速 [Submitted on: 7/15/2009 by: Tara Taylor, RN, CHPN速] Answers We don't measure arm circumference or do weights. [Submitted on: 7/16/2009 by: Sue Noll]

My understanding is that with the arm circumference the issue is the change over time and the measuring tape should not be loose or taut. Even if the skin is flabby the arm circumference will usually get smaller if the patient is not eating much or not at all. It is not meaningful on its own as a single piece of information. We are just starting to do these with debility patients to give additional justification for our services. There may be some medicare requirements involved but I am not expert in that area. [Submitted on: 7/16/2009 by: Patti Pollina, RN, CHPN]

The inpatient hospice where I work also recently started weights with an arm circum. for


the patients that are difficult to justify continuing on hospice service. The few patients this effects are usually CVA's, dementia, and the failure to thrive diagnosis's. Thanks for your input, Tara Taylor, RN,CHPN速 [Submitted on: 7/16/2009 by: Tara Taylor, RN, CHPN速]

These measurements are very important for recertification criteria. Sometimes this can be the only change in a patient that is deteriorating overall, but has not had a recent infection and does not have a Cancer DX. [Submitted on: 7/16/2009 by: Rebecca Gagne Henderson, RN, MSN, FNP, CHPN速, Healthcare @ Home]

Is there documented research in the literature addressing this issue? I have not been able to find anything and I know it exists. Any help would be appreciated. Thank you, Lee Mayer, NP [Submitted on: 7/17/2009 by: Lee Mayer, NP, Palliative Care, Daughters of Charity, O'Connor Hospital]

I haven't been able to find any literature on arm circumference, either. One problem we have found is that they measurements vary widely depending on the person doing the measurements. [Submitted on: 7/17/2009 by: Julia Gies, APRN, BC-PC, Providence Connections Program, Beaverton, OR]

I agree with you. We use them to help document loss of muscle mass/wt. loss in patients who do not have cancer. I was taught to measure the distance from the top of the humerus to the elbow; 1/2 way between is where we measure. I usually do it about every 3-4 weeks. Over time, you'd be surprised how it can decrease--esp. in end-stage dementia patients. [Submitted on: 7/19/2009 by: Evelyn Bollinger]

Question


79. Does anyone in home care/ hospice have a protocol, policy, or other type of stepwise approach being used for dealing with patients/ families where drug diversion is suspected? If you have something you are willing to share, you may send to my email address below. Thanks- Maria Ferrell, ARNP, ACHPN® [Submitted on: 7/21/2009 by: Maria Ferrell, ARNP, ACHPN®, Clinical Nurse Specialist, Kansas City Hospice & Palliative Care, Kansas City, MO] Answers Our group will do urine tox screen if the patient demonstrate any red flags. If we continue to have suspicion, we offer patients Subxone conversion. [Submitted on: 7/21/2009 by: Diane Keaney, RN, MSN, ACHPN®, Palliative Care Clinical Nurse Specialist, Bay Area Pain Medical Associates, Mill Valley, CA]

Maybe I'm misinterpreting, but I thought the question was about the family members diverting drugs from the patient to self administer or sell. Or are you saying that you do a urine drug screen on family members & alter the plan because of the results? And if they are selling it, how would that show anything? [Submitted on: 7/21/2009 by: Cindy Leipold, RN, MN, FNP-BC, FNPc, ACHPN®, Palliative Care Nurse Practitioner]

Sorry for the confusion. We check the patient to make sure there is opioid in the urine or the right opioid in the urine. For example if we prescribe MS Contin, the patient may divert it and use methadone instead. [Submitted on: 7/21/2009 by: Diane Keaney, RN, MSN, ACHPN®, Palliative Care Clinical Nurse Specialist, Bay Area Pain Medical Associates, Mill Valley, CA]

We have done the same with our organization. You can get a qualitative drug screen that can help show amounts and drug to help distinguish if the patient is actually taking the meds prescribed. If not, then diversion is a probability. [Submitted on: 7/21/2009 by: Leasa Roach RN, GNP-BC, ACHPN®, Hospice of Texarkana, TX/AR]


Dear Maria and Colleagues, I work in a oncology office as the palliative care consultant and we have had a few cases of diversion. As a team we assess for flags of abuse or diversion and carefully investigate use of medications and when those flags occur Although not a formal policy these are the steps we take to respond to red flags: • Record detailed reports of pain ratings and descriptions in patient record • Request patient keep and bring to their visits an accurate list of all PRN use of medications including pain ratings (we provide the forms). This helps with dose adjustments as well. • Utilize state reporting agency to monitor prescriptions that are filled by other physicians or at different pharmacies ( In OH we use http://www.ohiopmp.gov) • Toxicology screens PRN • Limit the amount that is prescribed with each prescription to further monitor use A few discoveries about toxicology screens... Not all medications are detected unless specifically requested for testing Qualitative and quantitative gives you the most information but does not directly correspond to the dosage the patient is taking. A pain management practice shared a form for us that accompanies our requests for all toxicology on which all medications the patient is prescribed or reports to have been taking are included. This form facilitates what the lab is measuring but other substances of abuse can be included. Hope this helps. Carol R Matthews [Submitted on: 7/21/2009 by: Carol R Matthews]

Hello All In our home hospice setting when there is concern of drug diversion by family member we will often have a lock box placed in the home with only the staff and pt having keys. If the concern is that the pt is involved with the diversion, we have medication carousel that distributes the medications at set times daily. Only the hospice staff have access to the carousel and are responsible for filling it weekly. We also make it very clear that the patient will only get refills on their narcotics every 30 days. Collaborating with the pt's PCP is also helpful in preventing multiple providers prescribing. This works well in the home hospice environment. Don't think these measures would work as well in the palliative care clinic setting. LHarrison [Submitted on: 7/21/2009 by: Laura Harrison]

Hello, Regarding issues of diversion, it is common for chronic pain doctors to have the patient complete a contract for pain control. This could be used in hospice as well. The other thing to think about his dispensing prescriptions on a very limited basis. Many hospice pharmacies would be willing to deliver or dispense medications every 3 or 4 days. This avoids the two week / one month prescription being lost. Justin [Submitted on: 7/21/2009 by: Justin Engleka MSN, CRNP, MBA, Hospice and Palliative Manager, Allegheny General Hospital]


Wow Justin, How much does delivery cost in your parts? That would be extremely expensive out here. [Submitted on: 7/22/2009 by: Rebecca Gagne Henderson RN, MSN, FNP, CHPN®, Healthcare@Home]

This has been an interesting topic, but I believe that if drug diversion is a valid concern then it will not matter what we do, there will always be a way for offenders to get around it. A glaring concern that sticks out with me is that if the drugs are being inappropriately accessed then it is not available for the patient. Since the patient is in a vulnerable position, they may not want to say anything for fear of vindictive action so the patient may be suffering in silence. Is this not an Adult Protective issue? Lana [Submitted on: 8/6/2009 by: Lana Nealand]

Good comment. I also believe that there is only so much you can do. At some point, restrictions are counterproductive and work against patients with legitimate needs for medication. [Submitted on: 8/6/2009 by: David Picella]

5. I have a question about the drug screenings for any of you that use them. I work in an ambulatory clinic that cares for the uninsured in an urban setting. We do not use drug screenings when we suspect misuse for a few reasons. 1) the misuse or diversion is often for $ and the drugs are sold and not used. 2) when the test is positive for say cocaine when we are prescribing Percocet are we then ‘policing” a population? For example we do not drug test our liver patients for alcohol use. And 3) when we test a patient and get confirmation we then are obligated to discuss treatment options with the patient. Should they want detox or rehab our resources are very limited. Has anyone addressed these issues with positive results? [Submitted on: 8/6/2009 by: Lorraine Thayer]


I work with the same type of population albeit it is "pain management" and most are not end of life. However given the current environment about opioid prescribing I think it is essential that providers prescribing opioids be careful with prescribing document well for protection. The examples listed below are all the reasons one would do urine drug screening In my view even if the patient has advanced disease if they are selling the oxycontin you prescribe and get caught, it is your license on the line and it is not serving them well If the person is using cocaine, it is not policing in my mind even with advanced disease, as in pain management, the use of opioids with our patients is under the condition that illicit substances not be used. They may also be selling their opioids to support their illicit drug habit. We counsel the patient before providing opioids. If the Urine screen comes back positive for illicit substances or negative for what is supposed to be in their system, then generally the patient will no longer receive opioids (or in cases where the patient has advanced disease a safer plan will be put in place if the patient has illicits in their system (many of us will just counsel about marijuana use but not stop opioids in this case). We will also offer options for treatment programs but most patients will opt to just continue their street use of drugs I have patients who are heroin abusers even on methadone maintenance who have opted to stop using heroin if their pain was controlled. They understand the UDS will be done and have been compliant. These are just my thoughts. It is interesting that a colleague and I have tried to submit an article about the use of pain management in a Palliative care substance abusing population that has been rejected by several journals as the topic was not thought to be relevant. I think people forget that many people with advanced disease may live months to years. In the current "opioiphobic" environment, I think we should be proactive about responsible prescribing. [Submitted on: 8/6/2009 by: Kathleen Broglio, ANP-BC, ACHPN速, CPE, New York Unversity School of Medicine, Bellevue Pain Center, New York, NY]

I agree which is why our facility does not use the drug screening tool. Thanks every one. Lorraine [Submitted on: 8/6/2009 by: Lorraine Thayer]

Great comments, and thanks all. It's an interesting range of responses to this issue and covers both caring for the patient and doing due diligence for the community. I don't think there are correct answers for every setting, and I'm glad to learn about how folks in different settings and regions have responded to this issue. We do contracts and drug screens on our outpatients as well as periodic monitoring of scripts from other providers. Checking at this level initially felt counter to my ethics and usual patient relationships, but these drug screens have indeed detected diversion of drugs by family members. I


understand the economic issues of the possibility of adding hundreds or thousands of dollars a month to a poor families budget by selling a prescription, but I also know that I have an obligation to the patient to 1) Not enable suboptimal pain control 2) not put them at risk of violence once they are known as a connection (not to mention the violence of arrest), or 3) not damage their family and community by facilitating diversion. That's how we do it in Eastern Kentucky. Edmund Pendleton [Submitted on: 8/7/2009 by: Edmund Pendleton]

Question 80. There was some discussion concerning disabling ICDs back in March. Does anyone have a written policy or protocol that they are willing to share. Our palliative care team has been tasked with writing a protocol to present to the medical staff. Thanks, Anne Jeffcott, GNP-BC, ACHPN Chillicothe, Ohio VAMC [Submitted on: 7/6/2009 by: Anne Jeffcott, GNP-BC, ACHPN Chillicothe, Ohio VAMC ] Answers We don't have a written protocol specifically for that - if they want it disabled we obtain a physician order and the cardiology tech goes to the home. [Submitted on: 7/6/2009 by: Sue Noll suenoll@sbcglobal.net]

Last year or so the NHPCO ethics committee wrote a position statement on disabling AICD's. http://nhpco.org/i4a/pages/index.cfm?pageid=4673 Mimi Mahon, PhD, RN, FAAN Advanced Practice Nurse, Palliative Care & Ethics Associate Professor School of Nursing George Mason University College of Health & Human Services [Submitted on: 7/6/2009 by: Mimi Mahon, PhD, RN, FAAN Advanced Practice Nurse, Palliative Care & Ethics Associate Professor School of Nursing George Mason University College of Health & Human Services, Fairfax, VA ]

Does anybody have a cmo policy? [Submitted on: 7/7/2009 by: Baccaro,Nancy [baccaro@uchc.edu]]


Hi Here is what we use. We also have a policy for disabling ICD. I hope this is helpful. Sorry I was not able to save it as an attachment so here it is. PURPOSE: To provide guidelines for the management of patients who have implanted cardioverter defibrillators (ICDs) who are on Do No Resuscitate (DNR) status, whose therapies have been withdrawn and for whom comfort measures are planned. POLICY: A. This policy may only be applied to those patients whose code status is DNR, whose therapies have been withdrawn and for whom comfort measures are planned. B. Documentation by the medical attending physician will be placed in the chart stating that a discussion has taken place with the patient or the patient's personal representative regarding disabling the ICD and the implications of doing so and that there is agreement to do so. The patient and family also must be aware that disabling the ICD has no effect on the pacing function of the device. C. An order is placed in CPOE to disable the ICD. a. From the Cardiology Department Orders, select "Cath/Pacer Notices" b. Then choose "Defibrillator Eval: Notice" c. Under "Reason" select "with deactivation" D. Nursing unit will request ICD "Patient Identification Card" from patient or family so that manufacturer of device may be identified. E. If order is placed during daytime hours (Monday through Friday, 7:30am-4:00pm) the nursing unit will call x 7436 or x 7510, provide information obtained as noted above in D., and Cardiology staff member will come to floor to disable device. F. If order is placed during all other hours (Monday through Friday, after 4:00pm and but before 7:30am, weekends or holidays): a. The manufacturer's representative, as identified above in D., will be contacted by the nursing unit and requested to come in and disable the device. See Appendix A for list for a list of manufacturers and phone numbers. i. When the representative arrives to disable the device, the representative will be accompanied to the patient's room by either the patient's nurse or resident physician, and the nurse or resident will remain with the representative throughout the representative's interaction with the patient and/or family. b. If a representative will not be available in an acceptable amount of time a magnet can be taped directly over the device to disable the device until such time that it can be programmed off. Magnets may be obtained from 8 West. c. Consider CARES and/or Hospice consult . G. A note will be placed in the chart by resident or staff member present at time of deactivation. H. NOTE: If the patient expires before the device is programmed off, inappropriate firing of the device may take place, which can be extremely distressing to both the family and staff. Be aware that after several (as many as 6-8) of these discharges, they will cease. If this may occur: a. Educate family present that this is the device firing and it will stop after 6-8 discharges. b. Locate a magnet , either from the Arrhythmia Clinic (on hours x 7510 and off hours, call 8 West). c. The magnet may be taped directly over the device to immediately stop these discharges. ______________________________ Karen Mulvihill MSN, APRN, ACHPN Coordinator Danbury Hospital CARES Program Hospitalist Service [Submitted on: 7/7/2009 by: Karen Mulvihill MSN, APRN, ACHPN Coordinator Danbury Hospital CARES Program Hospitalist Service, Danbury Hospital, Danbury, CT ]


Here is our policy for outpatient deactivations: Policy- Munson Home Health will work in cooperation with the pacemaker/implantable cardiac defibrillator (ICD) representatives to inactivate ICDs in the non-institutions setting. This will be done in a compassionate, planned environment with a health care provider present along with the industry representative after informed discussion and an inactivation order has been obtained. It is always preferable that the ICD be inactivated in a hospital or office setting. Procedure - 1. A candidate for non-institutional inactivation of an ICD will be either a Hospice or Palliative Care client. 2. A Hospice or Palliative Care provider will have an informed discussion with the client and appropriate significant others to obtain informed consent, this may be in the form of a POLST document or a Do Not Resuscitate (DNR). 3. The Health Care Provider will inform the attending /over-seeing physician and obtain an order for inactivation of the ICD. 4. The Health Care Provider will contact the appropriate ICD representative to schedule an appointment at a mutually agreeable location. 5. The Health Care Provider will meet the ICD representative prior to entering the home/facility and having contact with the patient/family. If the Health Care Provider cannot attend for any reason - the appointment will be rescheduled. The ICD representative will not meet the patient/family alone. 6. The Health Care Provider will assess/evaluate the patient prior to the inactivation and medicate for anxiety if indicated. 7. The ICD representative will inactivate the computer/ICD. The Health Care Provider will push the button to inactivate the ICD (not the ICD representative). 8. The Health Care Provider will document the proceedings and copy the attending/overseeing physician. [Submitted on: 7/7/2009 by: Michelle Witkop [Mwitkop@mhc.net]]

Iâ&#x20AC;&#x2122;ve attached our P and P. It is similar to the one below. However, company reps will only schedule M-F 8 to 5 pm visits with us. So we have included deactivation procedure by staff. We had one particularly difficult situation a few years ago and want to avert that ever happening again. [Submitted on: 7/7/2009 by: Bonnie Morgan [bmorgan@hov.org]]

Here is oursâ&#x20AC;&#x201D;I am copying our CMO orders and am getting there gradually! ZABLOCKI VA MEDICAL CENTER COMMUNITY LIVING CENTER MILWAUKEE, WI 53295 MEMORANDUM NO. 22 FEBRUARY 2009 PALLIATIVE CARE IMPLANTED CARDIOVERTER DEFIBRILLATOR DEVICES DEACTIVATION OF TACHYARRHYTHMIA THERAPIES 1. PURPOSE A. Implantable cardioverter defibrillators (ICD) can prevent premature death from an arrhythmia but may also prolong the dying process and make it more distressing. B. This policy outlines the importance of discussing with the resident and/or surrogate decision-maker the timing and purpose of deactivating the defibrillation function of the ICD in a terminally ill resident and


the mechanics for discontinuation. 2. POLICY A. Residents with an active implantable cardioverter defibrillator (ICD) will be identified upon admission to the Palliative Care Unit. B. Deactivation of the device’s tachyarrhythmia (shock) therapies will be discussed with the resident/family by the physician or nurse practitioner, optimally as part of the do-notresuscitate discussion. The discussion should include reassuring the resident/family that the brady (pacing) therapies will always remain on and functional. Turning the tachy therapies off will not result in immediate death. C. If an ICD is identified at a later time, the nurse identifying the presence of the device may consult with the resident/family to determine if they wish to have the device’s tachy therapies programmed off. Then the nurse should notify the MD/NP at an appropriate time that the device was identified and the wishes of the resident. 3. PROCEDURE A. For residents who wish to continue to have all ICD functions activated: 1) Identify in Progress Note and Care Plan (Individual’s Goal) that the resident/family desire to have all ICD therapies and functions active. 2) If resident has a wallet card identifying the type of device (company and model number), implant date, and serial number, a copy should be made of the card and filed in current medical record. B. For residents who wish to have the ICD tachy therapies deactivated: 1) RN should notify physician/nurse practitioner to obtain order for tachy therapies to be programmed off. 2) Physician/NP and RN should document resident/family’s wishes in a progress note. 3) During normal business hours (Monday-Friday, 0800-1630), contact the Electrophysiology Service to reprogram the device (ext. 42833 or contact the Cardiology secretary at ext. 42835 to have a member of the team paged). 4) For inhibition of tachy therapies during off hours/weekend/holidays, a magnet should be secured over the ICD by the RN. All tachy therapies (shocks) will be inhibited while the magnet is in contact with the device. The magnet will not affect the brady (pacing) features of the device. The Electrophysiology Service should be contacted during the next open office hours to reprogram the device and remove the magnet. The magnet must be left in place until reprogramming occurs in order for the “shock” function to remain inhibited. 5) Document the procedure in the progress notes and indicate on the Kardex that the ICD has been deactivated. 6) The magnet will be kept in the medication room on the Palliative Care Unit. 7) At time of death, inform the funeral home that the resident has an ICD. This is particularly important if the body will be cremated. 4. REFERENCES Braun, TC, Hagen, NA, Hatfield, RE, Wyse, DG. Cardiac Pacemakers and Implantable Defibrillators in Terminal Care. Journal of Pain and Symptom Management. 18:2, 1999, 126-131. Goldstein, NE, Lampert, R, Bradley, E, Lynn, J, Krumholz, H. Management of Implantable Cardioverter Defibrillators in End-of-Life Care. Annuals of Internal Medicine. 141:11, 2004, 835-838. Mueller, PS, Hook, CC, Hayes, DL. Ethical Analysis of Withdrawal of Pacemaker or Implantable Cardioverter-Defibrillator Support at the End of Life. Mayo Clinical Procedures. 78:8, 2003, 959-963. Nambisan, V, Chao, D. Dying and Defibrillation: A Shocking Experience. Palliative Medicine. 18:5, 2004, 482-483. 5. DEVELOPED BY: Mary Moat RN, MS, BC, ACHPN, Beth Hammer RN, MS, BC 6. RECISSION: ECC Memorandum No. 22, “Palliative Care Implanted Cardioverter Defibrillator Devices Deactivation of Tachyarrhythmia Therapies”, dated January 2006. 7. REVIEW DATE: February 2012 /es/ EDMUND H. DUTHIE, MD Medical Director, Community Living Center /es/ PHYLLIS HELMS, MSN, RN, NE-BC Division Manager, Rehabilitation, Extended, and


Community Care [Submitted on: 7/16/2009 by: Moat, Mary [Mary.Moat@va.gov]]

Question 81. Hi all.. I want to thank all of you for your recent postings and help with clinical issues. I have ANOTHER question... 1. Does anyone have any Palliative Care Screening tools that they use in the in-patient hospital setting to trigger a Palliaitve Care referral? 2. And if so, would you be willing to share your experience? Thank you, Sarah [Submitted on: 6/26/2009 by: Sarah Bullard, ANP-BC, Hospice of the Piedmont, High Point, NC] Answers Hello: CAPC web site has several tools but I will attach one that I used as a pilot study. Kelli Palliative Care Screening Tool Criteria – Please consider the following criteria when determining the palliative care score of this patient 1. Basic Disease Process a) Cancer (metastatic/recurrent) b) Advanced COPD c) Stroke (with decreased function by at least 50%) d) ESRD e) Advanced Cardiac disease-CHF, severe CAD, CM (LVEF<25%) f) Other lifelimiting illness Scoring Score 2 points each 2. Concomitant Disease Processes: a) Liver disease b) Moderate renal disease c) Moderate COPD d) Moderate CHF e) Other conditions complicating care Score 1 point overall 3. Functional Status of Patient: Using ECOG Performance Status Grade Scale 0 Fully Active, able to carry on all pre-disease activities without restriction. 1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature – housework, office. 2 Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours. 3 Capable of only limited self-care; confined to bed or chair more than 50% of waking hours. 4 Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair. Score As Specified Below Score 0 Score 0 Score 1 Score 2 Score 3 4. Other Criteria to Consider in Screening ♣ Team/patient/family needs help with complex decision-making and determination of goals of care ♣ Patient has unacceptable level of pain or other symptom distress >24 hours ♣ Patient has uncontrolled psychosocial or spiritual issues ♣ Patient has frequent visits to emergency department (>1x month for same diagnosis) ♣ Patient has more than one hospital admission for the same diagnosis in the last 30 days ♣ Patient has prolonged length of stay (>5 days) without evidence of progress ♣ Patient has prolonged stay in the ICU and or transferred from ICU to ICU setting without evidence of progress ♣ Patient is in an ICU setting with documented poor prognosis Score 1 Point each Total Score Scoring Guidelines: Total Score = 0-2 no intervention needed Total Score = 3 observation only, re-evaluate as needed Total Score = 4 consider palliative care consult (requires physician order) __________________________________________________


_______________________________ Nurse Signature Date/Time Kelli Fisher, RN, BSN Palliative Care Specialist 217-467-0321 pager, 217-788-3369 office [Submitted on: 6/26/2009 by: Kelli Fisher, RN, BSN, CHPN®, BC, Palliative Care Specialist]

Does any one have a CMO Policy for inpatients? [Submitted on: 6/26/2009 by: Baccaro,Nancy [baccaro@uchc.edu]]

Here are the tools from CAPC. http://www.capc.org/tools-for-palliative-careprograms/clinical-tools/ Karen McGough ARNP, AOCN [Submitted on: 6/26/2009 by: Karen McGough ARNP, AOCN, Nurse Practitioner, TideWell Hospice and Palliative Care, Sarasota, FL]

Here is ours at Milwaukee VA-- ZABLOCKI VA MEDICAL CENTER COMMUNITY LIVING CENTER MILWAUKEE, WI 53295 MEMORANDUM NO. 11 JUNE 2008 COMFORT MEASURES ONLY FOR THE DYING RESIDENT IN THE COMMUNITY LIVING CENTER 1. PURPOSE: To establish policies, definitions, responsibilities and procedures for approaching the treatment of a dying resident within the Community Living Center (CLC). 2. POLICY A. While our basic objective is to sustain life, aggressive efforts may not be warranted in specific situations. Comfort Measures Only (CMO) is a comprehensive and active approach to care in which comfort is understood by the resident, family, and caregivers to be the most important goal. Residents diagnosed as terminally ill and who have made the decision to assume DNR status (see PSM No. IV-6, Withholding Attempts at Resuscitation: The Do Not Resuscitate or “DNR Order”) may decide they do not wish to continue with aggressive efforts to prolong life, or a physician or nurse practitioner may make this recommendation to the patient or family. B. End of life issues are self-determined and the resident's autonomy to make treatment decisions will be respected. If the resident lacks decision making capacity, the resident's appointed health care agent, guardian of person, or next of kin will make treatment decisions. C. After consultation and discussion with the resident/family regarding the meaning of Comfort Measures Only care, an order is written by the physician or nurse practitioner for CMO and the standing order for CMO is completed. 3. RESPONSIBILITY A. CLC staff members and/or consultants are responsible for providing care to the resident consistent with the CMO Clinical Path. B. In addition to preserving the unique rights and needs of the CLC residents as outlined in the Resident Rights, Responsibilities, and Quality of Life (CLC Memorandum No. 1), the CLC staff must also act in a manner consistent with the code of behavior adopted for this medical center such as outlined in the Medical Center


Memorandum No. MIS-264, “Statement of Organizational Ethics”. 1. DEFINITION A. The CMO plan encompasses pain management, relief of anxiety, nutrition/hydration, and guidance for care givers on diagnostic testing, general medications, and activity as per the resident's/family wishes. B. The CMO Clinical Path (attached) defines goals, assessment, and interventions/responsibility for each of these areas, and will be instituted when a CMO order is written. C. The standing orders for CMO can be found on the Extended Care and Medical menus in CPRS and overprinted order sheets can be utilized during computer downtime. These should be individualized according to specific patient/family wishes. 2. PROCEDURE A. The decision to implement CMO may be made by the nurse practitioner, licensed physician (resident physician), and/or attending physician. B. The resident with decision-making capacity must make the decision regarding CMO, as it is a treatment decision requiring informed consent. C. If the resident lacks health care decision making capacity: 1) The Health Care Agent appointed via the Durable Power of Attorney for Health Care document will make the health care decisions, including those related to resuscitation, as defined for life-threatening treatment in Medical Center Memorandum PI-189, “Advance Directives for Health Care and Withholding/Withdrawal of Life Sustaining Treatment”, as well as decisions regarding CMO. 2) The guardian of person (if so appointed) will make decisions in the absence of an Advance Directive. 3) The next of kin will be contacted in the absence of a guardian of person, in the following order: the resident's spouse, adult children, parents, and adult siblings. The next of kin may provide consent for CMO in the absence of Advance Directives. D. Documentation in the medical record: 1) The nurse practitioner, licensed physician, or attending physician must enter a progress note denoting: a. A description of the resident's illness, decision making capacity, response to medical treatment, and prognosis. Terminally ill status should be documented. b. A description of the discussion with the resident and/or family regarding the definition of CMO and their particular wishes. 2) The standing orders for CMO will be initiated by the nurse practitioner or physician and will be individualized according to the resident or decision-maker's wishes. 3) The physician or nurse practitioner will write an order to initiate the CMO Clinical Path via use of the standing orders for CMO. 3. REFERENCES ECC Memorandum No.1, “Resident Rights, Responsibilities, and Quality of Life”, October 2002. Medical Center Memorandum No. PI-114, “Informed Consent”, December 2006. Medical Center Memorandum No. PI-189, “Advance Directives for Health Care and Withholding/Withdrawal of Life Sustaining Treatment”, August 2007. Medical Center Memorandum No. MIS-264, “Statement of Organizational Ethics”, February 2006. Medical Center Memorandum No. PI-182, “Ethics Council”, October 2005. 7. DEVELOPED BY: Mary Moat, RN, MS, GNP-BC, ACHPN 8. RECISSION: ECC Memorandum No 11, “Comfort Measures Only for the Dying Resident in the Extended Care Center”, November 2004 9. REVIEW DATE: June 2011 /es/ EDMUND H. DUTHIE, JR., MD Medical Director, Community Living Center /es/ PHYLLIS HELMS, RN, MSN Division Manager, Rehabilitation, Extended, and Community Care Attachments: Critical Path, Comfort Measures Only Doctor's Standing Orders for Comfort Measures Only Critical Path: Comfort Measures Only Care Areas - Community Living Center CLC Memorandum No. 11 CMO Date / Time Initialed: Description: CMO is a comprehensive and active plan of care in which comfort is understood by the patient, family, and caregivers to be the most


important goal. GOALS ASSESSMENT INTERVENTIONS / RESPONSIBILITY 1. PAIN MANAGEMENT: a) Pain free b) Breathing comfortably c) General physical comfort a) Patient verbalizes – Pain Scale Rating • Appearance (grimace, moan, PAINAD SCORE) • Family concerns b) Appearance, no matter what rate c) Patient verbalizes • Appearance a) Scheduled analgesics, no parameters (MD, NP) • PRN analgesics for breakthrough pain (MD, NSG, NP) • Seek non-IV route for pain management (MD, NSG, NP) • Consult pain specialist as needed (MD, NP) b) HOB elevated (NSG) • Suction PRN (NSG) • Aerosol humidity (NSG, RT) • Positioning (unless painful) (NSG) • Medication (MD, NSG, NP) • Ensure bowel movement at least q 2 days (NSG, NP, MD) • Check bladder q shift for distention (NSG) c) Mouth care q 2 h (NSG) • Skin care (NSG) • Positioning (unless painful) (NSG) 2. RELIEF OF ANXIETY: • Spiritual and emotional comfort • Patient verbalizes • Behavioral assessment • Family concerns • Anxiolytics as needed (MD, NSG, NP) • Attention and support of caregivers • If Roman Catholic, check anointed status (NSG) • Consult chaplain, social work, psych, liaison as needed (MD, NSG, NP) 3. NUTRITION / HYDRATION: • For comfort only • No hunger or thirst indicated by patient • PO as requested/directed by patient (MD, NSG, Dietary, NP, Family) • IV hydration and artificial feeding generally not appropriate unless requested by patient/family (MD, NP) 4. OTHER: a) Diagnostic tests/labs as acceptable to patient/family b) Meds only as needed for comfort c) Activity per patient’s wishes a) Reassesses medication regimen b) Assess patient’s wishes and capabilities a) Labs, x-rays, etc. ordered if acceptable to patient/family (MD, NP) b) Order only meds needed for comfort (MD, NP) • Discontinue all other meds (MD, NP) c) Provide support as necessary (MD, NSG, NP) 5 CARE CONSISTSENT WITH PATIENT AND FAMILY WISHES: • Family supports treatment plan • Prior/ongoing discussion with patient/family • Review advance directives • Education (MD, NSG, NP, Others) - Clinical path - Brochures for family information • Discharge planning as appropriate, i.e. Home Hospice This clinical path is a general guideline and does not represent a professional care standard governing provider’s obligations to patients. Care is revised to meet the individual patient’s needs. INSTRUCTIONS: Starting the Clinical Path Use of Clinical Path 1. Orders written 1. Nursing review daily 2. Stamp with patient’s name 2. Evaluate interventions / outcomes 3. Place in kardex 4. Review daily [Submitted on: 6/29/2009 by: Moat, Mary [Mary.Moat@va.gov]]

Does anyone have a protocol and policy for in-patient palliative care RN and LPN? Thanks Marie Mompoint [Submitted on: 7/16/2009 by: Marie Mompoint [FOXXIMISSI@aol.com]]

Question 82. We are caring for a gentleman who is undergoing chemo & XRT for tonsillar CA. His face has begun to redden & scale. We all realize that these are natural consequences of XRT, but


his girlfriend has asked about skin care options to improve the appearance & make it more comfortable. The Radiation Oncologist has suggested cortisone cream & we have discussed aloe gel, but I was wondering if any of you had additional suggestions? (I have loaned out my Textbook of Palliative Nursing, so I am down one of my usual resources). Any help would be appreciated! Cindy Leipold, RN, MN, FNP-BC, FNPc, ACHPN Palliative Care Nurse Practitioner [Submitted on: 6/25/2009 by: Cindy Leipold, RN, MN, FNP-BC, FNPc, ACHPN, Palliative Care Nurse Practitioner] Answers Cynthia, A few ideas to consider for radiation dermatitis (all should be discussed with radiation oncologist for approval): agree with low dose steroid cream (0.5% to 2.5% hydrocortisone) daily or twice daily for up to 7days may add benadryl PO for any itching r/t inflammation (steroid should help with this, too) if excoriated - may consider silver sulfadizine or Zinc oxide cream (daily or twice daily)- need to be careful with silver products if patient is still undergoing radiation- wait until done with XRT to use these products Xenaderm - as a barrier for radiation dermatitis-$$$$ not sure about aloe- would be concerned about possible contamination and subsequent infection; theoretically, would be helpful for soothing dry skin. Not sure of other properties.Good luck! Debbie [Submitted on: 6/25/2009 by: Deborah Fisher MS, RN,CS, PNP, CPON, Clinical Director, Pediatric Palliative Care & Pain Management Nursing Research Facilitator Virginia Commonwealth University Medical Center, Richmond, VA]

Not sure applicable in this situation, but I was told by a radiation pt. who tried everything else, she found that wet cool tea bags (she used lipton) were the only thing that helped her radiation burned skin. Sue Noll, RN-BC, CHPN Supervisor Hospice & Palliative Care Kansas Volunteer Leader for the Power Over Pain Action Network http://www.painfoundation.org/poweroverpain [Submitted on: 6/25/2009 by: Sue Noll, RN-BC, CHPN速, Supervisor Hospice & Palliative Care, Kansas Volunteer Leader for the Power Over Pain Action Network]

I had a doctoral student who did research on breast milk banking...and the uses of breast milk beyond feeding. Breast milk has been used for burned skin and radiation burns. If there is a family member that is breast feeding, a cotton pad can be soaked in the milk and layed over the burn or milk can be obtained from a milk bank. I have known patients who have done this with great relief. Marianne Matzo [Submitted on: 6/25/2009 by: Matzo, Marianne (HSC) [Marianne-Matzo@ouhsc.edu]]


I have used Xenaderm with excellent results on burns. There is not the problem with cream caking up b/o too much pain to clean area. It also relieves pain in contrast to SSD. I have not used it during XRT. I have seen a comparison of multiple creams and ointments related to interference with XRT and Skin Repair Cream from the Remedy line had the least reactivity and could be started prior to therapy to prevent tx disruption from burns. [Submitted on: 6/25/2009 by: Pfahl, Kathleen, [KPfahl@HospiceWR.org]]

Hello Irene, I am so pleased that you responded to this issue and are willing to share your use of essential oils. We have an individual at our hospital that uses aroma therapy on the inpatient psych unit, and has been kind enough to assist us with some of our patients with terminal agitation.It would be outstanding if we could expand the use of essentaial oils to include other areas of palliation. Any information is greatly appreciated. Thank you so much. [Submitted on: 6/26/2009 by: Kerry McGrath, Palliative Medicine, Carilion New River Valley Medical Center, Christiansburg, Virginia]

Do you have any published reports to back this up? My medical director always asks for the evidence? [Submitted on: 6/26/2009 by: Pfahl, Kathleen [KPfahl@HospiceWR.org]]

Mine too and this has been a problem although he has agreed to try a few things that have been successful so now is more open to it. I would highly recommend Jane Buckle’s book – Clinical Aromatherapy in Nursing. She cites several studies to support the use of essential oils (EO) in each chapter but many of these are not in English and not RCT’s. Cochran has some info on aromatherapy and massage but hard to tease out what can be attributed to the oils vs massage. If you search CINAHL you’ll find references of use of essential oils for wound care primarily and some anxiety issues. There is a C&S chart that shows the antimicrobial effects of EO that was done by a lab in the UK. I believe Jane has a more recent C&S chart in her book. I am attaching the chart FYI. This chart was included in the Aromatherapy certification course that was sponsored by the American Holistic Nursing association back in the mid 90’s. Irene


[Submitted on: 6/26/2009 by: Irene Gilliland [IGilliland@satx.rr.com]]

Question 83. Will you please share your subcutaneous infusion policies? Also, any literature you used to support policy, a list of the medications approved for infusion and any policies you used to educate nurses. I work in a large teaching hospital and we would like to have a policy for subcutaneous infusions for our palliative care patients. I am starting from scratch and I welcome all assistance. Thank-you, Cindy Brown, ACHPN [Submitted on: 10/8/2009 by: Cindy Brown [nursebrown@gmail.com]] Answers I am attaching our two policies. We will be revising these as soon as we settle on an indwelling Teflon catheter to replace our butterfly needles. I would very much like to see other institutions’ policies. Is anyone out there using Teflon catheters (or something other than the butterfly) to prevent needle sticks? Any specific product recommendations would be very helpful. Thanks, Jay THE MOUNT SINAI HOSPITAL, NEW YORK NURSING CLINICAL AND ADMINISTRATIVE MANUAL STANDARD: Policy No. 150 SUBJECT:SUBCUTANEOUS INFUSIONS VIA PUMP OR INJECTION FOR OPIOIDS, SEDATIVES AND ANTIEMETICS Page 1 of 3 Patient Population Original Date of Issue: March 2003 ü Neonate ü Pediatric ü Adolescent ü Adult ü Geriatric Reviewed: 10/04 Revised: 8/07 Policy The use of a subcutaneous access may be indicated for any patient with limited or no venous access who requires parenteral medication administration. Commonly used medications include opioids, sedatives, and antiemetics. These medications may be administered by subcutaneous continuous infusion or intermittent subcutaneous injections. The most common use of the subcutaneous pump or injection is for the administration of opioid medication. Performed by: Registered nurses who demonstrate competence in the insertion of an indwelling subcutaneous butterfly needle and subcutaneous infusions via a pump or injection may perform these procedures. 1. Any qualified prescriber (physician, nurse practitioner, midwife, certified registered nurse anesthetist and physician assistant) may order subcutaneous infusion/injection. NOTE: Orders entered by a physician’s assistant must be countersigned within 24 hours (except in the ambulatory setting). * Subcutaneous infusion orders should include name of medication, total volume of solution, dose concentration, infusion rate (mcg/hr, mg./hr and ml/hr). NOTE: For information specifically pertaining to patient controlled analgesia via intravenous infusion, refer to Nursing Policy No. 514 – Intravenous Patient Controlled Analgesia (PCA). 2. Most patients can absorb a volume of 2-3 ml/hr subcutaneously. For infusions >3 ml/hr, notify the prescriber to change the concentration, making the total volume <3 ml per hour. Page the appropriate service: Anesthesia Acute Pain (pager 2738), Anesthesia Chronic Pain (pager 0329), or Palliative Care (pager 917-632-6906). 3. The Pharmacy will prepare all highly concentrated subcutaneous opioid infusions. 4. Assess and


document needle insertion site for redness, swelling, wetness, or pain every 12 hours and PRN. 5. Change and document subcutaneous butterfly needle at least every 3 days or PRN. 6. All opioid/controlled substances must be documented on the medication administration record and the PCA flowsheet when indicated. 7. Discontinuing/Changing Subcutaneous Infusions a.) A valid order by the attending/provider is required to: * discontinue a subcutaneous infusion * change a subcutaneous infusion prescription b.) For narcotics, remove IV bag and tubing from pump and discard following policy # 144 – Controlled Drugs. c.) For anti-emetics or other non-controlled substances, remove IV bag and tubing from pump and discard following regulated medical waste procedure. 8. Document patient response. Procedure Inserting an Indwelling Subcutaneous Butterfly Needle for Administration of Subcutaneous Infusions via Pump or Intermittent Infusion Performed by: Registered Professional Nurses Equipment Location * Butterfly infusion needle 27-gauge. If 27-gauge is unavailable, use 25-gauge. Nursing Unit * Alcohol swabs * Transparent dressing (i.e. Tegaderm) * Non-sterile gloves Technique (Keypoints) 1. If medication is to be administered by subcutaneous infusion, connect butterfly infusion needle to the IV tubing and pump. 2. Prime subcutaneous infusion set with medication to be infused. 3. Select insertion site. The area below the clavicle is the preferred site since this area allows for good absorption of the drug and minimal interference with the patient’s mobility. If this area cannot be used, other sites routinely used for subcutaneous injections include the abdomen, upper thigh or outer aspect of the upper arm. 4. Prep site with alcohol. 5. Don non-sterile gloves. 6. Use thumb and forefinger to grasp area of subcutaneous tissue at selected site. 7. Insert primed butterfly needle, bevel up at 45-degree angle. 8. Remove gloves and discard. 9. Secure butterfly in place using transparent dressing. 10. Inspect site for signs of inflammation, wetness, swelling or pain. If signs and symptoms are noted, change site and document. 11. If indwelling subcutaneous butterfly needle is being used for intermittent injection, flush slowly with 0.25ml of normal saline after medication administration. 12. For continuous infusion, verify correct pump programming with medication order, then initiate infusion. 13. Butterfly infusion needle, IV tubing and insertion site must be changed every 3 days, more often if necessary. Label the dressing with the date, time, gauge, nurse’s initial and date and time to be changed. 14. Document procedure and nursing interventions in the medical record. 15. All doses of controlled drugs withdrawn and not administered must be wasted immediately in the presence of another nurse. Both nurses, one of whom must be a Mount Sinai Clinical Nurse, the one wasting and the one witnessing, must document the waste in the PYXIS medstation, PCA flowsheet or controlled substance record form, as applicable. 16. Document in the appropriate hospital forms/MSCIS: * infusion site * medication: name, dose and concentration * assessment of needle insertion site * patient’s response to medication References: 1. Phillips, L.D. Manual of IV Therapeutics: FA Davis Co. Philadelphia, 2001. 2. Nursing Procedures 3rd Edition. Springhouse, Pennsylvania 2000. 3. Smeltzer, S.C. & Bare, B.G. Brunner & Suddarth Medical - Surgical Nursing. Lippincott, 2000. THE MOUNT SINAI HOSPITAL, NEW YORK NURSING CLINICAL AND ADMINISTRATIVE MANUAL STANDARD: Procedure No. 151 SUBJECT: Subcutaneous infusion of fluids for Hydration Page 1 of 3 Patient Population Original Date of Issue: November 2007 ü Neonate ü Pediatric ü Adolescent ü Adult ü Geriatric Reviewed:


Revised: Subcutaneous Infusion of Fluids Subcutaneous fluids may be indicated in patients who have lost venous access and who are unable to maintain adequate hydration. Continuous subcutaneous hydration, also called hypodermoclysis, is the administration of fluids into the subcutaneous layer of the skin where there is an extensive lymphatic and blood vessel system through which fluids can be absorbed. (Lipschitz et.al). Subcutaneous hydration may be indicated in the presence of cognitive impairment, nausea and vomiting, infection, abdominal obstruction, cerebrovascular accident and in end of life care to meet patients’ and/or families’ ethical/religious/cultural beliefs about hydration until natural death (Sasson & Shvartzman, 2001). Subcutaneous hydration should not be used in emergency situations, when patients require administration of large amounts of fluids rapidly, those at increased risk of congestive heart failure or with coagulopathies (Sasson & Shvartzman). Performed by: Registered nurses who demonstrate competence in the insertion of an indwelling subcutaneous butterfly needle and subcutaneous infusions via a pump may perform this procedure. 1. Any qualified prescriber (physician, nurse practitioner, midwife, certified registered nurse anesthetist and physician assistant) may order subcutaneous infusions, NOTE: Orders entered by a physician’s assistant must be countersigned within 24 hours (except in the ambulatory setting). *Subcutaneous infusion orders should include the type of solution to be infused, total volume of solution and rate per hour (ml/hour). NOTE: For information specifically pertaining to patient controlled analgesia via intravenous infusion, refer to Nursing Policy No.514-Intravenous Patient Controlled Analgesia (PCA). 2. IV Solutions may include the following: (Harefuah, Dasgupta, Bins, Rochon) a) Isotonic saline (0.9%) b) Dextrose saline c) Dextrose 2.5% or 5% d) Up to 2 grams potassium chloride per liter of solution (Yap et. al, 2001) 3. Infusion Rates - 1.5 liter/day/injection site-may give up to 3 liters/day via 2 sites (Harefuah, Dasgupta, Bins, Rochon, Yap et. al) 1 liter/8 hours during a nocturnal infusion (Yap et. al, 2001) Procedure: Inserting an Indwelling Subcutaneous Butterfly Needle for Administration of Subcutaneous Hydration via Pump Performed by: Registered Professional Nurses Equipment Location * Butterfly infusion needle 27-gauge. If 27-gauge is unavailable, use 25-gauge. Nursing Unit * Alcohol swabs * Transparent dressing (i.e. Tegaderm) * Non-sterile gloves Technique (Keypoints) 1. If medication is to be administered by subcutaneous infusion, connect butterfly infusion needle to the IV tubing and pump. 2. Prime subcutaneous infusion set with medication to be infused. 3. Select insertion site. Lateral abdominal wall, anterior or lateral aspects of thighs, subclavicular region or back (inner or subscapular regions) may be used. 4. Prep site with alcohol. 5. Don non-sterile gloves. 6. Use thumb and forefinger to grasp area of subcutaneous tissue at selected site. 7. Insert primed butterfly needle, bevel up at 45-degree angle. 8. Remove gloves and discard. 9. Secure butterfly in place using transparent dressing. 10. Inspect site for signs of inflammation, wetness, swelling or pain. If signs and symptoms are noted, change site and document. 11. If indwelling subcutaneous butterfly needle is being used for intermittent injection, flush slowly with 0.25ml of normal saline after medication administration. 12. For continuous infusion, verify correct pump programming with IV solution order, then initiate infusion. 13. Butterfly infusion needle, IV tubing and insertion site must be changed every 3 days, more often if necessary. Label the dressing with the date, time, gauge, nurse’s initial and date and time to be changed. 14.


Document procedure and nursing interventions in the medical record. 15. Document in the appropriate hospital forms/MSCIS: * infusion site * IV solution order * assessment of needle insertion site References: 1. Phillips, L. D. Manual of IV Therapeutics: FA Davis Co. Philadelphia, 2001. 2. Nursing Procedures 3rd Edition. Springhouse, Pennsylvania 2000. 3. Smeltzer, S. C. & Bare, B. G. Brunner & Suddarth Medical-Surgical Nursing. Lippincott, 2000 4. Yap, L.K., Tan, S. H. & Koo, W. H. Hypodermoclysis or Subcutaneous Infusion Revisited. Singapore Medical Journal 2001 Vol 42 (11). 5. Sasson, M. & Shvartzman, P. Hypodermocylysis: An Alternative Infusion Technique. American Family Physician. Vol 64 No. 9 Nov., 2001 6. Dasgupta, M., Binns, MA, Rochon, PA. Subcutaneous Fluid Infusion in a Long-Term Care Setting. Journal of American Geriatric Society Vol 48, 2000. 7. Lipshitz S. Campbell, AJ, Roberts MS, Wanwimolruk, S. et. al. Subcutaneous Fluid Administration in Elderly Subjects. Journal of American Geriatric Society, Vol 39, 1991. [Submitted on: 10/8/2009 by: Jay R. Horton, ACHPN, FNP, MPH, Clinical Program Coordinator, The Lilian and Benjamin Hertzberg Palliative Care Institute, The Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, NY, jay.horton@mssm.edu]

Here is ours: (Please request through email, since too large to post.) [Submitted on: 10/8/2009 by: Moat, Mary [Mary.Moat@va.gov]]

Thank you. I am new this resource...It's great. You've probably done this already, but....I am looking for 1)hospital comfort care order sets and 2) DNAR policies. Would anyone like to share? Thanks, Anna [Submitted on: 10/8/2009 by: Anna Kostaroff MS, RN, CHPN, Palliative Care Coordinator, Henry Ford Wyandotte Hospital, Wyandotte, Michigan, Kostaroff, Anna [AKostar1@hfhs.org]]

There is some vagueness in what we use for a needle because our policies cross continuums of careâ&#x20AC;Ś.and our home care/hospice team has outside infusion companies but we have just used angiocaths with success as well. Carla Jolley ARNP,MN,AOCN,CHPN jollec@whidbeygen.org Procedure Continuous Subcutaneous Analgesic Infusion (CSAI) Procedure Departments: Med/Surg, Emergency, Critical Care, Home Health Care & Hospice, Medical Ambulatory Care Summary/Purpose: Description of the steps and key points for setting up a subcutaneous infusion for opioids and other symptom management medications as indicated****. CSAI can be used for patients who have difficulty maintaining


venous access, for whom a central line would be inappropriate or impossible, or for who it would be simpler and more efficient. Procedure: ________________________________________ **** Other medications that can be used are octreotide, midazolam, halperidol continuously. Intermittent dosing is possible with opioids and these medications: metoclopramide, chlorpromazine, and dexamethasone. 1. Calculate the maximum dose the patient can receive if basal and /or PCA functions of the infusion device are to be used. Existing studies show that CSAIs have the same analgesic affect as IVs and that they prevent the peaks and troughs administered with as needed (PRN) dosing. Morphine is considered the gold standard, hydromorphone is the opioid of choice when higher doses are required because it is more concentrated and allows for lower infusion rates. The preferred rate is 2 mls/hr or less, may be up to 3 mls/hr (but has been reported up to 5 mls/hr). 2. Site selection is based on the presence of adequate adipose tissue. It is recommended to be able to pinch a fat fold of 2.5 cm between thumb and forefinger. Preference is given to sites that will interfere least with the patient's mobility (if appropriate) and are not easily accessible by patients who may tug at the catheter causing accidental de-access. Appropriate SQ sites include the abdomen, thighs, upper arms, buttocks, and subclavicular areas. 3. Attach the extension set to the tubing from the PCA. Prime the extension set with the medication, maintain the sterility of the opposite end of the extension set. 4. Site preparation. A) Activate Chloraprep 3 ml applicator and press against skin to saturate sponge. Clean skin over area to be used with a light back and forth friction rub. Cover a block area of 2-3â&#x20AC;? in every direction. Allow to dry for 30 seconds. Chloraprep applied with friction reduces skin microorganisms B) After the site has fully dried, using a 25- or 27-gauge subcutaneous needle, or angiocatheter "pinch up skin fold" insert at an angle of 45 to 60 degrees; the needle of some subcutaneous/overthe-needle sets are attached at a right angle that results in a 90 degree angle insertion. When the subcutaneous device is place, the device is aspirated to ascertain the absence of blood prior to use. If there is a blood return, the needle or catheter should be withdrawn slightly and rechecked for blood aspirate. C) Rotate the site every 3-5 days or as clinically indicated. Relocate at least 2-3 inches from the previous site. For needed higher infusion rates, there are specially designed sets or set ups that allow infusion at 2 sites simultaneously. Site irritation includes leakage, pain, redness, bruising, burning or significant swelling. Teach patients and caregivers to assess site twice daily for problems described. Complications of SQ infusions can be cellulitis, absess formation at site, inadvertent puncture of a blood vessel resulting in bruising. D) Connect the extension tubing to the needle hub, make a loop in the extension tubing and cover the insertion site and loop with a transparent dressing. E) Secure the extension tubing where it exits the dressing with tape, as well as loop again to decrease tension or chance of dislodging the needle. Label the site with date and initials. Document appropriately related to the setting in the patient's chart or flow sheet. 5) Discontinuing the infusion or site change. A) When discontinuing the infusion or the site, gently remove the tape and transparent dressing while stabilizing the catheter hub with the nondominant hand. Remove needle or catheter, cleanse site with alcohol wipe, apply a dry dressing if needed. Use adhesive remover when appropriate for comfort. B) Document the discontinuation or site change and condition of


site. Associated Regulation(s)/Standard(s): Reference(s)/Resource(s): Coyle, N. (1996) Cancer Patients and Subutaneous Infusions. American Journal of Nursing, Vol 96 (3)p. 61. Gorski, L. (2009)Standard 63: Continuous Subcutaneious Access Devices. Journal of Infusion Nursing, Vol 32 (4) p 185-186. Justand, J.(2009) Continous subcutaneous Infusion:An efficacious, Cost-Effective Analgesia Alternative at the End of Life. Home Health Care Nurse,Vol 29 (3), pp140-147. Owens, D. (2005) Interdisciplinary Team Consult-Continuous Subcutaneous Infusions. Journal of Hospice and Palliative Nursing, Vol 7 (6). p 310. Weissman, DE.(2005) Subcutaneous Opioid Infusions Fast Fact and Concept #28; 2nd ed,. www.eperc.mcw.edu Originated: jollec . Last modified: Sep 22, 2009 [Submitted on: 10/8/2009 by: Carla Jolley [jollec@whidbeygen.org]]

We use a special subq needle but any 23-25 gauge needle will work. [Submitted on: 10/8/2009 by: Marlene Foreman [marlene@hospiceacadiana.com]]

Question 84. Some time ago there was a discussion on this list serv regarding the interstitial drainage of terminal edema. We have a patient for whom I think this is appropriate. Would anyone be willing to briefly discuss again and perhaps share their policy? Thank you in advance to all respondents. Tammy Hawkins, MSN, FNP-BC, CHPN Director St. Bernards Hospice [Submitted on: 10/7/2009 by: Tammy Hawkins, MSN, FNP-BC, CHPN, Director, St. Bernards Hospice, [thawkins@sbrmc.org]] Answers At the HPNA Conference interstitial drainage was discussed. The example used was drainage of pedal edema with needles. Deborah Greenspan, CHPN [Submitted on: 10/7/2009 by: D G [dgreens1@gmail.com]]

Dr. Mike Rallo has done this several times and can explain how it is done. His email is: m.rallo@columbushospice.com [Submitted on: 10/7/2009 by: Colette Greer Daniel [cgreer@knology.net]]


I don't understand the idea of having a "policy" for some of what is asked for here. I use nebulized Lasix, and I also drain peripheral edema at times. I don't have a policy for either. Almost any drug that is in a pure form can be nebulized. By pure I mean it has no preservatives, or is not a pill that is crushed and dissolved in liquid. Most drugs for IV use are without preservatives. You put them in the nebulizer with 2 ml NS and turn on the machine. I don't nebulize drugs if there is a better way of delivery: oral, IV. Having said that, most pills can be given rectally, as long as they aren't enteric coated. Just place them in the rectal vault. Some are actually better absorbed. I drain peripheral edema with small gauge huber needles, only if the patient is very uncomfortable and with the understanding that when stopped, the edema will return. I usually drain only scrotal edema, not extremity, because that is what is most distressing. Beverly Douglas ACHPN [Submitted on: 10/8/2009 by: Beverly Douglas [bevdouglas@tampabay.rr.com]]

Re: Nebulizers and needles Thank you for the details. Deborah Greenspan, RN CHPN [Submitted on: 10/9/2009 by: D G [dgreens1@gmail.com]]

Question 85. Hello to all: Do any of you feel like your referrals compete with Hospice? I communicate and collaborate with our hospice staff that are within the acute setting, but they seem very territorial and question why a hospice referral was not made? Now, my background is 15 years of hospice and 3 years of Palliative care. We have no in patient hospice, but our hospice staff talk with patients and families then coordinate care if hospice is chosen. I am frustrated: need a new job or team. Kelli [Submitted on: 11/17/2009 by: Kelli Fisher RN, BSN, CHPN, BC, Palliative Care Specialist, [Fisher.Kelli@mhsil.com]] Answers I work at a hospice now, and it is funny how the environment can "entrench" one's perspective. It seems like "hospice people" forget that just because hospice is great for some people it isn't the right choice at that moment for every person. There doesn't seem to be as much tolerance as there used to be for letting patients come to the decision in their own time. If people aren't ready yet, then hospice is not the right choice. It seems really hard for hospice people to accept that. Ellen Martin, RN [Submitted on: 11/17/2009 by: Ellen Martin, RN, Director of Program Integrity, Hospice Austin]


I was a hospice nurse for 16 years before starting our Palliative Medicine program. We too work at an acute care hospital. The hospice admission team stationed here are very collegial and they frequently ask for referrals to us if the pt/family isn’t ready for hospice. We frequently discuss patients and often see them together depending at what stage the pt/family is. It helps that we have an integrated healthcare system with a hospice and homecare division. In fact, we have a Palliative Homecare team as well with nurses, a chaplain and SW who I trained and they too can take patients who aren’t ready or never will be ready we meet every Thursday for an hour for IDT to discuss patients and the physician who lead the IDT makes home visits with the patient PCP referral. We don’t have that territorial/turf stuff but mostly I think because we try to cultivate cooperation, going to lunch with each other when we have time, talking to each other on different nursing units, sharing jokes in emails, that sort of stuff. Maybe because we are a small group, it can work. Good luck! Lin Sorensen, RN, CNS [Submitted on: 11/18/2009 by: Lin Sorensen, RN, CNS, Palliative Medicine Service, [lsorense@phs.org]]

This is a very good topic for discussion, particularly at this time when we are trying to get expanded coverage for palliative care services. I think some of the problems lie not in whether patients are “ready” for hospice or not, but relate more to the artificial barriers that have been established by the limitations of hospice in this country to basically an insurance benefit with limitations of care that force a certain level of “readiness.” My practice is in a cancer setting and we are trying to promote a model of integrated palliative care that doesn’t draw any lines between providing care depending on whether or not a patient is receiving active cancer therapy or not, but providing that kind of care at home remains a major challenge. Hospices have come a long way and many are accommodating palliative cancer therapies, but the fact is that they are not funded to support costly therapies such as radiation and chemotherapy, so patient’s often have to make very difficult decisions or we have to do a lot of complex paper shuffling to get them on and off hospice care to get them the care they need. I don’t see this so much as a competition as an unfortunate state of our health care system that doesn’t support the co-existence of state of the art palliative care with ongoing conventional disease treatment. Hopefully, we will be able to get beyond the “death panel” image and tear down some of these barriers so we can provide appropriate care regardless of where patients are on their journey through lifethreatening illness and referrals will become more common and not left to the last minute as they so often are now. Deborah Thorpe, PhD, APRN, AOCNS, ACHPN [Submitted on: 11/18/2009 by: Deborah Thorpe, PhD, APRN, AOCNS, ACHPN, Pain Medicine and Palliative Care, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, [deborah.thorpe@hci.utah.edu]]


I would agree that we forget sometimes that patients have the right to choose hospice or not. Patients have reasons that do not always make sense to those of us in Palliative Care for not choosing hospice. I do not press patients to make a different choice and I feel that patients should never feel any sense of being coerced into hospice and "giving up on aggressive "medical interventions." These are personal choices and we should respect them. I also don't feel as a Palliative Care Nurse Practitioner that I need to explain or defend the referrals I receive. I simply state that it was the patient's choice. Competition with end of life care providers is not a good thing for our branch of medicine and I think ethically we should avoid it. Just my thoughts here. Pat Hoban, FNP-BC, ACHPN [Submitted on: 11/18/2009 by: Pat Hoban, FNP-BC, ACHPN, Palliative Care Service, Munson Home Health, [phoban@mhc.net]]

I always try to inform and educate the staff of Hospice as well as case managers at the hospital and social workers that the choice of Palliative care in the hospital is for the patient benefit. As in our organization we have found through patient satisfaction surveys, patients who have had a palliative care consult in the hospital and then go home with hospice have a better understanding of the diagnosis and reasons why they are on hospice. We have also found families have a better acceptance of the disease processes and symptoms that accompany the diagnosis. Those without a palliative consult and go straight to a hospice consult have more difficulty in the 'field' understanding symptoms, disease states etc... So, it's not a matter of questioning if our services overlap, because at times they do. It isn't about competition with each other. Itâ&#x20AC;&#x2122;s about patient satisfaction. Good luck. Sarah Beam, MSN, CRNP [Submitted on: 11/18/2009 by: Sarah Beam, MSN, CRNP Pinnacle Health Palliative Medicine, [beamsarah@hotmail.com] ]

Prior to becoming a palliative NP for a large hospital in Long Beach, CA, I was a hospice nurse for 12 years. I became an NP as I realized in 2003 that Palliative Care was the future for hospice, right or wrong. I do not believe that patients will ever have the quality of death in the hospital that they experience in their own homes with their cats, books, and familiar smells. I liken it to the difference between a home birth and a hospital birth. The reality is that palliative care has an increasing motive to not refer patients to hospice. It is also a reality that the cost benefit of hospice is lost after 2.5 months on service. (Sorry, I cannot site the journal article I read that fact.) It is important, and part of our code of ethics that


every patient understands their rights and ALL of their options. Hospice is unlike any other medical intervention in that it must be elected. It is considered a right. In every initial discussion, I have with a patient I offer hospice as an option for now or in the future, and as part of patient education. Since it is not a competition, it is important to let our patients know all of their options. Rebecca Gagne Henderson RN, MSN, FNP, CHPN [Submitted on: 11/19/2009 by: Rebecca Gagne Henderson, RN, MSN, FNP, CHPN, Palliative Care Coordinator, Long Beach Memorial Hospital, [rebecca@endoflifedirectives.org]]

Competition between hospice and palliative care, hmmm. As a hospice RN Case Mgr. for over 20 years, my preference is for hospice care. As to "state of the art" chemo and Radiation therapy - is it really state of the art? Or, is it our health care system not wanting to ask the tough questions or not helping the patient and family to ask them? Is it appropriate to do chemo and radiation in the last months of life to perhaps take a patient's pain rating down a notch while at the same time causing them to feel weak and sick and spend the last little time they have in the hospital? Is it not better to use medication to provide these benefits? Do we talk about futility and why we do what we do or do we help patients to stay in denial by doing these therapies? I can't count the times that I have heard patients tell me that they're still having chemo or radiation because "there's a chance" the tumor may respond. When asked if prognosis has been discussed or if the oncologist has talked to them about cure vs. comfort - usually they say no. I realize this is often a case of patients hearing what they want to here - but is it fair for us to do these therapies when there is no benefit from them - or if the benefit is not more then the risk or the side-effects - or, God forbid we should mention it - the cost to the health care system as a whole? It is true that the bulk of health care dollars are spent in the last year of life? We, as hospice and palliative care professionals - we are the ones that should be teaching and changing the system, yet we let the system change us? I have had patients be guilt tripped into accepting chemo and radiation - these people ended up dying anyway and probably were much sicker then if they did not go through it. A lot of this has to do with us doing things without thinking or stopping to think - and also not asking the hard questions - of ourselves, our patients and our system as a whole. Georgie Minard, RN [Submitted on: 11/21/2009 by: Georgie Minard [apoet4justice@hotmail.com]]

Georgie, I agree, but it is not just the health care system, it is the unrealistic expectations of the patients. Sometimes the benefit of palliative care is that we don't have to force a square peg into a round hole. Rebecca Gagne Henderson, RN, MSN, FNP, CHPN [Submitted on: 11/22/2009 by: Rebecca Gagne Henderson RN, MSN, FNP, CHPN, Palliative Care Coordinator, Long Beach Memorial Medical Center ]


Hi, How would you handle a heart failure patient that is currently stable but with age and comorbities could qualify for hospice very soon unless he dies suddenly. This is an example of a patient I have seen as a student nurse practitioner. He does have a cardiologist. He is NYHA level 2 and ACC/AHA 2005 level C. Do any of the palliative services handle this type of patient or do these services only exist within the hospital? I see a role for basic palliative care in primary care however I have not witnessed it in action in any of my rotations as a family nurse practitioner student. Do any of the palliative care services work with primary care providers and act as a bridge to hospice? Patti Pollina RN, CHPN [Submitted on: 11/22/2009 by: Patti Pollina RN, CHPN]

Patti, That is exactly the type of patient we see in our Palliative Care Service. We received referrals from primary care and cardiology services all the time. We often partner with home health services with the goal to try and keep these folks out of the hospital as much as possible. Our goal is to provide symptom management and improve their quality of life as much as possible. True we do refer and recommend hospice services when the patient is appropriate and willing to accept those services. As an example I have one lady who has been on my service for over three years and she has only had one hospital admission for an elective surgery that has nothing to do with her heart or ES -COPD. Hope this helps. Pat Hoban, FNP-BC, ACHPN [Submitted on: 11/23/2009 by: Pat Hoban, FNP-BC, ACHPN Muson Home Health, Traverse City, MI, [phoban@mhc.net] ]

Question 86. Hi Everyone, I have a situation with a current patient in an acute psychiatric setting. He is end stage renal, CHF, Pleural effusion, GI Bleed (the hospital does not want to do surgery because there is nothing more they can do for him). He is a psych patient, schizoaffective disorder with psychotic features, violent behavior, sociopath among other diagnoses. He is currently receiving dialysis MWF at the local prison because of his violent behavior. He knows he is dying and has been c/o SOB and increasing abdominal pain- he has been ordered pepto bismol. The only medication he receives is Ativan 2mg IM for unpredictable behavior and nothing for his symptoms. I do agree that when he originally came to the unit he was very violent and aggressive, but his condition has since worsened and so has he. This is an acute mental health setting and we have a medical doctor in addition to the psychiatrists and psychologists and patient advocates. I documented about his condition and spoke to the oncall MD about his condition and he said their hands are tied and they cannot transfer him to


any hospice because he is too violent. He is on a unit with 2 other aggressive, psychotic, multiple diagnosed males. I had a prn order for O2 but that was D/c'd after I returned to work last night. I stayed in his room with him, talking to him and trying my best to offer him some EOL care. He has no order for any medications, no chaplain no nothing. He has been transferred to the local hospital several times and has been returned. He is unemployed and the MD said that he has already cost the state over 700,000 for his treatment and dialysis. So, I guess he has to stay on the mental health unit and die in a cold room with no care, no dignity. The medical director refuses to transfer him to hospice as well after the psychologists advocated for him to be transferred. It saddens me as a hospice nurse that so very few are moved to provide the care this patient needs. What can be done in a situation such as this? Whenever I see someone without a smile, I give them one of mine! Avonelle Rand, RN, MSN, BS [Submitted on: 12/22/2009 by: Avonelle Rand, RN, MSN, BS; M.A. Rand [sedonte@hotmail.com] ] Answers Is it possible to call in a hospice to provide care to him since he lives at the psych facility? Does the hospital have an ethics committee? If it is alright with you I would like to forward this to a colleague of mine who is a psychiatrist that specializes in palliative care? Please let me know. What about a POLST (physician order for life sustaining treatment). We have just passed legislation in CA mandating that these orders be honored. They include DNR/DNI, tube feedings, etc. Please let us know how it works out. Rebecca Gagne Henderson RN MSN FNP CHPN [Submitted on: 12/22/2009 by: Rebecca Gagne Henderson, RN, MSN, FNP, CHPN, Long Beach Memorial Medical Center, [rebecca@endoflifedirectives.org]]

Avonelle, This is a very difficult, and inhumane situation. Is the patient receiving his psychiatric medications? Enough to stabilize his behavior so that he could be treated at a hospice or as an inpatient hospice patient? Does this patient have an advocate or an ombudsman through the mental health system? The advocates should be intervening on his behalf, is there an ethics committee at this facility this should be addressed there? If his pain were better controlled, his aggression might be decreased. If he is imminently dying, is palliative sedation a possibility if he discontinues his dialysis? What this patient has cost the state is irrelevant to what this patients' right are as a human being. It would seem to me that if this acute psychiatric facility is not willing to transfer him elsewhere then they are duty bound to provide for his care both psychiatrically and medically. Best of luck in dealing with this situation. Pat [Submitted on: 12/23/2009 by: Patricia Hoban [phoban@mhc.net]]


We also have both types of patients (prison and behavioral health) in an acute setting and I find advocating for these patients can be very different and difficult. Part of it is regulatory; part of it is lack of understanding that these people deserve human caring for their suffering just like anyone else. Patâ&#x20AC;&#x2122;s recommendations are appropriate and your response in sitting with him at times may be the only thing that you will have the ability to control this time around. As more people develop dementia, along with behavioral characteristics this is likely to become an increasing problem. Ethical issues are rampant and I donâ&#x20AC;&#x2122;t believe we (palliative care) have enough guidelines for this type of patient and the care needs that are required. Shari Froelich RN, MSN, MSBA, APRN, BC, ACHPN [Submitted on: 12/23/2009 by: Shari Froelich RN, MSN, MSBA, APRN, BC, ACHPN, Palliative Care, Allegiance Health, [Shari.Froelich@allegiancehealth.org]]

I wonder if you talked to your local hospice if they could work with this facility to provide hospice in that setting? [Submitted on: 12/23/2009 by: Dawn M. Wold [Dawn.Wold@crmcwy.org]]

Yes, please contact your local Hospice. At our Hospice, we routinely provide care to patients in all types of settings, including jails. Cathy Emmett [Submitted on: 12/23/2009 by: Cathy Emmett [EmmettC@lifepath-hospice.org]]

1. CONSULT THE HOSPITAL ETHICS COMMITTEE STAT. There is no reason for this person not to receive the hospice Medicare benefit just because he is tagged as violent. Keeping this patient from comfort care is unethical. 2. This pt needs comfort medications asap. If your physician does not know what to do, he can consult your state's Hospice and Palliative Care Organization office NOW. This patient deserves to have something for his agitation, to relieve his dyspnea and pain... 3. Contact the National Alliance for the Mentally Ill (NAMI). They will advocate in ways you cannot even fathom. But you need to call them NOW. 4. Consider turning the attending in to your hospital's committee that deals with physician incompetence. Although there may be "nothing that we can do" for the pt's illness, there are lots of things that can be done to keep the pt comfortable. Wow... there is a serious knowledge gap in your hospital. Good luck! John D Chovan, PhD, RN, CNP, CNS


[Submitted on: 12/23/2009 by: John D Chovan, PhD, RN, CNP, CNS, [jchovan@columbus.rr.com]]

Hi, This is all too familiar. Unit MD are not comfortable with psych pt let alone dying/behaviorally challenging and difficult ones. If the symptoms of distress are treated, his behaviors will improve. It is appropriate to use antipsychotics to calm/pain medications or even morphine for dyspnea which would also control pain. An ethics consult is good because it puts together multiple folks with differing perspectives which can often yield useful strategies. A chaplain would offer some emotional support for the likely spiritual distress, even past regrets issues review. This type of presentation is often masking the real problem, spiritual distress. Keep at it, experiences help strengthen the team. Thanks Nina Miranda [Submitted on: 12/23/2009 by: Nina Miranda, (DPH), [Nina.F.Miranda@state.ma.us]]

What a horrible situation! I agree with the others. An ethics consult is a must in this situation. I can not imagine a hospice would not care for this gentleman, even if he is in the mental health setting. Have you talked with anyone from hospice to see what, if any, the barriers would be? They may be able to help advocate for him. Good Luck! Karen [Submitted on: 12/23/2009 by: Karen M. Mulvihill, [Karen.Mulvihill@danhosp.org]]

I am a bioethicist as well as HPN. The advice noted by John is exactly what I would have recommended. Be aware that not all hospitals have an effective ethics committee, in other words, sometimes they just function in name only. So, you may or may not get results from your committee. However, you still must do all of the steps suggested below for your patient. If you do not have a HPC MD on staff at your facility, then step #2 may be your best bet. But, also check on any of your local hospices that could see the patient in his residence (your facility). You would then get the benefit of their HPC MD for meds, etc. and to try just in time education with your doc. Step 4 may be dicey depending on your hospital's committee. Depending on your hospital structure and your reporting lines, get your CNO involved starting NOW. If that doesn't work please ask for help again through this communication as #4 is equally important once the patient's needs are met. Pamela M. Dalinis, MA, BSN, RN [Submitted on: 12/23/2009 by: Pamela M. Dalinis, MA, BSN, RN, Director, Clinical Education and Training, [PDalinis@itxm.org] ]


I think one of the barriers to getting hospice might be billing. A psychiatric inpatient unit would bill Medicare Part A. This would prevent hospice from billing. Some hospices might provide free care if that is the case. However, in an inpatient unit like that, it might require a contract to allow the hospice to provide care. Rob [Submitted on: 12/23/2009 by: Robert Smeltz, RN MA NP ACHPN Clinical Coordinator/Nurse Practitioner, Palliative Care Program, New York Univeristy School of Medicine, Bellevue Hospital, New York, NY, [Robert.Smeltz@nyumc.org] ]

Hi Pat, He is receiving his psychotropic meds and his psychiatric. He has not displayed any aggressive, violent, or unpredictable behavior because he can barely muster up enough strength to take a good breath. I reported back his declining condition to the psychologist this morning and she said that she tried to advocate for him but was shot down before she even stated her case (they told her there is nothing that they can do for him). Some of the nurses on the day shift are upset as well and they said they will be calling the center for advocates for the mentally ill which oversees several other local advocate offices. I will definitely keep you updated on this and how it unfolds. I am looking for a medical ethics committee in our area to take this to since the medical doctor is refusing to do anything and the medical director- a psychiatrist who also refused to transfer the patient, and the medical director over the entire campus also refused to provide EOL. [Submitted on: 12/23/2009 by: M A Rand [sedonte@hotmail.com]]

I forwarded to a friend and these are her comments: I am an advance care planning coordinator and ethics consultant, not a hospice or palliative care expert. This was forwarded to me by one of your colleagues. For what it is worth, my suggestions: First of all, I would make a referral to an ethics committee (your own or in a hospital near you) for a review of this case and to add some strength to your concerns. If the goal of care for this patient is approaching allowing a natural death to occur, behavior management and symptom management can both be tailored into his plan, so that when hospice referral is both safe and appropriate, the right plans are in place. There is no tenable rationale for withholding palliative measures (which can be delivered anywhere) from a person w/ a mental health diagnosis - regardless of how aggressive their behavior may be. Additionally, a referral to a palliative care service may provide your MD w/ some new ideas on the most cost efficient means for achieving a reduction in his suffering. It would be wonderful if this pt could have such a referral. The cost of his dialysis care has no bearing on the cost for reducing his suffering. A smooth transition can even be seen as a financial win/win: the


appropriate level of care delivered in the appropriate setting is both cost efficient and the gold standard. Discussion about his costs for a covered service muddies the waters. I hope this is helpful and that others have come to your assistance as well. Jane Dinnen, RN [Submitted on: 12/23/2009 by: [Michelle Witkop [Mwitkop@mhc.net]]]

Not all hospitals have ethics committees, or even palliative care services but they do all have administrators who are ultimately responsible for what goes on in their hospital. The administration needs to be made aware that a patient is receiving inadequate care (mention liability and the response may improve) [Submitted on: 12/23/2009 by: kmcgrath@i-plus.net]

Another thought is that the administrator of the entire campus should be notified in writing of your concerns on the treatment of this patient. The plan of care as it stands does seem to violate his civil rights as a vulnerable patient due to mental illness. I have found that putting concerns clearly into writing make it very difficult for administrators to ignore. As a former risk manager, I think the plan of care as it currently stands indicates real concerns from a liability stand point under care of a patient falling below acceptable professional standards of care. If one provider is not able to provide and adequate level of care as indicated by the patient's demonstrated needs, then that provider is duty bound to refer the patient to a provider who is able to give the patient the care they are in need of. Pat [Submitted on: 12/23/2009 by: Patricia Hoban [phoban@mhc.net]]

You also may want to check in and see if there is a patient advocate ombudsman to advocate for this patientâ&#x20AC;&#x201D;also, you didn't mention if there was any family members who could advocate for this patient. â&#x20AC;&#x201D;Mary Denise [Submitted on: 12/23/2009 by: Mary Denise Smith [smithm@ohsu.edu]]

Where is his Next of Kin or surrogate decision maker? If he is not competent to make decisions-, there should be someone that the discussions can be broached! In addition, if he is DYING then why is he still receiving dialysis? Is he a HOSPICE Patient at present? IF so, then perhaps the goals of care need to be addressed AGAIN?? GOOD LUCK!! Sounds like a difficult one!! Linda Chilton, MSN, APRN-BC


[Submitted on: 12/24/2009 by: Linda Chilton, MSN, APRN-BC, [lchilto@bellsouth.net]]

To me, the other option to hospice care is palliative care. Even if there isn't a hospice able to help, or the unit doc isn't comfortable doing that kind of care, I'm betting there may be either a hospice organization with a palliative care department, or a hospice physician who may be willing to help with the sx management. I agree with all of my esteemed colleagues' suggestions and insights. Good luck. Jessica Weinberger [Submitted on: 12/24/2009 by: Jessica Weinberger, [jetw69@aol.com]]

Question 87. Our hospital is looking to add presence of advance directives to a patient safety initiative that will be utilizing arm bands to alert staff to inquire about certain issues. I have been asked by our director of nursing is there is a standardized color being used to remind staff to inquire about the presence of an advance directive? Thanks so much. Susan [Submitted on: 12/14/2009 by: Susan Redding, MSN, Pitt County Memorial Hospital, Palliative Care, Greenville, NC, [sredding@PCMH.COM] ] Answers At Catawba Valley Medical Center in Hickory, all DNRs have a purple chart as well as a purple armband. Lenora [Submitted on: 12/14/2009 by: Lenora W. Smith, MSN, RN University of Phoenix Online Faculty, FNP/PCNP Graduate (12/09!), University of Alabama Birmingham, [lksmithrn@gmail.com] ]

I know that we looked at colored armbands to use in our In-Patient Hospice Houses a few years ago, but decided against it after researching and discovering that there have been some serious patient errors due to patients being transferred from one care setting to another and the different colors meaning different things at different facilities (Purple might mean Fall Risk at one hospital, but then patient goes to Nursing Home where it might mean DNR). I think a few states were looking at trying to standardize the colors across Healthcare settings, but have not heard anything about this recently. Cathy Emmett, MSN, ARNP [Submitted on: 12/14/2009 by: Cathy Emmett, MSN, ARNP [EmmettC@lifepathhospice.org]]


Washington State Hospital Association is the one that took the lead here….so all hospitals etc. have to have purple for no code, red allergies, and yellow for fall risk. This way if you transfer we are using the same coding. [Submitted on: 12/14/2009 by: Carla Jolley ARNP, MN, AOCN, CHPN, [jollec@whidbeygen.org]]

Please remember that having an advance directive does not equate to being a DNR. They are very different things. Whereas, I know that some hospitals and facilities have used color coded arm bands to identify patients who are DNR, I question the value of doing so for those with an AD. An AD is best viewed as a document to promote communication and to aid decision-making. As someone who has an AD, I am not sure if I would be too keen about having a band placed on me identifying me as such if I came in for knee surgery or to deliver a baby. [Submitted on: 12/14/2009 by: Terri Maxwell, PhD, ACHPN, [TMaxwell@excelleRx.com]]

I, too, would promote something different for advanced directives – I was merely pointing out what the facility was doing for DNRs. And it’s not Catawba Valley Medical Center as I previously stated. It’s Caldwell Memorial Hospital in Lenoir. I’m afraid I was getting clinical institutions mixed up – CVMC is where I did my NP clinical and I teach clinical for first year nursing students at Caldwell. My apologies for the confusion. :-) Lenora [Submitted on: 12/14/2009 by: Lenora W. Smith, MSN, RN University of Phoenix Online Faculty, FNP/PCNP Graduate (12/09!), University of Alabama Birmingham, [lksmithrn@gmail.com] ]

Again, none of which addresses the issue of advance directives only DNR status. The PA hospitals have adopted the uniform colored bands for safety only now patients have on four to five bands each. The bands have lost their value due to the shear number of them. Just an opinion from a NP not employed by a hospital system. Mary [Submitted on: 12/14/2009 by: Mary Lawhon Triano, CRNP-C, ACHPN, Palliative Medical Service, Scranton Temple Residency Program, Scranton, PA, [TrianoM@strpweb.org]]


Our facility not only has the wrist bands, but writes DNR on them. I believe they are red in color. This has had a negative effect on patients and families when they see this and think the patients won't be treated and they revert to full code. This has very effectively undone some very lengthy and productive conversations. While understanding the premise, I think that it is not a good idea. Advance Directives are a very different issue and we should put more energy into this than banding people. Shari Froelich RN, MSN, MSBA, ANP-BC, ACHPN [Submitted on: 12/15/2009 by: Shari Froelich RN, MSN, MSBA, ANP-BC, ACHPN, Palliative Care Allegiance Health, Jackson, MI, [Shari.Froelich@allegiancehealth.org]]

In response to Cathy's email, the VA is looking at going to the national standards for armband colors. (I'm not sure what they are yet.) [Submitted on: 12/15/2009 by: Ellen Davis, [moonkids2@yahoo.com]]

We use blue arm bands to communicate when there is an order. We do not use the arm band to communicate the presence of advanced directives. In the VA computerized medical record we have a note connected to a postings section. We are finding practice variability when the order is for DNR but the patient wants to be intubated or the patient wants to have resuscitation but DNI. Some nurses want to put a blue band on only if the order is for DNR/DNI and others want to put a blue band on and write specifics on it. What is the practice for those on this e-mail who are using an arm band? [Submitted on: 12/15/2009 by: Jane MCabe RN, MS, Palliative Care CNS, VA Eastern Colorado HCS, Denver, CO, [Jane.McCabe@va.gov]]

We currently have a quality improvement project group working on this issue and are exploring several options for better identification of and access to the patient’s advance directives. We have an electronic medical record and have recently instituted a practice of having the actual documents scanned and saved in the EMR. Currently they show up in a file labeled “Communications” which not everyone knows about and sometimes appear in a multi-page document with an admissions checklist as the first page so a lot of people actually miss the actual documents. We are working on making these more accessible and are hoping to change it to a folder with Advance Directives as a label so it will be clearer. Another option is to have it tied to an alert system like the allergies so it is very quickly accessible. The need for this project arose because we had several situations where patients who had clearly desired to be DNR came in to the ER with symptoms out of control and


because a family member was not readily available to speak for the patient they ended up intubated and in the ICU. Our outpatient clinics also want better access to this information so we are trying to come up with ways of making it clearer through the EMR. When we get our EMR issues worked out we hope to have a house-wide awareness/inservice day that will correspond with National Health Care Decisions Day which is in April each year. As a practice, whenever anyone from our team does a consultation note we always include a section in the plan labeled “Advance Care Planning” – if the patient has and established directive I review the key points that have been stipulated and identify the patient’s agent and note the date of the document and that it has been reviewed. If they don’t have a document or if information has been provided I document that process and the involvement of social work, which is usually the case. In Utah, patients may also use a MedicAlert bracelet that states :”UTAH DO NOT RESUSCITATE DECLARATION ON FILE or UTAH P.O.L.S.T FORM ON FILE” and that is recognized by our emergency medical services. Deborah Thorpe, PhD, APRN, AOCNS, ACHPN [Submitted on: 12/21/2009 by: Deborah Thorpe, PhD, APRN, AOCNS, ACHPN, Pain Medicine and Palliative Care, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, [deborah.thorpe@hci.utah.edu]]

Question 88. Acuity Tool. Does any one have an acuity tool for hospitalized patients who have been referred to a palliative care consult service.? [Submitted on: 8/24/2010 by: Karen McGough ARNP, ACHPN Sarasota FL ] Answers 88. Acuity Tool. Are you thinking about using Karnofsky score in assisting in determining needs and function? [Submitted on: 8/24/2010 by: peachymor@comcast.net]

88. Acuity Tool. You might also find an illness severity scoring tool such as the APACHE (Acute Physiological and Chronic Health Evaluation) helpful; this tool is often used as a mortality indicator in intensive care settings. [Submitted on: 8/24/2010 by: kathleen [kathleen_fahey@sbcglobal.net] ]

88. Acuity Tool. Are you in need of a patient workload acuity scale, or as others have


suggested, a performance scale? If the latter, Google "pps palliative performance scale" and check out the tool on the mywhatever site. Can't link it from phone. Similar to ECOG/Karnovsky. [Submitted on: 8/25/2010 by: Josie Howard-Ruben [josiehowardruben@gmail.com]]

88. Acuity Tool. Karen et al, I don't know if this is helpful, we are working on an acuity tool for our home program. It might help conceptualize a model for the in-patient setting - feel free to utilize and I would love any feedback. **Home Palliative Care Acuity Tool was attached. Please contact submitter to obtain. Sean M. Reed, RN, MS, ACNS-BC, ACHPN Director Palliative and Hospice Care Centura Health 1391 Speer Blvd. Suite 600 Denver, CO 80204 303.561.5385 Office. seanreed@centura.org [Submitted on: 8/25/2010 by: Sean M. Reed, RN, MS, ACNS-BC, ACHPN [seanreed@centura.org]]

Question 89. APN Billing Hospitalized Inpatient. I'm working on a project to move the salaried-based palliative care service to an APN billing service for hospitalized inpatients. Does anyone have a standardized note for either/both initial consults and follow-up visits that you'd be willing to share with me? Also, any advice about APN billing would be very welcomed! I've been on the CAPC website, but it's still a bit confusing. [Submitted on: 6/7/2010 by: Dawn Pavlu MSN, APN [dawn@pavlu.net]] Answers 89. APN Billing Hospitalized Inpatient. Dawn - If you would like to talk sometime I would be more than willing to share how we do things. I bill for inpatient consults and daily visits. We do it all based on time. I am happy to discuss with you. Deb Groath, DNP, ARNP Palliative Care and Hospice Mercy Medical Center - North Iowa 641.422.7978 groathd@mercyhealth.com [Submitted on: 6/7/2010 by: Deb Groath, DNP, ARNP [groathd@mercyhealth.com] ]

89. APN Billing Hospitalized Inpatient. Hey Dawn: Your overall documentation shouldn't change, but I would suggest you talk with the hospital billing dept to come up with a billing sheet for you to fill out on each pt you see. There should be different billing levels for Initial Consult, Follow-up Visit, Discharges, and for Private/Medicaid insurances. If you have all


levels on one sheet, then all you need to do is mark what you do for the pt on each sheet, then add the ICD codes for that pt. For example, I mark on my billing sheets an initial consult or follow-up visit at Level 1,2 or 3 (for time involved), then add the ICD codes I usually use for my pts such as debility, pain, dyspnea, N&V, malnutrition, etc. I hope this helps. [Submitted on: 6/7/2010 by: Carolyn White, FNP, MSN, ACHPN速 [cwwcats@aol.com]]

Question 90. APN Palliative Care Training. Can anybody recommend any courses or intense training for an APN prior to starting a palliative care position that would help achieve the competencies (e.g., complex pain management, symptom management, psychosocial support, communication) in palliative care that you would need to work as independently as possible? Thanks Ursula Baldoceda Northwestern Memorial Hospital Hospitalist Service -- Ursula The only life worth living is one that your really passionate about. [Submitted on: 5/12/2010 by: Ursula Baldoceda [ursulasofia@gmail.com]] Answers 90. APN Palliative Care Training. I would highly recommend the ELNEC courses available throughout the year and ACHPN core competencies book. I'm studying to advance my CHPN to ACHPN this year and these sources are invaluable! There is a free ELNEC in Phoenix 6.1011 that I will be (re)attending. I can pass on info if you're interested. Former NBCHPN President and friend of mine is presenting - Bonnie Morgan. Best, Kris KyoungFNP@gmail.com [Submitted on: 5/12/2010 by: Kristopher Young [kyoungfnp@gmail.com]]

90. APN Palliative Care Training. I would recommend the AAHPM Unipac series and Betty Ferrell and Nessa Coyle's textbook: Textbook of Palliative Care Nursing and the Oxford Textbook of Palliative Medicine. Linda Blum California Pacific Medical Center San Francisco [Submitted on: 5/12/2010 by: Linda Blum [lblumgnp@gmail.com]]

90. APN Palliative Care Training. I would recommend applying to your administrators to support attendance at PCEP (Palliative Care Education and Practice) course offered by Harvard Medical School. The training is excellent, especially in communication skills and the networking invaluable. But it costs $5000, however, for myself and fellow MD's the


experience was transformative. I have also heard positive appraisals of the annual CAPC meetings. Barbara Reville, MS, APRN-BC, ACHPN Assistant Director, Palliative Care Service Jefferson Palliative Care Center Department of Family & Community Medicine Thomas Jefferson University 1015 Walnut Street, Suite 401 Philadelphia, PA 19107 215-955-1807 (voice mail) 877-656-4509 (pager) www.jeffersonhospital.org/palliative [Submitted on: 5/13/2010 by: Barbara Reville [barbara.reville@jefferson.edu]]

90. APN Palliative Care Training. I recommend completing the review course that is offered for physicians who are taking boards for palliative care sub specialty. It is available on CD and gives a complete overview of all the important topics. The lectures / faculty were excellent. Highly recommend this for anyone who wants to enhance their PC knowledge base. Judy Passaglia RN, MS, ACHPN速 Palliative Care Program Manager / CNS Stanford Hospital & Clinics (650) 723 3736 jpassaglia@stanfordmed.org [Submitted on: 5/13/2010 by: Judy Passaglia RN, MS, ACHPN速 [jpassaglia@stanfordmed.org]]

90. APN Palliative Care Training. I have to agree with Judy. I used the UNIPAC books to study for my ACHPN and had no problem. The exam is more medically oriented than nursing. Karen [Submitted on: 5/13/2010 by: Mulvihill, Karen M. [Karen.Mulvihill@danhosp.org]]

Question 91. Outpatient Billing for LCSW Visits. I wonder if any Palliative Care Programs (outpatient) are currently billing for LCSW visits for patients? We had heard that Social Work can bill under Medicare Part B if they are LCSW and are providing a certain percentage of counseling. We are OT Hospice but are a Palliative Care Service. Can anyone provide insight into this area for us? Chris Coletta-Hansen MSN, ANP-BC, ACHPN Grand View Hospital 215-453-4118 c.hansen@comcast.net or chansen@gvh.org [Submitted on: 9/9/2010 by: Chris Coletta-Hansen MSN, ANP-BC, ACHPN [c.hansen@comcast.net]] Answers 91. Outpatient Billing for LCSW Visits. CAPC has info on their website, www.capc.org.


[Submitted on: 9/9/2010 by: rebecca@endoflifedirectives.org]

Question 92. Book Recommendations. We are Palliative Care Nurses, not only good at what we do but confident what we do is “right”. Recently on one of the blogs I follow (either Pallmed or Geripal) there was a recommendation for a new book called “No Good Deed” by Lewis M. Cohen, MD (the sub title is “A Story of Medicine, Murder, and the Debate over How we Die”). I read it and would like to pass the recommendation on. It really enlightened me on some things, especially that there is a large group out there (actually groups) who feel length of life is more important than quality of life and that patient autonomy is greatly over rated. After the “death squads” remark, many laughed it as a fringe who just doesn’t get Advance Directives and Palliative Care but that isn’t necessarily the case. Our Palliative Care Social Worker and I were discussing the book and she said she had lent it to a Palliative Care physician we know. He said not to recommend it because it will scare people. I believe it is important for Health Care professionals to read it and understand (as much as possible) the “others”. Several years ago we had a patient with end stage COPD. She was a DNI/DNR. The CNA working with me (who was a nursing student) came to me and said her sat was only 70% and she was very SOB. I thanked her and said I would give her some morphine and also suggested she not do another sat as she was already on an Oxymiser, didn’t want to wear a NRB, and we are treating the symptom. The CNA became very upset telling me “she is going to die we don’t do something”, that it shouldn’t matter if she didn’t want to be intubated. I treated it as a teaching moment and fortunately it remained that-scary to think it could have been else wise. Janice Janice Reynolds RN, BC, OCN, CHPN Mid Coast Hospital Brunswick, ME jkrrnocn@blazenetme.net [Submitted on: 7/5/2010 by: Janice Reynolds RN, BC, OCN, CHPN [jkrrnocn@blazenetme.net]] Answers 92. Book Recommendations. Thank you for the suggestion. Another good book to consider is Daniel Callahan's "The Troubled Dream of Life: In Search of a Peaceful Death", 2000, published by Georgetown Univ Press. I came across it, just stumbled on it, while browsing Amazon, & have found it a thoughtful treatise on life, death, and why assisted suicide isn't a good answer. The greatest gift for me was a new perspective on the doctors (usually surgeons, in my hospital practice) who don't seem to believe patients really die. I'm able to have a little compassion for their dilemma, and understand why PC is seen as "the enemy" many times. Since Scotland has introduced early legislation to approve "assisted dying" when "life is intolerable", we really have an obligation to be prepared for the debate. Mary Ann Mary Ann Misenhimer, RN, ANP, CHPN Sutter Medical Center, Sacramento, CA [Submitted on: 7/7/2010 by: Mary Ann Misenhimer, RN, ANP, CHPN


mamisenhimer@macnexus.org]]

Question 93. Measuring Acuity in Hospice Patients. I am looking for any tools that your facilities may use to measure acuity in the hospice patient population. Any help or direction will be greatly appreciated. Thank you for your time, Donita Overend 619 791 9199 [Submitted on: 1/29/2010 by: Donita Overend [doniovere@aol.com] ] Answers 93. Measuring Acuity in Hospice Patients. I’ve been working in Hospice and Palliative Care for 5 years now. I can’t say I’ve ever seen a tool per se for measuring acuity. For documenting continuing clinical decline, we use the Palliative Performance Status v2 which you can google. I will look for a supporting research article on the validity of the tool. We also look at wasting by measuring the forearm circumference on a weekly basis to track muscle wasting. I’ll be curious to see how others respond to this inquiry. Hope this was helpful. Sincerely, Mary Mary Lawhon Triano, CRNP-C, ACHPN Palliative Medicine Consult Service Scranton-Temple Residency Program 746 Jefferson Avenue Scranton, PA 18510 570343-2383 office # 570-704-8010 cell # trianom@strpweb.org [Submitted on: 1/29/2010 by: Triano, Mary [TrianoM@strpweb.org] ]

93. Measuring Acuity in Hospice Patients. Although developed for the pediatric population Canuck Place has developed an acuity tool that might be helpful as a starting point. They are in Vancouver and if you google it you will get the link and contact info, I'm afraid I don't have it with me at the moment, Good Luck Christy [Submitted on: 1/29/2010 by: Christy Torkildson [torkc@sbcglobal.net]]

Question 94. Care Packages for Hospice Admissions. Our hospice is interested in creating a small care package for each of our patients/families upon admission to our hospice program. We would like to get an idea from those who are have already instituted this addition to their care delivery...as to a list of what you include in your care package. Thanks very much for your helpful feedback. Anne Butler, RN, ANP-BC, CHPN Clinical Services Manager Evercare Hospice Elkridge, MD 21075


[Submitted on: 9/26/2010 by: Anne Butler [anniem416@gmail.com]] Answers 94. Care Packages for Hospice Admissions. At one of the hospice companies I worked with in the past, we arranged “welcome baskets” with the following: (the basket was really a bath basin with everything below inside it) Care supplies – gloves, lotions, ointments/moisture barrier cream, a chux pad lining the basket, emesis basin, wipes, oral toothettes, mouth wash. Other: handmade lap quilt from the volunteer group, note pad and pen, magnet for hospice contact, “Hard Choices for Loving People” booklet. The quilt was too big to fit, but was taken along with the basket. The CNA would bring a package of briefs (if needed) during the first visit. The basin/basket was then wrapped in cellophane and a large ribbon was tied around securing everything together. The admission RN would have 2-3 baskets in her car as well as the on-call support RNs. The baskets were very well received – both visually and functionally. [Submitted on: 9/27/2010 by: Holli Martinez [Holli.Martinez@nurs.utah.edu]]

Question 95. City Wide Advance Directive Project. Does anyone know the name of the town that made a community wide effort to get all people signed to have an advance directive? I remember some town doing a city wide project like this but can’t remember the town. Thank you Becca Rebecca Hawkins, MSN ARNP, ACHPN Palliative Care Nurse Practitioner CME Coordinator St Mary Medical Center 401 W Poplar Walla Walla, WA 99362 phone:509-522-5514 fax: 509522-5504 [Submitted on: 8/10/2010 by: Rebecca Hawkins, MSN ARNP, ACHPN [Rebecca.Hawkins@providence.org]] Answers 95. City Wide Advance Directive Project. Respecting Choices…La Crosse WI They have a website Carla Jolley ARNP,MN,AOCN,CHPN jollec@whidbeygen.org [Submitted on: 8/10/2010 by: Carla Jolley [jollec@whidbeygen.org]]

95. City Wide Advance Directive Project. I am a Respecting Choices facilitator. Here is a recent press release from this group. http://respectingchoices.org/news_upcoming_events/in_the_news/multifaceted_approaches_to_advance_care_planning [Submitted on: 8/10/2010 by: Josie Howard-Ruben [josiehowardruben@gmail.com] ]


95. City Wide Advance Directive Project. LaCrosse, WI -- the program is called Respecting Choices (http://respectingchoices.org/). I went through their training awhile ago -- well worth it. Pat ***************************** Patricia H. Berry, PhD, APRN, ACHPN, FAAN Associate Professor Associate Director, University of Utah Hartford Center of Geriatric Nursing Excellence University of Utah College of Nursing 10 South 2000 East Salt Lake City, Utah 84112-5880 voice: 801-793-5746 fax: 801-581-4642 e-mail: patricia.berry@nurs.utah.edu [Submitted on: 8/10/2010 by: Patricia H. Berry, PhD, APRN, ACHPN, FAAN [Patricia.Berry@nurs.utah.edu]]

95. City Wide Advance Directive Project. La Crosse, Wisconsin, Gunderson Clinic, Honoring Choices program. Also integrated ACP into EHR. [Submitted on: 8/10/2010 by: Mary Lagaard [mlagaard@yahoo.com]]

95. City Wide Advance Directive Project. As you have heard from other people on the listserve, the community I believe you are talking about is LaCrosse, Wisconsin. If you would like more information, you can visit respectingchoices.org or contact Matthew Isbell at mrisbell@gundluth.org. Bernard Hammes, PhD, Medical Ethicist and the Respecting Choices team from Gundersen Lutheran have worked hard over the years to move this project forward. I am sure they would be willing to answer any questions you might have. I am currently an APN working at Gundersen Lutheran in the Palliative Care Service so have seen the benefits first hand that occurs when patients and families come into the clinic and/or hospital with a completed Advance Directive on file. It makes a huge difference in making sure we are respecting their choices.... Sincerely, Carrie Carrie L. Lapham Advanced Practice Nurse- Connected Care (PalliativeCare) Ext. 59336 or 59345 Pager 0512 Mailstop: C04 - 003 [Submitted on: 8/11/2010 by: Carrie L. Lapham [cllapham@gundluth.org]]

Question 96. CNS Job Description. Can anyone share their Clinical Nurse Specialist job description with me? Thanks, Marilyn Marilyn Graves, RN,MSN, CHPN Clinical Nurse Specialist Office: 443849-8224 Gilchrist Hospice Care 11311 McCormick Road, Suite 350 Towson, MD 21031


[Submitted on: 1/13/2010 by: Marilyn Graves [mgraves@GilchristHospice.org]] Answers 96. CNS Job Description. Here you go—it’s from a few years ago- but will get your started. **Please contact submitter via email for the form. [Submitted on: 1/13/2010 by: Marilyn Bookbinder [MBinder@chpnet.org]]

96. CNS Job Description. This job description was drawn up in December of 2004 and we didn’t start the program until March of 2005. At that time we only had me, a CNS full time and a physician in the afternoons only. We now have a1.0 FTE physician, a .5 FTE CNS and a physician who is .5 as well. Last month we finally added a 1.0 FTE LIMSW who is learning to how he can bill as all of have been billing for our services since starting. *This 1st attachment is from CMS. *The 2nd is ours developed in 2004. We are now in the process in re-looking at the job descriptions to make changes to better describe what we do. In New Mexico CNS can have prescriptive authority with 400 hours spent job shadowing another provider with prescriptive authority. This requires a contract with the state BON unless done in the process of finishing the MSN program. Hope this helps, Lin Sorensen, RN, CNS Palliative Medicine Service (505) 269-6175 cell (505) 724-6134 office (505) 723-8995 fax lsorense@phs.org **Please contact submitter via email to obtain. [Submitted on: 1/13/2010 by: Sorensen, Linda [lsorense@phs.org]]

Question 97. CNS Role Within Hospice and Palliative Care. Hello, Exploring the CNS role of those who are working in Hospice and/or Palliative care. I am interested in your role and would like to contact you regarding your current position. If you have time, please share or send me your contact information to discuss this topic. Thank you, Donita Overend RN, BSN, MSN(c) A-CNS 619 791 9199 [Submitted on: 4/6/2010 by: Donita Overend RN, BSN, MSN(c) A-CNS [doniovere@aol.com]] Answers 97. CNS Role Within Hospice and Palliative Care. I am a practicing CNS in Palliative Care. Please feel free to contact me to discuss this further. Jame Restau, RN, MSN, ACNS-BC, OCN Baylor Medical Center at Irving Irving, Texas 75061 972-579-4376 [Submitted on: 4/6/2010 by: Jame Restau, RN, MSN, ACNS-BC, OCN [Jame.Restau@baylorhealth.edu]]


97. CNS Role Within Hospice and Palliative Care. I am also a practicing CNS in Palliative Care, with a very interesting role as a CNS on a Palliative Care team (700 bed facility, with 600 LTC residents, a 50 bed rehab unit, and a 50 bed long term acute unit). I'd be very happy to discuss the role. Anne Mahler, MS, RN (GCNS-BC, ACHPN) Hebrew Rehabilitation Center 617-363-8182 annemahler@hrca.harvard.edu [Submitted on: 4/6/2010 by: Anne Mahler, MS, RN (GCNS-BC, ACHPN)[mahlera3@yahoo.com]]

97. CNS Role Within Hospice and Palliative Care. I am a CNS and have been working in Palliative Care as an Advance Practice Nurse at Gundersen Lutheran Medical Center in LaCrosse, Wisconsin since l997. I work primarily in the hospital and round on palliative care patients that we are "attending" on and see patients that we are "consulting" on. I work with 6 physicians and 2 NPs. We also have an outpatient service. I would be happy to talk with you further. I will be back on service this Friday, April 9th. You can reach me by calling 1-800-362-9567, ext. 59345. Carrie Carrie L. Lapham Advanced Practice Nurse- Connected Care (PalliativeCare) Ext. 59336 or 59345 Pager 0512 Mailstop: C04 â&#x20AC;&#x201C; 003 [Submitted on: 4/7/2010 by: Carrie L. Lapham [cllapham@gundluth.org]]

97. CNS Role Within Hospice and Palliative Care. I am a CNS at Hospice of Acadiana, Inc. I function as Education Coordinator both within the institution and in the community such as nursing homes, schools of nursing, etc. I also orient staff, provide inservices, set up preceptors for nursing students rotating through our facility, and set up inservices from other agencies to our staff. We are on electronic documentation, I also provide education for new staff and ongoing education for current clinical staff. I do also function as an RN when the need arises as I see patients as a general RN and as a CNS as needed. I am not functioning as a consultant. I am part-time (30 hours a week). [Submitted on: 4/7/2010 by: Marlene Foreman [marlene@hospiceacadiana.com]]

Question 98. Palliative Care for the Developmentally Delayed. I am wondering if anyone as experience in providing palliative care to developmentally delayed. I am looking for articles that describe providing palliative care to this population as well as presentations that address this issue. Thank you Rob Robert Smeltz, RN MA NP ACHPN Clinical Coordinator/Nurse Practitioner


Palliative Care Program New York University School of Medicine Bellevue Hospital 462 First Avenue, 17S19 New York, NY 10016 (o) 212-562-5277 (f) 212-562-8537 [Submitted on: 9/11/2010 by: Robert Smeltz, RN MA NP ACHPN [Robert.Smeltz@nyumc.org] ] Answers 98. Palliative Care for the Developmentally Delayed. The International Journal of Palliative Nursing had several a couple of years ago that were helpful. Constance Dahlin, ANP, BC, ACHPN Palliative Care Service Massachusetts General Hospital Boston, MA [Submitted on: 9/11/2010 by: Constance Dahlin, ANP, BC, ACHPN [CDAHLIN@PARTNERS.ORG]]

98. Palliative Care for the Developmentally Delayed. A friend of mine, Dr. Neil Ellison has a Fast Fact #192 that he prepared with Drew Rosielle. The site is: http://www.mcw.edu/fastFact/ff_192.htm There are a few references on the FF that might help you out as well. Regards, Judy [Submitted on: 9/11/2010 by: Judy Dobson [pcnurse@verizon.net]]

98. Palliative Care for the Developmentally Delayed. What age group? You might find literature in the pediatric/adolescent literature. Christy [Submitted on: 9/11/2010 by: Christy Torkildson [torkc@sbcglobal.net]]

98. Palliative Care for the Developmentally Delayed. Hello Rob: There is a 2009 Fast Fact on this topic: http://www.mcw.edu/fastFact/ff_192.htm I also see there is an NHPCO initiative on this topic as well: http://www.nhpco.org/i4a/pages/index.cfm?pageid=4733 Finally, there is a book on this topic nearing publication -- I got an announcement from a colleague but gave it to one of my students. I will try to track it down (it does not come up on any searches...) and follow-up with you. As you well know, this is an important area which will only keep growing. My best to you and your colleagues. Please keep us informed if you learn anything that would be helpful to all of us. Best, Pat Berry ***************************** Patricia H. Berry, PhD, APRN, ACHPN, FAAN Associate Professor Associate Director, University of Utah Hartford Center of Geriatric Nursing Excellence University of Utah College of Nursing 10 South 2000 East Salt Lake City, Utah


84112-5880 voice: 801-585-9636 fax: 801-581-4642 e-mail: patricia.berry@nurs.utah.edu [Submitted on: 9/12/2010 by: Patricia H. Berry, PhD, APRN, ACHPN, FAAN [Patricia.Berry@nurs.utah.edu]]

98. Palliative Care for the Developmentally Delayed. The book Pat is referring to is â&#x20AC;&#x153;End of Life Care for Children and Adults with Intellectual and Developmental Disabilities,â&#x20AC;? edited by Sandra L. Friedman, MD and David Helm, PhD. ISBN 978-1-935304-07-04. It is available on the American Association on Intellectual and Developmental Disabilities website; https://bookstore.aaidd.org/index.aspx Hope this helps, Joan Carpenter, MN, RN, NP-C, ACHPN [Submitted on: 9/12/2010 by: Joan Carpenter, MN, RN, NP-C, ACHPN [joan.g.carpenter@gmail.com]]

98. Palliative Care for the Developmentally Delayed. I have written and taught end of life care for people living w DD. The resources are on the NYSARC website. In addition, if you have something specific...let me know, Geri Abbatiello, PhD, GNP-BC, ACHPN [Submitted on: 9/12/2010 by: Geri Abbatiello, PhD, GNP-BC, ACHPN [Dr.GeriAbbatiello@gmail.com]]

98. Palliative Care for the Developmentally Delayed. I went to a seminar where it was suggested that this population, specifically Down's Syndrome, is increasing in longevity, and therefore presents a new subgroup for palliative care focus. Deborah Greenspan, RN, CHPN President Los Angeles Regional Provisional Group Hospice and Palliative Nurses Association [Submitted on: 9/12/2010 by: Deborah Greenspan, RN, CHPN [dg.hpnala@gmail.com]]

98. Palliative Care for the Developmentally Delayed. You might also try the Developmental Disabilities Hospice & Palliative Care Discussion Forum (a collaboration between NYSARC Inc and the Hospice and Palliative Care Association of New York State): http://www.ddhospiceandpalliativecare.org/ Take care, Jay Jay R. Horton, ACHPN, FNP-BC, MPH Clinical Program Manager The Lilian and Benjamin Hertzberg Palliative Care Institute The Brookdale Department of Geriatrics and Palliative Medicine Mount Sinai School of Medicine One Gustave L. Levy Place, Box 1070 New York, NY 10029 (212) 241-5178


jay.horton@mssm.edu [Submitted on: 9/13/2010 by: Jay R. Horton, ACHPN, FNP-BC, MPH [jayrhorton@gmail.com]]

98. Palliative Care for the Developmentally Delayed. The DD population now referred to as ID (intellectually diasabled) are getting older and living in place. The Downs population who used to succumb to congential heart disease are having these corrected. There is a higher level of Dementia being examined in the population. Further, in the ID population, medical and surgical care has increased longevity so they are living longer and getting illnesses many other older adults experience. It would be good to be connected to groups who for years have worked and supported the population. New York State Association for Retarded Citizens was a fore runner here. Previously funded and educated folks working w DD and participated in grants for Train the Trainer in End of Life care for people living w DD Office Mental Retardation and Developmental Disabilities is another grants for Train the Trainer in End of Life care for people living w DD YAI.org Volunteers of America also supported grants for Train the Trainer in End of Life care for people living w DD If you look at the website you will see resources. Resources are also listed in the TRAINING MANUALS There is for an example: A Memorandum of Understanding which helps with the decision making for end of life...a big issue when treating folks with ID. Covert, Cathy Mental Retardation: A Handbook for the Primary Physician Seltzer, Marsha et. al. Life Course Perspectives on Adulthood and Old Age Aging ________________________________________ End-of-Life Care - A Guide for Supporting Older People with Intellectual Disabilities and Their Families and Resource Supplement 2 Volume Set - 2004; Anne L. Botsford, Ph.D. and Lawrence T. Force, Ph.D. A guide for supporting older people with intellectual disabilities and their families. Note â&#x20AC;&#x201C; A publication fee of $19.95 plus tax where applicable(includes shipping), is charged for this publication. To order, contact the state office at 518-439-8311 or by email at info@nysarc.org NYSARC, Inc. Advocacy Monograph Number 4 2008 - A collaborative project of NYSARC, Inc.; Hospice and Palliative Care of New York State; and Office of Mental Retardation and Developmental Disabilities The monograph represents a collaborative effort among professionals from the hospice and palliative care, developmental disabilities, legal and psychotherapy perspectives to offer a wide range of information. The monograph offers a cross systems training approach that enables staff in developmental disabilities agencies and staff in hospice and palliative care agencies to understand each other's systems and to build a team approach. Organizational and personal issues are addressed to help increase access to hospice and palliative care for people with developmental disabilities. To obtain a copy of the monograph, contact the NYSARC, Inc. State Office at 518-439-8311 or by email at info@nysarc.org [Submitted on: 9/15/2010 by: Geraldine Abbatiello [Dr.GeriAbbatiello@gmail.com]]


Question 99. End Stage Dementia and Haldol. We have a end stage dementia patient who has been doing well with Haldol for his dementia, but recently started to have episodes of severe hallucinations and acting out. Haldol gel and Ativan gel are not controlling them. Hard to get near him to take pills or give shots. Any suggestions would be greatly appreciated. Marcia Leonard RN BSN OCN CHPN Health Connect at Home P O BOX 1990 Kearney, NE 68848 308440-0255 308-865-7085 marcialeonard@catholichealth.net [Submitted on: 9/13/2010 by: Marcia Leonard RN BSN OCN CHPN [MarciaLeonard@catholichealth.net] ] Answers 99. End Stage Dementia and Haldol. Seroquel. Also - depending on type of dementia, Haldol and Ativan may be contraindicated (particulary in Lewy Body Disease). Careful also with Ativan in the elderly! Seroquel can be crushed. If he does have Lewy Body and Parkinsonianlike dementia and is on any levodopa, this too may be adding to the hallucinations. Sometimes a balance needs to be struck between cognition/behavior and movement. [Submitted on: 9/13/2010 by: [jpanke@verizon.net]]

99. End Stage Dementia and Haldol. You probably have already done this, but have you r/o fecal impaction, urinary retention, infection. I can't tell you the number of times I've been called in for terminal agitation and it turned out to be delirium and reversed with a straight cath or dis-impaction followed by miralax or lactulose. (Actually, my favorite moments-docs and staff nurses always surprised) Please, keep us abreast, Rebecca Gagne Henderson RN MSN FNP ACHPN [Submitted on: 9/13/2010 by: Rebecca Gagne Henderson RN MSN FNP ACHPN [rebecca@endoflifedirectives.org]]

99. End Stage Dementia and Haldol. Have not experienced the SE you are referring with Ativan and the elderly--dosing is very important--and usually request Elixir and do SL Each patient is different and needs to be treated differently in all dynamics of care. Regards, Cheryl Cheryl B. Dworman, BSN, RN, CDCS Cheryl B. Dworman, Inc. Nurse ConsultantPatient Advocate P.O. Box 251981 West Bloomfield, MI 48325-1981 [Submitted on: 9/13/2010 by: Cheryl B. Dworman, BSN, RN, CDCS [cbdinc2001@yahoo.com]]


99. End Stage Dementia and Haldol. Rule out causes for escalating episodes. Haldol and ativan are available as intensols. Concentration is 2mg/ml. You might try that route. I have not found the gels that effective. Hope that is a start. Cathleen Kilmartin GNP-BC, ACHPN [Submitted on: 9/14/2010 by: Cathleen Kilmartin GNP-BC, ACHPN [cathleenkilmartin@gmail.com] ]

99. End Stage Dementia and Haldol. More thoughts: 1. Have you ruled out neuroleptic malignant syndrome? http://en.wikipedia.org/wiki/Neuroleptic_malignant_syndrome 2. Any abnormal vital signs or lab values? 3. Can you get a lab to see if he has a UTI? 4. Do you have a psych nurse or doctor on your team? 5. Will the pt accept increased fluids? 6. Is he eating? 7. Was he an active alcoholic (liver)? 8. Is he on Tylenol (liver)? A fever, low sats or UTI increase agitation in the elderly. He may need more oxygen or less meds--he may have medication overload due to ineffective excretion,dehydration or organ impairment (liver, primarily). A psych nurse may have another approach in regaining pt trust to facilitate interventions. I agree about the urine and stool--they sometimes work--or don't--in concert with each other. I had a patient who was able to void only after passing a large BM. Deborah Deborah Greenspan, RN, CHPN President Los Angeles Regional Provisional Group Hospice and Palliative Nurses Association [Submitted on: 9/14/2010 by: Deborah Greenspan, RN, CHPN [dg.hpnala@gmail.com]]

99. End Stage Dementia and Haldol. Thinking back on what Rebecca said, I remember one gentleman who has admitted in the middle of the night with “mental status changes”…the kind that require 4 point restraints! He was a CVA patient with aphasia and normally a very quiet peaceful man. As we were pushing the Ativan, we happened to noticed what appeared to be a basketball in his lower abdomen. 1 Foley catheter and 2000 ml of urine later…the sweetest, quietest, happiest patient you ever could meet! Jeannette (Jeannie) Meyer, RN, MSN, CCRN, CCNS, PCCN, ACHPN Clinical Nurse Specialist for Palliative Care Santa Monica UCLA Medical Center and Orthopedic hospital 1260 15th St. # 1024 Santa Monica, CA 90404 Palliative Care Office #310 319-5112 Direct line # 310 319 1204 Blackberry#310 210-9270 Fax # 310 319 3226 Pager#310206-8477 Extension 96023 [Submitted on: 9/14/2010 by: Jeannette (Jeannie) Meyer, RN, MSN, CCRN, CCNS, PCCN, ACHPN [JMeyer@mednet.ucla.edu]]

99. End Stage Dementia and Haldol. Marcia, Have you thought about using depakote or


some form of valproic acid. Ask a pharmacist about time released sprinkles that can be put in applesauce. Sounds like hyperactive delirium perhaps. Marsha Farrell BSN, RN-BC, CHPN [Submitted on: 9/17/2010 by: Marsha Farrell BSN, RN-BC, CHPN [mfarrell@hospicefamilycare.org]]

Question 100. Dialysis and Metabolites. I am curious about dialysis and pain medications...can Barry or anyone else comment on this, i.e. what metabolites do not dialyze out, do you routinely give pain medicine post dialysis, which opoids and co-analgesics best, etc.... Thank you, Debra Davis, CNS, ARNp Shands UF Gainesville, FL [Submitted on: 1/19/2010 by: Debra Davis, CNS, ARNP avalon2004@cox.net] Answers 100. Dialysis and Metabolites. When this has come up on my Nursing Issues in Pain Management list serve, hydromorphone is overwhelmingly the analgesic of choice for patients with renal failure (metabolized in the liver. Others used are methadone, oxycodone, and fentanyl. There has been little evidence to support their use and how much (and what) is actually dialyzed out. All are metabolized in the liver and excreted in urine and feces (although methadone is primarily feces and with chronic use it can metabolize itself). Much in this area relies on expert opinion. Janice Reynolds RN, BC, OCN, CHPN Mid Coast Hospital Brunswick, ME [Submitted on: 1/19/2010 by: Janice Reynolds RN, BC, OCN, CHPN [jkrrnocn@suscommaine.net]]

100. Dialysis and Metabolites. When this has come up on my Nursing Issues in Pain Management list serve, hydromorphone is overwhelmingly the analgesic of choice for patients with renal failure (metabolized in the liver. Others used are methadone, oxycodone, and fentanyl. There has been little evidence to support their use and how much (and what) is actually dialyzed out. All are metabolized in the liver and excreted in urine and feces (although methadone is primarily feces and with chronic use it can metabolize itself). Much in this area relies on expert opinion. Janice Reynolds RN, BC, OCN, CHPN Mid Coast Hospital Brunswick, ME [Submitted on: 1/19/2010 by: Janice Reynolds RN, BC, OCN, CHPN [jkrrnocn@suscommaine.net]]


100. Dialysis and Metabolites. Meds that don't dialyze are problematic for toxic metabolites, eg morphine and oxycodone. Meds that dialyze are useful, such as hydromorphone, but have to be given post dialysis. Fentanyl and methadone don't have toxic metabolites and are the best choices (with hydromorphone from breakthrough). Anyway, it's complex. Here's a good resource: http://pain-topics.org/pdf/Opioids-RenalHepatic-Dysfunction.pdf ~~~~~~~~~~~~~~~~~~~~ Risa Denenberg risaden@gmail.com 917428-8312 http://risaden.blogspot.com/ ~~~~~~~~~~~~~~~~~~~~ [Submitted on: 1/19/2010 by: Risa Denenberg [risaden@gmail.com]]

100. Dialysis and Metabolites. http://www.eperc.mcw.edu/fastFact/ff_161.htm is on opiod use in renal failure Also remember the Fast Facts published in J of Palliative Medicine and stored at http://www.eperc.mcw.edu Martha A. Tice, MS, RN, ACHPN Phone 703.396.6102 Fax 703.538.2068 [Submitted on: 1/19/2010 by: Martha A. Tice, MS, RN, ACHPN [MTice@capitalhospice.org]]

100. Dialysis and Metabolites. ** Here are two articles on pain management in the care of patients with renal failure. Ginger Marshall Virginia Marshall, ACNP-BC, ACHPN Nurse Practitioner University of Utah Palliative Care Service 50 N. Medical Dr. SOM 4B120 SLC, Utah 84132 801-581-7818 ginger.marshall@hsc.utah.edu **Please contact submitter directly via email to obtain. [Submitted on: 1/19/2010 by: Virginia Marshall, ACNP-BC, ACHPN [ginger.marshall@hsc.utah.edu]]

Question 101. Hospital Policies for Patient Electing DNR Undergoing Surgery with Sedation. Would anyone be able to share their hospital policies for patients who have elected a DNR status and now will undergo surgery or a procedure requiring sedation? We are in the process of revising our DNR policy for the hospital and this is often an issue. Our current policy states that the surgeon or procedurist must talk with the patient before surgery to explain that the DNR is rescinded for the procedure and that post procedure the discussion needs to happen again. We haven't monitored this but I suspect it doesn't routinely happen - I could be wrong. We have staff who believe the DNR is suspended for 24 hours, however there is nothing that supports that. So we need to clean this up. I think, depending perhaps on the seriousness of the surgery, a palliative consult preop would be wise, especially for things like heart surgery.


If you can share what works for you (or what doesn't), Iâ&#x20AC;&#x2122;d appreciate it. Thanks Helen Wellens MSN, GNP, ACHPN Bellin Health Green Bay, WI [Submitted on: 3/10/2010 by: Helen Wellens MSN, GNP, ACHPN [hwellens@new.rr.com]] Answers 101. Hospital Policies for Patient Electing DNR Undergoing Surgery with Sedation. Our hospital mandates that if patients have a pre-op DNR status, they must be asked if they would like to suspend the DNR status during surgery. If the answer is yes, then the DNR status is immediately renewed as soon as the patient leaves recovery room. If the answer is no, then the DNR status stands during the surgery. The physicians involved in the surgery are the ones who have the discussion and a form is then signed by the MD and patient. Jeanne Weggel, APNP Palliative Care Coordinator Sacred Heart Hospital Eau Claire, WI 54701 715-717-4543 jweggel@shec.hshs.org [Submitted on: 3/10/2010 by: Jeanne Weggel, APNP [JWeggel@shec.hshs.org] ]

101. Hospital Policies for Patient Electing DNR Undergoing Surgery with Sedation. I cannot offer anything that supports that in the literature, however... As legal documents advance directives can be amended for comments or details. In the case of surgery, the patient wants to be intubated if that is what it takes (presumably someone has explained this necessity although I know many just "assume" and the patient gets a "surprise" when meeting the anesthesiologist just before being rolled to the OR or procedure room). Make a copy of the advance directive. In the comment portion, detail with the date that the patient agrees to intubation for the purposes of anesthesia, that the patient understands that extubation may involve difficulties that require the ET tube to remain in place for longer than would be required for anesthesia only, that the patient agrees to have the tube in place under those circumstances, with sufficient sedation, etc., etc. At that point the hospital's protocol for (God forbid) patients who cannot be extubated comes into play. The changes wouldn't just have to be initialed, they should have the standard witnesses to the patient's signature, and, frankly, I'd have it notarized if you have that kind of time, so there isn't any question that it is your patient's desire which is expressed. It will have to take a lot of someone's time to honestly be certain that the patient understands what they are designing. Anything else would either violate the patient's desires or violate the law (in that the law dictates that we cannot extubate a patient who is vent dependent unless we know they are brain dead--maybe varies from state to state). The palliative preop consult is a good idea, especially if weighing the probability of the patient finding him/herself intubated where the same patient did not want that outcome. I'd also think you'd have to get the surgeon and anesthesiologist onboard in a big way. [Submitted on: 3/10/2010 by: Christine Johnson


[Christine_in_Van_Alstyne@BrianAndChristine.com]]

101. Hospital Policies for Patient Electing DNR Undergoing Surgery with Sedation. Actually, in Ohio, they are orders that any APRN or physician can change without input from anyone. I always err on the less parental side of the fence. But I don't have to. [Submitted on: 3/10/2010 by: [jchovan@columbus.rr.com]]

101. Hospital Policies for Patient Electing DNR Undergoing Surgery with Sedation. **Here are a few articles on DNR in the OR Ginger Virginia Marshall, ACNP-BC, ACHPN Nurse Practitioner University of Utah Palliative Care Service 50 N. Medical Dr. SOM 4B120 SLC, Utah, 84132 801-581-7818 ginger.marshall@hsc.utah.edu **Three articles submitted. Please contact submitter directly via email to obtain. [Submitted on: 3/10/2010 by: Ginger Marshall [ginger.marshall@hsc.utah.edu]]

101. Hospital Policies for Patient Electing DNR Undergoing Surgery with Sedation. Hi - many years ago, I realized and many other nurses that the DNAR status was being reversed without patient understanding during surgical intervention. we took this to our ethics committee and eventually we decided to place a statement on the surgical consent that reads something like ; " For patients who have limitations in their treatment and DNAR status, during surgical procedures - the policy is that DNAR status is not maintained. however if you desire to continue DNAR status during your procedure...you must discuss this with your attending physician and anesthesia, and they acutally have a place on the consent to initial the continuing of DNAR status...and the RN makes sure these conversations happen. So most patients after the conversation - allow the reversal of the DNAR but some do not, and the OR either continues to keep the DNAR band on the patient and it is part of the plan of care, or the DNAR band comes off and the status is resumed after the recovery period. If you want the exact wording - I could send it. but the key thing is that it is the right of the patient to be informed and have choice....and it was a bit of a challenge to get some the anesthesia people and surgeons to go along with this...but it became policy. peg Peg Nelson, NP,BC-PCM NP and Director of Palliative and Pain Services nelsonp@trinity-health.org st. joseph mercy oakland pontiac, mi 48341 248.858.3399 [Submitted on: 3/12/2010 by: Peg Nelson, NP,BC-PCM [NELSONP@trinity-health.org]]


Question 102. Emergency Response Systems. I am looking for information on using "Lifeline" type systems for hospice patients. Our hospice currently pays for the Lifeline system for our patients who live alone or are alone during most of the day. We are evaluating the benefit of this service, in light of its considerable expense. I could find nothing in the literature regarding this type of system with hospice or palliative patients; although there were a few within the general geriatric population. I was wondering if anyone uses this type of service in their organization. Does your hospice pay for the service? Does the IDG determine which patients it is offered to? What criteria do you use to evaluate its efficacy? Thank you for your help! Lynn M. Robbin, RN, MSN, ANP-BC St. Francis Hospital and Health Services 1600 Albany St. Beech Grove, IN 46107 lynn.robbin@ssfhs.org [Submitted on: 1/29/2010 by: Lynn M. Robbin, RN, MSN, ANP-BC [Lynn.Robbin@ssfhs.org]] Answers 102. Emergency Response Systems. Hi â&#x20AC;&#x201C; I had the privilege of having my father-in-law cared for in my home by KC Hospice here in Kansas City. He had to move in with us earlier than he wanted because he lived in a remote area in New Mexico in the middle of winter. The NM hospice literally could not get out to him when he had symptom crises in the winter. Our KC hospice had a discount arrangement for Lifeline during the time that it was safe for him to be alone (could get out in case of fire, call 911, etc.) but would need help in case of a fall. They arranged, I believe, a 20% discount for the service for their patients. This seemed to work well for both patients and the hospice. Perhaps your hospice could look for a funder for your underserved patients who might not be able to afford paying even the discounted rate. Denise Sanders, MSN, APRN, BC, ACHPN Palliative Care Nurse Practitioner Truman Medical Centers Attn: Nsg. Admin. 2301 Holmes Kansas City, MO 64108 Phone (816) 4045617 Pager (816) 292-3778 Fax (816) 404-5219 [Submitted on: 1/29/2010 by: Denise Sanders, MSN, APRN, BC, ACHPN [Denise.Sanders@tmcmed.org]]

102. Emergency Response Systems. We use Lifeline on an as needed basis - turns out to be very, very rare that is needed. We pay for it in those cases. [Submitted on: 1/29/2010 by: Sue Noll [suenoll@sbcglobal.net]]

102. Emergency Response Systems. Good Morning, we do recommend Lifeline for patients that live alone, or are alone for most of the day. Our social workers often have coupons for a free month, and we offer them to our patients. However, like 24 hour caregiving services


we do not pay for the service, it is up to the families. Ellyn Schreiner MPH RN-C CHPN St. Thomas Hospice 630-856-6983 ellyn.schreiner@ahss.org [Submitted on: 2/1/2010 by: Ellyn Schreiner MPH RN-C CHPN [Ellyn.Schreiner@AHSS.ORG]]

Question 103. Facility Signage for Patient Rooms. Please share if your facility (acute care, SNF, inpatient hospice or long term care) has a practice of denoting patient rooms via use of a photographic symbol on or close to the door in which the following may be true: 1. A patient whose condition has deteriorated, 2. When life support is being terminated, 3. Death has occurred. My organization is considering using a photograph (willow tree is one possibility) to alert lab, housekeeping, other staff members not directly involved in the patient's bedside care of need to check with nursing before entering for routine needs. This suggestion was made to explore signage rather than rely on communication by nursing to all staff. Thanks in advance for any advice or experiences you can share. Cindy Frost ARNP, BC, AHCPN Nurse practitioner Palliative Cre Maine Medical Center Portland,Maine 04102 207-662-3500 [Submitted on: 8/19/2010 by: Cindy Frost ARNP, BC, AHCPN [cfrostanp@yahoo.com]] Answers 103. Facility Signage for Patient Rooms. Hi, Cindy! What a great idea. I am going to share this with our palliative care group. A couple of years ago a staff member came to me to talk about her motherâ&#x20AC;&#x2122;s death at a large hospital in another state. It was truly a horrific story, but the reason I bring this up now, is while the family was sitting with the body a lab person came in and got quite upset when the family wouldnâ&#x20AC;&#x2122;t let her draw blood. Then dietary brought her tray in. Lastly the CNA came in and prepared to do VS. She then realized the woman had passed away and offered her condolences (something no one else including the nurse had done). A simple sign on the door that could have conveyed a message to other staff would have helped immensely (there was a lot more to the story) but this is the only part which pertains to this issue. Janice Reynolds RN, BC, OCN, CHPN Mid coast Hospital Brunswick, Maine [Submitted on: 8/19/2010 by: Janice Reynolds RN, BC, OCN, CHPN [jkrrnocn@suscommaine.net]]

103. Facility Signage for Patient Rooms. The facilities where I worked previously just placed "See nurse before entering" signs on all of those doors. Jessica Weinberger [Submitted on: 8/19/2010 by: Jessica Weinberger [jetw69@aol.com]]


103. Facility Signage for Patient Rooms. I have worked places that use pictorial signs. Once everyone came to recognize the meaning it was very effective. I know different images have been used the only one that comes to mind is a butterfly. Miriam Volpin [Submitted on: 8/19/2010 by: Miriam Volpin [volpinm@ohsu.edu]]

103. Facility Signage for Patient Rooms. I retired a little over two years ago from Palliative Care in a 600+ bed general hospital in Fort Worth,Tx. We had faced a couple of situations like those that have been described here. We worked with the unit managers to introduce our idea and later had to do inservices with all the nursing staff (going to each unit for their team meeting), and then cover all the ancillary departments as well so that we had housekeeping, lab, x-ray, and everybody in the hospital on alert. As we contemplated this awesome task, we developed some universal guidelines that we circulated to all of these places along with a sample. The outcome was that anyone who saw a butterfly on the doorway would find the nurse to see if there was a need they could meet in the room. The indicator was a butterfly image on a 3" magnet that could be posted on the doorframe (where they were metal, of course). Then, for the wooden frames where no metal was nearby, we used a laminated 4" square with the butterfly in the middle and slipped it into the nameplate groove below the patient's name. Each building structure would have to evaluate their own process for effective attachment. I have a copy in my computer files of the Guidelines we developed, as well as a jpg of the image we used, which was taken from generally available artwork, so I'm not infringing on anyone's rights in sharing this with you. At one point, this idea was shared with the Critical Care Nurses at a national meeting, and it created a flurry of questions and correspondence so there very well might be others who will recognize this process/image. Best of luck to everyone, and keep up the good work!! Corrine Anderson, RN retired [Submitted on: 8/19/2010 by: Corrine Anderson [npanderson.cor@verizon.net]]

103. Facility Signage for Patient Rooms. Our acute care hospital has a practice of placing a magnet on the outside door frame of the rooms where a patient has just died. The magnet has a picture that is the symbol of our hospital's Palliative Care Service - a tree of life with four seasons depicted. The entire staff of the hospital was trained to know that the magnet on the door means the patient has died and there is a mourning family in the room. All know to respect the privacy of this tender moment. Ancillary staff stay away and the nurse, physician, palliative care and pastoral care staff are the only ones to enter. The magnet stays until the body has been removed and the family has left, after which the magnet is


returned to the nursing station for re-use. Jeanne Weggel, APNP Palliative Care Coordinator Sacred Heart Hospital Eau Claire, WI 715-717-4543 [Submitted on: 8/20/2010 by: Jeanne Weggel, APNP [JWeggel@shec.hshs.org]]

103. Facility Signage for Patient Rooms. I work at a non-profit Catholic hospital. At least 15 years ago one of our chaplains, Sr. Julie initiated in the ICU the idea and practice that when a death occurs staff is to place a placard on the doorway - it is a postcard-size color picture of an iris in soft tones. (not associated with our hospice or with our palliative care service - it is an emblem that stands alone and for all of us who work there - we know the significance is specific to the death of a patient.) In addition, the lights within the unit are turned down. These actions serve as a vital tacit communication piece to all staff that even as we remain busy with patient care - there has been a death. Noise level is reduced if at all possible. As staff becomes aware of who has died, those who have cared for that patient and family make effort to visit and express condolences. I've seen housekeepers make special effort to console those families they have met. This practice has been taken up on the floors and now exists throughout our hospital. We instruct our medical residents in the significance of these actions. In rounding you arrive to a floor with lights low - you know immediately that a death has occurred - and quiet respectful behaviors follow. Every now and then there is an unknowing person (usually a physician) who booms out, "Why are the lights low?" - when informed there is an immediate quieting of response. I know it benefits the families of the deceased. I think it helps staff to have specific behaviors to employ at the time of a death. (It counters the helplessness we all can feel.) And then deaths impact the families/friends visiting OTHER patients in the hospital...particularly when they have befriended one another in the halls or waiting rooms - or even when the families do not know one another - these actions serve as a statement of respect. There was a learning curve - but this is now done routinely throughout our hospital - definitely preventive of staff entering the room unnecessarily - and very simple to do. Mary Martin BSN RN Manager Palliative Care Services St. John Medical Center 1923 S. Utica Ave. Tulsa, OK. 74104 Office 918/744-2930 Pager 918/646-9977 [Submitted on: 8/20/2010 by: Mary Martin BSN RN [Mary.S.Martin@sjmc.org]]

103. Facility Signage for Patient Rooms. We use a white dove for all patients on comfort care measures at end of life. [Submitted on: 8/20/2010 by: Peggy Nelson [NELSONP@trinity-health.org]]


103. Facility Signage for Patient Rooms. Another perspective - Signage that didn't work in our setting: We also used a sign with a beautiful flower with the words "quiet please" on the door of patients who were actively dying in our designated hospice unit within our nursing home. In our environment, the hospice patients are located together, and the signs were up and down on a regular basis. The idea was to alert all staff, including dietary, housekeeping etc., of a dying person. The staff was very appreciate. We used it until several family members expressed strong feelings of fear and/or anger. For some, it was too much of a reminder to see the symbol on the door of residents close by and reminded them of what they and their loved one were going through. Often these were feelings there were not ready to deal with in such a 'public' way. We no longer use these symbols. Patrice Villars Associate Director, Hospice and Palliative Care San Francisco Veterans Medical Center [Submitted on: 8/20/2010 by: Patrice Villars [pvillars@pacbell.net]]

103. Facility Signage for Patient Rooms. We use a laminated card that is actually our facility bereavement card and has a lovely picture on the front. In red lettering it says, "Check with nurse before entering" and is to let staff that there is a grieving family and to be respectful. It also keeps phlebotomists,etc out before making a "faux pas" Jennifer Gentry MSN ANP ACHPN,FPCN Duke Hospital Palliative Care Service DUMC Box 3003 Durham, NC 27710 919660-7564 Fax 919-684-8569 [Submitted on: 8/20/2010 by: Jennifer Gentry MSN ANP ACHPN,FPCN [jennifer.h.gentry@duke.edu]]

103. Facility Signage for Patient Rooms. We use a card with a white dove on blue background with "Peace" at the bottom. All staff including ancillary staff know to check with the patient's nurse before going into room. Carlye L. Carr, MSN, FNP-BC Nurse Practitioner for Palliative Care Department of Hospital Medicine Durham Regional Hospital Duke University Health System 3643 N. Roxboro Road Durham, NC 27704 tel (919)470-8453 cell (919)812-9321 fax (919)470-8457 email: carlye.carr@duke.edu [Submitted on: 8/20/2010 by: Carlye L. Carr, MSN, FNP-BC [carlye.carr@duke.edu]]

Question 104. Fentanyl Infusions - Med.Surg. This question is for those practicing in a acute care area. The hospital I practice at, as a Palliative Care NP, is considering allowing fentanyl infusions for patients on the med/surg units. Currently hydromorphone and morphine are the opioids used on general units. The new infusion pumps can be programmed to deliver mcg and mg.


For those who use fentanyl infusion on a general unit have you had any unique problems in dosing/administering this opioid as compared to other opioids? If you were involved in introducing fentanly infusions to the medical and nursing staff, are there any points or techniques you found useful in increasing staff knowledge and comfort? The hospital has both medical residents and community physicians. If you have decided not to use fentanyl on a general in-patient unit I would appreciate hearing why you made that decision. Please respond to my email address: lgoodwin@att.net Thank you, Lorraine Goodwin NP [Submitted on: 1/15/2010 by: Lorraine Goodwin NP [Goodwin.Lorraine@scrippshealth.org]] Answers 104. Fentanyl Infusions - Med.Surg. We have used all three opioids for several years. Our pumps also allow mg/mcg based on what is programmed. We double check with initiation, changes and wasting. Nancy Joyner, RN, MS, APRN-CNS, ACHPN Clinical Nurse SpecialistPalliative Care Altru Health System- Altru Hospital 1200 So Columbia Road Grand Forks, ND 58201 njoyner@altru.org ph 701-780-5442 fax 701-780-1942 [Submitted on: 1/15/2010 by: Nancy Joyner, RN, MS, APRN-CNS, ACHPN [NJOYNER@altru.org]]

104. Fentanyl Infusions - Med.Surg. We have used fentanyl PCAs on wards for years, PCAs also used for all narcotic infusions. We are working to also get fentanyl IV push allowed on wards--once upon a time I guess it was only used for conscious sedation, but now it is great for fast acting symptom relief and very good in advanced kidney disease. [Submitted on: 1/16/2010 by: Barry Ress [barry.ress@yahoo.com]]

104. Fentanyl Infusions - Med.Surg. I work in an ICU at this time (not in a hospice function) and use Fentanyl in PCA's as it appears to have less delirium effects, is fast acting and effective in pain management Missy (MP) Heylen, RN, CHPN [Submitted on: 1/16/2010 by: Missy (MP) Heylen, RN, CHPN [missy_bequia@hotmail.com] ]

104. Fentanyl Infusions - Med.Surg. My reply is basically the same as Nancy's; we use all three with no special issues or policies. The pharmacy has a standard dose equivalency for all drips such that 1 ml of each drug is essentially equal strength. Our nursing team also uses the double checking system to avoid errors. One challenge is that the nurses think and talk


in ML (mililiters) and the prescribers tend to think and talk (and give orders) in MCG. This can lead to the need for additional phone calls etc. Another limitations is that the highest concentration available is 50 mcg/ml which means our subcutaneous infusions are limited to 150/hr--not nearly enough for many of our patients. We have ended using two sites or other measures to treat the pain. Sharmon Figenshaw ARNP Hospitalist/Palliative Care Providence Regional Medical Center Everett, WA Sharmon.figenshaw@providence.org 360201-0475 [Submitted on: 1/17/2010 by: Sharmon Figenshaw ARNP [sharmonrn@earthlink.net]]

104. Fentanyl Infusions - Med.Surg. We started using fentanyl PCA several years ago when we removed meperidine as a choice from the PCA order set. This helped with physician acceptance as it gave them an alternative to morphine and hydromorphone. We did a lot of staff education on the dosing, especially focusing on the equianalgesics so they know what dose to expect. Our ICU had used fentanyl IV for quite a while prior to that. We have Alaris pumps with guardrails so the nurse can only enter mcg for fentanyl. It seems to have worked well. Certainly allows better choices for prescribers, especially with patients who have renal failure. Helen Wellens MSN, GNP-BC, ACHPN Bellin Health Green Bay WI [Submitted on: 1/17/2010 by: Helen Wellens MSN, GNP-BC, ACHPN [hwellens@new.rr.com]]

Question 105. Geripal Blog. I would like to invite and encourage all of you to read and comment on a relatively new blog called GeriPal. It was started by two awesome palliative care & geriatric physicians. We/they are interested in any comments or thoughts from ALL disciplines. www.geripal.org Here is the description: GeriPal (Geriatrics and Palliative care) is a forum for discourse, recent news and research, and freethinking commentary. Our objective is to stimulate cross-fertilization of ideas. We aim to be inclusive. We welcome the perspectives of generalists, specialists, gerontologists, palliative care clinicians, and anyone else interested in care of the elderly or palliative care. Anyone who wants to comment on a post is welcome -just click the comment tab. -Patrice Patrice Villars, RN, GNP, ACHPN Associate Director, Hospice and Palliative Care Nurse Practitioner SFVAMC (415) 221-4810 ext 3798 [Submitted on: 2/20/2010 by: Patrice Villars, RN, GNP, ACHPN Patrice Villars [pvillars@pacbell.net]] Answers 105. Geripal Blog. This blog is a great resource with a recent posting on NPs, â&#x20AC;&#x153;GeriPal: A Call


for Hospice Reform: Nurse Practitioners Lead the Way.â&#x20AC;? Enjoy, Marian Grant [Submitted on: 2/20/2010 by: Marian Grant [msgrant@comcast.net]]

105. Geripal Blog. Marian, Thank you for circulating this post. I hope that this commentary offers food for thought not only for thinking about NP roles and improving hospice care, but to think from a systems viewpoint how we can maximize the best of our disciplines to serve patients with a variety of diagnoses at the end of life. A plug for GeriPal.org: This blog site is highly encouraging of perspectives and discourse of all disciplines. I encourage you to comment on this post in particular and any others as strikes your passion. -Patrice Villars Patrice.villars@va.gov pvillars@pacbell.net [Submitted on: 2/21/2010 by: Patrice Villars, RN, GNP, ACHPN [pvillars@pacbell.net]]

Question 106. GIP Units: Hospice & Hospital Partnerships. I have familiarized myself with the info on CAPC and am interested in hearing feedback from those of you with experience on the hospital side of these partnerships. Matter of fact.... any guidance or suggestions from the hospice side would also be appreciated! Pearls of wisdom to share? Tips on the implementation process? Impact on your organization's mortality rate? True partnership between the hospice and the hospital's palliative care team? (Examples of partnering and what worked well & what didn't) What do you wish you had known? So much to be considered and I know there's a wealth of information within our SIG. Feel free to contact me privately if preferred at: kristimgriffith@aol.com Thanks for sharing! Kristi Griffith, BSN, RN, CHPN Methodist Charlton Medical Center Dallas, TX [Submitted on: 6/12/2010 by: Kristi Griffith, BSN, RN, CHPN [kristimgriffith@aol.com]] Answers 106. GIP Units: Hospice & Hospital Partnerships. Kristi, Our palliative care unit provides the GIP Hospice benefit to patients who qualify. I would be happy to discuss with you. My contact information is listed below. Good luck, Phyllis Phyllis Whitehead, PhD, MSN, RN-BC, ACHPN Clinical Nurse Specialist Palliative Medicine Carilion Roanoke Memorial Hospital Office: 540-981-8126 Blackberry: 540-521-6048 Fax: 540-344-3641 pbwhitehead@carilionclinic.org [Submitted on: 6/13/2010 by: Phyllis Whitehead, PhD, MSN, RN-BC, ACHPN [pbwhitehead@carilionclinic.org]]


Question 107. Go Lytely as an enema. Has anyone used go lytely as an enema? I have heard this mentioned before, but have not done it nor have I seen any literature on it. I have a patient who is severely impacted. He has cardiomyopathy and is on a dubutamine drip. The cardiac team feels it can be the result of an illeus due to poor purfusion. He is not on opioids and does not have pain. He does not have nausea. We have tried many different agents (tap water enemas, oil retention enemas, dulcolox po and suppository, colace, lactulose, fleets enemas. We do not have senekot or mirilax available. Most recently, we tried go lytely oral prep, and he could not tolerate it, as that made him nauseous. Even when given slowly with an NG tube. He has had imaging, no evidence of obstruction, just a lot of stool in his bowel. He has been disimpacted a couple of times, but that has not helped. Thanks, Rob Robert Smeltz, RN MA NP ACHPN Clinical Coordinator/Nurse Practitioner Palliative Care Program New York Univeristy School of Medicine Bellevue Hospital 462 First Avenue, 17S19 New York, NY 10016 (o) 212-562-5277 (f) 212-562-8537 [Submitted on: 2/10/2010 by: Robert Smeltz, RN MA NP ACHPN [Robert.Smeltz@nyumc.org]] Answers 107. Go Lytely as an enema. I haven't used GoLytely as an enema but we use milk and molasses enemas frequently and find them to be well tolerated and very effective, especially with hard, impacted stool that is higher up or when the patient is having a combination of diarrhea and hard stool. It is an age old approach that still works! The instructions we use are listed below. Milk and Molasses Enema Instructions Ingredients: 4 ounces dark molasses 8 ounces warm water 3 ounces powdered milk (or 8 ounces milk without adding the water) Enema bag with attached, flexible catheter (no hard plastic tip) Directions: Mix the powdered milk and warm water or warm milk in a glass jar with lid. Shake well. Pour into the enema bag. Enema fluid should be no warmer than body temperature (like giving warmed milk to a baby.) Have the patient lie on the left side with the right leg slightly flexed. Liberally lubricate the catheter attached to the enema bag and insert into the rectum about 8 to 12 inches or as far as the tip will go without meeting resistance. If resistance is met, withdraw the catheter slightly. Administer the enema with the bag held 1-2 feet above the patientâ&#x20AC;&#x2122;s hips. If possible the patient should try to hold the enema for 12-20 minutes, or as long as tolerated. Repeat the enema every 4-6 hours as tolerated until there is no more formed stool. Continue even if there is liquid stool as long as there are still visible clumps of formed stool. The enema may be given alternately every 4-6 hours with 1-2 ounces of oral lactulose or Miralax (propylene glycolate). If the patient is severely nauseated and/or vomiting, start with the enemas and give several before trying the oral laxatives. Reference: Bisanz A: Managing bowel elimination problems in patients with cancer. Oncology Nursing Forum 1997, 24(4): 679-686. Deborah Thorpe, PhD, APRN, AOCNS, ACHPN Pain Medicine and Palliative Care Huntsman Cancer Institute University of Utah Salt Lake City, UT 84112 Phone (801)585-0254 FAX (801)581-4416


[Submitted on: 2/10/2010 by: Deborah Thorpe, PhD, APRN, AOCNS, ACHPN [deborah.thorpe@hci.utah.edu]]

107. Go Lytely as an enema. I have not heard of go lytely per rectum. Have you used combos, including metoclopramide or EES? Karen McGough ARNP, AOCN Tidewell Palliative Care Sarasota FL [Submitted on: 2/10/2010 by: Karen McGough ARNP, AOCN [karen.mcgough@verizon.net]]

107. Go Lytely as an enema. Haven't used Go-Lytely as an enema. Have you tried methylnaltrexone? [Submitted on: 2/10/2010 by: McCabe, Jane [Jane.McCabe@va.gov]]

107. Go Lytely as an enema. I haven't used GoLytely as an enema but of course you can use any liquid rectally. I like to use peroxide. You can use it straight or half strength, 500 ml in an enema bag, as high as you can get the tubing. The peroxide forms bubbles that literally push the stool out of the colon. Believe me it's effective! Beverly Douglas ARNP ACHPN Tampa, Florida [Submitted on: 2/10/2010 by: Beverly Douglas ARNP ACHPN [bevdouglas@tampabay.rr.com]]

107. Go Lytely as an enema. Haven't used Go-Lytely as an enema. Jane...would not use methylnaltrexone (Relistor), because Rob mentioned this patient is not taking opioids. Cynthia Wagner, MSN, RN-BC, CHPN Palliative Care / Pain Management Coordinator Paoli Hospital, Main Line Health Paoli, PA 19301 484-565-1646 office 215-265-0544 pager WagnerCy@mlhs.org [Submitted on: 2/10/2010 by: Cynthia Wagner, MSN, RN-BC, CHPN [wagnercy@mlhs.org]]

107. Go Lytely as an enema. Also maybe try the frozen Vaseline balls. A lot of clinicians have had luck with that when the other stuff isn't doing it. Just roll about 3-4 pea sized balls of Vaseline in sugar and put in the freezer till frozen about 15 minutes and swallow with water


or juice. Sheria [Submitted on: 2/10/2010 by: Sheria Robinson [sheria_robinson@yahoo.com]]

107. Go Lytely as an enema. I note that Miralax is not available. It is actually pretty cheap and OTC. An alternative might be the "clear soluble fiber" that can be had equally cheaply OTC in generic form (i.e, Equate at the Walmart stores). I had very good success with that with a cancer patient on total tube feeds x 8 months due to radiation to head and neck, chemotherapy and thick (and I choose that word purposely) outbreak of HSV-I throughout his mouth and tongue, with an overlay of candida in the ulcers. He received no fiber other than the clear soluble fiber above, 1 tablespoon in each tubed meal, which also included 750 ml fluid per tube and 1 liter LR per mediport. (Plenty of fluid.) He had an easily passed formed stool daily, in contrast to stools approximately 2x weekly prior to becoming ill. So you might try the clear soluble fiber. (also less annoying to the patient than all that attention to his nether end....) Christine Johnson RN CHPN (FNP-S) [Submitted on: 2/10/2010 by: Christine Johnson RN CHPN (FNPS)[Christine_in_Van_Alstyne@BrianAndChristine.com]]

107. Go Lytely as an enema. Certainly if you have had success with peroxide per rectum, then success speaks for itself. I recall, however, caveats about peroxide bubbles leaching into the circulation and collecting into an air bubble in places air bubbles ought not to be. Just thought I'd toss that in. Might be important, I don't know. Christine Johnson [Submitted on: 2/10/2010 by: Christine Johnson [Christine_in_Van_Alstyne@BrianAndChristine.com]]

107. Go Lytely as an enema. You're right there is that caveat, but as with everything, moderation. You would not repeat this enema, if it doesn't work the first time it's not going to, provided it was done correctly. And no more than 500 ml. You also would not use it more than once every 2-4 weeks. Beverly Douglas ARNP ACHPN Tampa Florida [Submitted on: 2/10/2010 by: Beverly Douglas ARNP ACHPN [bevdouglas@tampabay.rr.com]]

107. Go Lytely as an enema. How about something as simple as mineral oil po or NG, in


conjunction w/ something to help the pt expel the stool since he has an ileus? Mineral oil not only lubricates the GI tract but also softens the outer surface of the patient's stool, making it easier to pass. It also has no potential for medication interactions & our hospice pharmacy consultant has long been in favor of its additive use for pts with hard to manage constipation, w/ the usual recommendation being 2tbsp 1-2x/day until some oil is seen in the toilet or bedpan, then decreased to 1 tbsp. I have seen this work wonders. Our medical director also often recommends a "push-pull" bowel regime, meaning something given above, along w/ something also used below the impaction. Sometimes pts require combination therapy. With regard to fiber mixes, the pt has to be able to take in sufficient po fluids so as not to add to his constipation. Good luck. Many thanks, Rosemary Zaucha, RN, CHPN RN Case Manager - Pink Team Rainbow Hospice and Palliative Care Your community resource for comfort, care, and education E: RZaucha@RainbowHospice.org W: www.RainbowHospice.org T: 847 685 9900 F: 847 685 6390 [Submitted on: 2/10/2010 by: Rosemary Zaucha, RN, CHPN [RZaucha@rainbowhospice.org]]

107. Go Lytely as an enema. Nurses on our team have tried to make the sugar-coated Vaseline balls as recommended by a team doctor who had heard about it as "the magic bullet" - but had never tried using it in practice. First of all, Vaseline is hard to work with but more importantly it DOES NOT freeze or solidify. One of our nurses thought to try taking the unfrozen glob of Vaseline so she could honestly instruct her patients who might need this intervention & reported that she gagged & nearly threw up, and would not recommend it to pts. After receiving feedback this it is no longer recommended by the MD. Rosemary Zaucha, RN, CHPN RN Case Manager - Pink Team Rainbow Hospice and Palliative Care Your community resource for comfort, care, and education E: RZaucha@RainbowHospice.org W: www.RainbowHospice.org T: 847 685 9900 F: 847 685 6390 [Submitted on: 2/10/2010 by: Rosemary Zaucha, RN, CHPN [RZaucha@rainbowhospice.org]]

107. Go Lytely as an enema. Yes the Vaseline can be difficult to work with. The sugar is actually what makes it roll together and stay put. It doesn't solidify completely in the freezer but does get firm so it will stay put enough for swallowing. We've had success with them. May be easiest to get the Vaseline out with something and then pour the sugar over the top to form the balls. It also helps to put the whole container in the freezer for a bit so it's not all gloppy when you are starting. Sheria [Submitted on: 2/10/2010 by: Sheria Robinson [sheria_robinson@yahoo.com]]


107. Go Lytely as an enema. Are you at all concerned about the risk of frank aspiration of a petroleum product? Have you tried titrating dose of erythomycin? or neostigmine? like one would use for a patient with Oglivie's syndrome? Linda Blum, GNP CPMC Palliative Care San Francisco, CA [Submitted on: 2/10/2010 by: Linda Blum, GNP [lblumgnp@gmail.com]]

107. Go Lytely as an enema. No. We usually aren't administering medications orally if there is an aspiration risk and most all oral medications can be dangerous if aspirated. Petroleum based products, though used very infrequently in humans, are not all that unusual. This is the abstract of a French article from 1996 noted on Medline that did a comparison of paraffin (petroleum derived) product and lactitol. Sheria Title: [Study of early postoperative lactitol versus paraffin following anal surgery in 110 adult patients] Transliterated Title: Etude du lactitol comparé à la paraffine chez 110 adultes, en postopératoire précoce d'une chirurgie anale. Author(s): Copé R; Debou JM; Cohen S; Callens A Author's Address: Service de Colo-Proctologie, Hôpital Gouin, Clichy. Source: Annales De Chirurgie [Ann Chir] 1996; Vol. 50 (7), pp. 570-6. Publication Type: Clinical Trial; Comparative Study; English Abstract; Journal Article; Randomized Controlled Trial Language: French Journal Information: Country of Publication: FRANCE NLM ID: 0140722 Publication Model: Print Cited Medium: Print ISSN: 0003-3944 (Print) Linking ISSN: 00033944 NLM ISO Abbreviation: Ann Chir Subsets: MEDLINE MeSH Terms: Anus Diseases/*surgery Cathartics/*therapeutic use Emollients/*therapeutic use Gastrointestinal Transit/*drug effects Petrolatum/*therapeutic use Sugar Alcohols/*therapeutic use Adult; Aged; Cathartics/contraindications; Drug Administration Schedule; Drug Tolerance; Humans; Middle Aged; Postoperative Period; Sugar Alcohols/contraindications Abstract: The aim of this open and randomised clinical trial was to compare, in terms of efficacy, lactitol with petroleum jelly, regarding the time before recovery of intestinal transit in patients having undergone anal surgery. Efficacy, comfort and tolerability were assessed on day 4 and 7, the convenience of treatments at the end of the period. The main criterion for efficacy was the time taken to obtain the first stool after surgery. Lactitol appears to be more effective than petroleum in terms of recovery of intestinal transit: the first postoperative stool was obtained 13 hours earlier with lactitol. This difference is statistically significant whatever the comparison: survival analysis (p = 0.0018) or t test on means (p = 0.0014). The secondary criteria for efficacy are consistent with this first result: the mean number of stools per day was significantly higher with lactitol (p = 0.046), the daily dose could be-reduced for more patients under lactitol on day 4 (p = 0.004) and, also on day 4, the general efficacy assessment was significantly in favour of lactitol (p = 0.033). The separate analysis of the items included in the comfort score shows that stools are more often "normal or soft" in the petroleum group and that pain on defecation is frequently less severe in the lactitol group. This led to a significantly higher


comfort score in the petroleum group from D1 to D4 but not from D1 to D7. Tolerance was rated "good" by 97% of patients on day 7, and no statistically significant difference was observed for any of the tolerability criteria. Lactitol therefore appears to be an interesting choice, with a high benefit/risk ratio, in the treatment of the transitory constipation frequently observed immediately after anal surgery. [Submitted on: 2/10/2010 by: Sheria Robinson [sheria_robinson@yahoo.com]]

107. Go Lytely as an enema. I have not heard of Go lytely being administered as an enema, however it certainly is a good thought. This patient sounds like quite a challenge. If he has an ileus then this is a motility disorder and would call for some sort of colonic irritant. I wonder if an alternative therapy provider who specializes in colonic cleansing might be of some use? I will be interested to hear how this turns out. Lana [Submitted on: 2/17/2010 by: Lana Nealand [lnealand@uab.edu]]

Question 108. Criteria for Palliative Care in ICU settings. Looking for someone who has formalized the criteria for palliative care referrals in the ICU settings and willing to share. Would love to know your thoughts on how it has helped or not helped in your setting as well. If you have it to email, send it to my email address below. If you would like to fax - my number is 856-5823915 Thanks, Beth Wagner Beth Wagner MSN, CRNP, ACHPN [Submitted on: 3/29/2010 by: Beth Wagner MSN, CRNP, ACHPN [beth.wagner@comcast.net]] Answers 108. Criteria for Palliative Care in ICU settings. We use the screening tool from CAPC. All patients are screened on IDT rounds and the number of referrals more than doubles on those days when compared to others. I added admitted from SNF in the last section. Rebecca Gagne Henderson RN MSN FNP-c Palliative Services Coordinator Long Beach Memorial Medical Center [Submitted on: 3/30/2010 by: Rebecca Gagne Henderson RN MSN FNP-c [rebecca@endoflifedirectives.org]]

108. Criteria for Palliative Care in ICU settings. We've done work in this area. **See attachments. Likewise the group at U of Rochester, see their work attached. CAPC will have


some materials forthcoming. Meg Margaret L. Campbell, PhD, RN, FAAN Director, Nursing Research Detroit Receiving Hospital 4201 St. Antoine Detroit, MI 48201 313-745-3271 Assistant Professor - Research Center for Health Research College of Nursing Wayne State University m.campbell@wayne.edu **Please contact submitter for attachments directly via email. [Submitted on: 3/30/2010 by: Margaret L. Campbell, PhD, RN, FAAN [mcampbe3@dmc.org]]

108. Criteria for Palliative Care in ICU settings. **These are guidelines that our institution is developing that will trigger Pal Care referrals from nursing staff in the ICU. They are adapted from CapC and have not been tweaked or OK'd by Internal Medicine yet. Again, basically a first draft - but we feel like they are a good beginning step to move toward an eventual consensus in attempting to address the issues. Anne Anne Morgan MSN, CNM, FNP Palliative Care Coordinator Family Nurse Practitioner Bay Area Hospital 269-8538 – office & voice mail 269-4700 - BAH pager, just punch in your return number **Please contact submitter for attachments directly via email. [Submitted on: 3/30/2010 by: Anne Morgan MSN, CNM, FNP [anne.morgan@bayareahospital.org]]

Question 109. Homeless Hospice Care. My church is considering using one of the properties that it currently uses for low income housing as a residence for homeless people needing hospice care. Does anyone have any experience in establishing a hospice program for the homeless – especially with regard to setting up the housing? We are planning on communicating with some of our community hospices to discuss collaboration for providing the actual hospice care, and assume some of the potential clients will be eligible for Medicaid and/or Medicare if they don’t already have it, and we plan to look into health codes etc but need some good ideas. Would like to know where to start in terms of what needs to be considered regarding housing regulations (I am in Utah) and any other pearls of wisdom for undertaking such an endeavor. Thanks Deborah Thorpe, PhD, APRN, ACHPN, AOCNS Pain Medicine and Palliative Care Huntsman Cancer Institute University of Utah 2000 Circle of Hope Rm 2381 Salt Lake City, UT 84112 Phone (801)585-0254 FAX (801)581-4416 [Submitted on: 7/24/2010 by: Deborah Thorpe, PhD, APRN, ACHPN, AOCNS Deborah Thorpe [Deborah.Thorpe@hci.utah.edu]] Answers


109. Homeless Hospice Care. Start with your state hospice residence regulations and the NHPCO manual on hospice residences. [Submitted on: 7/25/2010 by: Linda Freda [lindafreda@hospiceofthecomforter.org]]

109. Homeless Hospice Care. Perhaps you could search the internet for residential facilities. It seems that the regulations for a residence is not as stringent as for an inpatient hospice facility. [Submitted on: 7/26/2010 by: Marlene Foreman [marlene@hospiceacadiana.com]]

109. Homeless Hospice Care. We looked at using a nunnery that a Catholic church wanted to donate to us. You still have to meet fire codes, safety regs, etc and the renovation costs were steep. We had looked at the church keeping the nunnery in their possession and they were going to provide the volunteers. If the area is already a homeless shelter, and this is where the patient "lives", then would think that the hospices in the area could come in to the shelter and provide services just like they would in a patients "home". The issue would be safety of medications required. Maybe the prison hospice programs out there would be good resource as well. Just some thoughts, Lori Lori F. Schiller, MSN, RN, NP-C Nurse Practitioner Palliative Medicine Services One Hiland Drive Petoskey, MI 49770 (231)4874825 Office (231)487-3019 Voice Mail (231)881-4345 Cell phone lschiller@northernhealth.org [Submitted on: 7/27/2010 by: Lori F. Schiller, MSN, RN, NP-C [lschiller@northernhealth.org]]

109. Homeless Hospice Care. Sarah House in Santa Barbara was originally designed for homeless and now also serves low income families. It is a wonderful place and they are very generous about sharing information so others can build similar homes. http://www.sarahhousesb.org/ I believe Randy is the contact name. [Submitted on: 7/27/2010 by: McGowan, Bonnie [Bonnie.McGowan@va.gov]]

109. Homeless Hospice Care. Abraham house is another place that provides EOL care for patients at no cost - I am sure they would be willing to share some of their information with you. You can find their information at http://www.theabrahamhouse.org/ hope this helps!


Missy (MP) Heylen RN CHPN [Submitted on: 7/27/2010 by: Missy (MP) Heylen RN CHPN [missy_bequia@hotmail.com]]

109. Homeless Hospice Care. You might also speak to the people at Our House of Portland www.ourhouseofportland.org/ They specifically serve people with HIV/AIDS, and originally focused on people with no family/resources (including people living on the street). Even though in the early years most of the residents were at end of life, they never were strictly a hospice in order to provide more flexible care. Miriam A.E. Volpin, BS, RN-CHPN Doctoral candidate Oregon Health & Science University School of Nursing [Submitted on: 7/28/2010 by: Miriam A.E. Volpin, BS, RN-CHPN [volpinm@ohsu.edu]]

Question 110. Hospital Credentialing Form for CNS. I am a CNS working at a residential hospice that aligns with a small community hospital. We are beginning to evaluate the formation and implementation of a palliative care team within our hospital. We currently do not have any APNs that have credentialing privileges at the hospital. Does anyone have a credentialing form that they can share that works well for CNSs instead of NPs? Thanks for your help. Mindy Justad RN-BC, ACNS-BC, ACHPN, CRNI mindyrn@live.com [Submitted on: 4/27/2010 by: Mindy Justad RN-BC, ACNS-BC, ACHPN, CRNI [mindyrn@live.com]] Answers 110. Hospital Credentialing Form for CNS. Mindy - I am a CNS that has been working in the hospital setting solely for the last 3 years. Prior to that, I rotated into and out of the clinic/hospital setting. I am considered a provider, similar to the NP and PAs. I would be happy to talk with you further regarding any specific questions you have. You can call me at 1-800-362-9567, ext. 59345. I will try to help! Carrie Carrie L. Lapham Advanced Practice Nurse- Connected Care (PalliativeCare) Ext. 59336 or 59345 Pager 0512 Mailstop: C04 - 003 [Submitted on: 4/27/2010 by: Carrie L. Lapham [cllapham@gundluth.org]]

Question 111. Huntington's Chorea. Have any of you had end stage patients with this disease- how would you determine hospice eligibility- what would you be looking for? Thanks.


[Submitted on: 3/12/2010 by: Bartel, Judy [JBartel@HospiceWR.org]] Answers 111. Huntington's Chorea. I've cared for several patients with this devastating disease. The worst part is discussing goals with the family who are often afflicted as well. The functional staging for AD is useful in predicting Huntington's end-stage. Death from Huntington's often occurs from dehydration and/or pneumonia. Meg Campbell Detroit Receiving Hospital [Submitted on: 3/12/2010 by: Campbell, Margaret - Meg (DRH) [mcampbe3@dmc.org]]

111. Huntington's Chorea. Huntington's is difficult to stage if the patients are young and otherwise healthy. They aspirate when they eat so they eventually die of aspiration pneumonia, aspiration pneumonitis or failure to thrive (uncommon). If the patient/family still wants to treat infections aggressively or if the patient has a feeding tube and eshews eating, they can live for years. I have had some patients who have been admitted and discharged a few times as goals of the family change. There has to be a very dedicated caregiver to keep them at home. There is lots of lifting and the patients can't usually sit up. They do have some pain in their extremities from contractures but the main problem is the personality changes (psychosis) and respiratory secretions/dyspnea/cough. Again, they qualify if the family is ready to stop treating aggressively and have significant aspiration problems. Maryalice Kelly, APN [Submitted on: 3/12/2010 by: Maryalice Kelly, APN [makelly@iglide.net]]

111. Huntington's Chorea. I work at a state facility in Massachusetts, we have a center of excellence Huntington's disease unit. 33 patients in total. Each family comes to this decision quite differently, individuality is key. The main thing with these folks is aspiration pneumonia from severe dysphagia, behavioural issues/impulse issues decreased insight in to limitations, hypersexuality is common. Injury from chorea related falls is problematic. Most people who come to the unit do so when they are no longer able to live alone or with family in community due to pneumonia, declines in condition. This is a daunting condition! Nina F. Miranda MS ACHPN APRN-BC [Submitted on: 3/12/2010 by: Nina F. Miranda MS ACHPN APRN-BC [Nina.F.Miranda@state.ma.us]]

111. Huntington's Chorea. Many years ago I was asked to evaluate a HC patient for hospice vs palliative care. In reality, at the time, the patient was still eating and just struggling with


the concept of a feeding tube. She was not hospice eligible at that time, but if there had been a good pall care team for the home, that would have been the better choice. I agree, individuality is the key with close supervision of aspiration and weakness as the 2 defining hospice features. Good luck, Jessica Weinberger, ACHPN FNP Nashville TN [Submitted on: 3/12/2010 by: Jessica Weinberger, ACHPN FNP [jetw69@aol.com]]

111. Huntington's Chorea. cachexia, dyphagia/ aspiration, restlessness/ thrashing and wounds secondary to this or falls. [Submitted on: 3/12/2010 by: Maria Ferrell [mferrell@kchospice.org]]

111. Huntington's Chorea. Like Meg, I have taken care of many persons with HD. In my experience, most die from either from aspiration pneumonia or acute head injuries sustained from falls. I would agree that you could probably use the FAST scale to help with prognostication, as dementia worsens in these persons as their HD course progresses. I would certainly recommend considering persons with repeated bouts of aspiration pneumonia for hospice. As an aside, I have also had a few HD pts who ultimately required palliative sedation for severe existential suffering manifested by injurious behaviors directed toward self, others, or both. Mark V. Harmon, BSN, RN-BC, CHPN Care Coordinator / Charge Nurse The Palliative Center for Caring St. Ann's Community Rochester, New York ---------------------------------------------- CNS Graduate Student Wegmans School of Nursing St. John Fisher College Rochester, New York [Submitted on: 3/12/2010 by: Mark V. Harmon, BSN, RN-BC, CHPN [hospicepalliativern@gmail.com]]

111. Huntington's Chorea. I have had a couple of HD patients who had hospice. Think of it like ALS or PD. Looks like ES dementia. Patients qualify for hospice under the debility and decline guidelines and goals of care ie no further hospitalizations, no vent support, feeding tubes are useful for medication administration. Linda Blum, GNP [Submitted on: 3/12/2010 by: Linda Blum, GNP [lblumgnp@gmail.com]]

111. Huntington's Chorea. I emailed all of you a few weeks ago regarding determining hospice eligibility for this population, now I have another question! We have a patient that


has many behavioral ramifications of this disease (numerous pharmacological interventions have not been of help) and safety implications from his thrashing behavior are an issue both to self and others. He does not have any ability to stand. What type of beds have you seen utilized? Currently- mattresses on the floor have been helpful for his safety, but cause implications for staff attempting to provide the care in this manner. Any companies or beds you are aware of that might meet this need? Thanks! [Submitted on: 3/30/2010 by: Bartel, Judy [JBartel@HospiceWR.org]]

111. Huntington's Chorea. We had a Huntington’s Chorea veteran at our VA and used a mattress with high/soft sides. We also padded the floor with matting(like wrestling mats) which helped eliminate injury. o o http://huntingtondisease.tripod.com/sitebuildercontent/sitebuilderfiles/physicalandoccupa tionaltherapyforhuntington12pgs.doc o Iona Tapered/ Raised Side Mattress o We were able to use the tapered raised side mattress for our veteran’s needs along with the matted flooring. • Other thoughts…….if they are young and small in stature, perhaps a youth bed would be appropriate. • Otherwise, would look at using a bariatric bed for them as it gives them more room to move. • I would check with your OT dept. to assist you in looking for other specialized mattresses. Other resources below: WALKING DEVICES – ROLLING WALKERS, STANDARD WALKERS, CANES Sammons Preston Rolyan P.O. Box 5071 Bolingbrook, IL 60440-5071 800-323-5547 STRIDER WALKERS Guardian Products 7477 Dry Creek Parkway Longmont, CO 80503 800-833-4000 The Shirley Walker Co., Inc. P.O. Box 981 Brooklandville, MD 21022 800-848-WALK SAFETY DEVICES – HELMETS, ELBOW/KNEE PADS Best Priced Products P.O. Box 1174 White Plains, NY 10602 800-824-2939 Sammons Preston Rolyan P.O. Box 5071 Bolingbrook, IL 60440-5071 800-323-5547 J.T. Posey Co. 5635 Peck Road Arcadia, CA 91006-0020 800-44-POSEY CHAIRS Broda Seating 385 Phillip St. Waterloo, Ontario N2L 5R8, Canada 800-668-0637 HUNTINGTON’S TILT IN SPACE RECLINER Gunnel Inc. 8440 State Street Millington, MI 48746 800-551-0055 Hill Rom 1069 State Road 46 East Batesville, IN 47006 800-445-3730 POSITIONING DEVICES – CUSHIONS, SUPPORTS, PADDING Alimed, 297 High Street Dedham, MA 02026-9135 800-225-2610 LUMBAR SUPPORTS J.T. Posey Co. 5635 Peck Road Arcadia, CA 91006-0020 800-44-POSEY EATING UTENSILS, NON-SKID MATTING, SHOWER BENCHES AND CHAIRS, SHOWER MITTS Alimed 297 High Street Dedham, MA 02026-9135 800-225-2610 care spoons covered mugs sure grip utensils long-handled brush plate guards non-skid dinnerware shower mitt shower bench/chair Access to Recreation 8 Sandra Court Newbury Park, CA 91320 800-634-4351 SPLINTING DEVICES – SPLINTS FOR HANDS, KNEES, ELBOWS Medassist – OP, Inc. P.O. Box 758 Palm Harbor, FL 34682 800-521-6664 BEDDING – PADDING, LOW BEDS, BED ENCLOSURES Vail Products 235 First Street Toledo, OH 43605 800-235-VAIL NOA Medical Industries 801 Terry Lane Washington, MO 63090 800-633-6068 Jolene R. Renda DNP APN/CNP VISN 12 Palliative Care Coordinator 608-372-1217 [Submitted on: 3/30/2010 by: Jolene R. Renda DNP APN/CNP [Jolene.Renda@va.gov]]


111. Huntington's Chorea. How about an electric HiLow bed? We use these in many of our facilities. They go to the floor, and yet can be raised for care. Ellyn Schreiner MPH RN-BC CHPN Clinical Educator/Supervisor St. Thomas Hospice phone: 630-856-6983 fax: 630-7349178 ellyn.schreiner@ahss.org [Submitted on: 3/30/2010 by: Ellyn Schreiner MPH RN-BC CHPN [Ellyn.Schreiner@AHSS.ORG]]

111. Huntington's Chorea. Hello all. In a person with HD who definitely cannot stand, I would most advocate for a Craig Bed (see attached PDF**). We had a Craig bed for one of my HD residents on a locked neurobehavioral unit several years ago. This bed was nice because it gave her the ability to move about within the bed while also preventing injuries related to rolling out of bed, hitting hard walls/surfaces, etc., that persons w/ HD often obtain d/t their increased movements. If you are unable to obtain a Craig bed (for what ever reason), I would then advocate for a low bed placed along one wall, thick padding to prevent the person from banging into the wall, a mattress on the floor along the "open" side of the bed, and then any extra padding that you may need on the head board and foot board. I know this goes without saying, but frequent monitoring and therapeutic presences by nursing staff should continue regardless of bed type... Mark V. Harmon, BSN, RN-BC, CHPN Care Coordinator / Charge Nurse The Palliative Center for Caring St. Ann's Community Rochester, New York ----------------------------------------------- CNS Graduate Student Wegmans School of Nursing St. John Fisher College Rochester, New York **Please contact submitter directly via email to obtain pdf. [Submitted on: 3/31/2010 by: Mark V. Harmon, BSN, RN-BC, CHPN [hospicepalliativern@gmail.com]]

Question 112. Inpatient Hospice NP Role. Hi group - looking for any NPs doing hospice inpatient care. I will be developing an NP role on a new inpatient hospice unit, and would appreciate anyone willing to share job descriptions and/or help as a sounding board. Please contact me offline daniel.cogan@vnsny.org DC [Submitted on: 8/21/2010 by: Daniel Cogan [Daniel.Cogan@vnsny.org]] Answers


112. Inpatient Hospice NP Role. Please contact me offline as well. Evelyn Bollilnger evelynb52@yahoo.com [Submitted on: 8/21/2010 by: Evelyn Bollinger [evelynb52@yahoo.com]]

Question 113. Building a Business Case for an Inpatient Palliative Care Unit. Hi All, I am looking to build a business case for an inpatient palliative care unit. We are trying to look at non-hospice patients, and how you generate revenue once your palliative care patient has out stayed their DRG. Any input is greatly appreciated. I know some commercial insurance companies will negotiate palliative care rates, similar to hospice....but what about the Medicare population. Karen ______________________________ Karen Mulvihill MSN, APRN, ACHPN Coordinator Danbury Hospital CARES Program Hospitalist Service [Submitted on: 9/2/2010 by: Karen Mulvihill MSN, APRN, ACHPN [Karen.Mulvihill@danhosp.org]] Answers 113. Building a Business Case for an Inpatient Palliative Care Unit. Go to the CAPC site (Google it) and they have a manual you can get “A Guide to Building a Hospital-based palliative care program”. The entire manual is about how to go about establishing a palliative care unit in the acute hospital setting. Don’t know what it costs right now but it is not that expensive. I received my copy from participating in the CAPC center of excellence training. 1st chapter is securing support, aligning with the hospital mission, reconnaissance: assessing hospital priorities, system assessment, etc. Hope this helps. Jane McCabe MS, RN Palliative Care CNS VA Eastern Colorado HCS 303-831-4519 x3461 [Submitted on: 9/3/2010 by: Jane McCabe MS, RN [Jane.McCabe@va.gov]]

Question 114. Isolation Policy for Inpatient Hospice. Does anyone have an isolation policy for an inpatient hospice unit that they can share? Marilyn Graves, RN,MSN, CHPN Clinical Nurse Specialist Office: 443-849-8224 Gilchrist Hospice Care 11311 McCormick Road, Suite 350 Towson, MD 21031 [Submitted on: 8/9/2010 by: Marilyn Graves, RN,MSN, CHPN [mgraves@gilchristhospice.org]] Answers


114. Isolation Policy for Inpatient Hospice. I am no longer with Alive but I know they have an isolation policy. I guess your best bet is to contact Mary Carr who is the employee health and infectious disease nurse at Alive. She may be reached at mcarr@alivehospice.org Good luck Jessica [Submitted on: 8/9/2010 by: Jessica Weinberger [jetw69@aol.com]]

Question 115. Hospital Setting Standard Order Set for Opioid Titration at end of life. We are in the process of trying to develop a standard-order-set (for the hospital setting) for opioid titration at end-of-life. We use an Analgesic Infusion Pump with PCA or NCA dosing. During this committee discuss, there have been various opinions on how fast to “titrate” up the opioids for the symptomatic patient…..specifically the frequency of increasing the basal rate. We have been looking closely at “Fast Fact #54” http://www.eperc.mcw.edu/fastFact/ff_54.htm but otherwise I have not found any other evidence to guide us. Can anyone share their practice? Do you have a “stand-order-set” which you would be willing to share? I have done a literature search, and not found any SPECIFIC evidence-based recommendations on the frequency of titration of the continuous rate. Cynthia Wagner, MSN, RN-BC, CHPN Palliative Care / Pain Management Coordinator Paoli Hospital, Main Line Health Paoli, PA 19301 484565-1646 office 215-265-0544 pager WagnerCy@mlhs.org [Submitted on: 2/12/2010 by: Cynthia Wagner, MSN, RN-BC, CHPN [wagnercy@mlhs.org]] Answers 115. Hospital Setting Standard Order Set for Opioid Titration at end of life. We were taught to titrate daily when studying for certification. Start with a scheduled amount plus plenty for breakthrough. Each day, take the scheduled amount of opioid, plus the mg of breakthrough taken the day before, and that becomes the new daily (divided, continuous, whatever) dose. Back off a little if the SE (drowsiness) become unacceptable. Switch to a different opioid using the standard conversion table, back off 25 pct and give that a try. I have only had one patient on a PCA pump, a young man with bililary cancer. We taught his wife to manage the boluses and keep track (it was a pretty basic pump, and it has been awhile, so I cannot say whether you could actually retrieve frequencies of the boluses or not. Anyway, if you are looking for the how-to, that might help. Christine Johnson [Submitted on: 2/14/2010 by: Christine Johnson [Christine_in_Van_Alstyne@BrianAndChristine.com]]

115. Hospital Setting Standard Order Set for Opioid Titration at end of life. I picked up a


copy of a great resource last fall at the NHPCO CTC called â&#x20AC;&#x153;Demystifying Opioid Conversion calculations: a guide for effective dosingâ&#x20AC;? by Mary Ann McPherson PharmD who is a Professor at the University of Maryland School of Pharmacy and a Hospice pharmacy. You might find it helpful. Jane McCabe RN, MS Palliative Care CNS VA Eastern Colorado HCS: Denver Jane.mccabe@va.gov 303-399-8020 x3461 [Submitted on: 2/16/2010 by: Jane McCabe RN, MS [Jane.McCabe@va.gov]]

115. Hospital Setting Standard Order Set for Opioid Titration at end of life. These are the standing orders we use on the hospice inpatient unit: If a pt is on a morphine or dilaudid drip: Bolus doses may be given every 15 minutes After a basal continuous drip has been started for 8 or more hours, if more than 4 bolus doses are given in any 8 hour period, may increase the continuous infusion by 25% for mild/moderate pain or 50% for moderate/severe pain May increase the bolus dose by 25% for mild/moderate pain or 50% for moderate /severe pain Please call physician after 3 dosage increases in either the bolus or continuous infusions Please call physician after 4 bolus doses are given in 4 hour period Susan Jessell, MSN, CRNP, ACHPN Palliative Medicine Services West Penn Hospital Pittsburgh,PA 15224 412-578-5524 Pager-412-917-0278 [Submitted on: 2/15/2010 by: Susan Jessell, MSN, CRNP, ACHPN [sjessell@wpaon.org]]

115. Hospital Setting Standard Order Set for Opioid Titration at end of life. I asked one of the NPs from our Post-operative PAIN Service to weigh in on this discussion. He added this: On pp. 18-19 of the 5th edition of the Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain published by the American Pain Society is a helpful guideline for estimating the hourly maintenance dose based on the elimination half-life of the opioid. There is a formula to guide the clinician found on page 19. [Submitted on: 2/17/2010 by: Marilyn Bookbinder [MBinder@chpnet.org]]

Question 116. Job Descriptions for Oncology-Palliative Care-Hospice Nurse Director and Clinical Director. I am trying to craft a more updated job description which would be a cross between a nurse director of a service/unit or a clinical director of an outpt clinic or hospice. Trying not to reinvent the wheel. If you think you have one that is creative, pls send to my personal email -NOT REPLY TO ALL- cdahlin@partners.org Thanks, Connie Constance Dahlin, ANP, BC, ACHPN Clinical Director Palliative Care Service Massachusetts General Hospital Founders House 602 55 Fruit St Boston, MA 02114 Tel 617.724.8659


[Submitted on: 3/24/2010 by: Constance Dahlin, ANP, BC, ACHPN [cdahlin@partners.org]] Answers 116. Job Descriptions for Oncology-Palliative Care-Hospice Nurse Director and Clinical Director. Don't know if it will help, but I attached mine. Valerie Ramsberger, RN, MSN, APN Palliative Care Director Trinitas Regional Medical Center Elizabeth, NJ 908-994-5851 **Please contact submitter directly via email to obtain. [Submitted on: 3/25/2010 by: Valerie Ramsberger, RN, MSN, APN [vramsberger@trinitas.org]]

Question 117. Justifying Personnel - Palliative Care Consultant. I would like to hear from any one of you if you have numbers to support : How many patients could a palliative care consultant be expected to see and manage in a day, And The type of hospital health care system you are working within. I am at a private, faith based hospital. I am the only FTE, NP that does palliative care consults. I am expected to cover the entire hospital except for mother/baby and pediatrics. At times I have 10-14 patients a day and cannot possibly see them all. Our consult service has tripled since we started 4 years ago and I have now asked for some “extra help”. The administrators do not think it is necessary and are wanting bench markings and “what are other hospitals doing?’ data. Our hospital is a 350 bed facility, we take everyone, our Pall. Care Team is made up of 1 full time NP, a “borrowed” Chaplain and a borrowed SW. There is no designated person besides myself on this team. I would love to hear from you regarding how justification of extra hours and/or extra personnel has been made. Thank you!!!! Lee Lee Mayer, MSN, NP Palliative Care Consult Service (408) 947-4723 O'Connor Hospital 2105 Forest Ave. San Jose, CA 95128-1471 Email LeeMayer@dochs.org [Submitted on: 12/4/2009 by: Lee Mayer, MSN, NP [LeeMayer@dochs.org]] Answers 117. Justifying Personnel - Palliative Care Consultant. There is good information about this on CAPC.org. Good luck! Denise Sanders, MSN, APRN, BC, ACHPN Palliative Care Nurse Practitioner Truman Medical Centers Attn: Nsg. Admin. 2301 Holmes Kansas City, MO 64108 Phone (816) 404-5617 Pager (816) 292-3778 Fax (816) 404-5219 [Submitted on: 12/4/2009 by: Denise Sanders, MSN, APRN, BC, ACHPN [Denise.Sanders@tmcmed.org]]


117. Justifying Personnel - Palliative Care Consultant. Lee: I too am a single NP program. Call me to discuss. My number is 509-522-5514 Becca Hawkins [Submitted on: 12/11/2009 by: Hawkins, Becca [Rebecca.Hawkins@providence.org]]

Question 118. Ketamine at the End of Life. Colleagues, our Acute Care service has passed a policy for Ketamine use and our team has been asked to draft one for our End of Life patients who are experiencing intractable pain. The monitoring that many patients require on Ketamine would be a burden for our patients. Does anyone have a policy and/or order set already developed that you could share? If so, would you please be gracious enough to contact me off-line? Thanks, Jeannie Jeannette (Jeannie) Meyer, RN, MSN, CCRN, CCNS, PCCN, ACHPN Clinical Nurse Specialist for Palliative Care Santa Monica UCLA Medical Center and Orthopaedic Hospital 1250 16th St. Santa Monica, CA 90404 Palliative Care Office # 310 319-5112 Blackberry # 310 210-9270 Pager #310 206-8477 Extension 96023 [Submitted on: 6/4/2010 by: Jeannette (Jeannie) Meyer, RN, MSN, CCRN, CCNS, PCCN, ACHPN [JMeyer@mednet.ucla.edu]] Answers 118. Ketamine at the End of Life. **This is a document from one of my favorite blog sites: http://www.palliativedrugs.com/ This site has been active for over 10 years and has an extensive document library. Clinicians also write in every day looking for some input on some of their patients with symptom management problems. It is a world wide experience to encounter the caring folks who use this site. The Ketamine article is not a specific policy, but the info in it is important, I think, to include in such a policy... Hope it helps. Regards, Judy Dobson, MSN, CHPN Hospice/Palliative Care Educator **Please contact submitter directly via email to obtain. [Submitted on: 6/7/2010 by: Judy Dobson, MSN, CHPN [pcnurse@verizon.net]]

118. Ketamine at the End of Life. **Here is competency and Ketamine policy for inpatient stay. We will be developing one for outpt shortly. Hope it helps. Probably should be updated. Marilyn Bookbinder, RN, PhD, FPCN Beth Israel Medical Center Department of Pain Medicine and Palliative Care Director of Nursing and Quality 12 Baird Hall 350 East 17th St New York, New York 10003 Mbinder@chpnet.org 212 844-1462 212 844-1503 (Fax) ** Please contact submitter directly via email to obtain. [Submitted on: 6/7/2010 by: Marilyn Bookbinder, RN, PhD, FPCN [MBinder@chpnet.org]]


Question 119. Ketamine IV versus oral use. I work at a large teaching hospital where Ketamine use is restricted to anesthesia only. Our Palliative Care Service is not able to prescribe this medication for our terminally ill patients with poor pain control. We are in the process of going before our P&T committee and are being told by anesthesia that restricted use is standard practice across the country. My question is: â&#x20AC;˘ Does your palliative care program in teaching hospitals have the ability to prescribe Ketamine both IV and orally? Thanks in advance, Namaste, Leslie Blatt, APRN Palliative Care Coordinator YNHH New Haven, CT [Submitted on: 11/2/2010 by: Leslie Blatt [leslieblatt@comcast.net]] Answers 119. Ketamine IV versus oral use. I have used Ketamine in the hospital setting both oral and IV. We have also used oral ketamine at home and in our hospice house. It is rare but not unheard of and we have never had difficulty obtaining the drug. Nanci Tansey, APRN, GNP Tidelands Community Hospice Georgetown, SC 843-520-7700 Areas first Hospice House [Submitted on: 11/2/2010 by: Nanci Tansey [tanseyprn@yahoo.com]]

119. Ketamine IV versus oral use. We have an inpatient palliative care program in a small community hospital that is a teaching hospital for several local medical schools, and yes we use both oral and IV Ketamine for symptom management. Kerry McGrath NP Carilion New River Valley Medical Center Christiansburg, VA [Submitted on: 11/2/2010 by: Kerry McGrath [kmcgrath@i-plus.net]]

119. Ketamine IV versus oral use. Hi Leslie, Have done some research and here are the results, which you may wish to bring up to committees, and push the issue --patients should not have uncontrollable pain. http://ajh.sagepub.com/content/17/2/127.short http://www.jpsmjournal.com/article/S0885-3924(98)00144-4/abstract Please scroll to bottom of the following: http://whocancerpain.wisc.edu/?q=node/171 http://www.anesthesia-analgesia.org/content/93/1/213.full Thank you for your continued advocacy for your patients!! G- Bless you and all of our colleagues for their continued support with the patient population. Hope this information provides you the necessary strength to obtain Ketamine for your palliative care patients. Best of luck Leslie. Enjoy a wonderful and productive day. Sincerely, Cheryl B. Dworman, BSN, RN, CDCS Cheryl B. Dworman, Inc. Nurse Consultant-Patient Advocate P.O. Box 251981 West Bloomfield, MI


48325-1981 PHONE/FAX 248-669-2002 [Submitted on: 11/2/2010 by: Cheryl Dworman, BSN, RN, CDCS [cbdinc2001@yahoo.com]]

119. Ketamine IV versus oral use. Our inpatient palliative care service treats with Ketamine IV and orally on the inpatient unit. We also manage our hospice patients in the community on oral Ketamine as needed. Kathleen Fink [Submitted on: 11/2/2010 by: Kathleen A. Fink [KFink@smdc.org]]

119. Ketamine IV versus oral use. We are drafting a Ketamine policy so I have the following questions for the group: -when you say palliative care pts...are they 'actively dying' &/or DNR? Or are they early in their treatment?(I ask because sometimes our patients are 'dismissed' by saying 'oh their pall care'...like they don't care if they suffer Side effects or have adverse outcomes). -do you use telemetry for the initiation of the IV dosing? -who is allowed to prescribe? -does your Board of Nursing limit nursing administration? -are they palliative care pts ONLY in your unit or do you administer in scatter beds? -what sedation scale do you use? Thanks Cheryl Vahl ARNP University of Iowa cheryl-vahl@uiowa.edu [Submitted on: 11/2/2010 by: Cheryl Vahl ARNP [cheryl-vahl@uiowa.edu]]

119. Ketamine IV versus oral use. Oral Ketamine is used; IV restricted to anesthesia only. I think that will change soon. Kathleen Fahey [Submitted on: 11/2/2010 by: Kathleen Fahey [kathleen_fahey@sbcglobal.net]]

Question 120. Levsin® versus atropine. Has anyone used Levsin® gtts for respiratory secretions and do they work better or same as atropine. I have noticed that the Levsin® sl tab works better than atropine gtts and just found out that there was gtts available for Levsin®. We are thinking of switching. Thanks! Marcia Leonard RN BSN OCN CHPN® Health Connect at Home P O BOX 1990 Kearney, NE 68848 308-440-0255 308-865-7085 marcialeonard@catholichealth.net [Submitted on: 10/13/2010 by: Marcia Leonard RN BSN OCN CHPN® [MarciaLeonard@catholichealth.net]] Answers


120. Levsin® versus atropine. In my opinion, Levsin® works as well as atropine. At my facility, Levsin® comes as a liquid, and the dose, 0.125 mg, is 1 ml. That's too much volume to be giving someone who I'm trying to dry up, so I don't use it. If I can get the tablet, I use that. Mostly I use atropine drops (4) and that usually works. If not, then scopalamine helps, and so does Lasix® 20 mg made into a paste and placed in the buccal mucosa. Beverly Douglas ARNP ACHPN® Tampa Florida [Submitted on: 10/13/2010 by: Beverly Douglas ARNP ACHPN® [bevdouglas@tampabay.rr.com]]

120. Levsin® versus atropine. Anecdotally, after 15 yrs I have found Levsin® to be ineffective and have abandoned its use completely. Never had to use more than 2gtts of atropine for 2 doses before effectiveness if started in a timely manner. Rebecca Gagne FNP ACHPN® [Submitted on: 10/13/2010 by: Rebecca Gagne FNP ACHPN® [rebecca@endoflifedirectives.org]]

120. Levsin® versus atropine. Atropine 2 to 4 gtts. q 4 hrs. prn for terminal secretions. If ineffective then Scop patch 1.5 mg. q 72 hrs. Levsin® used, but more effective for visceral pain in my practice. [Submitted on: 10/13/2010 by: [H20martin@aol.com]]

120. Levsin® versus atropine. Marcia, We used Levsin® drops for secretion control 1 dropper/hour (4 droppers at once). Personally, I found this more effective then atropine but do not know if this is evidenced based. Often the costs is what drives the choice between the 2. Missy MP Heylen RN, CHPN® [Submitted on: 10/14/2010 by: MP Heylen RN, CHPN® [missy_bequia@hotmail.com]]

120. Levsin® versus atropine. **Attached is a brief review of anticholinergic therapies for the management of secretions. There is very little evidence supporting one therapy over another. The use of scopolamine for terminal secretions is discouraged due to prolonged time to action. The cost of these therapies has gone up recently due to fewer manufacturers producing them. I hope this review is helpful. Best regards, Terri Terri Maxwell, PhD, APRN


Vice President, Clinical Initiatives excelleRx, Inc., an Omnicare company **Please contact submitter directly for document. [Submitted on: 10/14/2010 by: Terri Maxwell, PhD, APRN [TMaxwell@excelleRx.com]]

120. Levsin® versus atropine. Our compounding pharmacy makes hyoscyamine, (Levsin®) in a concentration of 0.125 mg in 0.25 ml. Something to consider if you have access to a compounding pharmacy. Elizabeth Mager-OConnor APN Valley Hospice Coordinator 15 Essex Road Ste. 301 Paramus, NJ 07652 201-291-6131 [Submitted on: 10/18/2010 by: Elizabeth Mager-OConnor APN [EMAGERO@valleyhealth.com]]

Question 121. Limitation of treatment form for surgery patient. Hi, We're working on a policy that includes the issues of "DNR in OR." Do any of your institutions have a form that is particular to a patient with an existing DNR going to surgery (different than the regular code status sheet)? If you have one that is patient friendly, would you mind sharing it? Any special protocols for this type of surgical patient? Any good ideas welcome! Thanks ! Anna Anna Kostaroff, MS, RN, CHPN® Palliative Care Coordinator Henry Ford Wyandotte Hospital 734287-9043 (office) 734-365-3210 (cell) [Submitted on: 7/8/2010 by: Anna Kostaroff, MS, RN, CHPN® [AKostar1@hfhs.org]] Answers 121. Limitation of treatment form for surgery patient. It has been my understanding that DNR does not apply in surgery or in the first 24-48 hours post-op. Perhaps there are specific circumstances where this is not the case. Even patients that have DNRs, it is not honored in surgery. [Submitted on: 7/8/2010 by: Marlene Foreman [marlene@hospiceacadiana.com]]

121. Limitation of treatment form for surgery patient. You're right that many hospitals automatically suspend DNRs. Our policy states that each of these patients must have their code status readdressed before (and after) surgery… a more detailed informed consent, if you will. Modifications can be made if there is agreement between physicians and patient. Most patients will assent to suspending DNR once they realize how similar anesthesia is to resuscitation, but there are some cases that don't fit the mold. We're trying to work out a


process - hence my request for forms/protocols. Anna Kostaroff, MS, RN, CHPN® [Submitted on: 7/8/2010 by: Anna Kostaroff, MS, RN, CHPN® [AKostar1@hfhs.org]]

121. Limitation of treatment form for surgery patient. Based on our agency, I think this is institution defined under medstaff rules. [Submitted on: 7/8/2010 by: NANCY JOYNER [NJOYNER@altru.org]]

121. Limitation of treatment form for surgery patient. Hi, This issue recently was addressed by our bioethics com. because surgeons and anesthesiologists were not always making it clear to pts. We determined that ethically, this issue needs to be discussed and documented by surgeon, so pt understands and has the right to refuse surgery or set limits on life support if they end up on a vent in ICU. But, it should be defined under med staff rules, and they need to determine the length of time the DNR is to be suspended for, just through post-op, or longer- we put that back to med staff. The main issue was informed consent for the pt... Debbie Monaghan RN, MSN Ed, CHPN® Palliative Care Sr. Specialist Sharp Memorial Hospital 858-939-3809 [Submitted on: 7/8/2010 by: Debbie Monaghan RN, MSN Ed, CHPN® [Debbie.Monaghan@sharp.com]]

121. Limitation of treatment form for surgery patient. Our Ethics Committee has been discussing this very issue. Currently our policy is that pt's with a DNR order going to the OR are supposed to be discussed & chave it clarified. But in reality it is often not discussed and the "default" is to suspend the DNR order when a patient goes to the OR. We are looking into this and reconsidering our policy based on the following: AORN Position Statement on Perioperative Care of Patients with Do-Not-Resuscitate or Allow-Natural-Death Orders (AORN: The Association of periOperative Registered Nurses) see link below for Position statement: http://www.aorn.org/PracticeResources/AORNPositionStatements/Position_DoNotResuscit ate/ Cynthia Wagner, MSN, RN-BC, CHPN® Palliative Care / Pain Management Coordinator Paoli Hospital, Main Line Health Paoli, PA 19301 484-565-1646 office 215-265-0544 pager WagnerCy@mlhs.org [Submitted on: 7/8/2010 by: Cynthia Wagner, MSN, RN-BC, CHPN® [WagnerCy@MLHS.ORG]]


121. Limitation of treatment form for surgery patient. Not working in hospital setting, I have been noticing on those pts being admitted to the sub-acute setting for rehab s/p an OR event that they are returning as Full Codes b/c the surgeons are not having the 'after the fact talk' or not deeming it as part of their job [i.e. relying on HBS d/ch services]. If the admits to us are being done by the same HBS 'moonlighters', the discussion is not done at that time either and the code status remains Full and it is only found haphazardly during the admit or upon d/ch by the NP. In light of this and other directives , our service area [for Kaiser] is starting a pilot project whereby an NP in the subacute setting will be making the rounds to address this issue via complying w/the need for POLST form discussion/completion [then getting the rounding MD sig, of course]. [Submitted on: 7/8/2010 by: Nada Ferris [1987enc@comcast.net]]

121. Limitation of treatment form for surgery patient. Perfect timing for this discussion! I just went to our Ethics Committee today to review the Resuscitation Policy in our hospital. All patients who go to OR are a full code, even if they are hospice patients requiring a palliative procedure. There are some heart surgeons who tell the patient they want 30 days of full code if they undergo the procedure. Of course, nothing in writing. Our general surgeons may suspend for 3-4 days. I appreciate the AORN site and will discuss further with our Ethics Committee. When I reviewed CMS Conditions of Participation for hospitals I did not find anything other than the Patients Right is to verbalize their wishes and have then honored. Is anyone aware of legislation that would address this issue? It may behoove us to check into the AMA or the American College of Surgeons to see if they have a position paper on this topic. Keep me in the loop please, Lori Lori F. Schiller, MSN, RN, NP-C Nurse Practitioner Palliative Medicine Services One Hiland Drive Petoskey, MI 49770 (231)4874825 Office (231)487-3019 Voice Mail (231)881-4345 Cell phone lschiller@northernhealth.org [Submitted on: 7/8/2010 by: Lori F. Schiller, MSN, RN, NP-C [lschiller@northernhealth.org]]

121. Limitation of treatment form for surgery patient. Must be in the air. :) Surgeons, anesthetists, CRNAs and AORN all have position statements on this. They seem to all agree that "policies that lead either to the automatic enforcement of all DNR orders and requests or to disregarding or automatic cancellation of such orders and requests may not sufficiently address a patient's rights to self-determination……The best approach is required reconsideration of previous advance directives." http://www.facs.org/fellows_info/statements/st_19.html There is no legislation that I'm aware of, other than the Patient Self-determination Act… and that's probably a good thing.


**I'm attaching a couple of articles that we're finding helpful. Anna **Please contact submitter directly to obtain attached articles. [Submitted on: 7/8/2010 by: Kostaroff, Anna [AKostar1@hfhs.org]]

121. Limitation of treatment form for surgery patient. Found these articles: http://depts.washington.edu/bioethx/topics/dnrau.html http://www.lucas-co-probatect.org/Do%20Not%20Resuscitate.htm http://www.geripal.org/2010/04/er-physicians-takeon-dnr-orders.html http://www.mywhatever.com/cifwriter/library/eperc/fastfact/ff23.html The following is an Out of The Hospital DNR but has good information and references http://www.njha.com/ps/pdf/dnr.pdf The following I feel is a great article and might open discussion further among staff in hospitals: http://www.allbusiness.com/healthcare/health-care-professionals-nurses-nursing/5508696-1.html Cheryl Cheryl B. Dworman, BSN, RN, CDCS Cheryl B. Dworman, Inc. Nurse Consultant-Patient Advocate P.O. Box 251981 West Bloomfield, MI 48325-1981 PHONE/FAX 248-669-2002 [Submitted on: 7/8/2010 by: Cheryl B. Dworman, BSN, RN, CDCS [cbdinc2001@yahoo.com]]

121. Limitation of treatment form for surgery patient. Hi Anna, I chaired the revamp of St. Anthony Central Hospital's Advance Directives policy which was completed June of 2009, and am now chairing the Centura State-Wide Advance Directives committee. In our policy draft, we have addressed these issues under "Surgical Procedures and Invasive Procedures for Patients with CPR Directives". I would be happy to copy and paste that section of the draft and forward to your email address, if you would like. It was reviewed by representatives from anesthesia prior to approval. We have faced similar issues being brought up by the list serv participants and I understand their complexity. We used "required reconsideration" in our policy draft. Let me know if this is helpful. Laurie De Lalio RN, MS, PMHCNS-BC, CT, ACHPN速 Palliative Care APN St. Anthony Central Hospital Denver, CO 80204 303-595-6472 office [Submitted on: 7/8/2010 by: Laurie De Lalio RN, MS, PMHCNS-BC, CT, ACHPN速 [deathmidwife@yahoo.com]]

121. Limitation of treatment form for surgery patient. Hi Everyone, Here is the portion of our Advance Directives policy draft that addresses DNR for patients undergoing surgical procedures: H.A. Surgical Procedures and Invasive Procedures for Patients with CPR Directives: 1. Patients with No CPR or Limited CPR orders may present a dilemma regarding appropriate therapy when undergoing anesthesia care or invasive ambulatory procedures.


Anesthesia care inherently involves depression of, and/or potential loss of central nervous system, cardiovascular and respiratory functions. Therefore, this type of care frequently requires a form of resuscitation. The following procedures are intended to provide guidance in the care of these patients during the perioperative period and prior to, during, and following invasive ambulatory procedures. a. A required reconsideration of the patient’s CPR status shall occur between the patient, his/her agent or proxy decision-maker, and the anesthesiologist, surgeon, cardiologist, and/or any other procedurist performing an intervention. i. A required reconsideration is an event that allows a patient or surrogate to participate in decisions about the use of cardiopulmonary resuscitation and that offers caregivers an opportunity to explain the significance of cardiac arrest and resuscitation in the perioperative setting. ii. The anesthesiologist, surgeon, cardiologist, and/or any other procedurist performing an intervention, should discuss with the patient and the medical care team which specific resuscitation modalities are appropriate to maintain adequate cardiopulmonary function during the administration of, and recovery from, the anesthetic and/or the procedures. (a) Included in this conversation shall be the anticipated risks and benefits of the procedure, the procedures which are “essential” and thus may not be refused (i.e. tracheal intubation for anesthetic and surgery), the likelihood of requiring resuscitative measures, a description of these measures and their reversibility, the chance of success, and the possible outcomes with and without resuscitation. Quality of life issues and religious and cultural considerations should also be discussed. (b) The patient’s goals for the postoperative period shall also be discussed. Doing so may facilitate discussions between the physician and the preoperative patient regarding which interventions are consistent with the above stated goals. a. Note: Physicians may find that when outcomes are prioritized over procedures, patients may authorize those physicians to use their clinical judgment to determine how specific interventions will affect the achievement of these goals. (e.g. “The patient desires resuscitative efforts during surgery and in the recovery unit only if the adverse events are believed to be both temporary and reversible, in the clinical judgment of the attending anesthesiologists and surgeons.”) b. A decision should then be reached prior to the surgery and/or procedure as to whether or not the designated CPR status will be temporarily changed or suspended. [FACILITY SPECIFIC -- The Informed Consent for Anesthesia/Sedation Analgesia] should be completed and placed in the medical record. c. The preoperative reconsideration discussion of do-not-resuscitate or allownatural-death decisions should be clearly documented and reported in the hand-off communication to direct perioperative care providers. d. If the patient has chosen to suspend or modify the do-not-resuscitate or allow-natural-death orders during the intraoperative period, a specific time frame should be defined for reinstating the preexisting do-not-resuscitate or allow-natural-death orders in accordance with the patient’s or surrogate’s decisions. e. If the above is not feasible (e.g. emergency surgery), care of the patient should be carried out with reasonable adherence to the patient’s directives, being mindful of the patient’s goals and values. Following stabilization and/or while the patient recovers from the anesthetic and/or procedure, but not typically longer than twenty-four (24) hours following stabilization, the anesthetic and/or procedure, the patient’s wishes shall be clarified and instituted. Let me know if you have questions or if I can be of further


assistance. Laurie De Lalio RN, MS, PMHCNS-BC, CT, ACHPN速 Palliative Care APN St. Anthony Central Hospital Denver, CO 80204 303-595-6472 [Submitted on: 7/8/2010 by: Laurie De Lalio RN, MS, PMHCNS-BC, CT, ACHPN速 [deathmidwife@yahoo.com]]

Question 122. Metallic taste in the mouth. Does anyone have some suggestions for relieving a metallic taste in the mouth? My patient is s/p taxol (last dose in July) and stage 4 prostate cancer with extensive liver metz. I've tried mint tea and lemon drop candy without much effect. Also, is there a name for having a metallic taste?? Thanks all, Dawn :) Dawn Pavlu APN, RN, CCRN Palliative Care Englewood Hospital, NJ [Submitted on: 9/25/2010 by: Dawn Pavlu, APN, RN, CCRN [dawn@pavlu.net]] Answers 122. Metallic taste in the mouth. Switching to plastic eating utensils may help. Mary Zuccaro ACHPN速 Capitola, CA [Submitted on: 9/25/2010 by: Mary Zuccaro ACHPN速 [maryznp@gmail.com]]

122. Metallic taste in the mouth. I can't remember if there is a name for it or not but it is often a medication side effect. Maybe call a local pharmacist like at Walgreens and ask what med causes or look up meds patient on. There is also a few sites on the internet with information just google metallic taste. http://www.metallictasterelief.com/ Sheria [Submitted on: 9/25/2010 by: Sheria Robinson [sheria_robinson@yahoo.com]]

122. Metallic taste in the mouth. Common problem with the taxane medications. In oncology, we have tired a number of things but nothing has emerged as "best practice". Usually peppermint helps according to patients and we tired prescribing zinc for awhile with some patients stating it helped. I believe the symptoms comes from damage to the nerves so takes awhile to resolve but usually does slowly Bec [Submitted on: 9/25/2010 by: Hawkins, Becca [Rebecca.Hawkins@providence.org]]


122. Metallic taste in the mouth. I don't know if there is a term that specifically defines a metallic taste, but I use the term "dysgeusia" to describe the impaired gustatory sense. Additionally, I don't have a remedy to cure the metallic taste; I believe this resolves with time. But working with patients in the community I know that it severely inhibits their appetite. I've found that Wendy's chili (not homemade or any other) is a food that patients can not only tolerate if having slight n/v with chemo but the metallic taste doesn't interfere with the taste of the food. I estimate this worked about 90% of the time (I don't have stock in Wendy's!). Good luck. Carol Bemis, NP, CHPN® Palliative Care St. Joseph's Hospital, AZ [Submitted on: 9/26/2010 by: Carol Bemis, NP, CHPN® [cpbemis@yahoo.com]]

122. Metallic taste in the mouth. Patients on chemo presenting with this problem seem to find eating sweets helpful. Some of them report adding fruits to their salad with good results. Grace Oligario, NP Detroit VAMC [Submitted on: 9/27/2010 by: Grace Oligario, NP [Grace.Oligario@va.gov]]

122. Metallic taste in the mouth. Long ago, as an oncology nurse, I found watermelon to be something close to a "miracle" food-for pts on chemo generally and for those with metallic taste in particular. It's well tolerated and addresses thirst in my palliative pts with minimal appetite as well-I often ask family members to bring some in when they can find it. Suzanne Hanen, RN GNP-BC CHPN® Palliative Care Consultation Service Winthrop University Hospital Suite 518 222 Station Plaza North Mineola, NY 11501 Pager: 516.291.6118 Desk: 516.663.2921 Fax: 516.663.4644 shanen@winthrop.org [Submitted on: 9/27/2010 by: Suzanne Hanen, RN GNP-BC CHPN® [SHanen@Winthrop.org]]

122. Metallic taste in the mouth. How's the pt's iron level? S/he may need iron. Deborah Greenspan, RN, CHPN® President Los Angeles Regional Provisional Group Hospice and Palliative Nurses Association [Submitted on: 9/28/2010 by: Deborah Greenspan, RN, CHPN® [dg.hpnala@gmail.com]]

Question 123. Non-Verbal Pain Scales. What pain scales does everyone use for non-verbal patients (non verbal, advanced cognitive impairment or unresponsive patients) and what kind of


validation and institutional policies exist for their use?? Please respond directly to: gentr054@mc.duke.edu Thanks, Jennifer Jennifer Gentry MSN ANP ACHPN®,FPCN Duke Hospital Palliative Care Service DUMC Box 3003 Durham, NC 27710 919-660-7564 Fax 919684-8569 [Submitted on: 12/14/2009 by: Jennifer Gentry MSN ANP ACHPN®,FPCN [jennifer.h.gentry@duke.edu]] Answers 123. Non-Verbal Pain Scales. PAINAD. [Submitted on: 12/14/2009 by: Marlene Foreman [marlene@hospiceacadiana.com]]

123. Non-Verbal Pain Scales. We use the PAINAD. Ellyn Schreiner MPH RN-C CHPN® St. Thomas Hospice 630-856-6983 ellyn.schreiner@ahss.org [Submitted on: 12/14/2009 by: Ellyn Schreiner MPH RN-C CHPN® [Ellyn.Schreiner@AHSS.ORG]]

123. Non-Verbal Pain Scales. We use the Checklist of Non-Verbal Indicators. If you go to http://prc.coh.org/pain_assessment.asp scroll down to #14 . This is a wonderful resource for validation of the different tools for non-verbal patients Janice [Submitted on: 12/15/2009 by: Janice Reynolds [jkrrnocn@suscom-maine.net]]

123. Non-Verbal Pain Scales. We use the FLACC scale (looking for facial signs/grimacing, leg and arm movement/restlessness, crying out or moaning, and consolability). Each is rated 02. which equals 0—10). Many thanks, Rosemary Zaucha RN Case Manager – Pink Team Rainbow Hospice Your community resource for comfort, care and education E: RZaucha@RainbowHospice.org W: www.RainbowHospice.org T: 847 685 9900 F: 847 685 6390 [Submitted on: 12/16/2009 by: Rosemary Zaucha [RZaucha@rainbowhospice.org]]

123. Non-Verbal Pain Scales. Good morning everyone, I would caution using the FLACC scale at this time for adults, while many do use this it has not been validated in the adult


population. The PAINAD is very similar, and has been validated in adult population. My staff have found it to be an easy conversion since much of the monitors are comparable. Ellyn Schreiner MPH RN-C CHPN® St. Thomas Hospice 630-856-6983 ellyn.schreiner@ahss.org [Submitted on: 12/16/2009 by: Ellyn Schreiner MPH RN-C CHPN® [Ellyn.Schreiner@AHSS.ORG]]

Question 124. Non-compete agreement. The NPs in my practice have been asked by our employer to sign a non-compete agreement. The MDs have had them for about 5 years. They are now asking the NPs and will be asking senior leadership to sign them. The agreement is a noncompete in the counties we serve for 1 year after termination. We get a $750 bonus for signing. It would cost $75000 to breach the contract. Signing is a condition of employment. I’m wondering if any others are seeing this – is this a trend? My personal email is below if you want to respond off the list. Thanks. Beth Martin RN, MSN, CCNS, ACNP-BC, ACHPN® bmartin@carolina.rr.com [Submitted on: 2/10/2010 by: Beth Martin RN, MSN, CCNS, ACNP-BC, ACHPN® [bmartin@carolina.rr.com]] Answers 124. Non-compete agreement. I have seen them and signed them. I personally have done everything possible not to sign them. It seems to me to be an impediment to free trade and I don't agree with them at all. Don Rehwaldt RN, MSN [Submitted on: 2/10/2010 by: Don Rehwaldt RN, MSN [don.rehwaldt@gmail.com]]

124. Non-compete agreement. My first employer had me sign this and he did implement it when I left. The problem was he was working in long-term care and worked in 4 -6 LTC facilities in a wide geographical area. So since I lived in the area where I worked, I was now prohibited to work where I lived. I ended up taking a job that I had to commute 40 minutes each way for because I was limited to working in my area. It was definitely problematic. When I first signed it, I thought I was not going to be a threat to taking away a practice from an MD in LTC, I wasn’t seeing office patients at the time. When I was offered a job by his former partner, he threatened to take us to court both me and the md who wanted to hire me. It was really a nightmare. Fran Hoh PhD APN CS ACHPN® [Submitted on: 2/11/2010 by: Fran Hoh PhD APN CS ACHPN® [franapn@aol.com]]


124. Non-compete agreement. Doesn't restraint of trade come into play? That's a serious legal concept which has been tried in the courts and not always supporting the employer. It would be one thing if you were culling patient records and actively taking patients with you. It is a whole other thing to be kept from gainful employment because a selfish (nicer than the other word I was thinking of) person wants an excuse to abuse you as an employee because he or she knows you either work for them or as a Wal-Mart greeter. It seems like there ought to be some provisions for reasonableness. After all, you can be forced to sign anything in order to work (in any other venue that would be coercion), but you cannot legally be forced to sign away your (Constitutional) rights, no matter what, and the right to practice your profession would seem to be pretty darned basic, perhaps on the level of a "right." (Ability to feed yourself and your family....) Maybe it is not apt (although it feels like it fits, to me), but they will continue to dish out what we are willing to keep taking..... I wonder if a proviso couldn't be added to indicate what circumstances would result in a revocation of the heretofore (sounds cool, huh) signed non-compete clause. It puts the liability more evenly across both "sides" and makes for fairness for us "underlings." Anybody here dually licensed as an attorney? I would love to have the take on this from an interested expert. Christine Johnson [Submitted on: 2/11/2010 by: Christine Johnson [Christine_in_Van_Alstyne@BrianAndChristine.com]]

124. Non-compete agreement. My understanding is that a non-compete agreement is to prevent an employee from starting their own business practicing in the same manner with the intent to protect his/her business contacts, etc. This is understandable, however, I don't think that the intent is to keep one from being employed by someone else in the same area. I do not believe that would be enforceable. Anyone can threaten to sue, but it does not mean they would be successful. Rebecca Gagne Henderson RN MSN NP-c Palliative Services Coordinator Long Beach Memorial Medical Center [Submitted on: 2/11/2010 by: Rebecca Gagne Henderson RN MSN NP-c [rebecca@endoflifedirectives.org]]

124. Non-compete agreement. In the MD community, it is also used to prevent the provider from going to another practice in a specific geographic area. Most MD providers I have worked with have signed them. [Submitted on: 2/11/2010 by: [kathleen.broglio@gmail.com]]


124. Non-compete agreement. It usually depends on your level in the organization. This is not an uncommon practice for senior management but very uncommon for the shift or hourly worker. Our organization has our EDs sign non-compete agreements precluding them from working for another hospice agency for one year if they leave on their own, i.e resign. I have seen unsuccessful law suits with physicians who have challenged noncompete agreements - when trying to open a separate private practice; however, I have never seen an individual employee who fought it be unsuccessful. As APNs, you would probably be held to the higher standard for MDs and senior executives. Christy [Submitted on: 2/11/2010 by: Christy Torkildson [torkc@sbcglobal.net]]

124. Non-compete agreement. It still does not seem appropriate to me. I had to negotiate with human resources to negate the non-compete agreement. It really seems like restraint of trade to me. If you live in a large urban area as I do, it is not feasible to leave your geographical area for a period of time in order to make a living in your specialty area. The problem that I had was that our service area for our hospice encompassed hundreds of miles and several counties. I live in Texas, and it was not reasonable to expect me to drive to find an area not serviced by our hospice. Another issue was that it was a national hospice agency and so it was impossible to work in Texas without working in an area that was not serviced by our hospice corporation. I agree with Christine Johnson that is seems very suspiciously like restraint of trade to me. If you do not take any patients or proprietary information, you should be able to work where you please. If I ever sign one again, I am going to have a lawyer modify the terms of the agreement and negotiate with the company prior to signing. Thanks, Don Rehwaldt RN, MSN [Submitted on: 2/11/2010 by: Don Rehwaldt RN, MSN [don.rehwaldt@gmail.com]]

124. Non-compete agreement. Non-compete clauses are very often upheld for the duration of the time that the clause prohibits an individual from "taking their patients/clients or contacts" with them when they leave an employer. Most professionals do sign some type of non-compete clause. Pat Hoban [Submitted on: 2/11/2010 by: Patricia Hoban [phoban@mhc.net]]

124. Non-compete agreement. The best advice came before I graduated from my NP program and came from a lawyer. She said: Consult a labor lawyer before you sign any agreement. They can also assist with re-negotiation if needed. Non-compete clauses have


been in physician contracts for quite some time and as NPs become more valuable assets, they are coming downward. These clauses will somehow discourage you from leaving your current place of employment by making it difficult for you secure employment in your geographic area. The way you get around this is to make sure that the clause that you are signing is specific to the job you do. If you are an acute care palliative care provider your clause should report that you cannot be an acute care palliative care provider within 30 miles (or something like that). If you change fields or go into LTC, you are not breaking your contract. I would get a lawyer. It would be worth the money. David P Klos, ANP-BC Palliative Care Coordinator / HBPC Providence VA Medical Center Providence, RI 02908 [Submitted on: 2/11/2010 by: David P Klos, ANP-BC [dpklos25@gmail.com]]

Question 125. NP Attending Billing in Hospice For those of you who are NPs serving as the hospice attending, can another NP see your patients and bill when you are off? Does the covering NP change the attending name to their name? see below : Medicare Claims Processing Manual, Chapter 11 – Processing Hospice Claims: • No payment is made for nurse practitioner services that can be performed by a registered nurse, nor is payment made for nurse practitioner services that are performed outside of the attending physician role. Nurse practitioner services are generally encompassed in the per diem payment rate. The only payment that can be made for services of a nurse practitioner is made for services furnished in the role of an attending physician. [Submitted on: 2/10/2010 by: Bartel, Judy [JBartel@HospiceWR.org]] Answers 125. NP Attending Billing in Hospice In my practice, all NPs are members of the same group. So anyone covering for me is part of the group and not an "outsider". This makes it easy, and yes, we can bill for all visits. Beverly Douglas ARNP ACHPN® Tampa Florida [Submitted on: 2/10/2010 by: Beverly Douglas ARNP ACHPN® [bevdouglas@tampabay.rr.com]]

125. NP Attending Billing in Hospice Beverly, To clarify please, I am assuming that your practice group is not part of the hospice staff is that correct? If your group were part of the hospice staff, then your services would fall either under "attending physician" or the per diem rate and which would not then allow you to bill for visits. Is your group part of the hospice staff? Pat Hoban, FNP-BC, ACHPN® [Submitted on: 2/10/2010 by: Pat Hoban, FNP-BC, ACHPN® [phoban@mhc.net]]


125. NP Attending Billing in Hospice Our group IS part of the hospice. The Medical Services Department consists of MDs and ARNPs. If we are attending, the ARNP serving the patient's team is the designated attending. If we are asked to serve in a consulting role and the community MD stays attending, the team MD is designated. We bill separately from the per diem. Beverly Douglas ARNP ACHPN® Tampa Florida [Submitted on: 2/10/2010 by: Beverly Douglas ARNP ACHPN® [bevdouglas@tampabay.rr.com]]

125. NP Attending Billing in Hospice I will soon be joining a group as the only APN and I will be seeing patients in acute care but under hospice service. Can you direct me to billing information? I am specifically looking for reimbursable services as an APN. My organization feels only physician services are billiable and that my services would be covered as RN services. That does not seem correct. Thank You Lorraine Thayer RN MSN APN OCN [Submitted on: 2/11/2010 by: Lorraine Thayer RN MSN APN OCN [Lorraine.Thayer@atlanticare.org]]

125. NP Attending Billing in Hospice Hello all. I am looking for information about how many APNs work in hospice agencies as medical staff and bill under their own NPI. I am planning a presentation with this information as the basis. I think APNs are underutilized in hospice agencies, and if Agency Administrators and Medical Directors that APNs pay for themselves and add value this could change. Please reply to my personal email, bevdouglas@tampabay.rr.com. Thanks. Beverly Douglas ARNP ACHPN® LifePath Hospice HPC Healthcare INC Tampa Florida [Submitted on: 3/10/2010 by: Beverly Douglas ARNP ACHPN® [bevdouglas@tampabay.rr.com]]

Question 126. Nurse's Aide Pain and Palliative Care Education. I have been asked to develop a one hour orientation on Pain & Palliative Care for newly hired “Patient Care Technicians” (aka: Nurses Aides) for my hospital system. Does anyone have any suggestions for me? Cynthia Cynthia Wagner, MSN, RN-BC, CHPN® Palliative Care / Pain Management Coordinator Paoli Hospital, Main Line Health Paoli, PA 19301 484-565-1646 office 215-265-0544 pager


WagnerCy@mlhs.org [Submitted on: 2/12/2010 by: Cynthia Wagner, MSN, RN-BC, CHPN® [WagnerCy@MLHS.ORG]] Answers 126. Nurse's Aide Pain and Palliative Care Education. Are you a certified ELNEC trainer? If so, the ELNEC-Geriatric curriculum was designed to be used for educating both nurses and CNAs. I used this curriculum as the educational intervention for my master's thesis last year and the CNAs (in a LTC facility) really liked it. Mark V. Harmon, BSN, RN-BC, CHPN® Care Coordinator / Charge Nurse The Palliative Center for Caring St. Ann's Community Rochester, New York ----------------------------------------------- CNS Graduate Student Wegmans School of Nursing Saint John Fisher College Rochester, New York [Submitted on: 2/12/2010 by: Mark V. Harmon, BSN, RN-BC, CHPN® [hospicepalliativern@gmail.com]]

126. Nurse's Aide Pain and Palliative Care Education. I found something that might help if you are not ELNEC certified trainers... 1. Go to www.geriatricpain.org and register for free (or log in as a Sigma Theta Tau member). 2. After verifying your registration, go into "Education" and select "Provider" 3. The ELNEC-Geriatric slide set for "Nursing Assistant Roles in Pain Management..." is provided here. I assume COH/AACN has provided registered users of this website permission to use these slides if they are posted there. Hope this helps. Mark V. Harmon, BSN, RN-BC, CHPN® Care Coordinator / Charge Nurse The Palliative Center for Caring St. Ann's Community Rochester, New York ---------------------------------------------- CNS Graduate Student Wegmans School of Nursing Saint John Fisher College Rochester, New York [Submitted on: 2/12/2010 by: Mark V. Harmon, BSN, RN-BC, CHPN® [hospicepalliativern@gmail.com]]

126. Nurse's Aide Pain and Palliative Care Education. Check out the ELNEC program through AACN. All teaching materials are included in the three day course. I have successfully modified their modules on pain, general intro materials, and the last hours of life into very effective training programs. You have full permission to use all of their materials as long as it isn't for private gain. Bonnie Freeman RN, MSN, CHPN®, ELNEC trained Vanderbilt University ANP-Palliative Care Program [Submitted on: 2/12/2010 by: Bonnie Freeman RN, MSN, CHPN® [freeman_bonnie@yahoo.com]]


126. Nurse's Aide Pain and Palliative Care Education. HPNA also has a specific Hospice and Palliative Nursing Assistant Core Curriculum. It is available on their website. Val Ramsberger, RN, MSN, APN Palliative Care Director Trinitas Regional Medical Center Elizabeth, NJ 07201 (908)- 994-5851 [Submitted on: 2/12/2010 by: Val Ramsberger, RN, MSN, APN [vramsberger@trinitas.org]]

126. Nurse's Aide Pain and Palliative Care Education. I don't know what your time frame is but if you go on the HPNA website: www.hpna.org. There is a curriculum book for hospice nursing assistants and there is a whole section in there on pain in end of life. Sheria [Submitted on: 2/12/2010 by: Sheria Robinson [sheria_robinson@yahoo.com]]

126. Nurse's Aide Pain and Palliative Care Education. We did a mandatory 2 hour program for our nursing assistants in our acute care facility. I obtained a $5000 grant from J&J. Our main focus was to make them feel that they are special, are part of the team, and have something to offer to the plan of care. To that end, we ordered pins for them that have pain with a red line through like the no smoking sign, and we offered the program on the same day as orientation so we could get the new nursing assistant hires as well as the currently working. We did 1045-12:45 AND 1:15-3:15 and we provided lunch, which were both paid for by the grant. I also paid the PRN nurses who taught the course, I had 2. and We trained 203 nurses aides from 3/09-12/09. But we did have administrative support to pay them for this, but our HCAPS scores did go up 1% which was part of the outcomes we were looking for. As far as content, we included things that were important for them. we identified different equipment a brief overview of how it works and what they should report to the nurse, with pca, epidural, etc. We told them what they should get in report from the nurse regarding pain as well as what they should report off to the next aide regarding pain. What they should ask the nurse about pain, how important it is to patient satisfaction. We reviewed the different things we do to patients that cause pain. We focused on non pharm things that they could provide. We also gave a pre and post test as that was part of the grant. Overall, it was really well received. It was a win win win, the nurses who presented got an inside look of what barriers the aids have, which they then presented at pain committee, the aides felt special and enjoyed the education, and the hosptial improved scores. If you want any more info feel free to call at 908 369-6823. Fran Hoh PhD APN CS ACHPN速 Overlook Hospital Summit, NJ [Submitted on: 2/12/2010 by: Fran Hoh PhD APN CS ACHPN速 [franapn@aol.com]]


126. Nurse's Aide Pain and Palliative Care Education. HPNA has a train the trainer program for CNAs. It’s a lot like the ELNEC training. They give you all the power points, pre test, post tests, evaluation forms and case examples with talking points. I have used this training to educate CNAs in two of our Nursing Homes and the in-patient hospital unit that we are opening 5 Palliative Care beds. The CNAs have given very favorable evaluations and as an educator with limited time for educational program development, it was a very good program to implement. We also use the training for RNs and LPNS. I’ve trained a total of 62 RN,LPNs and CNAs. I do the training over an 8 hour day. The modules are communication, pain, other symptom management and care of the patient as death is near. Feel free to contact me if you want more experiential information. Contact Nancy and Deanna Jean at HPNA for info on the program. Jane McCabe RN, MS Palliative Care CNS VA Eastern Colorado HCS 1055 Clermont St (118) Denver, CO 80220 303-399-8020 x3461 Jane.mccabe@va.gov [Submitted on: 2/12/2010 by: Jane McCabe RN, MS [Jane.McCabe@va.gov]]

126. Nurse's Aide Pain and Palliative Care Education. Fran, I think what you did is wonderful. We are converting a 19 bed medical unit to a Palliative Care Unit and we are currently training all nursing staff based on the ELNEC Training Model. I would however love a copy of your Nurses Aide Training if you are willing to share. I'm sure the Nurses Aides feel very special and a part of the team. Thanks, Donna [Submitted on: 2/12/2010 by: Donna Leno Gordon [donnalenogordon@hotmail.com]]

126. Nurse's Aide Pain and Palliative Care Education. **I will attach the power point presentation we used. Where are you located? Fran **Please contact submitter directly via email to obtain. [Submitted on: 2/12/2010 by: Fran Hoh PhD APN CS ACHPN® [franapn@aol.com]]

126. Nurse's Aide Pain and Palliative Care Education. I too am using the HPNA materials to train our nursing assistants and health techs. I work at the North Florida/South Georgia VA and we have just embarked on a very exciting journey in palliative/end-of-life care that will involve training all of our NAs/HTs in the system (over 350 of them) The material is wonderful, easy to use and very thought provoking for those who have taken the course. I


recommend it highly! Ellen Davis, MSN, RN, CHPN® Clinical Nurse Educator [Submitted on: 2/12/2010 by: Ellen Davis, MSN, RN, CHPN® [moonkids2@yahoo.com]]

Question 127. Nursing Bags - Infection control in the patient's home. Can anyone share with me what your current practice is for infection control of nursing bags in the patients' home? Marilyn Graves, RN,MSN, CHPN® Clinical Nurse Specialist Office: 443-849-8224 Gilchrist Hospice Care 11311 McCormick Road, Suite 350 Towson, MD 21031 [Submitted on: 5/11/2010 by: Marilyn Graves, RN,MSN, CHPN® [mgraves@GilchristHospice.org]] Answers 127. Nursing Bags - Infection control in the patient's home. Our policy is for the nurse or HHA to utilize a barrier under their bag when in the home, and wash bag annually or if visibly soiled. In homes that are dirty or cluttered we encourage staff to take in only what they need for that patient. Ellyn Schreiner MPH RN-BC CHPN® Clinical Educator/Supervisor St. Thomas Hospice phone: 630-856-6983 fax: 630-734-9178 ellyn.schreiner@ahss.org [Submitted on: 5/11/2010 by: Ellyn Schreiner MPH RN-BC CHPN® [Ellyn.Schreiner@AHSS.ORG]]

127. Nursing Bags - Infection control in the patient's home. The hospice where I am the backup RN wants us to put a sheet of newspaper on the floor and then set our bags on the paper. We are also supposed to keep our bags and supplies in a covered plastic container when they are in our cars. I have always wiped off the bag with a disinfecting wipe (Chorox or Lysol brands have the same chemicals). I personally am very cognizant of not carrying bugs from one location/patient to the next, but I also am cognizant that patients may feel offended if their floor or chair are seen as not good enough or clean enough to put a bag directly on. An alternative I like but which went over like a lead balloon in the meeting where this was discussed is, wipe the bag off in front of the patient before putting it down. That way the message is, I'm protecting you--you don't know where this bag has been! It also is more timely. JHMO Christine Johnson RN CHPN® LMFT FNP-S [Submitted on: 5/11/2010 by: Christine Johnson RN CHPN® LMFT FNP-S [Christine_in_Van_Alstyne@BrianAndChristine.com]]


127. Nursing Bags - Infection control in the patient's home. We had to have a barrier, some nurses would carry plastic bags and pull them out to cover the bag prior to placing on a chair or floor, or some would bring newspapers. [Submitted on: 5/11/2010 by: Melinda Mull [mmull@ouraynet.com]]

127. Nursing Bags - Infection control in the patient's home. Marilyn, Christine and list serve, I am not in Marilyn's situation, but I would definitely agree with Christine that wiping your bag off in front of the client makes sense in terms of infection control -- and demonstrates a level of respect for the client. Years ago, I attended home births (providing prenatal care, birthing services and postpartum care in the home). In my training, I was taught the following and I made it part of my routine. The first thing to do when entering the home, after verbally greeting whomever was there to meet me at the door - was to ask to be shown where I could wash my hands. I did this before shaking hands, or touching anyone children, spouses or my patients - again demonstrating an understanding of infection control and also sending a message of respect for the health and dignity of those I cared for in the home. Anne Morgan MSN, CNM, FNP Palliative Care Coordinator Family Nurse Practitioner Bay Area Hospital 269-8538 – office & voice mail 269-4700 - BAH pager, just punch in your return number [Submitted on: 5/11/2010 by: Anne Morgan MSN, CNM, FNP [anne.morgan@bayareahospital.org]]

127. Nursing Bags - Infection control in the patient's home. I would check with your state specific regulations. In SC the department of health and human services mandates ‘bag technique’ and will cite your organization if not done properly. Jennifer L. Huggins, MSN, ANP-BC Bon Secours Saint Francis Health System Palliative Care Team 864.255.1304 (office) 864.444.7788 (cell) jennifer_huggins@bshsi.org [Submitted on: 5/11/2010 by: Jennifer L. Huggins, MSN, ANP-BC [jennifer_huggins@bshsi.org]]

127. Nursing Bags - Infection control in the patient's home. As a Clinical Mentor and as a member of our Infection Control Committee this is a subject near and dear to my heart. We do encourage proper bag technique. We review that technique at our annual Skills Fair. Our basic teaching is this – anything that goes into a patient’s home or room (in a SNF or AL) that is coming back out with you should be on a barrier. All direct patient care staff should use barriers – not only nurses. Nursing bags should be washable or able to be wiped clean.


Bags are placed on a barrier, preferably not on the floor. After hand washing, nurse may access inside of bag for supplies/equipment. All reusable equipment is wiped clean prior to replacing in bag (after washing hands again.) In your car or other storage place, again should be on a barrier or some sort (paper, plastic.) Mary Ann Jurek, RN, CHPN® Clinical Mentor CR 300 and Teams 220, 230, and Extended Hours Hope Hospice and Community Services 2430 Diplomat Pkwy., E. Cape Coral, FL 33909 ph: 239-482-4673, ext. 34163 cell: 239-633-8627 maryann.jurek@hopehospice.org [Submitted on: 5/12/2010 by: Mary Ann Jurek, RN, CHPN® [MaryAnn.Jurek@hopehospice.org]]

127. Nursing Bags - Infection control in the patient's home. Unfortunately, there is a lack of evidence –based research on this topic. If anyone can find any, please advise me. Linda Freda RN, MSN, CHPN® Director of Education Hospice of the Comforter 480 W. Central Pkwy Altamonte Springs, FL 32714 407-379-0198 lindafreda@hospiceofthecomforter.org [Submitted on: 5/12/2010 by: Linda Freda RN, MSN, CHPN® [lindafreda@hospiceofthecomforter.org] ]

127. Nursing Bags - Infection control in the patient's home. A good resource I have found: Infection Control in Home Care and Hospice, second edition- Emily Rhinehart and Mary McGoldrick- ISBN is 0-7637-2667- Marilyn Graves, RN, MSN, CHPN® Clinical Nurse Specialist Office: 443-849-8224 Gilchrist Hospice Care 11311 McCormick Road, Suite 350 Towson, MD 21031 [Submitted on: 5/12/2010 by: Marilyn Graves, RN, MSN, CHPN® [mgraves@GilchristHospice.org]]

127. Nursing Bags - Infection control in the patient's home. We did a class for the hospice aides and then for the nursing staff on "Bag Technique." We role played proper and improper techniques and showed how to designate certain parts of the bag as "clean" and other parts as "dirty." Home Health manuals are a good resource for brushing up on "bag technique." We videotaped the classes and now use the training tape in orientation. We also created a handout that listed typical items to be carried in a nurse's bag or a hospice aide's bag along with our written policy on bag technique. Hope this helps. Marsha [Submitted on: 5/12/2010 by: Marsha Farrell [mfarrell@hospicefamilycare.org]]


127. Nursing Bags - Infection control in the patient's home. Could you please share with us the written policy on bag technique. Thanks, Vivianne Jakobs, RN, CNS [Submitted on: 5/12/2010 by: Vivianne Jakobs, RN, CNS [erehwon@san.rr.com]]

127. Nursing Bags - Infection control in the patient's home. Our organization also recently readdressed the nursing bag issue. **Attached is a summary of what I found. I am left with these impressions: • Research is needed (even the "Spalding Categories" have not been subject to research) • Organisms (including multiple drug resistance organisms) are found where ever there is an effort to culture including nursing bags, stethoscopes, pens, etc.) • Sticking to basic nursing principles is essential including: Evaluating the unique circumstances of the encounter with respect to the individuals involved. I was pleased with the attention to care in patient/family feelings noted in this dialogue! • Role model good infection control practices. • Bring as little into the homes as possible. (I advocated (unsuccessfully) for bringing in nothing but soap and paper towels (and our blackberries) and careful consideration of what supplies need to be in the home and bringing them and leaving them there. Expensive items such as durable medical equipment and even B/P cuffs to be removed and cleaned after the patient dies or is discharged, the way we do for established cases of MDROs) If I was doing a research project, I would try Tea Tree Oil Spray (meleluca) for bag disinfection. They are studying using this ON patients in ICU so it should be safe for bags. The current practice of wiping down equipment does not meet the requirement noted by product manufacturers for contact sufficient for disinfection. (several minutes of contact with the product to be disinfected may be required, another area where research is needed!) Thank to all of you who contributed to this dialogue. Catskill Area Hospice and Palliative Care 1 Birchwood Dr Oneonta, NY 13820 607-432-6773 **Please contact submitter directly via email to obtain document. [Submitted on: 5/13/2010 by: Maryanne Kehoe [Maryanne.Kehoe@cahpc.org]]

127. Nursing Bags - Infection control in the patient's home. Thanks, I will look for Tea Tree Oil. I usually do my bag weekly, but use alcohol. Margaret [Submitted on: 5/13/2010 by: [mekollmer@verizon.net]]

127. Nursing Bags - Infection control in the patient's home. I use tea tree oil as an antimicrobial in my fish tank and fish are pretty fragile about chemicals so.... The research I have read suggests tea tree oil is an excellent antimicrobial, and it smells wonderful. (I also


read that applied to a balding head, it encourages hair growth. Wear gloves?) :-) Another good cleaner that kills bacteria and gives viruses a run for their money is a combination of rubbing alcohol and white vinegar (I use half and half) diluted with 1-2 parts water. I also add a bit of lemon extract. It's gentle enough that it doesn't bother the cats if they happen to be in the vicinity (we rescue), it's cheap, and it is a great solvent for gunk on countertops, for example, but it doesn't etch granite. We have animals and one human in our house who are somewhat immune-compromised and so far so good. No one doubts--could even say that it is common knowledge--that rubbing alcohol and white vinegar are excellent bacteriocides, nonirritating, noncarcinogenic, kind to the environment, readily obtainable, inexpensive, and easily taught to families. Has anyone considered asking a college microbiology professor if he or she would be interested in having their class conduct experiments on what grows off medical bags treated with the various sprays, wipes, etc. versus one (or more) not treated with anything? It would be interesting to see if anything pathogenic comes out on any of the slides, and whether one treatment seemed to be more efficacious than any other. It is more fun that a literature search! Christine [Submitted on: 5/14/2010 by: Christine Johnson [Christine_in_Van_Alstyne@BrianAndChristine.com]]

127. Nursing Bags - Infection control in the patient's home. Maryanne: Do you know if Tea Tree Oil comes in a spray or do you make up your own? If so, in what base and what is the ratio? The directions on the oil I bought spoke about Olive Oil or Almond oil as a base for personal hygiene. Thank you, Jessica Weinberger FNP [Submitted on: 5/14/2010 by: Jessica Weinberger FNP [jetw69@aol.com]]

127. Nursing Bags - Infection control in the patient's home. Hi All Here is information for Tea Tree Oil Spray. I am delighted you are considering this wonderful item. I have used Tea Tree for years on patients. http://www.google.com/search?hl=en&source=hp&q=tea+tree+oil+spray&aq=f&aqi=g5gm2&aql=&oq=&gs_rfai= Regards, Cheryl Cheryl B. Dworman, BSN, RN, CDCS Cheryl B. Dworman, Inc. Nurse Consultant-Patient Advocate P.O. Box 251981 West Bloomfield, MI 48325-1981 [Submitted on: 5/14/2010 by: Cheryl B. Dworman, BSN, RN, CDCS [cbdinc2001@yahoo.com]]

127. Nursing Bags - Infection control in the patient's home. Practice continues to evolve.


Aaltonen, Richards, Webster, Davis (2009) surveyed 437 baccalaureate nursing programs on use of public health nursing bags. They were considering if continuing to teach bag technique is appropriate (they kept it in). Only 32% "continued to utilize a standard public health bag during home visits, the majority did not." Many associate degree programs do not include public health content so it would seem that most nurses are NOT taught this is school. The benefit/burden of bringing nursing bags into the home continues to require dialogue. Maryanne Catskill Area Hospice and Palliative Care 1 Birchwood Dr Oneonta, NY 13820 607-432-6773 [Submitted on: 5/17/2010 by: Maryanne Kehoe [Maryanne.Kehoe@cahpc.org]]

Question 128. Oncology Nurse Navigators. Has anyone had any experience working with nurse navigators. We have just started discussions for the hiring of oncology nurse navigators and it seems to me there would be an implicit duplication of palliative services. (feeling a little threatened right now) Any thoughts? Thanks, Rebecca Gagne Henderson RN MSN FNP ACHPN速 [Submitted on: 7/18/2010 by: Rebecca Gagne Henderson RN MSN FNP ACHPN速 [rebecca@endoflifedirectives.org]] Answers 128. Oncology Nurse Navigators. I work at a large cancer center in Arizona and we have use a navigator for a couple of years. Ours happens to be a social worker (it could just as well be an RN in the position), who works in conjunction with the American Cancer Society...our navigator meets all our new patients and it seems to me the position is complementary to what the RNs (such as myself, who works as a Clinical Coordinator) do - more consultative and supportive, helps the family get going in the right direction with an awareness of what is "out there" for services without actually "performing" any of those services. I'm sure I could gather better information for you (like a formal job description or such), as this is my anecdotal experience... Kim Faber, RN, MSN, OCN [Submitted on: 7/18/2010 by: Kim Faber, RN, MSN, OCN [kimberlyfaber@comcast.net]]

I am a pt. advocate/nurse consultant--some have referred to me as a navigator---do not feel threatened all I do is to complement the interdisciplinary staff by advising what I have viewed of the pt. Make suggests to benefit the pt, family, caregivers and staff caring for the pt. I also review charts to make sure nothing more can be done for the pt. I also am referred to pts by physicians, interdisciplinary staff, family members and friends. Hope this assists


you. Sincerely, Cheryl Cheryl B. Dworman, BSN, RN, CDCS Cheryl B. Dworman, Inc. Nurse Consultant-Patient Advocate P.O. Box 251981 West Bloomfield, MI 48325-1981 PHONE/FAX 248-669-2002 [Submitted on: 7/18/2010 by: Cheryl B. Dworman, BSN, RN, CDCS [cbdinc2001@yahoo.com]]

128. Oncology Nurse Navigators. There is a huge variation in definition and role for navigators (and not all are nurses--in fact, the original conception did not focus on nurses at all). The few instances of which I am aware have nothing to do with palliative care. The target group is often newly diagnosed patients or those new to the cancer center. Some focus on survivorship. It would be interesting to know what is the perceived need being addressed by your institution and how the role of "navigator" is being described. In September the Academy of Oncology Nurse Naviagators is holding its first annual Navigation and Survivorship Conference: http://www.aonnonline.org/conference.asp Tom Quinn [Submitted on: 7/18/2010 by: Tom Quinn [thomas.quinn@yale.edu]]

128. Oncology Nurse Navigators. The cancer center has just hired the first navigator and she is a nurse practitioner. They are currently defining the role, but after a recent talk I gave have decided that they would tag on palliative care to the role during the course of the illness and should the patient become terminally ill. Rebecca Gagne [Submitted on: 7/19/2010 by: Rebecca Gagne Henderson [rebecca@endoflifedirectives.org]]

128. Oncology Nurse Navigators. Sounds similar to what we are discussing. Our cancer center has proposed a position for a Palliative Care Navigator. This would be a Nurse Practitioner who would meet with the newly diagnosed Stage 3 or 4 patients (palliative not curative patients) along with the SW and other disciplines as identified on initial evaluation. NP would do education including advance care planning and symptom management. The NP would follow the patient through the trajectory including collaboration with palliative therapies (radiation, dietary, PT, lymph edema) as well as be point person for home care or hospice personnel when transition occurs. NP would also see those patients who needed to be seen for symptom management related to treatment and "add-ons" for assessment. Work closely with triage nurses and possibly supervise the infusion rooms. Also, we discussed the option of NP evaluating patient in ED to facilitate admission to inpatient area


since MD's are busy in clinic until after hours. Goals for care would be planned and hope is patient will be care for along the disease trajectory with a person to assist in "navigation" or case management throughout the system of care. That is the proposal but has not been initiated or accepted yet. We are still crunching numbers. If you have any input into this would appreciate as I am the one potentially getting the job :) Lori Lori F. Schiller, MSN, RN, NP-C Nurse Practitioner One Hiland Drive Petoskey, MI 49770 (231)487-4825 Office (231)487-3019 Voice Mail (231)881-4345 Cell phone lschiller@northernhealth.org [Submitted on: 7/22/2010 by: Lori F. Schiller, MSN, RN, NP-C [lschiller@northernhealth.org]]

Question 129. Prescription Regulations for Opiates. I need some help and can't think who else to turn to but the SIG. I am in PC in Texas, working for a large group of attendings that are pretty scattered across the city. I am doing house calls for palliative patients and have found that getting triplicates for my patients can be very time-consuming and tricky. Most attendings are of the belief that they have to have seen the patient before writing scripts. This can be a real problem when the patients are referred to me after discharge from the inpt facility as the MDs don't do house calls. I know that in the hospice world, many times the MD never sees the patient, only the nurse does. Of course, in hospice most have pharmacies that provide the meds but the prescribing rules should be the same...do the doctors cover each other’s patients? Is this legal? I can't find it addressed in any regulations when looking it up myself. I know that state rules vary but I am looking for any suggestions that anyone might have on how they are working within these types of constraints, particularly in Texas. Any suggestions are appreciated, even if is related to workflow, etc. Also, I ran across something last week about a study that someone did a study on how much time NPs can spend weekly on trying to secure opiate prescriptions for their patients when they don't have access to prescribing schedule IIs. I didn't get the name or the actual article, which I would love to get that if anyone knows who published that. Thanks in advance! Shreda Pairé, MS, RN, FNP-C, ACHPN® Advanced Certified Hospice & Palliative Care Nurse Practitioner Division of Geriatrics and Palliative Medicine The University of Texas Medical School at Houston Lyndon B. Johnson General Hospital 5656 Kelley St. Houston TX 77026 Phone: 713 566 4795 Fax: 713 566 2107 Email Shreda.Paire@uth.tmc.edu [Submitted on: 8/27/2010 by: Shreda Pairé, MS, RN, FNP-C, ACHPN® [shredanp@yahoo.com]] Answers 129. Prescription Regulations for Opiates. Shreda, I'm going to reply to this on the SIG, because this is an issue that everyone needs to be aware of. I feel your pain all too well. As an NP in hospice in one of the last two remaining states that do NOT allow NPs to prescribe


ANY scheduled medications, this can be a headache of migraine proportions. At my agency, we have handled it in the following manner: We are connected by laptop email and phone. When we get a call or see a patient who needs a controlled medication (we can't even prescribe schedule 5's) we write the script on our laptop in a form we use. We then email the form to one of the MDs we work with. If it's needed right away, we call the MD in question to let them know the email is on the way (we might text instead of call, depending on the urgency and time of day). The MD then knows to look in their email, open the form, sign it and send it on to the pharmacy. They do NOT see the patient in question that would be impossible. We have an average daily census of about 1200 patients, with a medical staff of 12. We are all out and about seeing patients, managing teams and accompanying IDG's, the MDs have all the death certificates to attend to, as well as fielding calls about admission criteria from the admission nurses. Our system has worked well for us for several years, but it's still a pain. We work tirelessly to get the laws changed. The evidence is clear that in states where NPs have full prescribing authority there are no issues with safety or increased drug addiction. It looks like Alabama will get a law passed in the near future, and Florida will stick out like a sore thumb on the US map of shame for maintaining its outdated policy. Beverly Douglas ARNP ACHPN® LifePath Hospice Tampa Florida [Submitted on: 8/27/2010 by: Beverly Douglas ARNP ACHPN® [bevdouglas@tampabay.rr.com]]

129. Prescription Regulations for Opiates. Beverly (and all)- My question would then be how are hospice drs allowed to write scripts for patients that they have not seen before. In reviewing all the regs that I can find, there is no "out" for a dr to write for a pt that they have not seen and that is what my attendings keep stressing to me. I know that it is done every day by hospices but how do they keep that legal? Surely some hospice docs out there have thought of these issues. If there is a way, I want to know so that I can also put it in place with my team so I can get these scripts out to these palliative patients of mine. Is this just a practice that goes on because it "always has" and no one has looked at it OR is there some sort of rule that I don't know about that is covering them legally? Does anyone know? Shreda Pairé, MS, RN, FNP-C, ACHPN® Advanced Certified Hospice & Palliative Care Nurse Practitioner Division of Geriatrics and Palliative Medicine The University of Texas Medical School at Houston Lyndon B. Johnson General Hospital 5656 Kelley St. Houston TX 77026 Phone: 713 566 4795 Fax: 713 566 2107 Email Shreda.Paire@uth.tmc.edu [Submitted on: 8/28/2010 by: Shreda Pairé, MS, RN, FNP-C, ACHPN® [shredanp@yahoo.com]]

129. Prescription Regulations for Opiates. For hospice care, the ATTENDING physician is


actually the one in charge, and the medical director oversees the palliative care that is being given. Orders FIRST, must come from the admitting attending physician for his patient. Then, the attending and the med. director cooperate in the development of the plan of care for the patient in question. Both physicians must sign the admitting plan of care as well as Medicare Benefit forms. From there, the patient continues to see the attending unless physically impossible (which is often the case), and the interdisciplinary team and medical director discuss the patient every 2 weeks. In the meantime, if opioids are needed or to be increased, it is actually the attending physicians' job to order it. If they don't know how to do it, the medical director makes sure it is done. In areas where NP's are working for hospice, they can make it happen. Meantime, the nurses are seeing the patient as frequently as needed for symptoms management and the other members of the team likewise. They are reporting the status of the patient and requesting meds as needed as the patient's condition changes, which, at the end of life, can happen often. In many hospices, medical director visits to the patient’s home are the norm, especially in large hospices where med. directors are full time. So, there is more regulation that it may seem, and those regs are in the CMS "Conditions of Participation". However, I have great compassion for the NP's who are trying to do this, while palliative care is still without the kind of regs that would enable them to do their job. It is a waste of time of valuable expertise that could be well spent seeing more patients! Blessings, Judy Dobson, MSH, CNS, CHPN® Former hospice director [Submitted on: 8/28/2010 by: Judy Dobson, MSH, CNS, CHPN® [pcnurse@verizon.net]]

129. Prescription Regulations for Opiates. However, the newer regs state that NPs can serve as the attending of record for hospice patients. So it is important that NPs can prescribe so they can fulfill the duties of the attending. Politics is always hard in this. One hopes that with health care reform there may be a way to expand NP practice to better serve patients. Constance Dahlin, ANP, BC, ACHPN® Palliative Care Service Massachusetts General Hospital Boston, MA [Submitted on: 8/28/2010 by: Constance Dahlin, ANP, BC, ACHPN® [cdahlin@partners.org]]

129. Prescription Regulations for Opiates. For most of the patients in my hospice, our medical group IS the attending. The community MD may continue in the role of a consulting physician, but they often turn over the care to us. The team ARNP is the attending with the MD for back up for scheduled medications. Beverly Douglas ARNP ACHPN® [Submitted on: 8/28/2010 by: Beverly Douglas ARNP ACHPN® [bevdouglas@tampabay.rr.com]]


129. Prescription Regulations for Opiates. Beverly, Are you referring to scripts for Hospice patients? I have office patients who are non hospice palliative care, who use local pharmacies, who require a hard copy script for all controlled substances. Karen McGough ARNP, ACHPN® Tidewell Hospice Sarasota, Florida [Submitted on: 8/30/2010 by: Karen McGough ARNP, ACHPN® [karen.mcgough@verizon.net]]

129. Prescription Regulations for Opiates. Karen, I am referring to hospice patients. Patients going to community pharmacies have to have hard scripts, which as you know must have MD signature. We don't have an outpatient palliative care service at LifePath Hospice (or Good Shepherd), only inpatient palliative care through our subsidiary Axis Palliative Care, which serves several hospitals in the area. Beverly Douglas ARNP ACHPN® [Submitted on: 8/30/2010 by: Beverly Douglas ARNP ACHPN® [bevdouglas@tampabay.rr.com]]

129. Prescription Regulations for Opiates. Here is a site from the Office of Diversion (Dept. of Justice and DEA) that lists a fax as an acceptable way to send a prescription. There is other info there as well. http://www.deadiversion.usdoj.gov/faq/general.htm#rx-4 Judy [Submitted on: 8/30/2010 by: Judy Dobson [pcnurse@verizon.net]]

Question 130. Outpatient Palliative Care Clinic. Hi everybody, We're working on our outpt clinic and need some help. Does anyone have an outpt brochure (we've started with getpalliativecare.org's info) that you could share? Also, do you have a referral sheet for referring clinicians to fill out on patients? We can use any and all info you might have to share!! Thanks! Diane E. Ranna, MN, FNP-C, ACHPN® Palliative Care Coordinator Piedmont Fayette Hospital 1255 Highway 54 West Fayetteville, GA 30214 Cell: (770) 833 - 6770 Phone: (770) 719 - 7295 Fax: (770) 719 - 6695 Email: diane.ranna@piedmont.org [Submitted on: 9/17/2010 by: Diane E. Ranna, MN, FNP-C, ACHPN® [cacopema@yahoo.com]] Answers


130. Outpatient Palliative Care Clinic. Diane, **Here is our brochure (same for all settings) and here is a screen shot of our consult request. In-patient and out-patient requests use the same request and they choose in or out so we know which direction to go along with what they think they want us to help with. Hope it helps. Jane McCabe MS,RN, AOCN, ACHPN® Palliative Care CNS VA Eastern Colorado: Denver **Please contact the submitter directly via email to obtain. [Submitted on: 9/17/2010 by: Jane McCabe MS,RN, AOCN, ACHPN® [Jane.McCabe@va.gov]]

130. Outpatient Palliative Care Clinic. Polly, **I didn’t send you the original, but I was able to PDF it -for you. Hospice of the Piedmont was the first hospice that I started working at in 1990! I’m a UVA grad who spent 18 yrs in C ‘ville. Linda Freda RN, MSN, CHPN® Director of Education Hospice of the Comforter 480 W. Central Pkwy Altamonte Springs, FL 32714 407379-0198 lindafreda@hospiceofthecomforter.org **Please contact the submitter directly via email to obtain. [Submitted on: 9/20/2010 by: Linda Freda RN, MSN, CHPN® [lindafreda@hospiceofthecomforter.org]]

130. Outpatient Palliative Care Clinic. I am enclosing the web address to access the brochure we have at the Huntsman Cancer Institute for our service. It can be accessed at: http://www.hci.utah.edu/pdf/brochures/painMedicineFinal.pdf **We have a form that our clinic nurse coordinator uses to fill out patient information when requests for outpatient referrals are received (attached) but that is done over the phone. We don't have a mechanism for them to be completed online. Our inpatient consults are ordered by electronic order entry and come to the consult pager, but only patient name and location are included - the ordering service is supposed to make a direct call with the reason for consult. I haven't tried to see if there is a way of including more information when the order is entered - but that might be helpful. We use the Cerner electronic medical record which includes order entry. Hope this is helpful. Deborah Thorpe, PhD, APRN, ACHPN®, AOCNS Pain Medicine and Palliative Care Huntsman Cancer Institute University of Utah 2000 Circle of Hope Rm 2381 Salt Lake City, UT 84112 Phone (801)585-0254 FAX (801)581-4416 **Please contact the submitter directly via email to obtain. [Submitted on: 9/20/2010 by: Deborah Thorpe, PhD, APRN, ACHPN®, AOCNS [Deborah.Thorpe@hci.utah.edu]]


Question 131. Palliative Care is sexy. I just have to share with you all that after much evangelizing for palliative care it appears that some of the MD's in my hospital have suddenly grasped on to the concept of palliative care. In the last three days I have seen orders for a "palliative PEG", "palliative tracheotomy", and (get this) a "palliative VP shunt". Help me somebody, PLEASE!! Rebecca Gagne Henderson RN MSN FNP ACHPN速 [Submitted on: 10/20/2010 by: Rebecca Gagne Henderson RN MSN FNP ACHPN速 [rebecca@endoflifedirectives.org]] Answers 131. Palliative Care is sexy. Wow, Rebecca! My first thought is to respond, "What is the symptom that is being palliated? For the PEG, is the pt saying that he/she is hungry and wants to be fed? [If not, what are we palliating, a pt's discomfort, or a physician's?] Best of luck to you, Mary Zuccaro, ACHPN速 Capitola, CA [Submitted on: 10/20/2010 by: Mary Zuccaro, ACHPN速 [maryznp@gmail.com]]

131. Palliative Care is sexy. My two cents are: 1. Palliative anything is the new catch phrase 2. Depending on the medical issue, PEGs are palliative, especially for pts with SBOs when they can function as venting PEG to allow pleasure eating, or with a head and neck cancer when undergoing treatment, or with ALS or Parkinsons dz. 3. Trachs, depending on the situation can be palliative if done for symptom management. Ditto for shunts. The terms should not be an excuse to defer goals of care discussion or to avoid difficult conversation. Just my nickel's worth (more than 2 cents) Linda Linda Blum, GNP [Submitted on: 10/20/2010 by: Linda Blum, GNP [lblumgnp@gmail.com]]

131. Palliative Care is sexy. Regarding How a PEG could be palliative: (besides addressing hunger) It could be functionally used more for venting (excess gas) as in the case of a gastric obstruction. I strongly believe it is far more palatable to vent for pressure than to ever support someone who has just vomited fecal material. - talk about losing one's spiritual faith in dignity for all after a violent & violating event like that occurs - 'Uck, ick puey' barely captures it - Obviously, a condition to be prevented by most reasonable means no doubt...and if those approaches do not help - I entirely support a venting gastrostomy or PEG for palliation. Sincerely, Harlee S. Kutzen, MN, PHCNS-BC, AHPCN-BC, APRN, ACRN Instructor of Nursing LA State Univ. Health Sciences Center New Orleans, LA [Submitted on: 10/20/2010 by: Harlee S. Kutzen, MN, PHCNS-BC, AHPCN-BC, APRN, ACRN [hkutz1@lsuhsc.edu]]


131. Palliative Care is sexy. This pt was being perfectly managed with octreotide. Of course, if it is necessary, but I have yet to have needed to order a palliative peg. This pt is days from death and as one of the staff RN's said "who's driving this money train?" [Submitted on: 10/20/2010 by: Rebecca Gagne Henderson [rebecca@endoflifedirectives.org]]

131. Palliative Care is sexy. Interesting. In tumor board today a “palliative total gastrectomy” was suggested to relieve bleeding related to carcinomatosis/gastric cancer in an 88 year old! We do need to be vigilante in our efforts to “defend” the meaning of palliation. [Submitted on: 10/21/2010 by: Kathleen Fahey [kathleen_fahey@sbcglobal.net]]

131. Palliative Care is sexy. I am wondering if there has been any honest thoughtful discussion re goals of care. Is the PC team involved or was this issue an incidental finding? If days from death, and symptoms managed, inserting a PEG is not usually appropriate. The risks involved with the procedure itself are a concern. Of course, there are many instances that a PEG, Trach or shunt are palliative. It depends where the patient is in his disease trajectory. I find that many providers who find themselves at the end of the reasonabletreatment- options- rope usually hang themselves with it by suggesting another treatment or procedure because they just don't know what else to say. Many providers have great difficulty in saying nothing and then dealing with the outpouring of sadness and grief. I try to have these meetings with providers and when they have nothing else to say I help them find the words (or sometimes just butt in!). Of course, we avoid the "there is nothing else to do" as we know this is not true. When I worked in home hospice, I often encountered families who would tell me that there "was nothing more that can be done". I would try to put that into perspective for them by asking "If there is nothing more to do, why am I so busy?" Good luck with your work. It is reassuring to know we are all dealing with many of the same issues in this sexy line of work we have chosen! At least we will never be board!! [Submitted on: 10/21/2010 by: Martha Quigley [marthaquigley@yahoo.com]]

131. Palliative Care is sexy. Palliative VP! Education NEEDED! Wow. Also, on the question of on-call pay. Our nurses are poorly paid at $4/hr. An NP should make far more. Maryanne


[Submitted on: 10/21/2010 by: Maryanne Kehoe [Maryanne.Kehoe@cahpc.org]]

131. Palliative Care is sexy. Being the “Devil’s Advocate” here (I know; there’s always one in the crowd…) I wonder if the practitioners are using this verbiage specifically because there was a discussion of goals and to make certain that it’s understood that the intervention is not an “aggressive” treatment, but being used to palliate a symptom and achieve better quality of life. As several of our colleagues have said, some of these interventions can be used for this purpose. Just a thought. (Although I do trust Rebecca’s judgment that this is probably not the case.) Thanks, Jeannie Jeannette (Jeannie) Meyer, RN, MSN, CCRN, CCNS, PCCN, ACHPN® Clinical Nurse Specialist for Palliative Care Santa Monica UCLA Medical Center and Orthopaedic hospital 1260 15th St. # 1024 Santa Monica, CA 90404 Palliative Care Office #310 319-5112 Direct line # 310 319 1204 Blackberry#310 210-9270 Fax # 310 319 3226 Pager#310206-8477 Extension 96023 [Submitted on: 10/21/2010 by: Jeannette (Jeannie) Meyer, RN, MSN, CCRN, CCNS, PCCN, ACHPN® [JMeyer@mednet.ucla.edu]]

131. Palliative Care is sexy. My concern is that the “palliative” may still be misunderstood. I still have discussions with oncologists who believe that any treatment that is not curative is palliative. Karen McGough ARNP ACHPN® [Submitted on: 10/21/2010 by: Karen McGough ARNP ACHPN® [kmcg14@verizon.net]]

131. Palliative Care is sexy. I'll admit I got this definition off of Wikipedia (not the most reliable source) but it made the point I want to make. (See below) Palliative care providers have struggled for years trying to get the medical community to understand that Palliative Care is NOT end of life care or hospice. Palliative Care can be years before they are close to death. So, if a patient who has Stage IIIB Lung cancer, where a cure is usually not achieved, then the chemotherapy they are receiving IS palliative if the goal is to help shrink the tumor, unblock an obstructive airway, relieve pressure on the diaphragm, etc. If a patient has heart failure, the new pacemakers can improve quality of life. A VP shunt can be palliative and improve the patients quality of life. Palliative Care does not exclude aggressive treatments at times. Honestly, I'm excited that after 10 years of struggling to initiate a Palliative Care program, my hospital executives are reading about and hearing this phrase used everywhere. They have now included a Palliative Care program in their strategic plan for 2011. Just think, in the broadest sense of palliative care, taking acetaminophen and decongestants for a cold (which is non-curative) is Palliative Care. "Palliative care (from


Latin palliare, to cloak) is any form of medical care or treatment that concentrates on reducing the severity of disease symptoms, rather than striving to halt, delay, or reverse progression of the disease itself or provide a cure. The goal is to prevent and relieve suffering and to improve quality of life for people facing serious, complex illness. Nonhospice palliative care is not dependent on prognosis and is offered in conjunction with curative and all other appropriate forms of medical treatment." Lori F. Schiller, MSN, RN, NP-C, ACHPN® Nurse Practitioner One Hiland Drive Petoskey, MI 49770 (231)487-4825 Office (231)487-3019 Voice Mail (231)881-4345 Cell phone lschiller@northernhealth.org [Submitted on: 10/22/2010 by: Lori F. Schiller, MSN, RN, NP-C, ACHPN® ]

131. Palliative Care is sexy. My concern is that the “palliative” may still be misunderstood. I still have discussions with oncologists who believe that any treatment that is not curative is palliative. Karen McGough ARNP ACHPN® [Submitted on: 10/21/2010 by: Karen McGough ARNP ACHPN® [kmcg14@verizon.net]]

131. Palliative Care is sexy. I did not go into grizzly details in the interest of HIPPA. I will say that a shunt on a patient in a vegetative state who was taken off of comfort measures is not palliative. I would love to say more, and there are more details that make this case even sadder, let alone immoral. Of course we are not just eol, and I am glad of that as well. I have started a housecall practice for frail elderly to improve their quality of life. I get excited when my palliative interventions make my inpatients feel so much better they are able to go home and be followed. Frankly, some things never change. Nurses need to trust that other nurses may know a thing or two, and the tone of your email was judgmental and condescending. I've been doing this long enough to remember when patients were abandoned when "nothing could be done". We do need to make sure that our specialty is not usurped by the people driving the runaway money train. I would like to believe that the reason some have become interested s because they have caught the vision and not because it is now reimbursable, alas, I have my doubts. Rebecca [Submitted on: 10/22/2010 by: Rebecca Gagne Henderson [rebecca@endoflifedirectives.org]]

131. Palliative Care is sexy. To me? Palliative care is following what the patient’s wishes are and providing quality of life to the end...........to the patient’s wishes. Sandra Kelly RN B.S.N. ELNEC Palliative Care Battle Creek Health System Phone: 269-966-8446 Pager: 269-4100110 "When your heart speaks, take good notes." -Judith Campbell


[Submitted on: 10/22/2010 by: Sandra Kelly RN B.S.N. ELNEC [kellys@trinity-health.org] ]

131. Palliative Care is sexy. I have worked oncology, hospice and now palliative care for almost 25 years. I am awed by what we all do on a daily basis to help patients through very difficult times. My response was out of the frustration that we are quibbling amongst ourselves as to what palliative care is or can be. If we can't all agree then how do we expect the medical community, from whom we need to be partnering with, understand and entrust their patients to our care. I would hope that this listserv is available for all to share our thoughts openly and honestly. Lori F. Schiller, MSN, RN, NP-C, ACHPN® Nurse Practitioner One Hiland Drive Petoskey, MI 49770 (231)487-4825 Office (231)487-3019 Voice Mail (231)881-4345 Cell phone lschiller@northernhealth.org [Submitted on: 10/22/2010 by: Lori F. Schiller, MSN, RN, NP-C, ACHPN® [lschiller@northernhealth.org]]

131. Palliative Care is sexy. One more voice to thank, Lori for taking the time to compose this reminder that palliative care is much more than care given during the last few days/hours of life. Many times our patient's benefit from invasive procedures (like PEG tubes for gastric decompression that allow persons with a bowel obstruction to enjoy tasting food or fluids) and other treatments that have been mentioned in this series of measures. Invasive procedures are not always needed or welcome, but we need to consider all options based on the patient's goals of care. Cindy Frost APRN, BC, AHPN-C Nurse Practitioner Palliative Care Maine Medical Center Portland, Maine [Submitted on: 10/24/2010 by: Cindy Frost APRN, BC, AHPN-C [cfrostanp@yahoo.com]]

131. Palliative Care is sexy. Lori, thank you for your words that speak to the real heart of this issue...one embedded in reverencing life, relieving suffering and comforting always~. I, too, have been privileged to work in this wonderful profession for nearly 25 years and despite the ongoing challenges (that are part of any human experience), I believe we have truly come light years as a profession that is deeply respected and ever more integrated into the core of quality care/service excellence. To say “Palliative Care is sexy this year” seems to dilute and diminish the true “attraction” which is enfleshed in the countless lives/stories of those who teach each of us what it means to embrace our “hidden wholeness”. When all is said and done, it seems as though the most compelling reason to choose palliative care begins within the context of cultivating a human relationship(s) that strengthens fragile trust, encourages courageous conversations and is grounded in highly competent,


respectful, compassionate care. Anne Butler, MSN, ANP-BC, CHPN速 United Healthcare Evercare Hospice Clinical Services Manager Elkridge, MD 21075 410-379-3581 [Submitted on: 10/24/2010 by: Anne Butler, MSN, ANP-BC, CHPN速 [anniem416@gmail.com]]

131. Palliative Care is sexy. I got into this conversation late as I was out of town for much of it. It is clear that the discussion got away from the original question and concern. The patient in the original scenario was days from death and the goals of the patient did not seem to include eating for pleasure. The concern, and I have been seeing this too, is that sometimes these procedures are being done when the goals of the patient do not support them. The question then, is how can we advocate for our patients and respond in that instance? It seems to me that perhaps a revisit with the primary team, or a family meeting, to establish or clarify goals of care would be in order. Beverly Douglas ARNP ACHPN速 LifePath Hospice, Tampa Florida [Submitted on: 10/24/2010 by: Beverly Douglas ARNP ACHPN速 [bevdouglas@tampabay.rr.com]]

131. Palliative Care is sexy. G-tube patient now expired. Shunt patient, still too unstable to go to LTC and maintained in vegetative state to wait and lay victim to the next microbe, which will throw him into sepsis and the ICU. Trach patient will get a POLST this week and move to LTC. Yeah, I would say we have more work to do. Rebecca [Submitted on: 10/24/2010 by: Rebecca Gagne Henderson [rebecca@endoflifedirectives.org]]

131. Palliative Care is sexy. Hi Beverly, What I have done is: "I am the patient's advocate and my patient does not desire to have .......................... the procedure you are discussing performed, the answer to your desire to perform this task is no." The procedure is never performed-we as nurses are advocates to our patients, when we observe the wrong we stand up and are heard. Sincerely, Cheryl Cheryl B. Dworman, BSN, RN, CDCS Cheryl B. Dworman, Inc. Nurse Consultant-Patient Advocate P.O. Box 251981 West Bloomfield, MI 48325-1981 [Submitted on: 10/25/2010 by: Cheryl B. Dworman, BSN, RN, CDCS [cbdinc2001@yahoo.com]]


131. Palliative Care is sexy. I agree, but not there 7 days a week, and much like Tigger, I am the only one. I am thankful that we will be able to hire 1.8 FTE NP's by years end, so we will do better in the future. [Submitted on: 10/25/2010 by: Rebecca Gagne Henderson [rebecca@endoflifedirectives.org]]

131. Palliative Care is sexy. Rebecca, I shouldn't prolong a long-enough thread, but…. even physicians in the journal literature and conferences sometimes refer to palliative care not being "sexy" enough. So, you're in good company. It's been commonly used to make an analysis of what's attractive at the moment.. e.g. neurosurgery is more sexy than palliative care. Thanks for sharing. Anna Anna Kostaroff, MS, RN, CHPN® Palliative Care Coordinator Henry Ford Wyandotte Hospital 734-287-9043 (office) [Submitted on: 10/25/2010 by: Anna Kostaroff, MS, RN, CHPN® [AKostar1@hfhs.org]]

131. Palliative Care is sexy. Rebecca, I appreciate your honesty. Bad news is we are all human. But we still get up and try every day to help someone feel better, to make a difference in someone else's life. Yes, we choose this work for very personal reasons, but it can still be very taxing. Hard to see it boiled down to a buzz word. Support for one another is crucial. Have you read "When Professionals Weep" by Renee S. Katz & Theresa A. Johnson? It's really good and speaks to the pain that you talk about. Very validating. I heard Renee Katz speak and she is amazing. Take care. Patricia Dowd-Timonen RN CHPN® MSN CNS-BC [Submitted on: 10/25/2010 by: Patricia Dowd-Timonen RN CHPN® MSN CNS-BC [dowdtim@comcast.net]]

Question 132. Palliative Sedation. Hi, I was wondering if any of you regularly use versed in end-of-life care and if so, can I call you to talk about its use. Let me know what is a good time to call and a contact number. Thanks in advance. Karen ______________________________ Karen Mulvihill MSN, APRN, ACHPN® Coordinator Danbury Hospital CARES Program Hospitalist Service [Submitted on: 5/12/2010 by: Karen Mulvihill MSN, APRN, ACHPN® ] Answers


132. Palliative Sedation. Hi At Cedars with palliative extubations I almost regularly use 2mg of versed IVP before extubation. Rita Hand [Submitted on: 5/12/2010 by: Rita Hand [Rita.Hand@cshs.org] ]

132. Palliative Sedation. Hi, Karen. We have a Palliative Sedation policy. Feel free to e-mail me off-line if you’d like to discuss. Take care, Jeannie Jeannette (Jeannie) Meyer, RN, MSN, CCRN, CCNS, PCCN, ACHPN® Clinical Nurse Specialist for Palliative Care Santa Monica UCLA Medical Center and Orthopaedic Hospital 1250 16th St. Santa Monica, CA 90404 Palliative Care Office # 310 319-5112 Blackberry # 310 210-9270 Pager #310 206-8477 Extension 96023 [Submitted on: 5/12/2010 by: Jeannette (Jeannie) Meyer, RN, MSN, CCRN, CCNS, PCCN, ACHPN® [JMeyer@mednet.ucla.edu]]

132. Palliative Sedation. NHPCO reissued their policy on this and has done a media blitz. Constance Dahlin [Submitted on: 5/12/2010 by: Dahlin, Constance M.,Msn,Rn,Cs [cdahlin@partners.org]]

132. Palliative Sedation. NHPCO has just come out with a statement on palliative sedation. I think it is very important that APN's are clear about the very definite distinction between a terminal wean (discontinuing a therapy that cannot benefit the patient) and palliative sedation (inducing sedation for symptoms that are intractable and intolerable without hastening dying). Thank you, Mimi Mahon Mimi Mahon, PhD, RN, FAAN Advanced Practice Nurse, Palliative Care & Ethics Associate Professor School of Nursing George Mason University College of Health & Human Services 4400 University Drive MSN3C4 Fairfax, VA 22030 703.993.1932 mmahon@gmu.edu [Submitted on: 5/12/2010 by: Mimi Mahon, PhD, RN, FAAN [mmahon@gmu.edu]]

132. Palliative Sedation. I agree. I was actually thinking about induced sedation for intractable symptoms. Jeannette (Jeannie) Meyer, RN, MSN, CCRN, CCNS, PCCN, ACHPN® Clinical Nurse Specialist for Palliative Care Santa Monica UCLA Medical Center and Orthopaedic Hospital 1250 16th St. Santa Monica, CA 90404 Palliative Care Office # 310


319-5112 Blackberry # 310 210-9270 Pager # 310 206-8477 Extension 96023 [Submitted on: 5/12/2010 by: Jeannette (Jeannie) Meyer, RN, MSN, CCRN, CCNS, PCCN, ACHPN® [JMeyer@mednet.ucla.edu]]

132. Palliative Sedation. One of the best documents I've seen on this is available at no cost to you all. The guidelines are there as well as medications to use, and tools to assess the comfort of the patient. It is at this site: http://www.eapcnet.org/download/forProjects/Sedation/PMJ%2823.7%29Cherny_et_al.pd f European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care Palliative Medicine 23(7) 581–593 ! The Author(s) 2009 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0269216309107024 pmj.sagepub.com Nathan I Cherny Shaare Zedek Medical Center, Department of Oncology, Cancer Pain and Palliative Medicine Unit, Jerusalem, Israel Lukas Radbruch Chair of Palliative Medicine, Aachen University, Aachen, Germany The Board of the European Association for Palliative Care Milan, Italy Abstract The European Association for Palliative Care (EAPC) considers sedation to be an important and necessary therapy in the care of selected palliative care patients with otherwise refractory distress. Prudent application of this approach requires due caution and good clinical practice. Inattention to potential risks and problematic practices can lead to harmful and unethical practice which may undermine the credibility and reputation of responsible clinicians and institutions as well as the discipline of palliative medicine more generally. Procedural guidelines are helpful to educate medical providers, set standards for best practice, promote optimal care and convey the important message to staff, patients and families that palliative sedation is an accepted, ethical practice when used in appropriate situations. EAPC aims to facilitate the development of such guidelines by presenting a 10-point framework that is based on the pre-existing guidelines and literature and extensive peer review. Introduction Therapeutic (or palliative) sedation in the context of palliative medicine is the monitored use of medications intended to induce a state of decreased or absent awareness (unconsciousness) in order to relieve the burden of otherwise intractable suffering in a manner that is ethically acceptable to the patient, family and health-care providers. Sedation is used in palliative care in several settings: (1) transient sedation for noxious procedures; (2) sedation as part of burn care; (3) sedation used in end of life weaning from ventilator support; (4) sedation in the management of refractory symptoms at the end of life; (5) emergency sedation; (6) respite sedation; (7) sedation for psychological or existential suffering. Procedural guidelines already exist for transient sedation for noxious procedures,1–4 in burn care5 and sedation used for end of life weaning from ventilator Judy Dobson,MSN, CNS,CHPN® 570-271-0444 Home 570-594-7175 Cell Hospice/palliative Care educator [Submitted on: 5/12/2010 by: Judy Dobson,MSN, CNS,CHPN® [pcnurse@verizon.net]]


132. Palliative Sedation. I have created a policy for the use of versed for intractable symptoms. I agree Mimi there is a distinction between the two. My question is more on the types of doses used and if anyone uses Versed without an actual policy...so as another Benzo option. Thanks Connie for the NHPCO update! I will be contacting those who responded to talk more about it. It seems like it is a medication issue at my institution, not so much an ethical one. Karen :) Karen Mulvihill MSN, APRN, ACHPN® Coordinator Danbury Hospital CARES Program Hospitalist Service [Submitted on: 5/12/2010 by: Karen Mulvihill MSN, APRN, ACHPN® [Karen.Mulvihill@danhosp.org]]

132. Palliative Sedation. Karen, We use it for seizures and third line for agitation separate from Palliative Sedation. Feel to call or email me. We have an independent palliative medicine consult service across multiple hospitals and hospices. Mary Mary Lawhon Triano, CRNP-C, ACHPN® Institute of Palliative Medicine PC 1-888-861-6255 pmt1209@gmail.com www.iopmpc.com [Submitted on: 5/12/2010 by: Mary Lawhon Triano, CRNP-C, ACHPN® [pmt1209@gmail.com]]

132. Palliative Sedation. I ordered it routinely for a patient that had a huge draining fistula from colon cancer whose wound care was especially painful. This patient was able to tolerate 2 mg SQ twice a day with wound care in addition to a high dose pain regimen. The patient survived for almost three months after that intervention was initiated. Anne Jeffcott, CNP, ACHPN® Chillicothe, Ohio [Submitted on: 5/12/2010 by: Anne Jeffcott, CNP, ACHPN® [ajeffcott@roadrunner.com]]

132. Palliative Sedation. I have to say that the article below should be used by EVERYONE in palliative care. It provides a wonderful framework on establishing guidelines! Karen Karen Mulvihill MSN, APRN, ACHPN® Coordinator Danbury Hospital CARES Program Hospitalist Service [Submitted on: 5/14/2010 by: Karen Mulvihill MSN, APRN, ACHPN® [Karen.Mulvihill@danhosp.org]]


Question 133. Palliative Chemotherapy. Hello, Does anyone have information on palliative benefits of trastuzumab without any adjuvant on HER2 positive metastatic breast cancer? This is being offered by another facility and the patient is requesting our facility to reimburse it as a palliative therapy. I do not believe it would be appropriate for this patient with liver failure and dependence on oxygen therapy, and prefer to focus on symptom control and interdisciplinary support. There are many complex psychosocial and economic issues at play, which I will not go into here but I would appreciate any insights in order to provide appropriate education to the patient and family. You may reply to me here or at ppollina@nah.org. Thank you. Patti Pollina CHPN®, APN, NP-C Nathan Adelson Hospice [Submitted on: 11/7/2010 by: Patti Pollina CHPN®, APN, NP-C [ppollina@earthlink.net]] Answers 133. Palliative Chemotherapy. I had a similar question recently about reimbursement for palliative chemo for symptoms related to colon cancer. This patient also has late stage Muscular Dystrophy and is a quadraplegic related to that diagnosis. I was told that the Hospice organization has to consider not only the cost of the chemotherapy itself, but also the cost of subsequent tests that are often indicated/desired. Although each case is considered individually, apparently it is the general custom of my organization to avoid accepting a patient who already has that plan in place. If a patient is already enrolled in the organization and develops symptoms that would be best controlled by palliative chemo, he/she might negotiate for payment, however. Polly Hawkes MSN FNP ACHPN® Hospice of the Piedmont and Piedmont Palliative Care Charlottesville, VA [Submitted on: 11/7/2010 by: Polly Hawkes MSN FNP ACHPN® [polly.hawkes@hopva.org]]

133. Palliative Chemotherapy. Would need to know EF (cardiotoxicity a huge issue especially if they got Taxol or Adriamycin) as well as her ECOG performance status or other functional assessment to ensure she is even a candidate to receive. Also, her blood count. Not sure if you know the drug or it's uses. It is used for metastatic breast cancer not responsive to other chemotherapy agents, including anthracycline but can be given alone to block the growth of breast cancer cells in HER2neu + patients. Oncologist will call anything that isn't curative a "palliative" treatment. In the past, I've asked the oncologist the question "is the drug truly palliating a symptom"? Will it decrease pain, dyspnea, etc. If not then the risk of side effects outweighs the benefit and I would not give. If you want to discuss in more detail contact me at the email below. Lori Lori F. Schiller, MSN, RN, NP-C, ACHPN® Nurse Practitioner Hospice of Little Traverse Bay One Hiland Drive Petoskey, MI 49770 (231)487-4825 Office (231)487-3019 Voice Mail (231)881-4345 Cell phone


lschiller@northernhealth.org [Submitted on: 11/8/2010 by: Lori F. Schiller, MSN, RN, NP-C, ACHPN® lschiller@northernhealth.org]

Question 134. Palliative Service Admitting Practices. To those of you with hospital palliative care services, do you admit patients or assume attending privileges? If yes, does your facility allow APN's to independently admit patients? We are having a discussion regarding who admits patients when it is presumed to be for end of life care. Currently that is focused on oncology but other situations arise as well. I work with a palliative care physician and she will often admit patients. However, when she is off, I cover the service. Our hospital bylaws mandate a physician see patients every day. So we're OK with consults, but not OK when she is admitting/attending. Wonder what others are doing? Thanks, Helen Wellens MSN, GNP, ACHPN® Bellin Health Green Bay, WI [Submitted on: 4/20/2010 by: Helen Wellens MSN, GNP, ACHPN® [hwellens@new.rr.com]] Answers 134. Palliative Service Admitting Practices. At our hospital, either the hospitalists or surgeons are the admitting and attending physicians. We act in a consulting role only for palliative care. The hospitalists and surgeons all have NPs/PAs who may see the patients daily incident to the MDs. The hospitalist NPs/PAs may write the admitting orders from the ER but it is discussed with the MD first. The other specialists (oncology, cardiology, renal, GI, etc) are also only in a consulting role. They can no longer be the admitting or attending physician. It makes it a bit less confusing as to who is running the show. Jennifer Bobolia, FNP ACHPN® Palliative Care Service Old Colony Hospice-Signature Healthcare Brockton Hospital Randolph, MA [Submitted on: 4/20/2010 by: Jennifer Bobolia, FNP ACHPN® [jjbobolia@comcast.net]]

134. Palliative Service Admitting Practices. Are you hired by the hospital or are you a hospital employee? Who is your collaborative MD? And what does that relationship look like? Thia [Submitted on: 4/20/2010 by: Kociszewski, Cynthia [ckociszewski@thocc.org]]

134. Palliative Service Admitting Practices. We are a consulting service only at our hospital. I


do not admit patient or assume attending. Many times if it is an EOL situation, either the oncologists or hospitalists have admitted the patient. Sometimes the admitting physician is pulmonology. Therefore, the patient is always seen by an MD from one of these practices, and I can see as consulting provider. Jennifer L. Huggins, MSN, ANP-BC Bon Secours Saint Francis Health System Palliative Care Team 864.255.1304 (office) 864.444.7788 (cell) jennifer_huggins@bshsi.org [Submitted on: 4/20/2010 by: Jennifer L. Huggins, MSN, ANP-BC [jennifer_huggins@bshsi.org]]

134. Palliative Service Admitting Practices. We (myself, another NP and a part time MD) are employees of a local, free standing hospice. We are fully credentialed members of the hospital medical staff. We have 2 supervising MDs, one is the hospice medical director and the other is a family practice MD who is also certified in hospice/palliative care. We are pretty independent in our practice as the part time MD is only on site with us one morning per week. Otherwise, they are available by phone/email for questions. We deal more with the hospitalists than our own MDs on a daily basis. If you have other questions, email me directly jjbobolia@comcast.net or jbobolia@oldcolonyhospice.com. Jen [Submitted on: 4/20/2010 by: Jennifer Bobolia, FNP ACHPN速 [jjbobolia@comcast.net]]

134. Palliative Service Admitting Practices. We are part of a hospitalist service and, as such, admit patients routinely--both direct admits if they are hospice patients coming in for GIP and ED patients who have obvious end of life needs. In our hospital, the requirement is for a "licensed practitioner" visit every day--when have lots of APNs (and Pas) who can do the daily visits, including admits. It may be a state to state variance (or and antiquated practice in your hospital?) Feel free to contact me directly for more information. Sharmon Sharmon Figenshaw ARNP PRMCE Hospitalist/ Palliative Care Sharmon.figenshaw@providence.org Work 425-261-4076 Work cell/Pager 425-903-1505 Cell 360-201-0475 [Submitted on: 4/20/2010 by: Sharmon Figenshaw ARNP [sharmonrn@earthlink.net]]

134. Palliative Service Admitting Practices. Hi Helen, I am a Nurse Practitioner who works with a physician. We have an independent consult service in palliative medicine in our community. We are consulted on patients under the physicians name or our service name in the hospitals or we have also been asked to provide primary care for the oncologists for their patients who need to be admitted with heavy symptom burden. The patients are admitted under the physician's name. We see the patients every day Monday - Friday but


we alternate on the weekends. This has worked out for us. If we get a new consult on the weekend and I see the consult, the physician needs to see the consult in order to comply with hospital bylaws and to bill for Medicare. I hope this helps. If you want to talk more, you can email me directly. Sincerely, Mary Lawhon Triano, CRNP-C, ACHPN Institute of Palliative Medicine, PC 1-888-861-6255 pmt1209@gmail.com www.iopmpc.com [Submitted on: 4/20/2010 by: Mary Lawhon Triano, CRNP-C, ACHPN [pmt1209@gmail.com]]

Question 135. Palliative Treatment for a 32 year old Cystic Fibrosis Patient. Hi everyone, I am wondering if there is anyone out there who has cared for an adult CF patient who would be willing to share any pearls of wisdom. I have never treated a CF patient. I am studying up and will speak to my med director, but I wanted to check with you all first. Thank you, Rebecca Gagne Henderson RN MSN FNP-c Palliative Services Long Beach Memorial Medical Center [Submitted on: 3/8/2010 by: Rebecca Gagne Henderson RN MSN FNP-c [rebecca@endoflifedirectives.org]] Answers 135. Palliative Treatment for a 32 year old Cystic Fibrosis Patient. I read your message and had to think for awhile. A few years ago I took care of two sisters who were in their late 50s with CF. They were very cachectic. The major issues were around boney pain secondary to cough and dyspnea. They also had major issues with anxiety and depression. We used opioids as our workhorse with good pulmonary toilet. We worked closely with their pulmonary doc to maximize their meds as long as it was a benifit. It was a tough situation particularly for the sister who survived longer knowing the outcome. Hope this is helpful. As I recall, there is not much in the literature. Sincerely,, Mary Lawhon Triano, CRNP-C, ACHPN速 Institute of Palliative Medicine PC 1-888-861-6255 pmt1209@gmail.com www.iopmpc.com [Submitted on: 3/8/2010 by: Mary Lawhon Triano, CRNP-C, ACHPN速 [pmt1209@gmail.com]]

135. Palliative Treatment for a 32 year old Cystic Fibrosis Patient. We have a 20 year old presently, we have treated a 32 year old in the past who died while on our palliative care consult service. Air hunger is present, and anxiety. Even more pronounced is the lack of developmental growth and how that impacts coping with chronic illness. In both of these cases considering the mother's influence was critical. Any strategy to impact pain and


anxiety is potentially effective, including psycho-social and right brain interventions. Roxanol, an antidepressant, art or music therapy, for example. Jan Mecklenburg, RN CHPN速 UHCMC Cleveland, OH [Submitted on: 3/10/2010 by: Jan Mecklenburg, RN CHPN速 [jan.mecklenburg@gmail.com]]

135. Palliative Treatment for a 32 year old Cystic Fibrosis Patient. I have worked for years with the adult CF population, Rebecca. We co-manage with the Adv Pulm Dz program at my hospital. The disease affects all secretory functions- lungs, sinuses, pancreas, GI tract. Bowel programs are the norm even without opiates. Most of the patients I treat have been ill for their entire lives. They are sophisticated consumers of medical care and know what they want- both in terms of treatment and in terms of palliation. I have found that most people fall into two groups- people who have learned to live and thrive with chronic disease and those who have great difficulty managing and have found a better-living-through-chemistry approach to coping. They are the folks who want their medications while in hospital to be given IV push. Especially opiates and diphenhydramine. Most of the care provided is palliative and is intended to control symptoms and infections. Lung transplant offers the oppurtunity for more time but the 5 year survival is low. Many people have great tolerance to opiates and malabsorption is a problem. It is typical for our patients to be on high dose opiates and aggressive bowel programs (senna, miralax, sorbitol, lactulose, pancreatic enzymes) to prevent obstipation and toxic megacolon. Please call me or write to me off line. I could talk your ear off. Hmmm...I think I see a poster coming or a talk. Linda Blum, GNP CPMC San Francisco Pager- 415-232-0772 [Submitted on: 3/10/2010 by: Linda Blum, GNP [lblumgnp@gmail.com]]

Question 136. Patient Narcotic Contract for Palliative Care. We are currently considering developing and implementing a contract for patients on narcotics. Does anyone currently use this in their practice? If so: 1. Would you share a copy with me or refer me to a good resource? 2. Do you use it for all patients? 3. If you do not use it for all patients, what criteria do you use for having a pt. sign a pain management contract? Thanks for your help. Mark Waters, RN, MPH, ANP-C Palliative Care Hospice of Wake County mwaters1@nc.rr.com mwaters@hospiceofwake.org [Submitted on: 5/12/2010 by: Mark Waters, RN, MPH, ANP-C [mwaters1@nc.rr.com]] Answers 136. Patient Narcotic Contract for Palliative Care. I don't work currently in palliative care.


However, if you look at the Jan/feb issue of JHPN you will see a sample in the article: Pain Management and substance use disorder in advanced illness by Anne Walsh and Kathleen Broglio. [Submitted on: 5/12/2010 by: [kathleen.broglio@gmail.com]]

136. Patient Narcotic Contract for Palliative Care. **At my previous employment, we implemented the attached pain agreement in an outpatient pain and palliative care clinic after a rash of trouble. We were finding that our patient population really needed clear "if this...then that" language. We required it for all patients. It really did seem to help clarify expectations from the outset. Jennifer Hester, DNP, APRN, ACHPN速 Palliative Care Clinical Nurse Specialist The Christ Hospital, Room 3147 2139 Auburn Avenue Cincinnati, OH 45219 513-585-4157 jennifer.hester@thechristhospital.com **Please contact submitter directly via email to obtain. [Submitted on: 5/14/2010 by: Jennifer Hester, DNP, APRN, ACHPN速 [Jennifer.Hester@thechristhospital.com]]

136. Patient Narcotic Contract for Palliative Care. **I am attaching two documents that we use. First is our standard patient information that goes to all patients on their first visit which provides basic information about the ground rules. We prefer not to put all patients on a written agreement (agreement is preferred term, because you cannot really establish a legal contract according to our risk management advisors) and reserve the written agreement as a behavioral modification intervention when we identify patients that have demonstrated problems in managing their medications, particularly those with documented substance abuse disorders and we want to reinforce participation in appropriate mental health care as a part of our ongoing management of their pain. We also give all our new patients the FDA handout "A Guide to Safe Use of Pain Medicine" which can be accessed at http://www.fda.gov/downloads/ForConsumers/ConsumerUpdates/ucm095742.pdf Deborah Thorpe, PhD, APRN, ACHPN速, AOCNS Pain Medicine and Palliative Care Huntsman Cancer Institute University of Utah 2000 Circle of Hope Rm 2381 Salt Lake City, UT 84112 Phone (801)585-0254 FAX (801)581-4416 **Please contact submitter directly via email to obtain. [Submitted on: 5/20/2010 by: Deborah Thorpe, PhD, APRN, ACHPN速, AOCNS [Deborah.Thorpe@hci.utah.edu]]

Question


137. Palliative Care Social Worker Role and Duties. Our hospital based PC program recently added a full-time, dedicated SW to our PC team! As the program manager, I'm now challenged with further defining this role and determining what duties fall within the PC SW's scope vs. the SW assigned to each unit. Unfortunately, there's been great resistance from the social workers on the units who want the PC SW to basically do everything regarding nursing home placement, transfer coordination, etc. Doing this has become quite cumbersome and has negatively impacted the ability of our dedicated PC SW to see other PC referrals in a timely manner, etc. We unfortunatey lack the teamwork required to work together on this as a shared responsibility. What's being done in your programs? What is reasonable? I feel a team approach is most appropriate, however that doesn't seem to be a truly viable option at this time. What would be helpful for me to know about your experiences? Your insight is greatly appreciated, kmr Kristi M. Griffith, BSN, RN, CHPN速 Manager Palliative Care Methodist Charlton Medical Center Dallas, TX kristigriffith@mhd.com [Submitted on: 7/17/2010 by: Kristi M. Griffith, BSN, RN, CHPN速 [kristimgriffith@aol.com]] Answers 137. Palliative Care Social Worker Role and Duties. Hi Kristi Unfortunately, it sounds like precedent has already been set with the PC SW doing the things that were traditionally unit based SW functions. I think you need a clear, well-developed description of the PC team role and function and specifically a job description for your PC SW to support the floor SW but not to be their 'overflow fix-all'. The job description should be specific to the role and responsibilities for PC and how they enhance patient care. For example, the PC SW will work collaboratively with the floor SW to ensure that the placement arranged by the floor SW will allow for hospice care and the PC SW will facilitate the hospice referral if that is the families/patients choice. You may want to check the CAPC website for samples of job descriptions and Stacy Remke is the SW at Minnesota Children's Hospital and although a pediatric program she is a great resource. I have included her on this e-mail. Stacy is also a member of the SWHPN as is Stacy Orloff at Suncoast in FL. Both are wonderful resources. NASW also has standards for SW for hospice and palliative care and they may help you frame the job description. Once that is done I would make sure that it is widely distributed and meet with the SW staff to answer any questions, etc. to make sure they are aware of how the PC SW role will be as you move forward. Good Luck. Christy Torkildson, RN, PHN, MSN [Submitted on: 7/17/2010 by: Christy Torkildson, RN, PHN, MSN [torkc@sbcglobal.net]]

Question 138. PCA by Authorized Proxy Protocols. Anyone have any protocols for PCA by proxy? Rebecca Gagne Henderson RN MSN FNP ACHPN速 Long Beach Memorial Medical Center


[Submitted on: 7/29/2010 by: Rebecca Gagne Henderson RN MSN FNP ACHPN® [rebecca@endoflifedirectives.org]] Answers 138. PCA by Authorized Proxy Protocols. ASPMN (American Society of Pain Management Nursing) has a position statement on PCA proxy. Check their website. Marsha Farrell, BSN, RN-BC, CHPN® [Submitted on: 7/30/2010 by: Marsha Farrell, BSN, RN-BC, CHPN® [mfarrell@hospicefamilycare.org]]

Question 139. PCA Infusion Policy. Does anyone have a policy they would be willing to share related to IV/SQ infusion with use of PCA pumps in home care or inpatient facility settings? ThanksMaria Ferrell, ACNS-BC, ARNP, ACHPN® Kansas City Hospice & Palliative Care 9221 Ward Parkway, Suite 100 Kansas City, MO 64114 phone 816-363-2600, ext. 2714 fax 816-523-0093 mferrell@kchospice.org [Submitted on: 7/27/2010 by: Maria Ferrell, ACNS-BC, ARNP, ACHPN® [mferrell@kchospice.org]] Answers 139. PCA Infusion Policy. Here you go, Pat Coyne. SUBJECT: NURSING CARE OF PATIENTS RECEIVING PCA OR CONTINUOUS SUBCUTANEOUS OPIATES ORIGINAL DATE: JULY 1991 I. PURPOSE To properly follow monitoring and infusion procedures for patients receiving subcutaneous infusions with or without patient controlled analgesia (PCA) for pain management. II. POLICY Only health care professionals verified in analgesia infusion pump operations and in serviced in care of patients receiving opiate analgesia will care for patients receiving subcutaneous infusions/PCA for pain control. III. EQUIPMENT A. Ordered opiate B. Analgesia infusion pump C. PCA tubing - do not need anti-reflux Y-connector D. Gloves E. Alcohol wipes F. 2x2's G. Tape H. 27 gauge butterfly needle or specific sub Q infusion set. III. PROCEDURE A. Set up infusion device with ordered medication (see quick programming guide). B. Determine site of SQ infusion/PCA which may include: thighs, chest, abdomen, and the upper arms. C. Put on gloves. D. Wipe the insertion site with an alcohol swab and let air dry. E. Insert the butterfly needle (27 gauge) into subcutaneous tissues, using a 30 - 45 degree angle with the bevel down. If using subcutaneous infusion set insert the set at a 90 degree angle. F. Tape the needle securely in place. G. Apply sterile dressing. H. Initiate infusion. I. Change needle q 3 days and as needed. J. Monitor subcutaneous site q shift for signs of infection or discomfort. IV. NOTE A. Subcutaneous infusions should be initiated and maintained with the least amount of volume possible to avoid infusing more than 2.5 cc/hr. B. If an infusion of greater than 2.5 cc/hr is required to maintain patient's


comfort, change the concentration of the opiate or change the opiate (i.e., from morphine to hydromorphone). C. The PCA dose interval should be increased to 15-20 minutes, as absorption will not be as rapid as IV PCA. D. An IV solution should not be used with SC PCA. SUBJECT: NURSING CARE OF PATIENTS RECEIVING PCA OR CONTINUOUS SUBCUTANEOUS OPIATES ORIGINAL DATE: JULY 1991 REVIEW/REVISE: NOVEMBER 2003 EFFECTIVE DATE: SEPTEMBER 1995 I. PURPOSE To properly follow monitoring and infusion procedures for patients receiving subcutaneous infusions with or without patient controlled analgesia (PCA) for pain management. II. POLICY Only health care professionals verified in analgesia infusion pump operations and in serviced in care of patients receiving opiate analgesia will care for patients receiving subcutaneous infusions/PCA for pain control. III. EQUIPMENT A. Ordered opiate B. Analgesia infusion pump C. PCA tubing - do not need anti-reflux Yconnector D. Gloves E. Alcohol wipes F. 2x2's G. Tape H. 27 gauge butterfly needle or specific sub Q infusion set. III. PROCEDURE A. Set up infusion device with ordered medication (see quick programming guide). B. Determine site of SQ infusion/PCA which may include: thighs, chest, abdomen, and the upper arms. C. Put on gloves. D. Wipe the insertion site with an alcohol swab and let air dry. E. Insert the butterfly needle (27 gauge) into subcutaneous tissues, using a 30 - 45 degree angle with the bevel down. If using subcutaneous infusion set insert the set at a 90 degree angle. F. Tape the needle securely in place. G. Apply sterile dressing. H. Initiate infusion. I. Change needle q 3 days and as needed. J. Monitor subcutaneous site q shift for signs of infection or discomfort. IV. NOTE A. Subcutaneous infusions should be initiated and maintained with the least amount of volume possible to avoid infusing more than 2.5 cc/hr. B. If an infusion of greater than 2.5 cc/hr is required to maintain patient's comfort, change the concentration of the opiate or change the opiate (i.e., from morphine to hydromorphone). C. The PCA dose interval should be increased to 15-20 minutes, as absorption will not be as rapid as IV PCA. D. An IV solution should not be used with SC PCA. SUBJECT: NURSING CARE OF PATIENTS RECEIVING PCA OR CONTINUOUS SUBCUTANEOUS OPIATES ORIGINAL DATE: JULY 1991 REVIEW/REVISE: NOVEMBER 2003 EFFECTIVE DATE: SEPTEMBER 1995 I. PURPOSE To properly follow monitoring and infusion procedures for patients receiving subcutaneous infusions with or without patient controlled analgesia (PCA) for pain management. II. POLICY Only health care professionals verified in analgesia infusion pump operations and in serviced in care of patients receiving opiate analgesia will care for patients receiving subcutaneous infusions/PCA for pain control. III. EQUIPMENT A. Ordered opiate B. Analgesia infusion pump C. PCA tubing - do not need anti-reflux Y-connector D. Gloves E. Alcohol wipes F. 2x2's G. Tape H. 27 gauge butterfly needle or specific sub Q infusion set. III. PROCEDURE A. Set up infusion device with ordered medication (see quick programming guide). B. Determine site of SQ infusion/PCA which may include: thighs, chest, abdomen, and the upper arms. C. Put on gloves. D. Wipe the insertion site with an alcohol swab and let air dry. E. Insert the butterfly needle (27 gauge) into subcutaneous tissues, using a 30 - 45 degree angle with the bevel down. If using subcutaneous infusion set insert the set at a 90 degree angle. F. Tape the needle securely in place. G. Apply sterile dressing. H. Initiate infusion. I. Change needle q 3 days and as needed. J. Monitor subcutaneous site q shift for signs of infection or discomfort. IV. NOTE A. Subcutaneous infusions should be initiated and maintained with the


least amount of volume possible to avoid infusing more than 2.5 cc/hr. B. If an infusion of greater than 2.5 cc/hr is required to maintain patient's comfort, change the concentration of the opiate or change the opiate (i.e., from morphine to hydromorphone). C. The PCA dose interval should be increased to 15-20 minutes, as absorption will not be as rapid as IV PCA. D. An IV solution should not be used with SC PCA. [Submitted on: 7/28/2010 by: Patrick Coyne [user479069@aol.com]]

139. PCA Infusion Policy. Hi Maria. **Please find attached a policy and competency that I developed for my acute inpatient hospice unit. These are specifically written for the CADD Prizm pump, but you can modify them as needed. Hello also to Patrick - thanks for sharing your information on PCA/SQ infusions - great to see you here on the list-serv :) **Please contact submitter directly to obtain via email. [Submitted on: 7/28/2010 by: Mark Harmon [hospicepalliativern@gmail.com]]

139. PCA Infusion Policy. Hi **Attached is our hospital wide PCA policy. Elizabeth Fracchia RRN, BSN Palliative Care Program Coordinator William W Backus Hospital Norwich, CT **Please contact submitter directly to obtain via email. [Submitted on: 7/29/2010 by: Elizabeth Fracchia RRN, BSN [peachymor@comcast.net]]

Question 140. Physician Oversight of NP in Palliative Care Program. This message/question is for Michigan-based NP’s who work in the hospital providing Inpatient Palliative Care consultations. I am working with our team to develop a business plan for a NP-led, scatterbed design, Palliative Medicine Consultation Service. Our goal was to have a physician ONLY for collaboration, advising and peer-review. We are being told by the hospital that mid-level providers (APN’s and PA’s) cannot see a patient on their own in the hospital and bill for them. They state we must have a physician see the patient with us and co-sign our charts. The physician then bills for the service. They have made this decision due to a recent state survey. It is my belief that they have misinterpreted the information provided by the state. It is my understanding that a NP can see patients, make recommendations, write orders and follow those patients independently and bill for those services under their own provider numbers. As long as the mid-level is not employed by the hospital,l and not included in their cost report, they can bill under the E&M codes through Part B. If there is anyone currently practicing and billing for services without a physician being physically present and co-signing their charting, please respond to me at my email address below. Any information you have


would be greatly appreciated. Lori F. Schiller, RN, MSN, NP-C lschiller@northernhealth.org (231) 487- 3019 voice mail (231) 487 – 4228 fax [Submitted on: 5/10/2010 by: Lori F. Schiller, RN, MSN, NP-C [lschiller@northernhealth.org]] Answers 140. Physician Oversight of NP in Palliative Care Program. These rules are state specific. You are correct that you can do this; it is allowed under CMS guidelines. However, you need to research your state's practice act. Hope this is helpful. I could not tell what state you are from based on the information posted on the SIG. Good luck. [Submitted on: 5/10/2010 by: Sanders, Denise E [Denise.Sanders@tmcmed.org]]

140. Physician Oversight of NP in Palliative Care Program. We had a similar issue and I called our Dept of Public Health (owns our Nurse practice act) and they clarified our question and sent a letter clarifying the issue as well. The state rules over the federal (CMS) when it comes to our scope of practice, and can easily be misinterpreted. That was very helpful and may be an option for you. Karen ______________________________ Karen Mulvihill MSN, APRN, ACHPN® Coordinator Danbury Hospital CARES Program Hospitalist Service [Submitted on: 5/11/2010 by: Karen Mulvihill MSN, APRN, ACHPN® [Karen.Mulvihill@danhosp.org]]

Question 141. Preceptors Needed for APN Clinicals. Hello to all, I will begin clinicals in the master's program for Adult Health CNS at Wright State University in Dayton, Ohio in Sept. 2010. My goal is to complete the certification exam for ACHPN through NBCHPN to obtain my COA next summer (2011). My interest is to find clinical CNS/NP preceptors in Hospice or Palliative Care in the surrounding areas of Dayton, Toledo, Columbus, Findlay, Lima, Ohio who can best help me achieve these goals. I am looking forward to hear from anyone who can offer their time and clinical expertise. Thanks. Nancy Kirk RN, BSN, CHPN® St. Rita's Medical Center Palliative Care 730 W. Market St. Lima, Ohio 45801 419-302-6358 (personal cell) nekirk@woh.rr.com [Submitted on: 7/23/2010 by: Nancy Kirk RN, BSN, CHPN® [nekirk@woh.rr.com] ] Answers 141. Preceptors Needed for APN Clinicals. Hi, Nancy-- In Texas, the various nurse practitioner professional organizations (I belong to NTNPA--North Texas Nurse Practitioners Assn) ask members upon application whether they will be willing to serve as preceptors.


(You have to be a little careful there--I have seen some students who were classmates and had not done their own clinicals, volunteer to precept!) The few universities with which I am familiar also keep lists (they tend to be on Excel spreadsheets) of preceptors the schools have already approved, so you might check with Wright State's school of nursing as well. At the HPNA leadership weekend in Pittsburgh, I met an advanced practice nurse whose practice is in hospice and palliative care, and buttonholed him for how to focus my schooling so that I would emerge able to "be like him." He suggested that if an independent study were available, to take advantage of that as well. Lastly, he suggested finding preceptors who were doing what I wanted to do, and contract with them for my clinicals. I hope this helps! Christine Johnson RN CHPN LMFT FNP-S [Submitted on: 7/23/2010 by: Christine Johnson RN CHPN LMFT FNP-S [Christine_in_Van_Alstyne@BrianAndChristine.com]]

141. Preceptors Needed for APN Clinicals. Hello Nancy! We already have UG RN students on Tues and Weds with FP residents on Thurs AM. I would be willing to take you on Mondays and I could check to see if one of my colleagues could take you on Fridays if those days fit your schedule. Thursdays might even work some weeks. We operate an APRN-lead Palliative Care Consultation practice in the hospital at Grant Medical Center, a Level I Trauma Center. Cheers, Elaine Glass, RN, MS, CNS at 614-566-8513, M-R, 8-4:30. [Submitted on: 7/23/2010 by: Elaine Glass, RN, MS, CNS [elaineglass33@hotmail.com]]

Question 142. Pt/Family Satisfaction Surveys: Skewed Results. A question for those with inpt consult services about results of Family/Pt Satisfaction Surveys: Do patients/family remember who you are and can they differentiate the care you provided at a remove of X nos of months/weeks? Background: Our survey is adapted from CAPC; sometimes the respondent will identify self or pt. And more often than I like, there is anger/discontent in the response, often confirmed in the free text comment. My impression is that this dissatisfaction seems to reflect situations, when we were called in usually at the end of a very difficult course.— protracted stay, poor communication, reluctant attending…By the time of contact respondents seem to be conflating all practitioners whether or not the last piece of hospitalization were well managed Also, if there was some problem once pt enrolled in hospice, that too seems to reflect in overall score. Finally, the number of responses is very low—especially for nursing home pts. Have you encountered similar skewing? Is there a “best” interval between discharge and survey? How do you distinguish between the care you have provided and the interventions others may or may not have provided? Do you routinely schedule contact between team and family after discharge and before the survey (if you have a mechanism for bereavement or follow up who does it and how is this contact is made)?


Any and all comments appreciated. Feel free to email me directly at address below. -Suzanne Suzanne Hanen, RN GNP-BC CHPN® Palliative Care Consultation Service Winthrop University Hospital Suite 518 222 Station Plaza North Mineola, NY 11501 Pager: 516.291.6118 Desk: 516.663.2921 Fax: 516.663.4644 shanen@winthrop.org [Submitted on: 5/14/2010 by: Suzanne Hanen, RN GNP-BC CHPN® [SHanen@Winthrop.org]] Answers 142. Pt/Family Satisfaction Surveys: Skewed Results. We are currently looking for a survey for PC. Just a few questions. Does anyone have a survey they are willing to share and how does that process work? Sandra Kelly RN B.S.N. Clinical Education Palliative Care Oncology/Med Surg Battle Creek Health System Phone: 269-966-8446 Pager: 269-410-0110 Fax: 269-966-8638 Twenty years from now you will be more disappointed by the things you didn't do than by the ones you did do. So throw off the bowlines. Sail away from the safe harbor. Catch the trade winds in your sails, Explore. Dream. Discover!!! [Submitted on: 5/14/2010 by: Sandra Kelly RN BSN [kellys@trinity-health.org]]

142. Pt/Family Satisfaction Surveys: Skewed Results. There is a good family satisfaction survey on the CAPC website. Mary Lawhon Triano [Submitted on: 5/14/2010 by: Mary Lawhon Triano [pmt1209@gmail.com]]

142. Pt/Family Satisfaction Surveys: Skewed Results. Mary thanks, We have been using a version of the CAPC survey— My question is how you have been using it—we aren’t getting enough of a response and we have found from the free text area that people are often responding to the overall experience of hospitalization and not primarily to our services part in it. So how often do you poll, how much contact do you have with pts/families between dc and the survey—who on your team is responsible (we have one NP and one MD part time with one other occasional MD on our team –no sw no bereavement person) for that contact.. Suzanne Hanen, RN GNP-BC CHPN® Palliative Care Consultation Service Winthrop University Hospital Suite 518 222 Station Plaza North Mineola, NY 11501 Pager: 516.291.6118 Desk: 516.663.2921 Fax: 516.663.4644 shanen@winthrop.org [Submitted on: 5/17/2010 by: Suzanne Hanen, RN GNP-BC CHPN® [SHanen@Winthrop.org]]


142. Pt/Family Satisfaction Surveys: Skewed Results. Dear Ms. Kelly, **Here is survey we developed based on input from several other Palliative Care Services. Good luck, Barbara Reville Barbara Reville, MS, APRN-BC, ACHPN速 Assistant Director, Palliative Care Service Jefferson Palliative Care Center Department of Family & Community Medicine Thomas Jefferson University 1015 Walnut Street, Suite 401 Philadelphia, PA 19107 215-955-1807 (voice mail) 877-656-4509 (pager) www.jeffersonhospital.org/palliative **Please contact the submitter directly to obtain via email. [Submitted on: 5/17/2010 by: Barbara Reville, MS, APRN-BC, ACHPN速 [barbara.reville@jefferson.edu]]

Question 143. Question regarding "Allowing Natural Death." Do you have an Allow Natural Death Policy (instead of DNR or both) at your institution? If so, please attach the policy, if you are permitted to share. Dena Jean Sutermaster, RN, MSN, CHPN速 Director of Education Products Hospice and Palliative Nurses Association One Penn Center West, Suite 229 Pittsburgh, PA 15276-0100 (412) 787-9301 FAX (412) 787-9305 denajeans@hpna.org [Submitted on: 1/15/2010 by: Dena Jean Sutermaster, RN, MSN, CHPN速 [denajeans@hpna.org]] Answers 143. Question regarding "Allowing Natural Death." No: DNR. Jessica [Submitted on: 1/15/2010 by: Jessica Weinberger [jetw69@aol.com]]

143. Question regarding "Allowing Natural Death." Ours is DNR also. I would be interested to hear if there are states that have "Allow Natural Death" wording in the legislation. In Texas, the regs state DNR so that is what legal wants the policies to say. Ellen [Submitted on: 1/15/2010 by: Ellen Martin [nurseellen1120@yahoo.com]]

143. Question regarding "Allowing Natural Death." This wording is on the DNR part of the POLST form used in California, but hospitals still seem to use DNR only.... [Submitted on: 1/16/2010 by: Barry Ress [barry.ress@yahoo.com]]


143. Question regarding "Allowing Natural Death." As described at the POLST website (http://www.ohsu.edu/polst/programs/index.htm The POLST form is "a documentation of medical orders on a brightly colored form and a promise by health care professionals to honor these wishes." It was started in Oregon, and has spread to 9 states, with 12 others developing programs (as well as some counties in other states). Generally there are several sections: CPR, Intubation, IV Fluids, Tube Feedings, Abx, and one has several options within each section Originally, it stood for "Physician's Orders for Life Sustaining Treatment" but the acronym has morphed in different programs. My personal favorite is "Provider's Orders for Scope of Treatment" as it does infer that only physician's can sign POLST orders (In Oregon NPs can, and I believe that is the case in other states as well). Also the use of "Scope of Treatment" helps when starting a conversation w/a patient and/or family member to what you are trying to do -- avoids the "you're trying to kill grandma" response. The most important part of the program however is that it is not institution-specific, but it follows the patient from site to site. So, a NH resident may have a POLST in their chart. If they need to be transferred to a hospital, the EMTs know the scope of treatment they are to provide, and at admission this information is also available. It has been well received and adopted in many of the states it has been implemented in. A search on Hickman as author will provide a number of manuscripts about it. Going to the website cited above will provide you with examples of the different forms along with other resources. Miriam A.E. Volpin, BS, RN, CHPN速 Doctoral candidate Oregon Health & Science University School of Nursing Hartford Building Academic Geriatric Nursing Excellence Scholar 503.997.1039 [Submitted on: 1/16/2010 by: Miriam A.E. Volpin, BS, RN, CHPN速 [volpinm@ohsu.edu]]

143. Question regarding "Allowing Natural Death." In NC, the form is called a MOST form Medical Order for Scope of Treatment. Lenora Smith, MSN, RN FNP/Palliative Care NP Graduate, 2009 [Submitted on: 1/16/2010 by: Lenora Smith, MSN, RN [lksmithrn@gmail.com]]

143. Question regarding "Allowing Natural Death." In California only physician can sign, I was told because of lobbying by EMTs for this by one MD involved with development in this state. [Submitted on: 1/16/2010 by: Barry Ress [barry.ress@yahoo.com]]

143. Question regarding "Allowing Natural Death." In Oregon, NPs and PAs, as well as MDs


can and do sign the POLST form regularly. There is now a statewide electronic system that can be accessed by EMTs that provides POLST information about a patient. I believe that they can access the information "in the field" but I do not know the mechanics of this. The statewide EMR for POLST is voluntary and the information is housed by the Center for Ethics at Oregon Health Science University (OHSU). Anne Morgan MSN, CNM, FNP Palliative Care Coordinator Family Nurse Practitioner Bay Area Hospital 269-8538 – office & voice mail 2694700 - BAH pager, just punch in your return number [Submitted on: 1/18/2010 by: Anne Morgan MSN, CNM, FNP [anne.morgan@bayareahospital.org]]

143. Question regarding "Allowing Natural Death." The POLST and DNR/DNI as I see it are actually different entities. DNR/DNI is usually an order that applies when a patient is hospitalized and in most states/institutions must be a physician’s order. The POLST form or MOST as in NC and other variations that will likely arise, are supplements to advance directives that actually allow the DNR/DNI status to be carried beyond the hospital setting because they carry the weight of a medical order. In Utah APRNs and PAs are authorized to sign these documents, however if the patient is hospitalized, at least in my institution, the attending physician must verify the patient’s DNR/DNI status. Many people have discussed replacing the designation DNR/DNI with Allow to Die Naturally designation as a means of changing the perspective from doing something aggressive (which in a terminal situation has a poor chance of a good outcome) to one of a more realistic “letting nature take its course without interference” approach. As I see it, it is a matter of semantics and as long as people are clear as to the actual meaning it doesn’t matter what we actually call it! If it helps patients and families to better understand the concept and relate their care to the concept of “allowing natural death” versus DNR, then it might be a good thing to make the transition to that wording. It would certainly take a lot of education – but that would be a great opportunity which we could use (especially in overcoming the “death panel” image!). Deborah Thorpe, PhD, APRN, AOCNS, ACHPN® Pain Medicine and Palliative Care Huntsman Cancer Institute University of Utah Salt Lake City, UT 84112 Phone (801)585-0254 FAX (801)581-4416 Improving Quality of Life for Cancer Patients and Families [Submitted on: 1/19/2010 by: Deborah Thorpe, PhD, APRN, AOCNS, ACHPN® [deborah.thorpe@hci.utah.edu]]

143. Question regarding "Allowing Natural Death." **See attached for our policy and form. This change in practice has made resuscitation or AND (allow natural death) a physician order and not necessarily a patient/family choice. Mary Hicks, ANP-BC, ACHPN® Palliative Medicine St. John Hospital and Medical Center Detroit, MI 313-343-3072 **Please contact


submitter directly to obtain via email. [Submitted on: 1/19/2010 by: Mary Hicks, ANP-BC, ACHPN® [Mary.Hicks@stjohn.org]]

143. Question regarding "Allowing Natural Death." I become concerned about “Allow a Natural Death” because of how someone (family) might interpret it. I was at a Palliative Care Conference several years ago and a nurse told us of a daughter who refused to allow her mother to have any pain medicines because she wanted her to die a “natural death” (nothing that was said could sway her from believing opioids hastened death). I personally like it the term but…. Janice [Submitted on: 1/19/2010 by: Janice Reynolds [jkrrnocn@suscom-maine.net]]

143. Question regarding "Allowing Natural Death." I believe the AND is very important to add to every patient who does not want agressive treatment. It would read DNR/DNI/AND We are currently working on this issue as DNR/DNI can still mean drips, dialysis, etc. AND makes it clear that should a patients BP or kidneys begin to shut down that drips should not be started or restarted. Rebecca Gagne Henderson RN MSN NP-c CHPN® Long Beach Memorial Hospital [Submitted on: 1/19/2010 by: Rebecca Gagne Henderson RN MSN NP-c CHPN® [rebecca@endoflifedirectives.org]]

Question 144. Schwannoma and Neuropathic Pain Agents. Dear Colleagues, A hospitalist asked if I had experience/knowledge regarding warming a patient before extubation so that the physician could pronounce time of death. Is there a protocol or any information to assist us with this situation? Second question: 42yo female with schwannoma s/p several resections. She is taking opioids with moderate relief but it is also lowering her bp. She describes her pain on the side of her head as "sharp". Has anyone treated this effectively with neuropathic pain agents? Thanks you for your time and assistance. Carol Bemis, NP Palliative Care Program St. Joseph's Hospital 350 West Thomas Road Phoenix, Arizona 85013 602-406-5252 [Submitted on: 9/1/2010 by: Carol Bemis, NP [cpbemis@yahoo.com]] Answers 144. Schwannoma and Neuropathic Pain Agents. There is an adage within the trauma world that a patient isn't dead until they are "warm and dead". This refers to hypothermia


patients who can live in a suspended state with very slow heart rate for long periods of time and seem dead. It is generally not necessary to warm patients in an ICU situation when their usual temperature has not fallen below 96 degrees. Time of death is when respirations have ceased and the cardiac monitor shows absence of rhythm. I've never seen the particular pain scenario you describe but I don't know why neuropathic modalities couldn't be tried. Is the patient on a steroid? That could be useful. Beverly Douglas ARNP ACHPN速 LifePath Hospice Tampa Florida [Submitted on: 9/1/2010 by: Beverly Douglas ARNP ACHPN速 [bevdouglas@tampabay.rr.com]]

Question 145. Scrotal Edema/Pain. Dear Colleagues, Besides doing a large volume paracentesis, diuretics, and elevation, is there anything else you can suggest for a very uncomfortable gentleman with unknown etiology of ascites/fluid overload/ anasarca with a hx of esophageal cancer? Thanks so much for your help. Carol Bemis, ANP Palliative Care Program St. Joseph's Hospital and Medical Center Phoenix, Arizona 85013 602-406-5252 [Submitted on: 12/16/2009 by: Carol Bemis, ANP [cpbemis@yahoo.com]] Answers 145. Scrotal Edema/Pain. How about a trial of dexamethasone? Robert Smeltz, RN MA NP ACHPN速 Clinical Coordinator/Nurse Practitioner Palliative Care Program New York University School of Medicine Bellevue Hospital 462 First Avenue, 17S19 New York, NY 10016 (o) 212-562-5277 (f) 212-562-8537 [Submitted on: 12/16/2009 by: Robert Smeltz, RN MA NP ACHPN速 [Robert.Smeltz@nyumc.org]]

145. Scrotal Edema/Pain. I have found that for the pain Lidoderm patches applied to the inner thigh as close to the scrotum as possible has helped several of our patients. Of course as we all have found in our practice, Lidoderm patches work well for some and do nothing for others but is worth a try. We have also used cold packs with some degree of relief. Lin Sorensen, RN, CNS Palliative Medicine Service (505) 269-6175 cell (505) 724-6134 office (505) 723-8995 fax lsorense@phs.org [Submitted on: 12/16/2009 by: Lin Sorensen, RN, CNS [lsorense@phs.org]]


145. Scrotal Edema/Pain. Scrotal support may also be helpful. [Submitted on: 12/16/2009 by: Marlene Foreman [marlene@hospiceacadiana.com]]

Question 146. Symptom Management for Patient Complaining of Feeling Hot. Patient with advanced head and neck cancer complains of feeling hot. Fan is somewhat helpful. I would appreciate any suggestions for symptom relief. Thank you. Cindy Brown, ACHPN® Tampa General Hospital Palliative Care [Submitted on: 8/31/2010 by: Cindy Brown, ACHPN® [cjbrown@tgh.org]] Answers 146. Symptom Management for Patient Complaining of Feeling Hot. Tumor sweats? Hormonal? Mary Zuccaro, ACHPN® Capitola, CA [Submitted on: 8/31/2010 by: Mary Zuccaro, ACHPN® [maryznp@gmail.com]]

146. Symptom Management for Patient Complaining of Feeling Hot. Flushing as adverse drug effect? [Submitted on: 8/31/2010 by: [rebecca@endoflifedirectives.org]]

146. Symptom Management for Patient Complaining of Feeling Hot. Consider using small cold water bottles, roll them over pulse points and/or hold in hand. It allows the individual a measure of control as short term relief achieved. The sealed water bottles can be rotated back to refrig as they come to room temp. Dorothy Lippman Salovesh, GNP-BC, FNP-BC, ACHPN® Palliative Care NP St. Jude Medical Center, Fullerton CA [Submitted on: 9/1/2010 by: Dorothy Lippman Salovesh, GNP-BC, FNP-BC, ACHPN® [dlippman@rocketmail.com]]

146. Symptom Management for Patient Complaining of Feeling Hot. Peppermint to inhale, Biofreeze gel to large muscle groups. Tomasita Jacubowitz, ACHPN®, BC Gerontology and Adult Health Palliative Care Nurse Practitioner Hospice and Palliative Care of Greensboro (HPCG) 2500 Summit Avenue Greensboro, NC 274705 336- 621-7575 Email:


tjacubowitz@hospicegso.org [Submitted on: 9/1/2010 by: Tomasita Jacubowitz, ACHPN速, BC [TJacubowitz@hospicegso.org]]

146. Symptom Management for Patient Complaining of Feeling Hot. When discussing heat relief for someone with Multiple Sclerosis, I recently heard about cold gel packs that people wear, I assume draped around their neck, when they are out in the heat. I've not seen these myself, but I wonder if this would be helpful for your patient? Another thought might be body rubs that might contain menthol or peppermint. I've had peppermint/menthol foot treatments and they are very cooling, and you get the added benefit of a foot massage. Virginia Gillispie, RN, ND Department of Palliative Medicine Kaiser Permanente of Colorado Ph# 303.636.3235 [Submitted on: 9/7/2010 by: Virginia Gillispie, RN, ND [Virginia.C.Gillispie@kp.org]]

146. Symptom Management for Patient Complaining of Feeling Hot. I've heard cucumber is also cooling. Deborah Greenspan, RN, CHPN速 President Los Angeles Regional Provisional Group Hospice and Palliative Nurses Association [Submitted on: 9/7/2010 by: Deborah Greenspan, RN, CHPN速 [dg.hpnala@gmail.com]]

146. Symptom Management for Patient Complaining of Feeling Hot. Gel packs advertised for MS patients are very heavy, they are not that useful if someone is weak. [Submitted on: 9/10/2010 by: [woc5@optonline.net]]

146. Symptom Management for Patient Complaining of Feeling Hot. When I was trying to manage my husband's nausea with chemotherapy (he's well now, thanks), I tried my mother's old nurse remedy of putting cold at the base of his skull. (I think she graduated in 1950.) I found some icepacks that were much better than those generally meant for the intended purpose. These were in the sports section of either Target or WalMart. They come as a sheet of maybe 50 "cubes" which actually are just water in ice cube shaped pockets, all of these are on this sheet of plastic that is very bendable. I think the intention was to be able to wrap them around food for camping or something like that. I put them (frozen) on the bias of a kitchen towel, rolled it up like a scout's kerchief, and put it behind his neck and


around front. The ends were just long enough to secure in front. They stayed cold for quite a while, maybe a couple of hours? without being uncomfortably cold. The shape and firmness supported his neck and head and were actually comfortable. I can't tell you much about the weight of the item. Maybe a pound or two. My thought is, if our "thermostat" is the hypothalamus, perhaps gently cooling the blood flow to that part of the brain might help the patient feel less hot. My reasoning is based on stopping hot flashes in their tracks by chugging ice water, something I discovered in my own experience. Seemed like something worth sharing. Oh, the packs cost something like $5. [Submitted on: 9/11/2010 by: Christine Johnson [Christine_in_Van_Alstyne@BrianAndChristine.com]]

146. Symptom Management for Patient Complaining of Feeling Hot. I agree with use of those cold packs. They are very useful for that. I also use them to put in my son's cooler when we go out to other cities for track meets. It keeps all our snacks cool and they lasted for even the 3-day meets without have to constantly re-freeze them. I'm their team nurse and when one of the members tripped over a hurdle and fell on her knee, it came in handy for quick treatment of the swelling. Marla Bernard, RN Case Manager [Submitted on: 9/11/2010 by: Marla Sykes-Bernard [msbernard@live.com]]

146. Symptom Management for Patient Complaining of Feeling Hot. Great idea - you can also freeze rice - however, it only lasts about 15 minutes. [Submitted on: 9/12/2010 by: Karen McGough [kmcg14@verizon.net]]

146. Symptom Management for Patient Complaining of Feeling Hot. A bag of frozen peas also works well. Gabi Kaplan RN, MSN, AOCN Clinical Educator Care Alternatives Hospice Cranford, NJ [Submitted on: 9/13/2010 by: Gabi Kaplan RN, MSN, AOCN [gabiaocn@hotmail.com]]

146. Symptom Management for Patient Complaining of Feeling Hot. Hello All, Have you tried any products made for women with hot flashes? Here in the South we also have these thin bandana's that are filled with a material that expands when wet? I am attaching a link to a page as an example not an endorsement. http://coolbandanas.com/ Good luck, Melody


Spragg Eschete BN, RN Saint Francisville, Louisiana [Submitted on: 10/15/2010 by: Melody Spragg Eschete BN, RN [southernsnow@bellsouth.net]]

146. Symptom Management for Patient Complaining of Feeling Hot. I have used these bandanas personally. They are cool, not cold and last for hours. I make them and can share the directions. For hot flashes, I prefer rice or cherry pits in a cloth bag that I keep in the freezer. Their effect is short - about 15 minutes. Anyone who would like directions for making the cool bandanas and/or how to find cherry pits, can contact me directly. Karen McGough ARNP, ACHPN® karen.mcgough@verizon.net [Submitted on: 10/16/2010 by: Karen McGough ARNP, ACHPN® [karen.mcgough@verizon.net] ]

146. Symptom Management for Patient Complaining of Feeling Hot. I have used frozen peas an corn--first wrap in a snack or sandwich bag, take a twin size pillowcase or travel pillow case place the plastic bag inside pillow case and wrap around neck-stay frozen for about 15min and cooling effect for 30-45min. Use if for menopausal women, babies with high fevers, cancer patients with hot flashes from disease process or chemo. This is a very inexpensive cooling technique. You can refreeze and reuse. Thank you for requesting solutions. Good Luck Cheryl Cheryl B. Dworman, BSN, RN, CDCS Cheryl B. Dworman, Inc. Nurse Consultant-Patient Advocate P.O. Box 251981 West Bloomfield, MI 48325-1981 [Submitted on: 10/16/2010 by: Cheryl B. Dworman, BSN, RN, CDCS [cbdinc2001@yahoo.com]]

Question 147. Tenesmus. I have my third case in the last 2 months. I treated the others as neuropathic pain with excellent results. Unfortunately, this case is not responding completely to the TCA. Any suggestions? Rebecca Gagne Henderson RN MSN FNP ACHPN® [Submitted on: 9/13/2010 by: Rebecca Gagne Henderson RN MSN FNP ACHPN® [rebecca@endoflifedirectives.org]] Answers 147. Tenesmus. Has your patient tried acupuncture? Jessica Weinberger FNP ACHPN® Nashville TN


[Submitted on: 9/13/2010 by: Jessica Weinberger FNP ACHPN速 [jetw69@aol.com]]

147. Tenesmus. No. Where do they put the needles, dare I ask? Yikes! Do you know if there is anything in the literature regarding this? Thanks, Rebecca [Submitted on: 9/13/2010 by: Rebecca Gagne Henderson [rebecca@endoflifedirectives.org]]

147. Tenesmus. Rebecca There are many acupuncture points in the body that can help alleviate pain in other areas of the body. It is quite helpful and worth trying it out. An acupuncturist and explain this better than I do but needles are not placed in the rectal area or bladder area - you can achieve the same results with arms and legs... Have you tries an B&O suppository - that might easy some of the pain and spasm - old method but quite effective too Marianne Wachalovsky MS, FNP, RN-BC, CHPN速 818 Stillson Dr. Petaluma, CA 94954 707-781-9722 (home) 707-591-5731 (cell) [Submitted on: 9/14/2010 by: Marianne Wachalovsky MS, FNP, RN-BC, CHPN速 [mariannew@comcast.net]]

147. Tenesmus. Wish I had thought of B/O suppository. Tried and true for many things. [Submitted on: 9/14/2010 by: Rebecca Gagne Henderson [rebecca@endoflifedirectives.org]]

Question 148. Terminal Secretions. For those of you who are billing, what CPT code do you use for terminal secretions? Thanks, Dawn :) Dawn Pavlu, APN Palliative Care Englewood Hospital & Medical Center Englewood, NJ 07631 [Submitted on: 10/24/2010 by: Dawn Pavlu, APN [dawn@pavlu.net]] Answers 148. Terminal Secretions. What is the procedure? Are you looking for ICD9 codes? If so: 786.09 Other respiratory: distress. Insufficiency. I could not find secretions for resp symptoms. Rebecca


[Submitted on: 10/24/2010 by: Rebecca Gagne Henderson [rebecca@endoflifedirectives.org]]

148. Terminal Secretions. I use the code for excessive sputum in my facility. [Submitted on: 10/24/2010 by: [cwwcats@aol.com]]

148. Terminal Secretions. Thanks. Yes, I meant ICD-9 code. Dawn [Submitted on: 10/24/2010 by: Dawn Pavlu [dawn@pavlu.net]]

148. Terminal Secretions. 786.40 abnormal sputum (includes excessive sputum) You lucked out. Just bought a 2010 ICD9 book today. Rebecca [Submitted on: 10/24/2010 by: Rebecca Gagne Henderson [rebecca@endoflifedirectives.org]]

148. Terminal Secretions. We generally use the code for respiratory distress 786.09. We use the 786.40 code for abnormal sputum with ALS patients etc who truly have a salivatory overproduction, or occasionally for the sputum production that causes people to be gagging/spitting up etc. Terminal secretions are usually managed with both anticholinergics and opioids--the result of not treating them would be terminal respiratory distress so that is how we code it. Sharmon Sharmon Figenshaw ARNP, ACHPN速 PRMCE Hospitalist/ Palliative Care Everett, WA Work 425-261-4076 Pager 425-903-1505 Cell 360-201-0475 [Submitted on: 10/25/2010 by: Sharmon Figenshaw ARNP, ACHPN速 [shar@dslnorthwest.net]]

148. Terminal Secretions. I use the one on salivary gland secretion disorder. [Submitted on: 10/31/2010 by: Elaine Glass [elaineglass33@hotmail.com]]

Question


149. Third Spacing in the Scrotum. Hi Everyone, Does anyone have any information regarding drainage in severe third spacing in the scrotum? Also, if you have any journal citations this would help. I am also wondering if anyone has an opinion if you believe it would be better to do nothing in these circumstances. Some of my male colleagues believe so. Thanks for your help, Rebecca Rebecca Gagne Henderson RN MSN FNP ACHPN速 [Submitted on: 6/22/2010 by: Rebecca Gagne Henderson RN MSN FNP ACHPN速 [rebecca@endoflifedirectives.org]] Answers 149. Third Spacing in the Scrotum. Typically we just provide support and treat symptoms, i.e. pain, diuretics (depending on cause); but trying to reposition seems to be what work best for both the edema and the discomfort. [Submitted on: 6/23/2010 by: Christy Torkildson [torkc@sbcglobal.net]]

149. Third Spacing in the Scrotum. Dear Rebecca, I do not know the discipline training of your colleague who recommends "doing nothing" under such a clinical issues. Immediately, the complex matrix of physical distress, emotional pain with such a private and personal part of their body image, the possible spiritual struggles which could be entangled with such an imitate part of your patient becoming almost, if not actually a tortured part of his sexual past or present being. Clinically, the alteration of our most private body areas due to edema are always emotionally sensitive no matter what degree of pain or discomfort is included. Usually in order for that portion of the body to become edematous in the first place insinuates edema in other close regions of the body (such as acities, buttock edema, unilateral or bilateral thigh edema and gross heaviness of extremities. I know this is an obvious connection, but what it makes me think of first and foremost - is that the patient is most probably unable to physically reach or visualize their own genital region. Inferences of need for assistance with bathing, and in particular, drying of this vulnerable area is near to impossible. If their penis appears to be showing signs of edema, and or your patient is incontinent or having trouble manipulating a urinal because of acities or fatigue, it may be time to consider an indwelling catheter. An impeccable visual assessment is critical to optimal comfort and promotion of best skin integrity. Basic physics use of gravity has been the most successful intervention to reduce third space volume to whatever degree possible. Using cornstarch powder as a drying agent to keep thigh skin from adhering to scrotal skin. Wrapping scrotom in available soft cotton material (pillow case or clean t-shirt); and use of small pillow or rolled wash clothes placed under the base of scrotom to gently elevate to tolerance and comfort; also modest separation of thighs and use of pillows between entire leg to feet for support and reduced pressure on scrotom while on his sides as tolerated. Of course this is the perfect opportunity for educating the patient and the partner + primary


caregiver in these care, comfort, support, and skin integrity prevention techniques to promote your patient's best quality of life and most meaningful care & assistance by his caregivers. Use of nystatin powder PRN if candidiasis infection is found in skin folds. Generally the patient who is third spacing to this degree is so protein deficient that duiretics serve to merely lower systemic blood pressure, increase fatigue and risk for falls secondary to hypotension without much, if any effect on third spaced tissue. I generally do not ever use diuretics at this time of life. I know it is late, my internet is down so unfortunately I cannot attach references at this time. Thanks for asking this important question. Best wishes in your patient care. Sincerely, Harlee [Submitted on: 6/23/2010 by: Kutzen, Harlee S. [hkutz1@lsuhsc.edu]]

149. Third Spacing in the Scrotum. Try soaking some Kling wrap in Epsom's Salts and then wrapping it around the swollen scrotum and penis if needed. Have the pt stay spread eagle with a sheet tent over his legs to provide privacy. Let it dry 20-30 minutes and then remove. The salt should suck out the edema through the really thin skin of the scrotum. Unfortunately this lasts only about 1/2 day depending on the source of the edema. However if the fellow can stand this embarrassing procedure, he usually feels better. Teaching a wife or girlfriend to do the procedure rather than the nursing staff is also a good idea. Oh yes, the swollen area must not have any open areas - if so, the salty water will burn like the Dickens. Good Luck! Elaine Glass, APHPN, Palliative Care at Grant in Columbus OH [Submitted on: 6/23/2010 by: Elaine Glass, APHPN [elaineglass33@hotmail.com]]

149. Third Spacing in the Scrotum. I have used needle drainage. I use 27 gauge huber needles, usually two, placed at the areas of greatest edema, with the tubing left open. I place several clean towels under the scrotum and surrounding the tubing to absorb the drainage. These are changed as they become wet. This may sound draconian, but I have had men kiss me and hold my hand in gratefulness for relieving this distress. It is not painful, and because of the one directional nature of fluid movement due to pressure, there is minimal risk of infection. Beverly Douglas ARNP ACHPN速 LifePath Hospice Tampa Florida [Submitted on: 6/23/2010 by: Beverly Douglas ARNP ACHPN速 [bevdouglas@tampabay.rr.com]]

149. Third Spacing in the Scrotum. Harlee When you can if you could forward any references I to your list serve response re: third spacing scrotum I would appreciate it. Liz Fracchia Palliative Care Program Coordinator Wm W Backus Hospital Norwich, CT 06360


[Submitted on: 6/23/2010 by: Liz Fracchia [peachymor@comcast.net]]

149. Third Spacing in the Scrotum. References for scrotal edema removal: http://www.palliativedrugs.com/forum-read?&f=1&i=12091&t=12091 Judy Dobson,MSN,CHPN速 570-271-0444 Home 570-594-7175 Cell [Submitted on: 6/23/2010 by: Judy Dobson,MSN,CHPN速 [pcnurse@verizon.net]]

149. Third Spacing in the Scrotum. To all needing some references for lower edema: Try these... However, there is a ton of info on various techniques used just for scrotal edema on the website: www.palliativedrugs.com They have a bulletin board and document library with great info. It's a free site...just need to create login. Judy You might reference an article "Reduction of edema of lower extremities by subcutaneous, controlled drainage: Eight cases" in the American Journal of Hospice & Palliative Medicine, Vol.21, Number 3, May/June 2004. The principles of drainage in this article have been generalized to other areas of edema with good success and we, in a large USA hospice, are using the technique (not as first line of defense, of course). Please let us know what helps. pat Reply To This Message Re: Drainage procedures for lymphoedema Author: Mr Gary Frank Nurse Edmonton Palliative Care Program Canada Date: 09-07-2007 Hi folks. Dr. Lawrence Clein of Regina, Saskatchewan (CANADA)has been doing this procedure and wrote it up in American Journal of Hospice and Palliative Medicine(2004),Vol.21, No. 3, 228-232. He did an excellent presentation for our group last year about it. We've been trying the procedure and find it very helpful for selected patients. Gary Frank Reply To This Message Re: Drainage procedures for lymphoedema Judy Dobson,MSN,CHPN速 570-271-0444 Home 570-594-7175 Cell [Submitted on: 6/23/2010 by: Judy Dobson,MSN,CHPN速 [pcnurse@verizon.net]]

149. Third Spacing in the Scrotum. In the American Journal of Hospice and Palliative Care Volume 27, Number 4, the June 2010 copy on page 272 is an article regarding subcutaneous drainage for lower extremity edema. It may answer your questions. Our Medical Director has done this procedure with the lower extremities but not with the scrotal area. Michelle Witkop, DNP, FNP-BC [Submitted on: 6/27/2010 by: Michelle Witkop, DNP, FNP-BC [Mwitkop@mhc.net]]


149. Third Spacing in the Scrotum. Hello all, I am a Palliative Care NP working in a hospital setting and have recently been approached by an independent hospice to do home visits when the new hospice regs go into effect Jan 2011 requiring regular home visits to continue qualification of hospice patients. Is there anyone in the state of Virginia that is currently making outpt hospice visits that could educate me about whether I need to refile with the state for endorsement for outpatient visits? Thanks for any info. Kerry McGrath NP Palliative Medicine New River Valley Medical Center 2900 Tyler Rd Christiansburg VA 24073 540-731-2614 [Submitted on: 7/29/2010 by: Kerry McGrath NP [kmcgrath@i-plus.net]]

Question 150. Trigger Sheets for Automatic Referrals. Colleagues, Are there any facilities using trigger sheets to get automatic referrals to your PC programs? Thanks, Stephanie J Ramsey, RN,MSN,NP-C Palliative Care Coordinator Carolina Medical Center Office 704-355-7700 Blackberry 704-804-9336 Pager 704-355-4088 #8365 Ascom 704-446-0751 [Submitted on: 6/4/2010 by: Stephanie J Ramsey, RN,MSN,NP-C [Stephanie.Ramsey@carolinashealthcare.org]] Answers 150. Trigger Sheets for Automatic Referrals. We use the CAPC screening tool. Rebecca Gagne Henderson RN MSN FNP-c [Submitted on: 6/4/2010 by: Rebecca Gagne Henderson RN MSN FNP-c [rebecca@endoflifedirectives.org]]

150. Trigger Sheets for Automatic Referrals. Can someone share what the CAPC tool is? Our team is considering using 1 yr ICU mortality criteria as a springboard to discuss with attendings re: possible consults. We also use Health Trac frequent admit data for heart failure - none of these generates an "automatic referral," though, but we have discussed this on our team Virginia Gillispie, RN, ND Department of Palliative Medicine Kaiser Permanente of Colorado Ph# 303.636.3235 [Submitted on: 6/6/2010 by: Virginia Gillispie, RN, ND [Virginia.C.Gillispie@kp.org]]

150. Trigger Sheets for Automatic Referrals. Virginia, Are you speaking of the APACHE data? If so, we should talk as that is precisely what I am doing. **I cannot find the original CAPC


form, but this is what I have. I added two items at the bottom section: 1) was patient residing in SNF prior to hospitalization? 2) is patient a previous palliative referral? So this is no longer the CAPC form it is based on the CAPC form. Rebecca Gagne Henderson RN MSN FNP Palliative Coordinator **Please contact submitter directly via email to obtain. [Submitted on: 6/6/2010 by: Rebecca Gagne Henderson RN MSN FNP [rebecca@endoflifedirectives.org]]

150. Trigger Sheets for Automatic Referrals. Go to The Center to Advance Palliative Care and register. It is free. They have many tools you can download. Also, we utilized a study that was done : Proactive palliative care in the medical intensive care unit: Effects on length of stay for selected high-risk patients Sally A. Norton, PhD, RN; Laura A. Hogan, MS, RN, ACHPN; Robert G. Holloway, MD, MPH; Helena Temkin-Greener, PhD, MPH; Marcia J. Buckley, MS, RN, BC-PCM; Timothy E. Quill, MD We used their criteria and I showed the study to the ICU physicians. I also was able to get one of the Intensivists to be my champion and he helped with education to his peers. We have since added a few more criteria then what is in the study, but it helped get us started with an evidence base. I now rarely have any of the intensivists I work with refuse to allow PC involvement. Debbie Monaghan RN, MSN Ed, CHPN速 Palliative Care Sr. Specialist Sharp Memorial Hospital 858-939-3809 [Submitted on: 6/7/2010 by: Debbie Monaghan RN, MSN Ed, CHPN速 [Debbie.Monaghan@sharp.com]]

150. Trigger Sheets for Automatic Referrals. Thank you Rebecca for sharing your screening tool. I will try and find out the source of the one yr ICU mortality criteria, but I know that Southern California Kaiser has been using it. It is as follows: Patients with over 6 points should be targeted for palliative care: Gender=male : 1 point Dependent in 1 to 4 ADLs: 2 points 5 or more dependent ADLs: 4 points Heart Failure: 2 points Cancer -local: 3 points Cancer - mets: 8 points Renal impairment- cre >3.0: 2 points Poor nutritional index, albumin 3.0 to 3.4: 1 point Poor nutritional index, Albumin <3.0: 2 points I can be reached at 303.345.8156 Sunday through Thursday, if anyone wants to talk about this further! Virginia Gillispie, RN, ND Department of Palliative Medicine Kaiser Permanente of Colorado Ph# 303.345.8156 [Submitted on: 6/7/2010 by: Virginia Gillispie, RN, ND [Virginia.C.Gillispie@kp.org]]

150. Trigger Sheets for Automatic Referrals. **We've just recently instituted triggers for our ICU nurses and case managers to input a palliative care consultation. Of course, we follow it


with a call to the attending to clarify, again, our services extend beyond hospice referrals.... Diane Diane E. Ranna, MN, FNP-C, ACHPNÂŽ Palliative Care Coordinator Piedmont Fayette Hospital 1255 Highway 54 West Fayetteville, GA 30214 Cell: (770) 833 - 6770 Phone: (770) 719 - 7295 Fax: (770) 719 â&#x20AC;&#x201C; 6695 **Please contact submitter directly via email to obtain attached document. [Submitted on: 6/10/2010 by: Diane E. Ranna, MN, FNP-C, ACHPNÂŽ [cacopema@yahoo.com]]

Question 151. Update on Psychiatric Patient and Hospice. Hi Everyone, I just wanted to take a moment to update you on a case I shared with you a few weeks ago. I drafted a letter and sent it to: Nursing Director Administrator Psychiatric Medical Director Medical Attending Chief Medical Director Data Management And everyone else associated with his case. We sent the letter with our signatures embedded at the bottom of the letter. The results: He was transferred out to the local hospital for SOB and given O2 there. He was also given a sitter from our unit who knew him. When I came back to work a few days later, the hospital transferred him back to us. I did all of documentation on him- a behavior note and an EOL note for symptom management. It fell on deaf ears. The psychiatrists and psychologists agreed with me, but said their hands are tied. The psychologist said that since he is a ward of the state, he is incompetent to make a decision to stop dialysis and start hospice. Since the state has legal rights, then why aren't they making the right decision and sending him to hospice? I saw a note where his records were sent to a nursing home for placement but they refused him because of his psychiatric history. Bottom line, funding and the state. I pressed the psychologist and psychiatrists to advocate even more during the next meeting and they told me that since no advance directives were in place their hands were tied. I asked about the fact that he is a ward of the state and she said the legal department and other individuals ruled him competent to make decisions, but nothing has been done. His current orders for his ESRD, CHF, peritonitis, pleural effusion, ascites, GI bleed, etc. are Morphine 2 mg po Q8hrs. Ativan 1mg po Q8hrs O2 2L/NC if sat below 92 Vital signs q 4hrs Dialysis Q MWF In addition to his psychotropics I searched around the campus and found a spiritual activity therapist and paged him explaining the situation to him and asking him to visit our patient. He has been seen twice and both times he has cried through tears while he was praying with him. He also sang church songs on his own. He wants to see his mom before he dies, but that is not possible since his family lives over 5 hrs away and do not have the financial means to travel at this time. So he is back with us. They opened another side of our unit and he on that side along with 6 other stable patients. However, since he has orthopnea he wakes up frequently screaming and banging on the door and the walls. He remains on 1:1 observation with 2:1 when he leaves for dialysis. The medical directors have not been doing anything else. And the hospital bed we ordered for him is gone so he is back on the flat bed with no elevation. I sit with him at night after making rounds on my other patients and listen as he talks about all he's done and who he wants to apologize to. As far as the medical committee


for our community, it is at the hospital that keeps sending him back to us so they are only as good at their game. The Department of Justice will be here at our facility next week I believe and I do hope they grab his chart and see how this man is being allowed to die. Thanks for all of your feedback and support. I used all of it to advocate for my patient! Whenever I see someone without a smile, I give them one of mine! Avonelle Rand, RN, MSN, BS Graduate Nursing Faculty Doctoral Student (Counseling Psychology) AvonelleRand@email.phoenix.edu Avonelle.Rand001@umb.edu (706)-664-3002-cell [Submitted on: 1/17/2010 by: Avonelle Rand, RN, MSN, BS [sedonte@hotmail.com]] Answers 151. Update on Psychiatric Patient and Hospice. You are to be commended for your efforts on behalf of this patient. Additional thoughts came up when my practice group looked at your letter. Have you considered contacting Amnesty International for this patient? Pat [Submitted on: 1/17/2010 by: Patricia Hoban [phoban@mhc.net]]

151. Update on Psychiatric Patient and Hospice. Or a local or national organization for rights for the mentally ill? Good luck Jessica Weinberger [Submitted on: 1/17/2010 by: Jessica Weinberger [jetw69@aol.com]]

151. Update on Psychiatric Patient and Hospice. Or the local (or even national) media? Sometimes that kind of attention will shame institutions into doing the right thing. Miriam Volpin [Submitted on: 1/17/2010 by: Miriam Volpin [volpinm@ohsu.edu]]

151. Update on Psychiatric Patient and Hospice. It seems to me, that the major barrier to humane treatment is the system that was set up to protect people in the first place....the guardian. My understanding (this may be wrong, but it is conventional wisdom) is that a court appointed guardians are told not even to approve dnr orders and to ensure that all technology is used to keep someone alive. Maybe it needs to return to court as a human rights issue, that this person is being tortured and forced to endure what someone with capacity would not. It seems to me that early law cases (prior to quinlan) held that even someone without capacity would not have to endure what a "reasonable" person would not (I want to say it was in Massachusetts, maybe perkins school v somebody).... Marianne


Matzo [Submitted on: 1/17/2010 by: Matzo, Marianne (HSC) [Marianne-Matzo@ouhsc.edu]]

151. Update on Psychiatric Patient and Hospice. Having worked for an agency of last resort, I'm actually surprised the guardian ad litum has not stepped in. do you or your staff have the name of the person designated as the guardian? The person may be a ward of the state, but they should have a specific person noted as the guardian to make decisions and/or bring these weightier issues to the court. Jessica Weinberger [Submitted on: 1/17/2010 by: Jessica Weinberger [jetw69@aol.com]]

151. Update on Psychiatric Patient and Hospice. One thing of note--the morphine is nearly homeopathic at 2 mg PO q8, but also if a significant dose were given, it has potential to affect cognitive function adversely (likely delirium) in ESRD patient, and the metabolite that does this does NOT predictably dialyze out! If he gets delirious, the ativan could make that worse--always a tough choice when the patient already on psychotropics. [Submitted on: 1/17/2010 by: Barry Ress [barry.ress@yahoo.com]]

151. Update on Psychiatric Patient and Hospice. In California, we have moved along with court appointed county employee conservators, and now they can choose DNR and comfort care if there is physician certification about late life illness in some circumstances. [Submitted on: 1/17/2010 by: Barry Ress [barry.ress@yahoo.com]]

151. Update on Psychiatric Patient and Hospice. How about NAMI? Being a Psych nurse in my previous career, this really hits home to me. Please, everyone, I urge you to help create a Psychiatric specialty in Palliative Care, as they have in Pediatrics. This is a specialty and one which frightens most healthcare workers. Is anyone going to the Annual Assembly? Please speak about this at your workshops. I have also had instances, more than I care to recount or relive, in hospice care that devasted me with extrapyramidial effects and psychosis in patients being unaddressed and unreported to the hospice nurse or the doctor. I was working hospice triage in the field. The doctor was not a psychiatrist nor did we have a Psych consult on staff, and the regular hospice nurse also had no background in psych. In one case, the patient's husband had a psych history and his psychosis was exacerbated by


worry of his wife's condition. I was not informed about his psych history, nor his paranoid, agitated and hostile condition when I went to see the patient, and did not know he would turn on me after welcoming me to the home. Thank goodness he was wheelchair bound and I had some background in psych. If he had been more mobile and stronger, I think we would have been in trouble. The LVN on continuous care was frightened and didn't know what to do. As a team, I think all team members should be informed of psych background and have avenues for back-up if needed. Deborah Greenspan, RN CHPN® [Submitted on: 1/17/2010 by: Deborah Greenspan, RN CHPN® [dgreens1@gmail.com]]

151. Update on Psychiatric Patient and Hospice. Unfortunately, we have run into similar situations. This is an area that needs more exploration from a number of perspectives. I am an PMHHP working with a palliative care team. I would be interested in hearing from any other psychiatric APN’s involved in palliative care. Please email me directly: perleymj@tx.rr.com Mary Jo Perley, PhD, PMHNP-BC Assistant Clinical Professor UTA School of Nursing, Arlington (perley@uta.edu) Instructor, Internal Medicine UNTHSC Texas College of Osteopathic Medicine (mperley@hsc.unt.edu) [Submitted on: 1/17/2010 by: Mary Jo Perley, PhD, PMHNP-BC [perleymj@gmail.com]]

151. Update on Psychiatric Patient and Hospice. I apologize if I do not know all the details of this case as I did not follow the previous notes, but I am outraged at the inappropriate medical care offered to this gentleman. In Minnesota, if someone is a ward of the state, the physicians can draft a letter to the state requesting DNR/DNI and requesting limited treatment. The guardian should be taking into account the wishes of the patient if he is able to express himself (as it sounds like he might be able to do as assessed by the legal dept). However, even if he is full code and continuing on dialysis, there is no reason he couldn't receive better symptom management. I would consider oral dilaudid on a scheduled basis (alternatively fentanyl or metadone) for a renal pt. Perhaps his psych meds could be increased for anxiety instead of use of Ativan (not knowing the meds) and he defineitly should be able to have O2 (no matter the sats), a fan and have a bed where the head can be elevated. I agree that psychiatric pts as well as developmentally disabled individuals often receive terrible end-of-life care as guardians and states are not educated and feel bound by outdated information. These people are subjected to things in the name of providing care that is not related to their disability/worried re the slippery slope. When, in fact they receive worse care by doing INappropriate aggressive care which causes suffering when most reasonable individuals/families in similiar situations would choose comfort /palliative/ hospice care. This is a HUGE area that needs attention in Palliative care. I like the idea of a subspecially of pscyhiatric /palliative NPs. There are not many psychiatrists available and


not many understand end of life. Thank you for this diallogue!!! I am going to the annual assembly and hope this will be discussed. Thanks for bringing this case to our attention. Thank you for your care in the face of tremendous barriers!!! Kris Allen RNCNP ACHPN速 [Submitted on: 1/17/2010 by: Kris Allen RNCNP ACHPN速 [Kris.Allen@NorthMemorial.com]]

151. Update on Psychiatric Patient and Hospice. In Michigan, a guardian can only "approve" or consent to a plan of care presented by the physicians for no further aggressive treatment for a patient. In other words, the physicians must recommend no further aggressive treatment and referral for hospice or palliative services. Pat [Submitted on: 1/18/2010 by: Patricia Hoban [phoban@mhc.net]]

151. Update on Psychiatric Patient and Hospice. Several years ago, we had a situation at our hospital involving a patient who was a ward of the state and in need of appropriate end of life care. The geriatrician following the patient who was hospitalized and in our MICU with full resuscitation status and at the end of life, consulted palliative care for help. After two very long conversations with the attending and with the guardian, it became apparent that the issue was one of verbiage. The guardian indicated he had over 100 persons for whom he was appointed guardian and that in order to make a ward DNAR or to initiate hospice type care, he needed, per NC law, to have documentation in the chart that the ward was "terminal and incurable" or "in a persistent vegetative state." The attending had been using terminology like "grave prognosis" and "incompatible with life" however, this was not the verbiage required by the then current NC law. When the attending was made aware of this, the appropriate documentation was completed in the chart, the patient was made DNAR and comfort care measures were instituted. Following this experience our palliative care steering committee pulled together a workgroup that developed a guideline for providers dealing with persons who are wards of the state and in need of compassionate end of life care. **Attached is the document we developed. Of course, this is state specific and in fact NC statutes were amended in Oct.2007 and the descriptors of these conditions were edited somewhat for clarity and the situation of advanced dementia was added as a trigger for withholding/withdrawing life supportive technology. Bottom line, this document, although current at the time, has been edited as well to reflect current state law. Our palliative care team was subsequently invited to present at several conferences for the NC Guardian Asso. to discuss the rights of all persons, including wards of the state, to compassionate and appropriate care at the end of life. There are still a number of folks in the community who interpret the right to care as the right to all care, whether appropriate to end of life situations or not. There is still a lot of education to be done. But in this case, pointing out the legal need to use the right language moved the care of this patient where it needed to


be. Susan Redding, MSN Pitt County Memorial Hospital Palliative Care PO Box 6028 Greenville, NC 27835-6028 252-847-0868 252-847-7096 FAX Page 252-847-4999, enter #3821 and the return phone number **Please contact submitter directly via email to obtain the document. [Submitted on: 1/18/2010 by: Susan Redding, MSN [sredding@PCMH.COM]]

151. Update on Psychiatric Patient and Hospice. When I was working as a Hospice NP, I also had a patient who was in the ICU who was a resident of a group home for persons with developmental disability. He had been very active prior to a stroke which left him quadraplegic and on a ventilator but awake. ARC (the Association for Retarded Citizens) was the state appointed guardian. Everyone of the people involved in his care from the director of ARC to the counselors at his house met with me and the Hospital Chaplain to discuss, among other things, his quality of likfe and ability to understand what was happening to him. There were about 7 or 8 persons involved. After several meeting, it was decided to compassionately wean him. The day before I went to his group home to talk about him to his peers in a way that they would understand and to help them remember him in a positive way and grieve appropriatelyy. I also went to the Adult Day Center that he attended ans talked to the staff about how a decision like this was made. Sometime later, the director of ARC invited me to speak to the families and staff about advance directives and determining quality of life in this special population. As a result, the organization decided to work with every member to help them develop advanced directives for every one before a critical event took place. I realize that this was an exceptional opportunity but it ended up to be a positive event for everyone involved. Bonnie S. Dank, MPH,MS,RN,CS,CRNP Psychiatric/Adult Nurse Practitioner [Submitted on: 1/18/2010 by: Bonnie S. Dank, MPH,MS,RN,CS,CRNP [congobirdnurse@yahoo.com]]

151. Update on Psychiatric Patient and Hospice. I can't remember what state you are in but if you want some feedback from a psychiatrist/pain/hospice specialist, contact Dr. Barry Cole at bc@paineducators.org or 7024972235 as I discussed this case briefly with him. He was also a former Medical Program Coordinator for Nevada Division of Mental Health. [Submitted on: 1/24/2010 by: [kathleen.broglio@gmail.com]]

Question 152. Ventilator Protocol in the ER. To all, We are looking at creating a ventilator withdrawal


protocol for patients arriving at the ER with a fatal intracranial hemorrhage. Does anyone out there have a current policy for this? We were thinking of using one particular unit to transfer these patients to in order to get them out of the ER to better area for the withdrawal. Respectfully, Stephanie J Ramsey, MSN, RN, NP-C Palliative Care Coordinator Carolinas Medical Center Office 704-355-7700 Blackberry 704-804-9336 Fax 704-355-3631 Ascom 704466-0751 Pager 704-355-4088 #8365 [Submitted on: 8/2/2010 by: Stephanie J Ramsey, MSN, RN, NP-C [Stephanie.Ramsey@carolinashealthcare.org]] Answers 152. Ventilator Protocol in the ER. The CAPC website has a very well written ventilator withdrawal protocol. Check there. [Submitted on: 8/4/2010 by: [peachymor@comcast.net]]

152. Ventilator Protocol in the ER. We would not want to prolong anything, but the ED environment is not conducive to EOL care. I would prefer a patient like this either be moved to a "special" room in the ED that is not so sterile, where the family can truly be present during extubation. Otherwise, I would admit them and then withdrawal in a quiet more appropriate setting. These last moments are the ones the family is going to remember. Karen [Submitted on: 8/9/2010 by: Karen M. Mulvihill [Karen.Mulvihill@danhosp.org]]

Question 153. Video on the Dying Patient. Dear Friends: This is an urgent request. There is an investigation of “dying patients” in our institution by the misunderstanding of the use of opioid continuous infusions at end of life. I have been asked if there is any video that speaks to what a patient goes through as they are dying. I am not aware of any but was wondering if any of you have. It would be something that explains maybe that a patient is fearful of pain and suffering or portrays the struggle at the end of life. Hope you can help. Thank you in advance. Becca Rebecca Hawkins, MSN ARNP, ACHPN® Palliative Care Nurse Practitioner CME Coordinator St Mary Medical Center 401 W Poplar Walla Walla, WA 99362 phone:509522-5514 fax: 509-522-5504 [Submitted on: 8/10/2010 by: Rebecca Hawkins, MSN ARNP, ACHPN® [Rebecca.Hawkins@providence.org]] Answers


153. Video on the Dying Patient. There is a clip from the movie Wit which gives a very good portrayal of this. Rob Robert Smeltz, RN, MA, NP, ACHPN速 Clinical Coordinator/Nurse Practitioner Palliative Care Program New York Univeristy School of Medicine Bellevue Hospital 462 First Avenue, 17S19 New York, NY 10016 (o) 212-562-5277 (f) 212-562-8537 [Submitted on: 8/10/2010 by: Robert Smeltz, RN, MA, NP, ACHPN速 [Robert.Smeltz@nyumc.org]]

153. Video on the Dying Patient. It sounds like you need literature to support you though...not necessarily a video. [Submitted on: 8/10/2010 by: [sheria_robinson@yahoo.com]]

153. Video on the Dying Patient. What does "investigation" mean, what was the trigger, who is doing it? If I read between the lines, it sounds like someone had an agenda before they got started. If this is the pharmacy P & T committee or drug utilization committee, the hospital QA committee, or your ethics group, they should be looking for evidence. There has not been a single study that has implicated opioid treatment at end of life as contributing to early death. On the contrary, all studies to date show opioids to be either neutral or to actually be associated with slightly longer survival. The following URL is to a very short newsletter item I wrote earlier this year. At the end of the item is a link to a reference list. http://archive.constantcontact.com/fs079/1102000702257/archive/1103021022521.html Tom Quinn [Submitted on: 8/10/2010 by: Tom Quinn [thomas.quinn@yale.edu]]

153. Video on the Dying Patient. Becca- This could be an excellent educational opportunity for your institution. If you are looking for a video, I recommend the NHPCO product catalogue which is available online @ www.nhpco.org. Some videos that come to mind are; "Letting Go", "Dying Wish", and the "Facing Death" video series. Also, it may be beneficial to offer an ELNEC program. Linda Freda RN, MSN, CHPN速 Director of Education Hospice of the Comforter 480 W. Central Pkwy Altamonte Springs, FL 32714 407-379-0198 lindafreda@hospiceofthecomforter.org [Submitted on: 8/10/2010 by: Linda Freda RN, MSN, CHPN速 [lindafreda@hospiceofthecomforter.org]]


153. Video on the Dying Patient. Becca, I have to agree with Tom and what the evidence shows. I have MDs in my institution that tell patients it may shorten life, then I have to come in and back peddle that it Has not been shown to do so. Then I have to provide education. A lit review and presentation may be your best evidence. Even a chart review on some drip patients To review their symptom management at the EOL. Good Luck! Karen Mulvihill [Submitted on: 8/11/2010 by: Karen Mulvihill [Karen.Mulvihill@danhosp.org]]

153. Video on the Dying Patient. If you are looking for an excellent video on dying from the patient's perspective, I highly recommend the PBS video set On Our Own Terms: Moyers on Dying in America. "Veteran PBS journalist Bill Moyers blends interviews and research to describe the intimate experiences of patients, families, and caregivers as they struggle to infuse life's ultimate rite of passage with compassion, comfort, and meaning." http://tinyurl.com/32js2y3 Suzanne Franka, MSN, APRN, CNS, CHPN速 Performance Improvement Education Specialist TX, AL, GA, SC, VA, KS, MO, IA, WI, MI SouthernCare Hospice [Submitted on: 8/11/2010 by: Suzanne Franka, MSN, APRN, CNS, CHPN速 [suzanneaustin@live.com]]

153. Video on the Dying Patient. Becca, You may want to look at scenes from the movie WIT starring Emma Thompson. It has been a few years since I viewed the whole film but it shows Thompson's character dying in the hospital. It is very well acted and realistic. (My opinion.) There is also an article that I like entitled: Opioid Use at End of Life Does Not Hasten Death J Pain Symptom Management 2006; 32:532-540. Hope this helps, Marsha Farrell, BSN, RN-BC, CHPN速 [Submitted on: 8/12/2010 by: Marsha Farrell, BSN, RN-BC, CHPN速 [mfarrell@hospicefamilycare.org]]

153. Video on the Dying Patient. Agree with the movie WIT comments Excellent teaching tool depending on the objectives Can get a copy on Amazon for $10.00 or so [Submitted on: 8/12/2010 by: Verosky, Denise [veroskydr@upmc.edu]]


153. Video on the Dying Patient. A new Video is "The most excellent dying of Theodore Jack Heckelman" by White Feather Publishing whitefeather@directcon.net. It costs $24.95. Connie Borden SF [Submitted on: 8/13/2010 by: Connie Borden [BordenSheets@aol.com]]

153. Video on the Dying Patient. Re the movie WIT The DNR conversation between nurse and pt is excellent to me. Each time I watch the movie I am a bit uncomfortable about the one sided portrayal of the physicians. Generally people are more complex, even if we do not understand the motivations. I mentor a variety of health care students, including nursing, pharmacy, medicine, as well as residents, and I try to be sensitive to all professions. I feel the movie can be offensive, and I don't want to alienate. Also, I wish it were 60 rather than 90 minutes long. Jan Mecklenburg, CNP Cleveland [Submitted on: 8/15/2010 by: Jan Mecklenburg, CNP [jan.mecklenburg@gmail.com]]

153. Video on the Dying Patient. The book, "How We Die" is very graphic. It shows the necessity of attending to the dying in compassionate ways which includes symptom management and pain relief. Deborah -- Deborah Greenspan, RN, CHPN速 President Los Angeles Regional Provisional Group Hospice and Palliative Nurses Association [Submitted on: 8/15/2010 by: Deborah Greenspan, RN, CHPN速 [dg.hpnala@gmail.com]]

Question 154. Volunteering at a Pediatric Hospice. Hello everyone: One of my good friends just emailed me and is going to begin a training program this week to volunteer at a Pediatric Hospice. She was inquiring about any suggestions for excellent books etc. that may be worthwhile to read in preparation for her transition into this wonderful ministry. Any suggestions are greatly appreciated. With gratitude, Anne Butler, ANP-BC, CHPN速 Clinical Services Director Evercare Hospice and Palliative Care 410-379-3581 [Submitted on: 9/13/2010 by: Anne Butler, ANP-BC, CHPN速 [anniem416@gmail.com]] Answers 154. Volunteering at a Pediatric Hospice. "The Spirit Catches You and You Fall Down" by Ann Fadiman. While not about hospice specifically, it highlights how the medical system can be so out of synch with what the family wants and feels is valuable. This book really raises


awareness of the role of the family in caring for an ill child -which is such an important part of hospice. Mary S. Wheeler, MSN, RN, ACHPN速 Director of Education and Quality Improvement The Washington Home & Community Hospices [Submitted on: 9/13/2010 by: Mary S. Wheeler, MSN, RN, ACHPN速 [MWheeler@communityhospices.org]]

154. Volunteering at a Pediatric Hospice. Great Books for the younger set: http://www.4rss.com/20091210899/eagerly-awaited-an-angel-in-the-sky-becomes-firstbook-endorsed-by-santa-america-to-be-read-to-children-in-hospicecare.html?change_css=blue Any of the Dr. Seuss books are fun; Thomas the Engine Thank you to your friend, Cheryl Cheryl B. Dworman, BSN, RN, CDCS Cheryl B. Dworman, Inc. Nurse Consultant-Patient Advocate P.O. Box 251981 West Bloomfield, MI 48325-1981 [Submitted on: 9/13/2010 by: Cheryl B. Dworman, BSN, RN, CDCS [cbdinc2001@yahoo.com]]

154. Volunteering at a Pediatric Hospice. "Shelter from the Storm" by Joanne Hilden Christy Torkildson [Submitted on: 9/13/2010 by: Christy Torkildson [torkc@sbcglobal.net]]

Question 155. Warming a Patient Before Extubation. Dear Colleagues, A hospitalist asked if I had experience/knowledge regarding warming a patient before extubation so that the physician could pronounce time of death. Is there a protocol or any information to assist us with this situation? Thanks you for your time and assistance. Carol Bemis, NP Palliative Care Program St. Joseph's Hospital 350 West Thomas Road Phoenix, Arizona 85013 602-406-5252 [Submitted on: 9/1/2010 by: Carol Bemis, NP [cpbemis@yahoo.com]] Answers 155. Warming a Patient Before Extubation. Perhaps I am missing something and if so, please forgive me. Pronouncement isn't the exact time of death, it is the time the patient is first assessed as having no heart beat, no respirations for a minute or more. I cannot see what warming a patient has to do with it. The patient fails to breath, fails to initiate a heart beat, listen for one minute. It sounds to me as if the hospitalist is still thinking in terms of life and cure, else why attempt anything artificial surrounding the death. Again, if I am out of line,


please forgive me. [Submitted on: 9/1/2010 by: Christine Johnson [Christine_in_Van_Alstyne@BrianAndChristine.com]]

155. Warming a Patient Before Extubation. Ditto. I have worked trauma ICU and the only time I would think there would be a question is in cases of severe hypothermia. I have never heard of “warming” a body to pronounce??? Debbie Monaghan RN, MSN Ed, CHPN® Palliative Care Sr. Specialist Sharp Memorial Hospital 858-939-3809 [Submitted on: 9/1/2010 by: Debbie Monaghan RN, MSN Ed, CHPN® [Debbie.Monaghan@sharp.com]]

155. Warming a Patient Before Extubation. There is an adage within the trauma world that a patient isn't dead until they are "warm and dead". This refers to hypothermia patients who can live in a suspended state with very slow heart rate for long periods of time and seem dead. It is generally not necessary to warm patients in an ICU situation when their usual temperature has not fallen below 96 degrees. Time of death is when respirations have ceased and the cardiac monitor shows absence of rhythm. Beverly Douglas, ARNP, ACHPN® LifePath Hospice Tampa Florida [Submitted on: 9/1/2010 by: Beverly Douglas, ARNP, ACHPN® [bevdouglas@tampabay.rr.com]]

155. Warming a Patient Before Extubation. I think the hospitalist is confusing this with determining brain death - in which case the patient must be normothermic to meet brain death criteria ("you're not dead 'til your warm and dead). I have worked ICU for many years and have never encountered temperature as an issue in withdrawal of life support. Linda Hazelgren ACNP, CCRN Fredericksburg, VA [Submitted on: 9/2/2010 by: Linda Hazelgren ACNP, CCRN [mlhazelgren@msn.com]]

Question 156. YouTube Video on Massachusetts General Palliative Care Team. You will see one of us, Connie Dahlin, in this video where the team > talks about the benefits of palliative care for lung cancer patients > from the latest study. Congratulations Connie! > > http://www.youtube.com/watch?v=XHtHXGhTIC4&feature=channel Marian Grant, DNP,


ACNP, ACHPN速 Assistant Professor University of Maryland School of Nursing 410-706-4286 655 West Lombard Street Baltimore, MD 21201 [Submitted on: 8/21/2010 by: Marian Grant, DNP, ACNP, ACHPN速 [msgrant@comcast.net]] Answers 156. YouTube Video on Massachusetts General Palliative Care Team. This is a good way to get out the word about the new research that has been published in NEJM. However, I am offended that Connie was identified as merely "RN" after all that she has contributed as an APRN to the literature and world of Advanced Practice Hospice and Palliative Care Nursing. It completely skipped over her credentials and role on the team and in the study. Beverly Douglas ARNP ACHPN速 LifePath Hospice, Tampa Florida [Submitted on: 8/21/2010 by: Beverly Douglas ARNP ACHPN速 [bevdouglas@tampabay.rr.com]]

156. YouTube Video on Massachusetts General Palliative Care Team. I was so pleased to see the integration of palliative care with chemo- and radiation therapy. When my husband developed metastatic lung cancer last year, I took it upon myself to learn everything I could about keeping him strong and comfortable, as much as I could. I campaigned hard for pain management (he brought stomatitis to a new extreme--immediately after the first treatment, herpes I and candida moved in and stayed there, leaving his mouth like it has been scrubbed with brillo) and for antifungals and antivirals. At first all I knew to avoid was dehydration and malnutrition. He received a liter of LR every day via port, and 3 to 4 liters of a specially concocted combo of generic ensure plus, protein powder, supplements designed to encourage healthy development of red and white blood cells, to combat nausea, along with vitamins and a powder developed in Europe the name of which for the life of me I cannot remember today. The only time he got dehydrated was when an "oncologist" gave him drugs to shrink the size of a tumor he didn't have. That infusion was drawn out over three days and hypovolemia never seemed to occur to anyone but me. (And I am "just" a nurse, so you know how well my ideas were received.) Now that he has finished his treatment, such as it was, we finally found a good oncologist who cares not just for curative treatment but for comfort. Of course we wish we had found her from the beginning. When she asked about having seen other physicians and we told her the litany of sad events, she said to me (in contrast to the others who regularly yelled at me), "sometimes the doctor can learn from the patient." So I can tell you, there is at least one in the Dallas area who, like the APRN and the physicians in the video, really are able to keep both concepts in mind. Thank you for the video. Maybe it will educate the public and providers will have to listen to patients and families. [Submitted on: 8/21/2010 by: Christine Johnson


[Christine_in_Van_Alstyne@BrianAndChristine.com] ]

Question 157. CMS Requirement - Face-to-Face Encounter January 2011. Hello All ~ I am hoping we can learn from each other on this one and do things smarter not harder. The upcoming CMS requirement, for all hospice patients coming into their 3rd benefit period and for every 60 day recert period there after, to be seen F2F by an NP or MD, has resulted in a great deal of shuffling of NP responsibilities in my organization. While much detail was given to where the 'attestation signature' should be, little was given on the content of the Face to Face encounter other than to say the NP will provide their "clinical findings" to the recertifying physician. We did sit in on the NHPCO Webinar. So what are y'all doing? In actuality, this needs to be implemented in December for those patients recertifying in the first weeks of January. We will be doing our visits 2 weeks prior to the IDT meeting, which is 2 weeks prior to the actual recert date, so we will be starting our program in early December. We keep tossing documentation ideas around i.e: clinical/ dx decline; functional, nutritional, cognitive decline, etc. Then the next question is depth of detail. Since this is 'administrative' and not reimbursed, it is all about time ~ drive time, face to face time, chart review time, etc. Also we use Allscripts as our EMR. I was grateful for the 30 day window, but the next few months are going to be interesting Thanks Meg Ramstad MSN ARNP, APN-C Halifax Health- Hospice of Volusia Flagler Port Orange, Fl 32128 meg.ramstad@halifax.org 386-322-4701 [Submitted on: 11/15/2010 by: Meg Ramstad MSN ARNP, APN-C [mramstad@cfl.rr.com]] Answers 157. CMS Requirement - Face-to-Face Encounter January 2011. I have been trying to work under the F2F ruling for the past several months so we would be ready. The 30 day window will definitely help! I have a single page form that is our recertification form. I am able to document my visit and patient assessment with an emphasis on their disease progression, decline, and other factors that paint a picture of why they are hospice appropriate. For our patients who have a non-cancer diagnosis, I include the worksheets that our intermediary has for helping determine prognosis. I also document time and date on the form, and our medical director uses this information in writing his statement for recertification. I find it easiest to take a blank monthly calendar to start with. We use healthcarefirst EMR, so I am able to go in and print off the recertifications that would be discussed at the upcoming IDG. This allows us to discuss my visit during team meetings. Our business office also has a person to help me with tracking these, as she logs in my visits to make sure I am not missing anyone. Moving the deadline to 30 days has helped me arrange these visits around vacations and holidays. I would be glad to discuss this with anyone who has questions and am certainly up for suggestions as well. My number and direct email are listed below. Have a great evening everyone!! Leasa Roach RN, GNP-BC, ACHPN速 leasaroach@msn.com


Hospice of Texarkana, TX/AR (903) 733-1559 [Submitted on: 11/16/2010 by: Leasa Roach RN, GNP-BC, ACHPN® [leasaroach@msn.com]]

157. CMS Requirement - Face-to-Face Encounter January 2011. Leasa, Thanks for the information on how you and your organization handle the face to face recert criteria. One question or issue I have is as I read the regulations, the face to face encounter is to be done by the hospice medical director or the nurse practitioner. You as the NP are signing off on the recert correct? There is no reason for this information to be given to the medical director for his sign off as I read it. Anyone with any other information or input. Mary Lawhon Triano, CRNP-C, ACHPN® Institute of Palliative Medicine 1 Country Club Place Clarks Summit, PA 18511 1-888-861-6255 pmt1209@gmail.com [Submitted on: 11/16/2010 by: Mary Lawhon Triano, CRNP-C, ACHPN® [pmt1209@gmail.com]]

157. CMS Requirement - Face-to-Face Encounter January 2011. According to Medicare regulations, an NP can neither certify nor recertify a patient for hospice, both must be done by a physician. David Hall FNP Willamette Valley Hospice [Submitted on: 11/16/2010 by: David Hall FNP [DavidH@wvh.org]]

157. CMS Requirement - Face-to-Face Encounter January 2011. I think the hand off is the language in the face to face in the home health care plan of care in that NP’s can’t sign that …. It is an attestation statement in the previous 90 days or in 30 days after the referral Carla Jolley ARNP, MN, AOCN, CHPN® jollec@whidbeygen.org [Submitted on: 11/16/2010 by: Carla Jolley ARNP, MN, AOCN, CHPN® [jollec@whidbeygen.org]]

157. CMS Requirement - Face-to-Face Encounter January 2011. I have been patiently waiting for CMS to allow APN’s to do these visits. However, I am bummed that the language says NP and not APN. I am a ACHPN certified CNS and it looks like we are not included in the CMS regs. When I called CMS thay said it was just a knowledge deficit on the part of those who wrote it and probably should have said APN. Are there any CNS’s who have figured out how to make this work? Irene Gilliland RN CNS ACHPN® PhD San Antonio, TX


[Submitted on: 11/16/2010 by: Irene Gilliland RN CNS ACHPN® PhD [IGilliland@satx.rr.com]]

157. CMS Requirement - Face-to-Face Encounter January 2011. According to the AAHPM Guide to the F2F Encounter, only NPs and MDs can do this visit. It may be due to the difference in clinical education between CNS's and NPs. Please don't take that in a negative manner, I have been educated on both tracks and know the difference. Beverly Douglas ARNP ACHPN® LifePath Hospice Tampa FL [Submitted on: 11/16/2010 by: Beverly Douglas ARNP ACHPN® [bevdouglas@tampabay.rr.com]]

157. CMS Requirement - Face-to-Face Encounter January 2011. A hospice physician or NP can complete the face to face encounter (visit) to determine continued hospice eligibility but the MD must sign the certification (and provide a brief narrative). The NP needs to provide the clinical findings from the encounter to the physician who is considering recertification. Nicole DePace MS, GNP-BC, CHPN® [Submitted on: 11/16/2010 by: Nicole DePace MS, GNP-BC, CHPN® [nmdepace@yahoo.com]]

157. CMS Requirement - Face-to-Face Encounter January 2011. I have been waiting, too, as I am also a CNS. The wording is very disturbing to me. If the underlying problem is a knowledge deficit, what are APN's doing to address that? Has someone from HPNA been involved in any discussion with CMS? What about NACNS? Evelyn Bollinger MS, RN, CNS Chicago, IL [Submitted on: 11/17/2010 by: Evelyn Bollinger MS, RN, CNS [evelynb52@yahoo.com]]

157. CMS Requirement - Face-to-Face Encounter January 2011. I can surely appreciate a CNS perspective in this matter, but it seems clear that it is NP only. As a NP, I appreciate the role of my colleague CNSs. However, I do believe it is related to educational preparation there is a marked difference in the two roles. Surely, this was the reason? I know CMS has delineated PCP -primary care provider - status to NPs. Not sure this is true for CNSs? Maybe this has some implication? Kristopher Young, MSN, NP-C, RN-BC, CHPN®


[Submitted on: 11/17/2010 by: Kristopher Young, MSN, NP-C, RN-BC, CHPN速 [kyoungfnp@gmail.com]]

157. CMS Requirement - Face-to-Face Encounter January 2011. I have contacted NACNS (National Association of Clinical Nurse Specialists) for help in this matter. It has seemed absurd that a CNS with years of hospice experience is unable to perform these visits while an NP with no hospice experience would be hireable to perform this. Rita Ewing, RN, ACNSBC, CHPN速 College Station, Texas [Submitted on: 11/17/2010 by: Rita Ewing, RN, ACNS-BC, CHPN速 [ritaewing@yahoo.com]]

157. CMS Requirement - Face-to-Face Encounter January 2011. I too have contacted NACNS. I see you are in TX. I wonder if CNAP would be helpful. Irene [Submitted on: 11/17/2010 by: Irene Gilliland [IGilliland@satx.rr.com]]

157. CMS Requirement - Face-to-Face Encounter January 2011. I have also contacted NACNS. I will be curious to hear what they have to say. Evelyn Bollinger MS, RN, CNS Chicago, IL [Submitted on: 11/17/2010 by: Evelyn Bollinger MS, RN, CNS [evelynb52@yahoo.com]]

157. CMS Requirement - Face-to-Face Encounter January 2011. In response, I also am a CNS with ACHPN certification and 19 years Hospice experience and 27 years as a nurse educator. I asked the question during the comment period. NHPCO sent those comments in to CMS. I also was very disappointed at the results. I feel I am better qualified than many others that are included in providing the face to face. Actually, our hospice nurses are certified as CHPN and would be able to let the physician know what is going on with the patient. We do this now. The nurse discusses the patient condition in IDG and our physicians determine recert or not. The nurse completes a form so the physician can write the narrative that is now required. I would like the NACNS to assist us in allowing APRN to visit for the face to face encounter to assist the hospice physician to recertify the patient. Thanks for continuing this effort. [Submitted on: 11/18/2010 by: Marlene Foreman [marlene@hospiceacadiana.com]]


157. CMS Requirement - Face-to-Face Encounter January 2011. In NJ there is no such thing as NP- we are all APN. (both NP and CNS) I wonder how that will work... Lisa Hapeman [Submitted on: 11/18/2010 by: Lisa Hapeman [lhapnurse@aol.com]]

157. CMS Requirement - Face-to-Face Encounter January 2011. In Illinois, CNS and NP as well as CNM and Nurse Anesthetists are all considered APNs and have title protection. It seems the issue is with CMS. [Submitted on: 11/18/2010 by: Evelyn Bollinger [evelynb52@yahoo.com]]

Question 158. Dobutamine, Dopamine and Milrinone drips in an IPU hospice setting. Anyone have experience with dobutamine, dopamine and milrinone drips in an IPU hospice setting? Our nurses are uncomfortable working with this when pts are not monitored as they are in acute settings- any advice? Marilyn Graves, RN,MSN, CHPN速 Clinical Nurse Specialist Office: 443849-8224 Gilchrist Hospice Care 11311 McCormick Road, Suite 350 Towson, MD 21031 [Submitted on: 11/1/2010 by: Marilyn Graves, RN,MSN, CHPN速 [mgraves@GilchristHospice.org]] Answers 158. Dobutamine, Dopamine and Milrinone drips in an IPU hospice setting. Contact any of your local home IV therapy companies. Patients are cared for at home on these meds via CADD pumps all the time. This is without monitoring, other than vital signs. The patients typically are on stable continuous drip doses........... [Submitted on: 11/1/2010 by: [peachymor@comcast.net]]

158. Dobutamine, Dopamine and Milrinone drips in an IPU hospice setting. We do this all the time, both inpatient and at home. The point is that the dose is not changed, so the patient does not have to be monitored. They are considered "(insert drug name here) dependent" and would have distressing symptoms without it. Most people die with the drug still going, but some do decide at some point (especially if renal failure occurs) to stop. You need to support the nurses' anxiety about having the drugs in place and their feeling


that there is some crisis going on, since these have been in their experience used in ICU settings only. There is no crisis, the patient is stable, it's just another drug. Beverly Douglas ARNP ACHPN® LifePath Hospice Tampa FL [Submitted on: 11/1/2010 by: Beverly Douglas ARNP ACHPN® [bevdouglas@tampabay.rr.com]]

158. Dobutamine, Dopamine and Milrinone drips in an IPU hospice setting. I wondered when I read the first post and then the subsequent ones, whether the nurses who are anxious are not as acquainted with the concepts of hospice and palliative care as they could be. When comfort, and not life extension, is the goal, and, as the responder below points out, they are dependent on that/those drug(s), the drugs are not there for the usual purposes. On the other hand, it's good to know they are that conscientious. I haven't seen many nurses who cared that much in quite some time. It's refreshing. Christine Johnson RN CHPN® LMFT [Submitted on: 11/1/2010 by: Christine Johnson RN CHPN® LMFT [Christine_in_Van_Alstyne@BrianAndChristine.com]]

158. Dobutamine, Dopamine and Milrinone drips in an IPU hospice setting. We do move infusion dependent patients into our inpatient palliative care unit. We have an ‘atypical’ policy which states that the drugs are “for maintenance only” on a non-monitored unit for symptom management. Medication can be “tapered” off; but if ‘titration” up is planned, then the patient goes back to the monitored unit. Cheryl Vahl ARNP, University of Iowa Cheryl-vahl@uiowa.edu [Submitted on: 11/1/2010 by: Cheryl Vahl ARNP [cheryl-vahl@uiowa.edu]]

Question 159. Community-based Palliative Care. I am hoping that some of you will be able to enlighten me. I am increasingly hearing of home health agencies and hospices offering home based "palliative care". There are limitations to home health agencies as there is a requirement that each patient must have a skilled nursing need and be home bound while on service. Many of the patients they want to admit do not have a skilled need or are home bound. Also, I am curious if the hospices are falling back to the practice of "pre-hospice" as they did in the 1990's when they ended up with their hands being slapped by CMS. I pressed a "palliative care" program as she marketed to me and finally admitted they were billing the Hospice Benefit. Am I missing something? I am leery of referring our discharged patients as I do not


want to be complicit in these potentially questionable activities. Thank you, The ever controversial, Rebecca Gagne Henderson [Submitted on: 11/17/2010 by: Rebecca Gagne Henderson [rebecca@endoflifedirectives.org]] Answers 159. Community-based Palliative Care. Rebecca, I too would be leary of an agency that is billing for a hospice benefit for palliative care - unless the patient (or decision-maker) clearly meets the criteria and has willingly and knowingly signed the consent. That being said the regulations for home health vary by state, in many you just need to have a skilled need and do not need to be home-bound, in fact I think that criteria is now only in a minority of the state regs. Most of the agencies I have worked with have provided palliative care under their home health license, hospice often provide palliative care for a select number of patients usually at no cost until they are ready and appropriate to transition to hospice. Many would argue that any patient requiring palliative care meets the skilled need criteria, I for one cannot imagine that they do not. The challenge is that under home health they do not receive the supportive services that hospice is so expert at i.e. social work, pastoral care, volunteers. Although there are agencies that carry both licenses and provide that support to the palliative care patients at no additional charge. Thankfully in the pediatric world the healthcare reform bill has now made law that children can receive concurrent care while on hospice (for children on Medicaid), it will be a long time coming for adult's I'm afraid. Christy Torkildson Mobile: 925-984-3201 [Submitted on: 11/17/2010 by: Christy Torkildson [torkc@sbcglobal.net]]

159. Community-based Palliative Care. I'm not sure how the agency you pressed can bill Medicare without an EOB signed. My hospice has a Palliative Care program. We don't bill Medicare for it. We have contracts with a couple of insurance companies to provide inhome palliative care. It is not skilled home health and it isn't hospice. We also provide palliative care on a private pay basis, tho that is rare. There is a hospice in a nearby metro area run by a health system that also provides insurance. They have a "pre-hospice" program, but it is a separate insurance benefit and is strictly limited. If you don't want to be complicit, ask to see what consents patients sign when they come onto service. That will include info about billing for services. David Hall FNP Willamette Valley Hospice [Submitted on: 11/17/2010 by: David Hall FNP [DavidH@wvh.org]]

159. Community-based Palliative Care. â&#x20AC;&#x153;provide palliative care for a select number of


patients usually at no cost until they are ready and appropriate to transition to hospice.” This would scare me – I believe it is called an enticement and it is very illegal. You can’t provide the same care and not bill as you do when you bill. David Hall FNP Willamette Valley Hospice [Submitted on: 11/17/2010 by: David Hall FNP [DavidH@wvh.org]]

159. Community-based Palliative Care. Hi, I work for a home health/hospice agency and am the program coordinator for our community palliative care program. Our patients are receiving active treatment but have a high symptom burden or psychosocial needs. Some of our patients are also on home health (if they meet the criteria) but many are not as they are not home bound nor have a skilled need (which can be hard to define) for any length of time so sometimes it is difficult to justify keeping them on but we keep seeing them and call home health back in if things change. We have an NP (my visits are billed, Medicare Part B), an RN (her visits can be billed as part of the hh benefit otherwise they are not billed) and a social worker - whose visits are never billed. We can pull spiritual support from our hospice department but try to use other community resources. Many of our patients transition to hospice but some do not. Our program is a collaboration between the local cancer center, a social hospice and the home health/medical hospice agency which distributes the cost of providing the service. Susan Gibson RN FNP-BC, CHPN® [Submitted on: 11/17/2010 by: Susan Gibson RN FNP-BC, CHPN® [smgrn@cox.net]]

159. Community-based Palliative Care. Sorry I can't text as well as typing - I meant that several agencies will take patients at no cost but usually limit the number due to the cost factor so 3-10% of their patient population may be no pay; not as enticement that I agree is quite illegal. Christy Torkildson Mobile: 925-984-3201 [Submitted on: 11/17/2010 by: Christy Torkildson [torkc@sbcglobal.net]]

159. Community-based Palliative Care. In the region I work, the hospices that have "palliative care" use it as a "bridge to hospice" which in reality translates to a way to keep hands on the patient until he is ready for hospice. I do not see any hospice truly providing palliative care outside the benefit because it can not be reimbursed except private pay. the area I practice in is unable to support private pay. Palliative care by hospice is a marketing tool for the most part Mary Lawhon Triano Mary Lawhon Triano, CRNP-C, ACHPN® Institute of Palliative Medicine PC 1-888-861-6255 pmt1209@gmail.com www.iopmpc.com [Submitted on: 11/17/2010 by: Mary Lawhon Triano, CRNP-C, ACHPN®


[pmt1209@gmail.com]]

159. Community-based Palliative Care. I hope you are providing palliative care to your hospice clients and just aren't aware that that's what you are doing? Any time you are managing symptoms and side effects so that the patient's quality of life is better, you are providing palliative care. With your credentials, it appears that perhaps you are lamenting the attitude in the region where you work, rather than care you (or those you supervise or can influence) provide. Perhaps it's more than time for community consciousness raising and professional education opportunities. Christine A Johnson RN CHPN速 LMFT [Submitted on: 11/18/2010 by: Christine A Johnson RN CHPN速 LMFT [Christine_in_Van_Alstyne@BrianAndChristine.com]]

159. Community-based Palliative Care. If social worker licensed and have Medicare provider number they can bill for services as well. Lori F. Schiller, MSN, RN, NP-C, ACHPN速 Nurse Practitioner Hospice of Little Traverse Bay One Hiland Drive Petoskey, MI 49770 (231)4874825 Office (231)487-3019 Voice Mail (231)881-4345 Cell phone lschiller@northernhealth.org [Submitted on: 11/18/2010 by: Lori F. Schiller, MSN, RN, NP-C, ACHPN速 [lschiller@northernhealth.org]]

159. Community-based Palliative Care. Our hospital system is looking at providing community-based palliative medicine service. The model will include NP, SW and chaplain services. The program will be "housed" in the post-acute care setting (Home Health agency, Hospices, Adult Day Care, and Skilled Nursing Facility owned by system are under this title). The NP in MI needs a collaborative agreement with the physician but can practice independently. Billing to insurance is done using the NP's provider numbers and medications prescribed using their own DEA number. It takes a lot of paperwork and time (months) to get the provider numbers through Medicare, Medicaid and other private insurances and reimbursement is 80% of what they pay MDs. In the collaborative agreement the MD delegates prescriptive authority to the NP. We have some limitations to prescribing Schedule 2 medications but usually my physicians have been available for back up. The Community-based Palliative Medicine service can be thought of as an outpatient practice on wheels. Instead of making the patients come to an office, I will do home visits. Eventually we may rent space to see patients in the office as driving all over Northern Michigan isn't cost effective. Home visit reimbursement for Level 5 visit under Medicare fee


schedule is about $200 I think, then NP gets 80% of that. In my rural area I can only do 4-5 visits a day. In most physician offices you need 15 visits a day to offset the overhead. Like hospices our Palliative Medicine program will ask the sytem foundation to write grants and do fundraising. The patient population we will be focusing on will be oncology patients undergoing chemotherapy but who have incurable disease (Stage 3b Lung, Glioblastomas, Pancreatic etc) as well as partnering with our cardiac group for class III/IV Heart Failure patients who need symptom management or advance care planning. CAPC has information online regarding the development of different models of Palliative Care programs at www.capc.org We attended one of their Palliative Care Leadership Centers in MN and learned a lot from a system that has inpatient PC, community-based and SNF-based. Hope this helps answer some questions, Lori Lori F. Schiller, MSN, RN, NP-C, ACHPN速 Nurse Practitioner Hospice of Little Traverse Bay One Hiland Drive Petoskey, MI 49770 (231)4874825 Office (231)487-3019 Voice Mail (231)881-4345 Cell phone lschiller@northernhealth.org [Submitted on: 11/18/2010 by: Lori F. Schiller, MSN, RN, NP-C, ACHPN速 [lschiller@northernhealth.org]]

159. Community-based Palliative Care. Thanks, but our palliative care social worker is employed by the non-profit, non-medical social hospice who do not charge for any of their services ever. We all work together but are not all employed by the same agency - a challenge sometimes but it allows us to be creative and flexible. We do use the hh agency social worker for 'nuts and bolts' of resourcing and so do charge for her visits. I visit patients at home, in skilled nursing facilities, board and care, we have a weekly clinic and I can see them in the hospital as we have an inpatient palliative care team as well. One of our goals was continuity of care. Susan Gibson RN FNP-BC CHPN速 [Submitted on: 11/18/2010 by: Susan Gibson RN FNP-BC CHPN速 [smgrn@cox.net]]

159. Community-based Palliative Care. I wonder for us if the difference is that our palliative care is a separate program from hospice. The patients are either in hospice or palliative care - not both. That is how and why we bill as they are separate entities and separate patients. Deb Groath [Submitted on: 11/18/2010 by: Deb Groath [GROATHD@mercyhealth.com]]

159. Community-based Palliative Care. It is also important to note that all states implement the state benefits differently and offer different services so although Federal programs,


many services are state run outside of the technical Federal Medicare Hospice benefit. For example, one state deleted the 6 months requirement from their state statues another changed it to 12 months. Medicare via CMS requirements remain unchanged but for those particular states they can often offer expanded services that they can get reimbursed by different payors. Home health is almost always a state run benefit so the difference between states is significant. Christy Torkildson Mobile: 925-984-3201 [Submitted on: 11/18/2010 by: Christy Torkildson [torkc@sbcglobal.net]]

159. Community-based Palliative Care. How exciting to see such a long line of emails on community based palliative care! As many of you know- there are not as many resources for developing , implementing and measuring COMMUNITY BASED PALLIATIVE CARE as there are for acute based palliative care. Regardless of who (person, discipline or organization) is providing the community based palliative care, it would be reasonable for a referral source to PC or recipient of PC or any of you to ask the following questions of the community based PC provider: STRUCTURE/ACCESS( see Domain 1 in National Consensus Guidelines for Quality Palliative Care) 1. How is the PC program structured- is it with MDs, APNS, RNs, SW, Spiritual Care , Volunteers- other disciplines- does it have holistic approach? 2. Do they work off of a definition for PC ( perhaps CMS definition or CAPC, or anyone of the national organization) Do they have criteria for admission? Age limitations? Disease limitations? 3. How does community based PC fit with their agency mission? 2. What hours are they available ( 24/7) - ? or days or what? 3. Where do they provide community based care ? ( Home, NH, RCF, outpatient clinic, hospital) - each PC community provider might only operate in certain settings Physical Care( Domain 2) - again see NCP for Palliative Care Guidelines 1. Do they use standardized assessment tools for symptom assessment? And other preferred practices in Domain 2? So in general does the program use the National Consensus Guidelines to adhere to or strive to. do they even know what those are? Use those guideline yourselves to question the community provider on how they address all of the 8 domains- I think if you do that you will know if they are a quality PC providerregardless if they are run by a hospice,, home health , hospital or other organization. As far as Revenue.... Ask the program how is the patient billed for the services- patients need to know if they will be billed or not. If the program is not billing for their revenue-- they may have donated monies to cover services or grants or other sources of revenue--- a program should be willing to share in general how the program is funded. I'll stop there- but it is so great that many mire people are starting to see the benefit of Community based PC and how it can work as a partner with acute care PC, oncology clinic, other disease state clinics and hospices and home health-- all can be done well if the model strives to work with the National Consensus Project Guidelines for Quality Palliative care- they are the North Star.. Judy Bartel, MSN, ACHPN速, CHPCA速 Director of Clinical Programs Hospice of the Western Reserve 19201 Villaview Road Cleveland, Ohio 44119 jbartel@hospicewr.org 216-486-6024 fax- 216 481-4940


[Submitted on: 11/18/2010 by: Judy Bartel, MSN, ACHPN速, CHPCA速 [JBartel@HospiceWR.org]]

159. Community-based Palliative Care. We are a community based Palliative Care Program and we do bill for our services. I would be glad to talk with anyone who is interested in how we do this. We do in-patient, and out-patient consultations and we see the patients where ever they are located. ECF, AFC, homes etc. Pat Hoban, FNP-BC Palliative Care Service Munson Home Health phoban@mhc.net [Submitted on: 11/18/2010 by: Pat Hoban, FNP-BC [phoban@mhc.net]]

159. Community-based Palliative Care. I did want to clarify something-- an NP or MD CAN bill for Palliative Care when seeing patients in "Consultation" with the invitation of the PCP. In my organization, I am doing Palliative Care Consults in Nursing homes to any patient who needs symptom management, no matter where he or she is on the disease continuum. I bill out of Medicare Part B, so my services can be used both with skilled and "unskilled" LTC patients. Although sometimes I see patients for end-of-life care when they are on skilled beds and unable to qualify for both room and board AND Hospice Medical Benefit, most of my patients are nowhere near meeting Hospice criteria. The Nursing Homes love it because their patients and staff are happier and there is no financial burden to the facility. Of course, conversion to Hospice eventually will be a nice perk for my organization, but it's not the only goal and is not a "done deal" by any means. There are at least four Hospice organizations in our area from which our patients choose. [Submitted on: 11/18/2010 by: Polly Hawkes [polly.hawkes@hopva.org]]

Question 160. Dexamethasone for Treatment of Bone Pain. I just got a call from a close friend who is a superb hospice nurse who is struggling to get the medical team at her hospice to consider ordering IV Decadron for a patient with advanced disease/severe bone pain. Is anyone able to provide some supporting evidence/best practice(s) that will provide greater understanding to this hospice medical team of the benefit of this intervention? Thanks for your feedback/insights. [Submitted on: 11/2/2010 by: Anne Butler [anniem416@gmail.com]] Answers


160. Dexamethasone for Treatment of Bone Pain. **Attached is an evidence-based review of corticosteriods for bone pain. Dexamethasone exerts its effect quickly, so it is usually very easy to assess whether or not it is helping. If it doesn't provide additional relief in the first 48-72 hrs, you can simply d/c it. Unless the patient is unable to tolerate PO, there is no advantage to giving decadron IV. Usual starting dose is 4 mg po q day. Dosing in the am is recommended to help prevent steroid-induced insomnia. Good luck, Terri Terri Maxwell, PhD, APRN Vice President, Clinical Initiatives excelleRx, Inc., an Omnicare company [OUR MISSION] To advance public health and well-being through a passionate commitment to the appropriate use of medication **Please contact the submitter directly via email to obtain the document. [Submitted on: 11/3/2010 by: Terri Maxwell, PhD, APRN [TMaxwell@excelleRx.com]]

160. Dexamethasone for Treatment of Bone Pain. That seems unbelievable to me that the use of dexamethasone is not one of the medications that is used for bone pain. We order it on a regular basis for patients who have bone pain from metastasis or compression fractures. We start with a twice a day dosing usually 4 mg at breakfast and lunch and we make sure that the patient is on a PPI. We tend to be more cautious with diabetic patients but we will usually still order it if the pain is severe and will monitor blood sugars. We very seldom find that this does not provide relief. Thanks for the evidence-based review. Sherill [Submitted on: 11/3/2010 by: Sherill Trevino [shtrevino@havenhospice.org]]

160. Dexamethasone for Treatment of Bone Pain. We give Decadron via a subcutaneous site. Maybe the team would be less anxious with a s.c order. We often write the initial order to be p.o/s.c. The order can be QD, as to BID is not necessary (though I still tend to break it up with doses >16mg, with last dose at 3pm). We make sure the pt is on a PPI, unless unable to swallow, . Change the sc site q3days and prn. Pt's typically require anywhere from 4mg-24mg/day. [Submitted on: 11/3/2010 by: Nicole Christenson [nicole@lanquest.net]]

160. Dexamethasone for Treatment of Bone Pain. â&#x20AC;&#x153;Evidence Mattersâ&#x20AC;?? Can one subscribe as an individual? Cheryl Waitkevich Palliative Care Saint Peter Hospital Olympia, WA [Submitted on: 11/3/2010 by: Cheryl J Waitkevich [Cheryl.Waitkevich@providence.org]]


160. Dexamethasone for Treatment of Bone Pain. Wanted to add that you can subscribe to the National Comprehensive Cancer Network's Clinical Practice Guidelines free of charge. Look under the Supportive Care guidelines for Adult Cancer Pain. The algorithms are used by most oncologists and include EBP (with references). NSAIDS and glucocosteroids are listed for bone pain. There is also a Palliative Care Guideline listed under supportive care. Go to http://www.nccn.org/ and register. Lori F. Schiller, MSN, RN, NP-C, ACHPN速 Nurse Practitioner Hospice of Little Traverse Bay One Hiland Drive Petoskey, MI 49770 (231)4874825 Office (231)487-3019 Voice Mail (231)881-4345 Cell phone lschiller@northernhealth.org [Submitted on: 11/5/2010 by: Lori F. Schiller, MSN, RN, NP-C, ACHPN速 [lschiller@northernhealth.org]]

Question 161. Evidence-based Review of Corticosteriods for Bone Pain. Could whoever sent out that article and/or the citation for it, please redo that? I have searched through my email (and the trash!) and I do not have it. What a great article to have... Thanks, Christine Johnson RN CHPN速 LMFT [Submitted on: 11/3/2010 by: Christine Johnson RN CHPN速 LMFT [Christine_in_Van_Alstyne@BrianAndChristine.com]] Answers 161. Evidence-based Review of Corticosteriods for Bone Pain. I Googled and got this. Is this what Terri sent earlier? http://www.hospicepharmacia.com/assets/pdf/evidencematters0107.pdf [Submitted on: 11/3/2010 by: Josie Howard-Ruben [josiehowardruben@gmail.com]]

Question 162. Fees for NP PRN Visits. Does anyone out there have a fee schedule for NP's performing prn home visits? Do you charge per visit or per hour? Thanks in advance, Diane Ranna [Submitted on: 11/17/2010 by: Diane Ranna [cacopema@yahoo.com]] Answers 162. Fees for NP PRN Visits. Our program charges based on time. Patients say they have always had it paid for and no problems with any insurance including medicare and


medicaid. We charge for all visits - inpatient, home, outpatient, and nursing home visits. Deb Groath, ARNP, DNP, ACHPN® Mercy Medical Center - North Iowa Mason City, Iowa groathd@mercyhealth.com [Submitted on: 11/18/2010 by: Deb Groath, ARNP, DNP, ACHPN® [GROATHD@mercyhealth.com]]

162. Fees for NP PRN Visits. Actually, I meant what does the program pay the NP for visits? Does the NP get paid by the hour or by the visit. Not reimbursement of services for the patient... Thanks! Diane [Submitted on: 11/18/2010 by: Deb Groath, ARNP, DNP, ACHPN® [GROATHD@mercyhealth.com]]

162. Fees for NP PRN Visits. In Phoenix, I am also going to become 'per diem' at a local hospice to do the same. Its actually a done deal. Actually, I work for the parent company for this hospice which maybe skew things? I will be getting $125 a visit. The rate is not negotiable. How does this compare to others? Kristopher Young,MSN, NP-C, RN-BC, CHPN® [Submitted on: 11/18/2010 by: Kristopher Young,MSN, NP-C, RN-BC, CHPN® [kyoungfnp@gmail.com]]

162. Fees for NP PRN Visits. Do you get compensated for mileage as well? Lisa [Submitted on: 11/19/2010 by: [lhapnurse@aol.com]]

162. Fees for NP PRN Visits. Yes, mileage as well, a customary rate. [Submitted on: 11/19/2010 by: Kristopher Young [kyoungfnp@gmail.com]]

Question 163. Isolation Policy. Does anyone have an isolation policy for an in-patient hospice unit that they can share? Marilyn Graves, RN,MSN, CHPN® Clinical Nurse Specialist Office: 443-8498224 Gilchrist Hospice Care 11311 McCormick Road, Suite 350 Towson, MD 21031


[Submitted on: 8/9/2010 by: Marilyn Graves, RN,MSN, CHPN速 [MGRAVES@GilchristHospice.org]] Answers 163. Isolation Policy. Hi Marilyn! I am no longer with Alive but I know they have an isolation policy. I guess your best bet is to contact Mary Carr who is the employee health and infectious disease nurse at Alive. She may be reached at mcarr@alivehospice.org Good luck Jessica [Submitted on: 8/9/2010 by: Jessica Weinberger [jetw69@aol.com]]

163. Isolation Policy. **Here's 2 documents for our inpatient hospice center. One is general and second is more specific. The second document has more pages and you may find HMIC, which is our inpatient center. Probably on page 8, 9 or 10, different prevention technique between home care and HMIC. Hope this is helpful. Jung Ok Ha, ANP **Please contact submitter directly via email to obtain documents. [Submitted on: 10/13/2010 by: Jung Ok Ha, ANP [smilejungok@hotmail.com]]

Question 164. Length of Stay. Does anyone have parameters that they use on admission for determining length of stay that they would share? thanks! Marilyn Graves, RN,MSN, CHPN速 Clinical Nurse Specialist Office: 443-849-8224 Gilchrist Hospice Care 11311 McCormick Road, Suite 350 Towson, MD 21031 [Submitted on: 12/6/2010 by: Marilyn Graves, RN,MSN, CHPN速 [MGRAVES@GilchristHospice.org]] Answers 164. Length of Stay. At our institution we decided that we would not try to validate the program using LOS, but to look at cost per day compared to non-pall care pts. We do not count the first 2 days PC and do not count the day of discharge. We also do not count the first 2 days of hospitalization. LOS many times is longer because in general PC gets the outlayers. [Submitted on: 12/6/2010 by: [rebecca@endoflifedirectives.org]]


164. Length of Stay. We do use administrative support and this is quite helpful for the data collection and input into CAPC. We follow CAPC guidelines for parameters to track to prove our worth. My MD partners and I work vigilantly at trying to be efficient about time management yet useful. Jan Mecklenburg, CNP Palliative Care UHCMC, Cleveland, OH [Submitted on: 12/8/2010 by: Jan Mecklenburg, CNP [jan.mecklenburg@gmail.com]]

Question 165. Contacting Beareaved Families. The University of Iowa Healthcare Palliative Care program is interested in finding out what other institutions do for bereavement follow-up with families of deceased patients. 1. Do you send a unit-based or institutional-based sympathy cards? If so, at what time interval after the death? 2. Are the cards handwritten or commercially printed? 3. Do you do a unit-based or institutional-based personal follow up phone call after the death? 4. Do you do any after death family survey to evaluate their experience? 5. If you do a survey, at what time interval do you send it out? Cheryl Vahl MSN ARNP AOCN ACHPN速 Cheryl-vahl@uiowa.edu University of Iowa 200 Hawkins Drive Iowa City IA TEL: 319.384.8690 [Submitted on: 12/10/2010 by: Cheryl Vahl MSN ARNP AOCN ACHPN速 [cherylvahl@uiowa.edu]] Answers 165. Contacting Beareaved Families. 1. We send both an individual Palliative card and an institutional Bereavement card. 2. Commercially printed 3. Palliative patients receive bereavement calls through our department. 4. Not at this time Jeannette (Jeannie) Meyer, RN, MSN, CCRN, CCNS, PCCN, ACHPN速 Clinical Nurse Specialist for Palliative Care Santa Monica UCLA Medical Center and Orthopaedic hospital 1260 15th St. # 1024 Santa Monica, CA 90404 Palliative Care Office #310 319-5112 Direct line # 310 319 1204 Blackberry#310 210-9270 Fax # 310 319 3226 Pager#310206-8477 Extension 96023 [Submitted on: 12/10/2010 by: Jeannette (Jeannie) Meyer, RN, MSN, CCRN, CCNS, PCCN, ACHPN速 [JMeyer@mednet.ucla.edu]]

165. Contacting Beareaved Families. 1. Both. We send out a personalized card from the team caring for the family and we have a bereavement newsletter that goes out a specifically times periods. 2. Both see above. 3. Initial condolences are given by care team followed up call by grief support. Families can attend support groups or have 1:1 counseling if needed. Actively supported for 12mo following death 4. Family Evaluation of Hospice Care (FEHC) is the standard. There is also a Family Evaluation of Palliative Care Survey out now


too I think. The FEHC was validated in at least one study but only evaluates hospice services not family experience you would need a better qualitative survey to do that. 5. I think the survey goes out between 4 and 6 months following the death but I'm not for certain. Sheria [Submitted on: 12/10/2010 by: Sheria Robinson [sheria_robinson@yahoo.com]]

165. Contacting Beareaved Families. May I suggest actively following the bereaved family members for 13 months rather than 12? That gives you a month after the first anniversary of the death, which can be a difficult time. Christine [Submitted on: 12/12/2010 by: Christine Johnson [Christine_in_Van_Alstyne@BrianAndChristine.com]]

165. Contacting Beareaved Families. Yes you're right we do 13 months for that reason not 12. Sheria [Submitted on: 12/12/2010 by: Sheria Robinson [sheria_robinson@yahoo.com]]

Question 166. Maternal Bereavement. Greetings, Question. I was recently informed of a mother who lost her baby about 3 months preterm. She delivered in the hospital and was allowed to grieve with the baby in the room. The concern for many was that the hospital staff left the underdeveloped baby which fit in the palm of her hand with her for 2 days in the room. Apparently the baby had started to decompose the second day and some work had to be done to loosen what was left to cremate the baby for the mother. It sounded like this mom definitely needed some time to spend with the baby and say good bye (she has a whole photo album with pictures she carries from the delivery and she sleeps with the ashes) but what really is an appropriate length of time to allow this mom to say goodbye and who determines that? She now feels like she is suffering/ that it is so hard because she spent so much time with baby after it was born. But its hard to say if she really feels that way or if she is just restating what others may have voiced. Sheria Grice Robinson 313-717-6207 [Submitted on: 12/11/2010 by: Sheria Grice Robinson [sheria_robinson@yahoo.com]] Answers 166. Maternal Bereavement. Many years ago, I experienced a neonatal death with a postterm baby, so I have had that experience of having to say goodbye to an infant. I'm not sure what best practice is now, but I think the key is having staff with expertise in letting mom


know that it is time to start letting go of the physical body, after a couple of hours, and reassuring mom of the tender and respectful care the child will be given afterward. [Submitted on: 12/12/2010 by: Anne Jeffcott [jeffcott.anne01@gmail.com]]

166. Maternal Bereavement. This is sound advice. I thought of the need to have a grief therapise there to help iwth this transition .... Dr Geri Abbatiello Fellow Thanatology [Submitted on: 12/12/2010 by: Dr Geraldine Abbatiello [Dr.GeriAbbatiello@gmail.com] ]

166. Maternal Bereavement. There are also photographers who come into the hospital to photograph the mom and baby. I wasn't sure about this on a personal level, but I must say the pictires were in good taste and just beautuful... Lee Mayer [Submitted on: 12/12/2010 by: Mayer, Lee (OCH) [LeeMayer@dochs.org]]

166. Maternal Bereavement. The organization of professional photographers "Now I Lay Me Down To Sleep" comes to our hospital and take pictures of infants and children in Palliative Care and Hospice. Google Now I Lay Me Down To Sleep in your area. The service is free and they have an area coordinator. Flotyl Gresham, RN MSN Palliative Care Coordinator Le Bonheur Children's Hospital 901-233-9768 [Submitted on: 12/15/2010 by: Flotyl Gresham, RN MSN [greshamf@lebonheur.org]]

166. Maternal Bereavement. Hi Sheila, There really is no good way to determine an appropriate time frame for grieving following a fetal loss. Having worked in this area for 18 years of my nursing career, I learned to take my cues from the mom/partner. I do think it is important to listen to the mom and hear/sense what her needs for connecting and letting go are. I once had a mom who delivered an anencephalic baby (known to the parents prior to the delivery) who, after her baby died, wanted to sleep with him in her arms all night and couldn't bear to be parted from him. This was her way to bond and let go. As nurses on the unit, we absolutely supported her in this. Several weeks following this event, she sent us a letter thanking us for our kindness, compassion and sensitivity in a very difficult situation. Hospitals that have a decent sized labor and delivery unit may have some kind of program for fetal demises/loss, whether that is a packet with information in it, including support group information, and/or a bereavement specialist to personally address the mom/partner


and other family, if needed. I specialized in this work for many years and found the needs to be unique to this patient population. I would inquire in your geographical area what support groups are available to this patient population so you can be prepared to refer, if needed. If desired, I would also recommend following up to see if the hospital has a childbearing loss program in place. Please feel free to contact me if you have further questions. Laurie De Lalio RN, MS, PMHCNS-BC, CT, ACHPN® Palliative Care APN Department of Professional Practice St Anthony Central Hospital Denver, CO 80204 303-595-6472 office lauriedelalio@centura.org [Submitted on: 12/16/2010 by: Laurie De Lalio RN, MS, PMHCNS-BC, CT, ACHPN® [deathmidwife@yahoo.com]]

Question 167. Admission to Hospice for Patients with Dementia. What are you using to admit the patient who has dementia to hospice? CMS requires 7A of the FAST tool, yet there are others available that are more suitable. Hospice of the Valley in Phoenix uses the MMSE, EPERC Fast Facts have one on the Mitchell risk factor tool, and now there is a new tool researched and published in JAMA, November 3, 2010—Vol 304, called ADEPT. I realize that the patients' goals of care should guide these decisions, but Medicare doesn't always see it that way. Please share your current practice. Thanks, Judy Dobson, MSN, CNS, CHPN® [Submitted on: 12/13/2010 by: Judy Dobson, MSN, CNS, CHPN® [pcnurse@verizon.net]] Answers 167. Admission to Hospice for Patients with Dementia. Our hospice uses the FAST scale. [Submitted on: 12/13/2010 by: Susan Roberts [susiescaptains@yahoo.com]]

167. Admission to Hospice for Patients with Dementia. Our MAC is Palmetto and the LCD that we follow includes the following criteria: For Beneficiaries with Alzheimer’s Disease to be eligible for hospice, the individual should have a FAST level of greater than or equal to 7 and specific comorbid or secondary conditions (that can cause significant impairment). [Submitted on: 12/13/2010 by: Linda Freda [lindafreda@hospiceofthecomforter.org]]

167. Admission to Hospice for Patients with Dementia. I thought the MMSE charged per use now for the current version.


[Submitted on: 12/13/2010 by: Sheria Robinson [sheria_robinson@yahoo.com]]

167. Admission to Hospice for Patients with Dementia. We use the FAST scale at 7A and use co-morbidities as applicable. Our hospice is currently under audit by CMS and we have had most of our denials for dementia patients. We are currently fighting each denial but it has been very difficult to get the auditing contractors to budge much. The other hospices in our area of Michigan are experiencing that same thing. Pat [Submitted on: 12/14/2010 by: Patricia Hoban [phoban@mhc.net]]

Question 168. NP with Non-Medicare Hospice. Can a NP practice as an NP in a non-Medicare certified hospice that legally cannot provide skilled care? Seems like an oxymoron to me....anyone know? Sally Lippitt Houston, MSN, FNP, RN-C, ACHPN速 P0 Box 536 Garberville, CA 95542 [Submitted on: 11/17/2010 by: Sally Lippitt Houston, MSN, FNP, RN-C, ACHPN速 [lippitthouston60@gmail.com]] Answers 168. NP with Non-Medicare Hospice. How a nurse practitioner can practice is dictated by the scope of practice as dictated by that NP's state's nurse practice act. If the issue is that the hospice is "non-Medicare," then Medicare has nothing to say about how the hospice is managed or who does what. Unless the hospice is hoping to get Medicare certification, in which case it is a good idea to adhere to medicare guidelines as demonstration of the ability and intent to do so. Christine A Johnson RN CHPN速 LMFT [Submitted on: 11/18/2010 by: Christine A Johnson RN CHPN速 LMFT [Christine_in_Van_Alstyne@BrianAndChristine.com]]

168. NP with Non-Medicare Hospice. I don't see why not. It would be the same as working with any other MD in a specialty practice. You could still bill the private insurance as an NP for services etc, if your have been determined to be a service provider. Also I believe that it would follow the rules of "home health care" ..... A nursing home is generally a nonMedicare certified long term care facility or the non-Medicare beds of a contracted facility. If the hospice has a contract with the facility, or is the owner of a facility, a patient may receive services at the Routine Home Care and Continuous Home care levels at this location. .... Medicare Hospice Management: Structure, Process and Service Delivery By Cathy D. Ott


pg 152 [Submitted on: 11/18/2010 by: mramstad [mramstad@cfl.rr.com]]

Question 169. Study Guides for the Hospice and Palliative APN Exam. I became an NP in 2008. I have been a CHPN for eight years but I am looking for the best resources to help me prepare for the Advance Practice Hospice & Palliative nurse exam in December 2010. Can someone send me a few resources? I have checked out the HPNA website and may order the Core Curriculum for Advance Practice Hospice & Palliative Nurses, 2007, but wonder what other resources I should be studying from. Thanks, Geraldine Nabozny NP Colunbia Memorial Hospital Hudson, NY [Submitted on: 11/5/2010 by: Geraldine Nabozny NP [gnabozny@nycap.rr.com]] Answers 169. Study Guides for the Hospice and Palliative APN Exam. AAHPM Unipac series, HPNA APN practice manual, fast facts, know reasons for n/v (patho) & tx and conditions of participation, good luck. Hardest test I ever took. Don't forget ethics. [Submitted on: 11/5/2010 by: Denise [denise03@kc.rr.com]]

169. Study Guides for the Hospice and Palliative APN Exam. Just took the test and really only used the Core Curriculum to study but had also just reviewed the AAHPM Unipac series since my doc had just taken his Palliative Care boards. Lori F. Schiller, MSN, RN, NP-C, ACHPN速 Nurse Practitioner Hospice of Little Traverse Bay One Hiland Drive Petoskey, MI 49770 (231)487-4825 Office (231)487-3019 Voice Mail (231)881-4345 Cell phone lschiller@northernhealth.org [Submitted on: 11/5/2010 by: Lori F. Schiller, MSN, RN, NP-C, ACHPN速 [lschiller@northernhealth.org]]

169. Study Guides for the Hospice and Palliative APN Exam. Hi, I agree with references already listed. I focused a great deal on medical issues, but found if you are working with palliative care you are probably knowledgeable already. I found that the test contained more about cultural differences and approach to our patients than I had reviewed. Don't forget ethics! Liz Elizabeth Mager-OConnor APN Valley Hospice Coordinator 15 Essex Road Ste. 301 Paramus, NJ 07652 201-291-6131


[Submitted on: 11/5/2010 by: Elizabeth Mager-OConnor APN [EMAGERO@valleyhealth.com]]

169. Study Guides for the Hospice and Palliative APN Exam. I think we need to start a FAQ if we don't have one already. This question gets asked about twice a year. I used the AAPM's review guide for physicians. It was about $500, but there was a discount available to members of HPNA if I recall and my hospital reimbursed me for the books & CD. I also used notes that a colleague of mine took when she went through Deb Heidrich's workshop on palliative care nursing. Of course, Betty and Nessa's book is a great resource, too. I took on the advanced practice test and passed it the first time. Good luck! John [Submitted on: 11/5/2010 by: John D Chovan PhD RN CNP CNS [jchovan@columbus.rr.com]]

169. Study Guides for the Hospice and Palliative APN Exam. It is a tough test, but if you have been CHPN that long, you’ll be fine. Don’t forget about different Religions and their impact on care (ie. Muslim vs. Jewish vs. Hindu). I neglected to study as much of that and those about tripped me up. Big on assessment and primary diagnosis to then begin workup (ie. New onset shortness of breath and assessment pneumonia vs. pleural effusion and how to determine which). Good Luck!! Amanda Hudson Lucas, MSN, ACNS-BC, CCRN, ACHPN® Clinical Nurse Specialist-Center for Palliative Care Medical Center of Central Georgia 777 Hemlock ST. HB 47 Macon GA 31201 Ext: 478 633-4897 Beeper: 478 633-2002 #1106 lucas.amanda@mccg.org "There are no mistakes, no coincidences. All events are blessings given to us to learn from." Elisabeth Kubler-Ross [Submitted on: 11/5/2010 by: Amanda Hudson Lucas, MSN, ACNS-BC, CCRN, ACHPN® [Lucas.Amanda@mccg.org]]

169. Study Guides for the Hospice and Palliative APN Exam. If you are able to get your hands on the UNIPAC, which is a self study for the physicians, it is very helpful. AAHPM have it available but the books are very expensive. They just came out with a new version. I took the test twice and past it the second time. I found it difficult because the test was more geared towards palliative care and I am involved with more hospice care since I am caring for patients in an inpatient facility. There were many questions related to psycho-social issues. I did purchase the Core Curriculum for ARNPs after I took the first test and that is very helpful and is probably your best source of information. Wishing you the best, Sherill Trevino, ARNP


[Submitted on: 11/5/2010 by: Sherill Trevino, ARNP [shtrevino@havenhospice.org]]

169. Study Guides for the Hospice and Palliative APN Exam. Hello I used the core curriculum, it was quite good. Fast facts on line have some good brief guideline focused data as well as Matzos book on Palliative care. Good luck, it is a tough exam, but doable. [Submitted on: 11/5/2010 by: Miranda, Nina (DPH) [Nina.F.Miranda@state.ma.us]]

169. Study Guides for the Hospice and Palliative APN Exam. As a Hospice CNS, I found the exam to be very focused on Oncology. My practice is strictly Hospice with less than 10% with a cancer diagnosis so knowledge of chemo drugs is not something I need to know. I actually have not seen a patient with a cancer diagnosis since last year. The few patients with cancer diagnoses have been off chemo for some time so side effects are not an issue for me. My recommendation is to look at the oncology prep books. Good Luck! I am putting a portfolio together for recert next year. Irene Gilliland RN CNS ACHPN速 PhD [Submitted on: 11/5/2010 by: Irene Gilliland RN CNS ACHPN速 PhD [IGilliland@satx.rr.com]]

169. Study Guides for the Hospice and Palliative APN Exam. What is the exact title for the HPNA APN Practice Manual? [Submitted on: 11/5/2010 by: Emilie Brinson [brinsonemilie@gmail.com]]

169. Study Guides for the Hospice and Palliative APN Exam. I took the certification exam one month ago and used the core curriculum for advanced practice nurses and the UNIPAC series. I found the core curriculum most helpful and the only portions of the UNIPAC series beneficial. UNIPAC 5 discusses the Interdisciplinary Team and there were quite a few questions on that as well as UNIPAC 6 which discusses Ethical and Legal Dimensions and there were questions from that. The questions were focused on the different roles of the advanced practice nurse (educator, clinician, researcher, consultant). I expected more on critical thinking skills, medication management, etc but very few regarding that. Focus on the core curriculum book and you should do fine. Deb Groath, ARNP, DNP Palliative Medicine and Hospice Mercy Medical Center - North Iowa 641.422.7978 groathd@mercyhealth.com [Submitted on: 11/5/2010 by: Deb Groath, ARNP, DNP [GROATHD@mercyhealth.com]]


169. Study Guides for the Hospice and Palliative APN Exam. Agreed - I was able to check the UNIPAC out of an academic library to view, and then purchased the handbook to keep. Core curriculum helped also. Also, as said below - lots of psychosocial-type and cultural questions. Good Luck ! Julie Schneider, RN, ANP-BC, ACHPN速 [Submitted on: 11/5/2010 by: Julie Schneider, RN, ANP-BC, ACHPN速 [jmschneid1226@comcast.net]]

169. Study Guides for the Hospice and Palliative APN Exam. On www.hpna.org and is titled: Core Curriculum for the Advanced Practice Hospice and Palliative Nurse (c) 2007. Pricing HPNA Members: $75.00. Non-HPNA Members: $100.00. ISBN13 - 978-1-934654-02-6. Edited by Mary Jo Perley, PhD, APRN, BC and Constance M. Dahlin, RN, APRN, BC-PCM. The goal of the curriculum is to provide a foundation of knowledge from which APNs can practice palliative care. This book is divided into three sections: an introduction to the roles, advanced skills and issues facing APNs in hospice and palliative care; management of complex life-limiting, progressive illnesses; and special clinical issues. This curriculum is also a resource for any APN working with patients with life-limiting illness. Lori F. Schiller, MSN, RN, NP-C, ACHPN速 Nurse Practitioner Hospice of Little Traverse Bay One Hiland Drive Petoskey, MI 49770 (231)487-4825 Office (231)487-3019 Voice Mail (231)881-4345 Cell phone lschiller@northernhealth.org [Submitted on: 11/8/2010 by: Lori F. Schiller, MSN, RN, NP-C, ACHPN速 [lschiller@northernhealth.org]]

Question 170. Treatment of Nausea and Vomiting in Pancreatic Cancer. Hi Folks, I have a pt with endstage pancreatic cancer in my nursing home. I am expecting that soon she will not be able to tolerate oral anti-emetics soon. What is the best approach to treating her if she reaches a point where she cannot take oral meds. I can treat her pain with SC infusion. Are ABH suppositories "out" as a treatment option now, or what is the best combination continuous sc infusion? Thanks for your help. Kathleen Boyle-Giannini CRNP [Submitted on: 12/16/2010 by: Kathleen Boyle-Giannini CRNP [Kathleen_BoyleGiannini@foulkeways.org]] Answers


170. Treatment of Nausea and Vomiting in Pancreatic Cancer. Think about olanzapine oral dissolving tab(Zydis). Works on multiple receptors, can be dosed 1-2X per day, offers great relief and ease of administration. Kerstin McSteen, ACHPN® [Submitted on: 12/16/2010 by: Kerstin McSteen, ACHPN® [Kerstin.McSteen@allina.com]]

170. Treatment of Nausea and Vomiting in Pancreatic Cancer. Also we have used Scopolamine patches which have also helped. We use subcut haldol but do not know if the nursing facility would be open to that. Sherill Trevino [Submitted on: 12/16/2010 by: Sherill Trevino [shtrevino@havenhospice.org]]

170. Treatment of Nausea and Vomiting in Pancreatic Cancer. Consider haliperidol subcut infusion. I give it starting at 0.5-1 mg per hour. You can also give it intermittently, 0.5-2 mg sub cut q4h prn. Beverly Douglas ARNP ACHPN® Tampa FL [Submitted on: 12/16/2010 by: Beverly Douglas ARNP ACHPN® [bevdouglas@tampabay.rr.com]]

170. Treatment of Nausea and Vomiting in Pancreatic Cancer. You can do intermittent subq injections of haloperidol or haloperidol liquid-2 mg per ml. Sometimes it may take only a .51mg dose to be effective. That amount of oral dose can be given to someone who is not swallowing. [Submitted on: 12/16/2010 by: Linda Freda [lindafreda@hospiceofthecomforter.org]]

170. Treatment of Nausea and Vomiting in Pancreatic Cancer. We use a gralla suppository (dexamethasone 5mg/ metoclopramide 10 mg/ diphenhydramine 20 mg) 1 PR q 6h prn. Works well. Marsha Farrell, BSN, RN-BC, CHPN® [Submitted on: 12/16/2010 by: Marsha Farrell, BSN, RN-BC, CHPN® [mfarrell@hospicefamilycare.org]]

170. Treatment of Nausea and Vomiting in Pancreatic Cancer. Also consider haloperidol SC and/or ondansetron oral dissolving tablets. We have migrated away from ABH gel or


suppositories due to costs although they can be effective. Kenneth Goff, APN, ACHPN速 [Submitted on: 12/16/2010 by: Kenneth Goff, APN, ACHPN速 [kgoff@nwacircleoflife.org]]

Question 171. Palliative Care Services under Home Health Guidelines. Wondering if anyone knows of a successful PC Home Health program that is operating under Medicare Home Health guidelines, which includes requirements of "essentially home-bound, skilled care provided, etc.". Thanks in advance. Please response to me directly if you know of outpatient PC services being offered in this way. Deanna [Submitted on: 12/16/2010 by: Deanna Brame ] Answers 171. Palliative Care Services under Home Health Guidelines. Sutter Health has the Advanced Illness Management program run under home healthcare benefit. They have multiple branches throughout northern California. If you need further information, feel free to contact me off of the listserv (e.g. email me directly, do not hit reply). -- Ab Brody, RN, PhD, GNP-BC Assistant Professor NYU College of Nursing 726 Broadway, Room 1075 New York, NY 10003 Tel: 212-992-7341 Fax: 212-995-3143 Email: Ab.Brody@nyu.edu [Submitted on: 12/16/2010 by: Ab Brody, RN, PhD, GNP-BC [Ab.Brody@nyu.edu]]

171. Palliative Care Services under Home Health Guidelines. We have one of these programs as well. My contact info is below if you're looking for additional info. Maria Ferrell, ACNSBC, ARNP, ACHPN Kansas City Hospice & Palliative Care 9221 Ward Parkway, Suite 100 Kansas City, MO 64114 phone 816-363-2600, ext. 2714 fax 816-523-0093 mferrell@kchospice.org [Submitted on: 12/17/2010 by: Maria Ferrell, ACNS-BC, ARNP, ACHPN [mferrell@kchospice.org]]

Question 172. Max Subcutaneous Infusion with Opioid. Hi, Quickly looked at our website and tried to scan old SIG emails, and I can't find the answer to the following: What is the max dosing in cc/hour for a continuous SUBCUTANEOUS opioid infusion? The EPERC site says no greater then 3cc/hour. Also, I need a reference to give to our pharmacist. Thanks for your help. Carla Tozer Chicago, IL Northwestern Memorial Hospital


[Submitted on: 12/22/2010 by: Carla Tozer [cmtozer@gmail.com]] Answers 172. Max Subcutaneous Infusion with Opioid. Our team recently wrote and implemented a subcut policy. In our research, we found that most studies recommended no more than 3mL/hour for a continuous infusion and up to 2mL/hour for intermittent administration. For a quick overview, see: Weissman, DE. Subcutaneous Opioid Infusions Fast Fact and Concept #28; 2nd edition, July 2005. End-of-Life Palliative Education Resource Center. www.eperc.mcw.edu Holli Martinez FNP-BC, ACHPN Nurse Practitioner Palliative Care Service, University of Utah Hospital Department of Internal Medicine office: 801-581-5826 fax: 801-585-9166 holli.martinez@nurs.utah.edu [Submitted on: 12/22/2010 by: Holli Martinez FNP-BC, ACHPN [Holli.Martinez@nurs.utah.edu]]

172. Max Subcutaneous Infusion with Opioid. Our policy also states no greater than 3cc/hr. Ellyn Schreiner MPH, RN-BC, CHPN Clinical Educator/Supervisor Adventist St. Thomas Hospice 630-856-6983 630-856-6999 (fax) ellyn.schreiner@ahss.org [Submitted on: 12/22/2010 by: Ellyn Schreiner MPH, RN-BC, CHPN [Ellyn.Schreiner@AHSS.ORG]]

172. Max Subcutaneous Infusion with Opioid. Then what do you use when patient needs more than 3ml/hr for continuous infusion and IV route is not desired? Debra Layer, NP Dorn VAMC Columbia, SC [Submitted on: 12/22/2010 by: Debra Layer, NP [Debra.Layer@va.gov]]

172. Max Subcutaneous Infusion with Opioid. We try changing the concentration of the medication to decrease volume if necessary and possible. Ellyn Schreiner MPH, RN-BC,CHPN Clinical Educator/Supervisor Adventist St. Thomas Hospice 630-856-6983 630-856-6999 (fax) ellyn.schreiner@ahss.org [Submitted on: 12/22/2010 by: Ellyn Schreiner MPH, RN-BC,CHPN [Ellyn.Schreiner@AHSS.ORG]]


172. Max Subcutaneous Infusion with Opioid. In addition to increasing the concentration we have at times opted to use a second subQ site and pump if needed, Martha A. Tice, MS, RN, ACHPN Phone 703.396.6102 Fax 888.781.0159 [Submitted on: 12/22/2010 by: Martha A. Tice, MS, RN, ACHPN [MTice@capitalhospice.org]]

172. Max Subcutaneous Infusion with Opioid. Hi, San Diego Hospice has participated in a few studies on SQ infusions and they may be the ones to ask. I used one of their P&Pâ&#x20AC;&#x2122;s on SQ infusion as our guideline here. They are usually quite willing to share. Try their Pal Med Connect Hotline: Palliative Medicine Resource Hotline 1-877-PAL-MED4 (1-877-725-6334) Debbie Monaghan RN, MSN Ed, CHPN Palliative Care Sr. Specialist Sharp Memorial Hospital 858-939-3809 [Submitted on: 12/22/2010 by: Debbie Monaghan RN, MSN Ed, CHPN [Debbie.Monaghan@sharp.com]]

172. Max Subcutaneous Infusion with Opioid. Choices for the patient should be predicated upon prognostication. If the patient is not bed bound the team and the patient should consider a PICC before considering a second SC site. If the patient is bed bound and nonambulatory the second site would probably be an appropriate intervention and would not affect her quality of life. We have done this in the past. The correct limit is 3cc/hr sc. Rebecca Gagne Henderson NP ACHPN [Submitted on: 12/23/2010 by: Rebecca Gagne Henderson NP ACHPN [rebecca@endoflifedirectives.org]]

172. Max Subcutaneous Infusion with Opioid. Any patient that we have used a second subQ site was a hospice patient actively dying and not a candidate to have a PICC line placed. I would agree that a patient for which the GI route for pain meds is not possible but still has a prognosis of weeks, PICC placement should be part of the benefits and burdens, goals of care discussion. Martha A. Tice, MS, RN, ACHPN Phone 703.396.6102 Fax 888.781.0159 [Submitted on: 12/23/2010 by: Martha A. Tice, MS, RN, ACHPN [MTice@capitalhospice.org]]


Question 173. New Medicare Regulation on Advance Care Planning. Does anyone know if APNs can also bill for advance care planning now? Thanks, Marian Grant [Submitted on: 12/29/2010 by: Marian Grant [msgrant@comcast.net]] Answers 173. New Medicare Regulation on Advance Care Planning. Yes, APNs can bill for care planning now under the Encounter for Palliative Care code V66.7. [Submitted on: 12/29/2010 by: Nancy Joyner [njoyner@altru.org]]

173. New Medicare Regulation on Advance Care Planning. For those of you who are in hospice service can you tell us how you are handling short-term admissions and admissions where the patient is actively dying when the nurse arrives to do the admission. Our hospice is struggling with this and the financial implications of these situations. Thanks, Pat [Submitted on: 12/30/2010 by: Patricia Hoban [phoban@mhc.net]]

173. New Medicare Regulation on Advance Care Planning. Pat, Can you be a little more specific about what you mean? Handle what? Care plan, medications, teaching, comprehensive assessment, bereavement? It is challenging financially when you get a spate of actively dying patients or patients with very short length of care. What problems do you see for your hospice that seem to be the biggest cost? David Hall FNP Willamette Valley Hospice [Submitted on: 12/30/2010 by: David Hall FNP [DavidH@wvh.org]]

173. New Medicare Regulation on Advance Care Planning. With the short LOS for hospice, cost of sending equipment or medications to the patient, staff salaries to admit the patient and then the patient expires within 1-2 days and the per diem re-imbursement does not cover the admission costs. What does your hospice do with patients that are actively dying when the nurse arrives in the home. Some responses indicate that those patient go directly into GIP or continuous care. Thanks for the help. Pat [Submitted on: 12/30/2010 by: Patricia Hoban [phoban@mhc.net]]


173. New Medicare Regulation on Advance Care Planning. At my facility we are considering "GIP" status to mean out of symptom control..A patient that is actively dying and comfortable with standard interventions is not a candidate for "GIP" If anyone has a different interpretation that would certainly help with the tremendous effort and cost that goes into the admission of these short term patients. I know that we receive push back from nursing homes that tell us repeatedly that other hospices do not interpret the guidelines in the same manner. Thanks for the dialogue on this matter. Liz [Submitted on: 12/31/2010 by: Elizabeth Mager-O'Conner [EMAGERO@valleyhealth.com]]

173. New Medicare Regulation on Advance Care Planning. Hi Elizabeth - You are correct, GIP status does mean out of control symptoms. It is akin to the "ED for hospice," as I explain it to patients / facilities. This definition has helped them understand the nature of GIP status and how it differs from Routine status. Actively dying and comfortable (in a SNF) is not a candidate, just as the same in-home patient would not qualify. There must be a clinical rationale for uncontrolled symptoms to warrant this status. In larger hospices with their own Palliative Care Unit(s), GIP status is truly "inpatient" care. However, as we know, this is not feasible financially for many hospices and thus, they contract with SNFs (who have 24/7 RNs). My experience in hospice comes after having worked for the nation's largest freestanding hospice for five years, Hospice of the Valley (www.hov.org), and this is how I educated staff to understand the difference and to offer talking points to help others better understand. I do hope this helps! Happy New Year! Kris Kristopher Young, MSN, NP-C, RNBC, CHPN Family Nurse Practitioner HPNA Arizona State Ambassador [Submitted on: 12/31/2010 by: Kristopher Young, MSN, NP-C, RN-BC, CHPN [kyoungfnp@gmail.com]]

173. New Medicare Regulation on Advance Care Planning. The general tenor for GIP in our area is that symptoms that cannot be managed in another setting except a hospital or designated inpt hospice facility.... Constance Dahlin, ANP, BC, ACHPN Palliative Care Service Massachusetts General Hospital Boston, MA [Submitted on: 12/31/2010 by: Constance Dahlin, ANP, BC, ACHPN [cdahlin@partners.org]]

173. New Medicare Regulation on Advance Care Planning. I work for a free standing hospice. We have been getting requests recently from hospital wanting current inpatient admitted to GIP, usually with the intent that patient be discharged the next day or expected


to die before discharge. Most have been actively or pre-actively dying. This improve their mortality statistics. We are trying not to upset referral sources and to follow regulations about GIP being for symptoms that can't be controlled at home. Anyone else with the same experience? Opinions? How do you handle this? David Hall FNP [Submitted on: 12/31/2010 by: David Hall FNP [DavidH@wvh.org]]

173. New Medicare Regulation on Advance Care Planning. We work with 2 hospitals who let actively dying patients stay in the hospital and private pay a daily room rate. We admit them to RCH, bring in meds from the retail pharmacy. GIP doesn't fit for these folks, their symptoms are under control, family just doesn't want them moved. [Submitted on: 12/31/2010 by: Sue Noll [suenoll@sbcglobal.net]]

173. New Medicare Regulation on Advance Care Planning. What do you do when the patient's symptoms are now controlled but they look like death is imminent? Do you discharge them or keep them GIP for another day? Thanks, Helen Wellens MSN, GNP Bellin Health Green Bay WI [Submitted on: 12/31/2010 by: Helen Wellens MSN, GNP [hwellens@new.rr.com]]

173. New Medicare Regulation on Advance Care Planning. I guess we can't bill for it after all. Too bad for many. Hopefully it will be shown in a different light so that people do not refer it to "rationed care" and "death panels." Angie Fuller, RN, MS, APNP, ACHPN Nurse Practitioner Life Choices Palliative Care Tomah Memorial Hospital Tomah, WI 54660 (608) 374-0250 (608) 374-0256 (f) [Submitted on: 1/5/2011 by: Angie Fuller, RN, MS, APNP, ACHPN [boaz@centurytel.net]]

173. New Medicare Regulation on Advance Care Planning. To be honest, I am unsure it should be a billable event to discuss a patent's prognosis, disease trajectory and options. It should be part of every discussion a competent clinician has with their patient. Should there be separate billing to give a patient a diagnosis or a lab value? Besides, if it becomes billable these discussions will be relegated to those less capable or gifted in providing compassionate advance care planning. I am not convinced that having these discussions poorly is better than the discussions not occurring at all. I know that it is time consuming


and can be an emotionally draining task, but these discussions are the most rewarding part of my job. I would do them for free, heck, I do do them for free. Rebecca Gagne Henderson MSN, NP-C, ACHPN [Submitted on: 1/6/2011 by: Rebecca Gagne Henderson MSN, NP-C, ACHPN [rebecca@endoflifedirectives.org]]

173. New Medicare Regulation on Advance Care Planning. Without turning this into a political thread (although what is government if not politics), we probably should have expected this as a concession to those entities who have made the "death panel" concept part of the public's perception of health care reform. Christine Johnson RN CHPN LMFT [Submitted on: 1/6/2011 by: Christine Johnson RN CHPN LMFT [Christine_in_Van_Alstyne@BrianAndChristine.com]]

173. New Medicare Regulation on Advance Care Planning. I do not think they remember that the Patient Self-Determination Act REQUIRES we give ALL inpatient info on Advance Directive! All this does is actually allow the providers to bill for counseling on advance care planning. It is just ridiculous! Karen Mulvihill [Submitted on: 1/7/2011 by: Karen Mulvihill [Karen.Mulvihill@danhosp.org]]

Question 174. Insurance Approval for Ritalin. I have had several patients have their prescription for Ritalin denied by their insurance carrier because it is not being used for: Attention Deficit Disorder Attention Deficit Hyperactive Disorder Narcolepsy Idiopathic Hypersomnolence MS related fatigue or depression Even though the palliative care literature supports the use of a CNS stimulant for cancer-related fatigue, I have been unsuccessful getting this med approved for palliative care patients. Has anyone had any luck getting these type of meds approved for their patients when it does not fall into the narrow category listed above? Thanks, Mark Waters, RN, MPH, OCN, ANP-BC Palliative Care Nurse Practitioner Hospice of Wake County 250 Hospice Circle Raleigh, NC 27607 919-828-0890 (phone) 919-828-9514 (fax) mwaters@hospiceofwake.org [Submitted on: 1/3/2011 by: Mark Waters, RN, MPH, OCN, ANP-BC [mwaters1@nc.rr.com]] Answers 174. Insurance Approval for Ritalin. This drug is included in Walmart's $4.00 plan. Might be


the easiest way to go. Irene Gilliland RN CNS ACHPN PHD(c) San Antonio, TX [Submitted on: 1/3/2011 by: Irene Gilliland RN CNS ACHPN PHD(c) [IGilliland@satx.rr.com]]

Question 175. Morphine as a Bronchodilator? I volunteer to answer questions related to hospice and palliative care on a general informational website and today received a question concerning morphine given, not for pain, but for bronchodilation. This is a first for me. The patient in question has lung cancer, with the affected lung no longer functioning. The questioner states there is no acute or chronic pain. No mention was made of mental status, side effects, or mets (distant or otherwise), etc. There is a history of joint replacement and confinement to a recliner or similar chair for some period of time. I do not know the patient's age. Anyone have any insights on this reasoning? Sharing is appreciated. Christine A Johnson, RN, CHPN, LMFT [Submitted on: 1/4/2011 by: Christine A Johnson, RN, CHPN, LMFT [Christine_in_Van_Alstyne@BrianAndChristine.com]] Answers 175. Morphine as a Bronchodilator? I have heard of using inhaled morphine for dyspnea, not bronchodilation, but studies showed it didn't really work. Someone was doing a study with inhaled fentanyl, I think, but I haven't seen it. Might have been Patrick Coyne, but not sure of my memory there. Debbie [Submitted on: 1/5/2011 by: Debbie Monaghan [Debbie.Monaghan@sharp.com]]

175. Morphine as a Bronchodilator? I thought there was an agonist effect on beta 2 nerves to some degree, which is the reason for vasodilation, also. I can't find a thing online to back me up, though.... Diane Ranna [Submitted on: 1/5/2011 by: Diane Ranna [cacopema@yahoo.com]]

175. Morphine as a Bronchodilator? I'm not sure one could even expect a bronchodilator effect on a tumor filled lung, but certainly morphine relieves SOB by slowing the respirations. We give morphine for the dyspnea of CHF because of the vascular smooth muscle relaxation, not for pain. The goal is to use whatever works for the symptom. [Submitted on: 1/5/2011 by: Anne Jeffcott [jeffcott.anne01@gmail.com]]


175. Morphine as a Bronchodilator? Patrick Coyne did do the research on this. [Submitted on: 1/5/2011 by: Dahlin, Constance M.,MSN,RN,CS [cdahlin@partners.org]]

175. Morphine as a Bronchodilator? Nebulized fentanyl citrate improves patients' perception of breathing, respiratory rate, and oxygen saturation in dyspnea Authors: Patrick J Coyne, Ramakrishnan Viswanathan, Thomas J Smith Impact factor: 2.42, Cited half life: 7.1, Immediacy index: 0.26 Journal: Journal of Pain and Symptom Management [ ] Dyspnea, a subjective symptom of impaired breathing, occurs in 70% of terminally ill cancer patients. Current treatments are suboptimal and little is known about the patient's perception of effect. We tested nebulized inhaled fentanyl citrate on patient perceptions, respiratory rate, and oxygen saturation. The study was conducted using a convenience sample of 35 cancer patients on a dedicated oncology unit. We assessed patient perception (did breathing stay the same, worsen, or improve), respiratory rate, and oxygen saturation by pulse oximetry at baseline, 5 minutes, and 60 minutes. Twenty-six of 32 (81%) patients reported improvement in breathing, 3 (9%) were unsure, and 3 (9%) reported no improvement. Oxygen saturation improved from 94.6% at baseline to 96.8% at 5 minutes and 96.7% at 60 minutes (P = 0.0069 compared to baseline). Respiratory rates improved from a baseline of 28.4/min to 25.9/min at 5 minutes and 24.1/min at 60 minutes (P = 0.0251 compared to baseline). No side effects were observed. Inhaled nebulized fentanyl citrate significantly improved patient perception of breathing, respiratory rate, and oxygen saturation. This inexpensive and readily available treatment may offer substantial relief of end-of-life dyspnea. Randomized trials, dose, and length of effect trials are underway. Journal of pain and symptom management. 01/03/2002; 23(2):157-60. ISSN: 0885-3924 [Submitted on: 1/5/2011 by: Patrick Coyne [user479069@aol.com]]

175. Morphine as a Bronchodilator? **Attached is a brief evidenced-based review of the role of opioids in the management of dysnpea. Please feel free to share. Sincerely, Terri Terri Maxwell, PhD, APRN Vice President, Clinical Initiatives excelleRx, Inc., an Omnicare company **Please contact submitter directly via email for attachment [Submitted on: 1/5/2011 by: Terri Maxwell, PhD, APRN [TMaxwell@excelleRx.com]]

175. Morphine as a Bronchodilator? There has been some research on the benefits of


inhaled morphine for dyspnea as well as P.O. morphine... acting on the mU receptors in the lungs. I am personally not aware of any bronchodilating effects. GAA [Submitted on: 1/5/2011 by: Geraldine Abbatiello [Dr.GeriAbbatiello@gmail.com]]

175. Morphine as a Bronchodilator? Thank you for sending this attachment. Another source would be the ONS PEP Card (now in book form) for Dyspnea. It states there that oral and parental forms of short acting opioids effectiveness have been established. While Pat's study is good it is only a small one (I believe it is "Likely to be effective") and as for other inhaled opioids their effectiveness has not be been established. I believe this link will get you to the journal article http://ons.metapress.com/content/c21324512r838824/fulltext.pdf and while it does say Cancer related dyspnea-dyspnea is dyspnea. Janice Reynolds RN, BC, OCN, CHPN Mid Coast Hospital Brunswick, ME [Submitted on: 1/5/2011 by: Janice Reynolds RN, BC, OCN, CHPN [jkrrnocn@comcast.net]]

175. Morphine as a Bronchodilator? Two other thoughts on this subject, while morphine is not a bronchodilator, it does cause some minor vassal dilation. The other is to teach patients, family members, and sometimes HCP that dyspnea is subjective and like pain it is based on patient report, family report, or signs and symptoms and not by objective criteria. I had a family recently who had a difficult time getting past that; they felt if it was subjective it wasn't real but imagined. They finally got it using the pain analogy. And there still is that HCP who wants to know "what there sat is?" Janice [Submitted on: 1/5/2011 by: Janice Reynolds RN, BC, OCN, CHPN [jkrrnocn@comcast.net]]

175. Morphine as a Bronchodilator? Thank you all for the kind and thoughtful responses. I am a bit relieved to know I wasn't the only one who had to research this a bit! I do not know the route by which the morphine was administered. Bronchodilation, rather than relief of dyspnea, was specified, but also anxiolytic effect, so dyspnea might have been the true target. The asker did make note of the family's "concern about addiction" (arg!!!!) being the reason for "titrating down." I'll forward your thoughts, integrate your wonderful insights and data for myself--thank you all again so much! Christine [Submitted on: 1/5/2011 by: Christine Johnson [Christine_in_Van_Alstyne@BrianAndChristine.com]]


175. Morphine as a Bronchodilator? Hello, My understanding of morphine and dyspnea is that it works on the MU receptors in the lungs (as previously mentioned). I have used it in two end-of-life COPD cases and it greatly improved the quality of the lives of these patients. One client was able to be comfortable and die peacefully, the other client is still living and whereas before was housebound, now feels she can go out for supper with her children (in an electric wheelchair). I’m so amazed at the effect morphine has on dyspnea and how much it has improved these client's lives. Ursula [Submitted on: 1/5/2011 by: Ursula Danner [udanner@tbaytel.net]]

175. Morphine as a Bronchodilator? In the book Palliative Medicine - a case-based manual 2nd edition, an Oxford Medical Publication; in chapter 16, cardiac disease by Romayne Gallagher on page 180 the following is written: In a patient with advanced heart failure, who remains in NYHA class IV failure despite the best balance of cardiac medications, the addition of opioids can provide significant relief of the dyspnea and pain of often experienced. A systematic review of opioids used in advanced disease of any kind showed significant relief from dyspnea with the use of oral or parenteral opioids. Inhaled opioids did not show a significant benefit. The mechanism of action of opioids is though to be through several actions: • Reduction of cardiac venous return by depression of sympathetic reflexes and histamine release. This results in venodilation • Suppresion of the CO2 sensitive respiratory center in the medulla, resulting in a reduction of the perceived breathlessness • A central effect of relaxation that relieves the distress of dyspnoea. • Blocking airway irritant receptors resulting in less bronchospasm. Then, further goes ahead to describe how much to use and which medication to use. I find this book extremely interesting and useful and educational as it goes through case by case. Hope this helps Marianne Marianne Wachalovsky RN-BC, MSN, FNP Palliative Care Nurse Practitioner NorthBay Healthcare mwachalovsky@northbay.org 707.646.4218 [Submitted on: 1/5/2011 by: Marianne Wachalovsky RN-BC, MSN, FNP [mariannew@comcast.net]]

175. Morphine as a Bronchodilator? Terry--thank you. the "Evidence matters" newsletters you have shared are wonderfully clear and well cited. Helpful background and when addressing housestaff concerns. Pat-- Do you know of anyone doing the randomized trials, dose, and length of effect trials mentioned in your abstract. I looked for some a year or so ago to support our use of nebulized fentanyl in a somewhat reluctant setting. Thanks -Suzanne Suzanne Hanen, RN GNP-BC CHPN Palliative Care Consultation Service Winthrop University Hospital Suite 518 222 Station Plaza North Mineola, NY 11501 Pager:


516.291.6118 Desk: 516.663.2921 Fax: 516.663.4644 shanen@winthrop.org [Submitted on: 1/5/2011 by: Suzanne Hanen, RN, GNP-BC, CHPN [SHanen@Winthrop.org]]

175. Morphine as a Bronchodilator? We attempted to trial the fentanyl here. Could not pull it off at this site, over 1000 pt's get it annually. We in fact published how we failed to trial it here in 2009. Hope someone else will. I think there is so much research re neblized morphine no studies will be attempted. Pat [Submitted on: 1/5/2011 by: Patrick Coyne [user479069@aol.com]]

175. Morphine as a Bronchodilator? I have given nebulized morphine. Sometimes it works, despite the studies. Of course morphine sl, po or IV works very well. Karen McGough ARNP ACHPN [Submitted on: 1/5/2011 by: Karen McGough, ARNP, ACHPN [kmcg14@verizon.net]]

175. Morphine as a Bronchodilator? Morphine crosses the blood brain barrier and suppresses the feeling of SOB - although nebulizing morphine has not been proven more effective it is absorbed directly by the membranes and so transported to the Cerebral Cortex and so decreases the perception of dyspnea Investigators are studying the efficacy of nebulized morphine for relief of dyspnea; however, present evidence does not support this route except in extraordinary circumstances. 33-35 While nebulized morphine cannot be recommended as an evidence-based treatment now, it has been considered a promising treatment because it acts locally on opiate receptors in the airways.7 If the opioids are not absorbed systemically, they will not cause the unacceptable side effects that systemic opioids sometimes cause, including somnolence, constipation, and urinary retention.(Spector et al, 2007) I have attached the article for your reading pleasure Regards, Missy (MP) Heylen RN, CHPN [Submitted on: 1/6/2011 by: Missy (MP) Heylen, RN, CHPN [missy_bequia@hotmail.com]]

175. Morphine as a Bronchodilator? The morphine was not administered via nebulizer. If the MOA involves crossing the blood brain barrier, then the route of administration (absent metabolic involvement) should not make any difference except for the speed of uptake. Thanks. Christine A Johnson RN CHPN LMFT


[Submitted on: 1/6/2011 by: Christine A. Johnson, RN, CHPN, LMFT [Christine_in_Van_Alstyne@BrianAndChristine.com]]

Question 176. Profuse Sweating - Cancer Patient. Does anyone have any suggestions for managing hyperhidrosis related to malignancy? We have a patient with metastatic melanoma having problems... especially at night. We are planning on trying propanolol 10 mg @ hs and see if it helps and perhaps primrose oil. Thanks in advance, Marsha Farrell BSN, RN-BC, CHPN [Submitted on: 1/7/2011 by: Marsha Farrell BSN, RN-BC, CHPN [mfarrell@hospicefamilycare.org]] Answers 176. Profuse Sweating - Cancer Patient. Hi, I am not an expert in the management of this symptom, but my colleagues wrote an excellent evidence-based review of this topic (attached). I hope that it is helpful. **Management of Excessive Sweating By: Jennifer Johansen, PharmD, BCPS; Nimmy Matthews, PharmD(c); Ellie Vershvovsky Sincerely, Terri Terri Maxwell, PhD, APRN Vice President, Clinical Initiatives excelleRx, Inc., an Omnicare company [OUR MISSION] To advance public health and well-being through a passionate commitment to the appropriate use of medication **Please contact submitter directly via email for article. [Submitted on: 1/7/2011 by: Terri Maxwell, PhD, APRN [TMaxwell@excelleRx.com]]

176. Profuse Sweating - Cancer Patient. This may not be useful, but I recently learned of an occasional side effect of acetaminophen--sweating! I had noticed it myself (thought it was just that postmenopausal night sweat thing), but my mother (81 and without cancer) had been taking Tylenol PM, switched to plain diphenhydramine HCl and night sweats stopped. So, it the patient is taking any APAP perhaps a trial of not taking it..... Christine Johnson RN CHPN LMFT [Submitted on: 1/8/2011 by: Christine Johnson, RN, CHPN, LMFT [Christine_in_Van_Alstyne@BrianAndChristine.com]]

Question 177. Getting Patient Back to Mexico. We have a patient who is an undocumented worker, found down and now in persistent vegetative state. His brother is here from Mexico on a visa


to be with him and is the only family member here. The patient, although fragile, is currently stable, off vent and DNAR. The family would like to get him back to Mexico. They realize he may die but would like to get him back with his family. We are working with the consulate, but are having difficulty getting verification that the patient will have coverage for medical care in Mexico. We think we can get the medical transport for him to get back paid for. Any ideas regarding facilitating verification of medical coverage in his home country? Thanks so much. Susan Susan Redding, MSN Pitt County Memorial Hospital Palliative Care PO Box 6028 Greenville, NC 27835-6028 252-847-0868 252-847-7096 FAX Page 252-847-4999; enter #3821 and the return phone number [Submitted on: 1/11/2011 by: Susan Redding, MSN [sredding@pcmh.com]] Answers 177. Getting Patient Back to Mexico. Susan, While working in CA I had a pt that wished to return to Mexico - he also was a DNR - the best we could offer was that his family would take him by car and hopefully reach Mexico before he passed. Having a DNR in place and being enrolled in hospice would hopefully have been enough in case of need before they reached the border. While knowing that, it would be better to continue on without stopping in case the pt passed away enroute .. No easy way out... or they take the risk traveling or they stay. Missy (MP) Heylen, RN, CHPN [Submitted on: 1/11/2011 by: Missy (MP) Heylen, RN, CHPN [missy_bequia@hotmail.com]]

177. Getting Patient Back to Mexico. There are only 2 hospices in Mexico. When I was admin of VNA hospice in L.A., this was not an uncommon occurrence. These were hospice patients so we would explain to them the potential for pain and suffering and that should they leave the US they probably would not have the care they needed to remain comfortable. If they chose to leave, we would refill there meds and off they would go. We only heard back once from a family begging for refills to be sent to them. It is a terrible situation for the pt, family, and team. I have the contact info for the nursing professor advocating for better hospice services in Mexico. When I get home, I will send. Rebecca Gagne Henderson [Submitted on: 1/11/2011 by: Rebecca Gagne Henderson [rebecca@endoflifedirectives.org]]

177. Getting Patient Back to Mexico. Good luck! Iâ&#x20AC;&#x2122;ve never had any and we are a border city. I do know of a hospice in Tijuana, just south of us here in San Diego, and the name of a physician who runs (or used to anyway) the hospice. Where in Mexico does the family live?


Whenever I have had people return to Mexico it was with family transporting across the border themselves. Have not had dealings with Mexican insurance and donâ&#x20AC;&#x2122;t believe any pt we had here had or was eligible for any in Mexico. Debbie Monaghan RN, MSN Ed, CHPN Palliative Care Sr. Specialist Sharp Memorial Hospital 858-939-3809 [Submitted on: 1/11/2011 by: Debbie Monaghan RN, MSN Ed, CHPN [Debbie.Monaghan@sharp.com]]

177. Getting Patient Back to Mexico. You know, I wonder if an appeal to charitable institutions or churches might be helpful...? For transportation OR care once the patient has returned. Hmm...just an idea. Susan B. [Submitted on: 1/12/2011 by: Susan Brennan [susanebrennan@comcast.net]]

177. Getting Patient Back to Mexico. Mexico is supposed to have socialized medical. Would Hospice care be covered under this umbrella? Bettye [Submitted on: 1/12/2011 by: Bettye Rollins [rollinsbettye@hotmail.com]]

Question 178. Do Outpatient Palliative Care Clinics Reduce Hospital Readmissions and Overall Costs? I am currently a Palliative Care NP working in a hospital setting at Gundersen Lutheran Medical Center in LaCrosse, Wisconsin. We also have an outpatient Palliative Care Clinic. I am being challenged to show research that indicates that Outpatient Palliative Care Clinics reduce hospital readmissions as well as overall costs. Is anyone able to direct me to a study (s) that specifically demonstrates this type of cost savings from the standpoint of an outpatient Palliative Care Clinic setting? My gut reaction says that these clinics DO reduce costs, but it would sure be helpful to have the research to back me up!! Thanks so much! Carrie Carrie L. Lapham Advanced Practice Nurse- Connected Care (PalliativeCare) Ext. 59336 or 59345 Pager 0512 Mailstop: C04 - 003 [Submitted on: 1/12/2011 by: Carrie L. Lapham [cllapham@gundluth.org]] Answers 178. Do Outpatient Palliative Care Clinics Reduce Hospital Readmissions and Overall Costs? **Attached is a study that was done in a home based palliative care program in Hawaii. I worked at Kaiser but was not involved in the study. It does not address outpatient clinics but does show savings from a home based program. You may want to contact the people at


Dartmouth Hitchcock Palliative Care program as they have had an outpatient program in place for a period of time. **Please contact submitter directly via email to obtain the document. [Submitted on: 1/13/2011 by: Kathleen Broglio [kathleen.broglio@gmail.com]]

Question 179. Continuing Education Opportuniites. I am compiling a resource list of continuing education conferences for myself and my colleagues. We are aware of and have attended AAHPM, HPNA and NHPCO conferences. Iâ&#x20AC;&#x2122;m wondering if you could provide information on local or regional conferences that may be of interest. Iâ&#x20AC;&#x2122;d like information on anything related to hospice or palliative care (in all settings). Additionally, if there are resources in other formats (web-based learning etc) that you have found helpful, please share that too. You can respond to me off the listserv at bmartin@carolina.rr.com Thanks so much! Beth Martin RN, MSN, ACNP-BC, ACHPN, CCNS Hospice and Palliative Care Charlotte Region Charlotte, NC [Submitted on: 1/14/2011 by: Beth Martin RN, MSN, ACNP-BC, ACHPN, CCNS [bmartin@carolina.rr.com]] Answers 179. Continuing Education Opportuniites. Have you considered the American Society for Pain Management Nurses? [Submitted on: 1/14/2011 by: Geraldine Abbatiello [Dr.GeriAbbatiello@gmail.com]]

179. Continuing Education Opportuniites. Hello: These have been helpful to me: Education on Palliative and End of Life Care (EPEC). www.epec.net End of Life Online Curriculum www.endoflife.standford.edu End of Life Palliative Education Resource Center link to Education Materials: www.eperc.mcw.edu I'm really interested in hearing about conferences and workshops that have more of a medical/clinical focus (as in palliative medicine). Ursula Danner RNEC MPH Palliative Nurse Practitioner Northwest Community Care Access Center Thunder Bay, Ontario, Canada [Submitted on: 1/15/2011 by: Ursula Danner, RNEC, MPH [udanner@tbaytel.net]]

Question 180. Epogen and Hospice Head/Neck Cancer Patient. I am looking for any information to help clarify the use of epogen in a hospice patient with head and neck cancer. He is still able to eat


about 40 % of his food, is sleeping more and has elected hospice. The family realizes we cannot provide this treatment and are purchasing out of pocket. Would there ever be a reason to continue this treatment? I would normally recommend to discontinue. Thank you, Liz Elizabeth Mager-OConnor APN Valley Hospice Coordinator 15 Essex Road Ste. 301 Paramus, NJ 07652 201-291-6131 [Submitted on: 1/14/2011 by: Elizabeth Mager-OConnor APN [EMAGERO@valleyhealth.com]] Answers 180. Epogen and Hospice Head/Neck Cancer Patient. Last I looked (when I was going through chemo and radiation with my husband who had lung carcinoma stage IIa), there was a black box warning on epogen and neupogen to the effect that they should not be used if cure was the patient's goal. Apparently the stimulation is fairly general, of rapidly replicating cells--like RBC's and WBC's-- and that they sometimes generalize to cancer cells, which are also rapid replicating. I didn't like that, but also did not like his counts to be so low, and in frustration when they dipped REALLY low, turned to our naturopath who recommended AC-11 and AHCC. No black box warnings and in my review of everything scholarly I could find online, showed at least no SE's. I should add that this was Wednesday afternoon after a particularly bad result on his CBC post chemo. Mike said, try this, to which I responded, will it work by Friday morning? He said to take a double dose but only through Friday, then back down to the recommended. (It has been a year and a half or so, and I cannot tell you what the doses were.) I will tell you that we felt we had nothing to lose, he took the recommended doses, his counts were high enough by Friday (less than 48 hours later) that they stopped nagging about the epogen and neupogen. I have also learned that they can cause fairly severe bone pain, and I know they are expensive. The family might want to check out these natural alternatives. I would not share this if I didn't have first had experience. Of course, it could have been a miracle, but I strongly suspect the supplements simply "worked." I'll also add that I had my husband on a controlled diet via peg (good thing since he had horrible stomatitis) and he was receiving other supplements as well, plus protein powder, dried berry powder, crushed multivitamin, citrus pectin, and a couple of other things. However, the only thing that changed in those two days was the AC-11. I think the AHCC was started at another time. The AC-11 is for the immune system. Just my humble two cents--and an invitation to research it, since now you know about it.... Christine A Johnson RN CHPN [Submitted on: 1/14/2011 by: Christine A Johnson RN CHPN [Christine_in_Van_Alstyne@BrianAndChristine.com]]

180. Epogen and Hospice Head/Neck Cancer Patient. As an Oncology nurse and an ONS


Chemo Therapy & Biotherapy Trainer, I had to comment here. First of all, neither medication was ever block boxed with a warning that they shouldn’t be used if cure was the patient’s goal. With Neupogen and now Neulasta (granulocytic colony stimulating factors) are one of the major break-through which has increased survivorship. Neutropenia and febrile neutropenia used to be the top dose limiting treatment factor. I have seen people die from neutropenia. With Epogen and Procrit, they are black boxed almost to the effect listed (if cure is a goal) but it is because of the risk of serious vascular and cardiovascular events which may shorten life. This is for CRF patients as well as cancer patients. With cancer patients, there is the added REM program now which only allows them to be given for chemotherapy induced anemia. Which is why it surprises me the Head and Neck cancer patient is still receiving it. It doesn’t sound like he would be able to. I am afraid I can’t share sentiment “but I strongly suspect the supplements simply ‘worked’." There needs to be good research to recommend other therapies. While it isn’t going to hurt isn’t going to necessarily help. In cancer, things happen. Sometimes there isn’t an understanding of why or how. Also, the understanding of hematopoiesis is poor. Cellular stimulation is not generalized and cancer cells are not stimulated. Janice Reynolds RN, BC, OCN, CHPN Mid Coast Hospital Brunswick, ME [Submitted on: 1/16/2011 by: Janice Reynolds RN, BC, OCN, CHPN [jkrrnocn@comcast.net]]

180. Epogen and Hospice Head/Neck Cancer Patient. Janice, I would never have posted such a thing had I not read it for myself. I first read it in July, 2009. I don't know when it first was published, though. Don't feel bad, our oncologist at that time (the one who didn't bother to read the path report and treated my husband for head and neck stage three instead of lung stage two A) also did not believe me, and his onsite pharmacist looked it up, came back, and said, "she's right." I have cut and pasted here the entire black box warning for epogen. provided by the manufacturer. The source URL is http://www.epogen.com/professional/safety/safety.html The emphasis is mine. I think it is reasonable to assume that "myelosuppressive therapy" includes chemotherapy since we know that is the problem with anemia and neutropenia with patients receiving that therapy. Sorry if I have stepped on any toes. WARNINGS: INCREASED MORTALITY, SERIOUS CARDIOVASCULAR EVENTS, THROMBOEMBOLIC EVENTS, STROKE and INCREASED RISK OF TUMOR PROGRESSION OR RECURRENCE Chronic Renal Failure: • In clinical studies, patients experienced greater risks for death, serious cardiovascular events, and stroke when administered erythropoiesis-stimulating agents (ESAs) to target hemoglobin levels of 13 g/dL and above. • Individualize dosing to achieve and maintain hemoglobin levels within the range of 10 to 12 g/dL. Cancer: • ESAs shortened overall survival and/or increased the risk of tumor progression or recurrence in some clinical studies in patients with breast, nonsmall cell lung, head and neck, lymphoid, and cervical cancers. • To decrease these risks, as well as the risk of serious cardio- and thrombovascular events, use the lowest dose needed to avoid red blood cell transfusion. • Because of these risks, prescribers and hospitals must


enroll in and comply with the ESA APPRISE Oncology Program to prescribe and/or dispense EPOGEN® (Epoetin alfa) to patients with cancer. To enroll in the ESA APPRISE Oncology Program, visit www.esa-apprise.com or call 1-866-284-8089 for further assistance. • Use ESAs only for treatment of anemia due to concomitant myelosuppressive chemotherapy. • ESAs are not indicated for patients receiving myelosuppressive therapy when the anticipated outcome is cure. • Discontinue following the completion of a chemotherapy course. Perisurgery: EPOGEN® increased the rate of deep venous thromboses in patients not receiving prophylactic anticoagulation. Consider deep venous thrombosis prophylaxis. [Submitted on: 1/16/2011 by: Christine Johnson [Christine_in_Van_Alstyne@BrianAndChristine.com]]

180. Epogen and Hospice Head/Neck Cancer Patient. **I have attached relevant 2010 evidence-based clinical practice guidelines from the National Comprehensive Cancer Network. Linda Freda RN, MSN, CHPN Director of Education Hospice of the Comforter 407379-0198 lindafreda@hospiceofthecomforter.org **Please contact submitter directly via email to obtain. [Submitted on: 1/17/2011 by: Linda Freda RN, MSN, CHPN [lindafreda@hospiceofthecomforter.org]]

180. Epogen and Hospice Head/Neck Cancer Patient. It was the inclusion of Neupogen which bothered me most. It is not black boxed and never has been. While the use of erythropoietin stimulating factor (Epogen and Procrit) has been controversial for several years, many physicians were using it inappropriately. The increased tumor progression was most likely due to angiogenesis which the esf encouraged/supported. I do see a comparison to the bone marrow transplant for breast cancer years back. There were sob stories on the news of women demanding bone marrow transplants and the evil insurance companies refusing to pay because they were experimental. They became a standard of practice. Then the actual clinical trials were completed showing that bone marrow transplants actually reduced life expectancy in breast cancer patients. The unfortunate issue with black boxing, is the lack of accountability for practitioners who use a medication inappropriately because they feel it will work (arrogance based medicine). Risperidone is a good example. Its black box warning “reads not approved for dementia-related psychosis; incr. mortality risk in elderly dementia pts on conventional or atypical antipsychotics; most deaths due to cardiovascular or infectious events; extent to which incr. mortality attributed to antipsychotic vs. some pt characteristic(s) not clear” Yet who is it frequently ordered for? Janice [Submitted on: 1/18/2011 by: Janice Reynolds [jkrrnocn@comcast.net]]


180. Epogen and Hospice Head/Neck Cancer Patient. You did, however, say that procrit had never been black boxed. It takes a lot of damage for black boxing to happen to a medication. I take them seriously. When it is my family member, as this was, I take it very, very seriously. I have discovered that when I take the role of a "sheeple," no one benefits but the people sending out bills. We too have seen a number of providers who misuse or inappropriately use all sorts of medications which by their nature are dangerous to patients. We had one who gave three four-day courses of chemo for a cancer the patient did not have. When he "discovered" his error, he chalked it up to "the art of medicine." Incidentally, although the patient had Medicare, payments were collected before each treatment, or there would be no treatment. I find the continued use of black boxed medications without patients being educated as to risks a HUGE violation of the right to informed consent. I'd like to point out that my post was very open about what it was, that I was talking about one case study, my own observation and, I believe, I ended with an invitation that someone, somewhere might like to pursue more formal research. (There is some, not sure how temporally remote, and certainly some was done by the company that manufacturers the supplements.) [Submitted on: 1/18/2011 by: Christine Johnson [Christine_in_Van_Alstyne@BrianAndChristine.com]]

180. Epogen and Hospice Head/Neck Cancer Patient. I would be careful about using atypical antipsychotics as an example in this scenario as they do have a time and place in helping to manage paranoia and delusions in patients with dementia. You can prescribe risperdone or other atypicals to help with these symptoms when symptom management and keeping patients in the least restrictive environment (e.g. home, assisted living rather than SNF) are the goals of care and the healthcare decision maker is informed of the greater stroke and cardiac risks. If the goals of care are for life prolongation, then no, risperdone is not an appropriate treatment. I think things are a little less black and white than you might allude to here. Just like we might use high doses of opioids in a comfort care situation with high pain levels in a dying patient that could have the side effect of respiratory drive suppression to the point where the patient is no longer breathing is a fairly common use in palliative/hospice care so long as this is congruent with patient/DPOA wishes and goals of care, however this same course of treatment might be highly inappropriate in a patient where curative care was the goal. The keys are education and situation, black box warnings are just that, warning and the consequences of ignoring it need to be laid out appropriately to decision makers and the situation the patient is in needs to be appropriate as well. -- Ab Brody, RN, PhD, GNP-BC Assistant Professor NYU College of Nursing 726 Broadway, Room 1075 New York, NY 10003 Tel: 212-992-7341 Fax: 212-995-3143 Email: Ab.Brody@nyu.edu


[Submitted on: 1/18/2011 by: Ab Brody, RN, PhD, GNP-BC [Ab.Brody@nyu.edu]]

Question 181. Bone Metastasis Pain Management. We have had several young actively dying patients with bone mets with uncontrolled pain. Our medical director is hesitant to go "out of the box" and prescribes high doses of Morphine which has little effect other than making them unresponsive. Does anyone have any protocols that they use that I could present to him? Thanks, Pam Bennett, RN, BSN [Submitted on: 1/17/2011 by: Pam Bennett, RN, BSN [wpgremily@comcast.net]] Answers 181. Bone Metastasis Pain Management. **Attached is a evidence-based review of the use of corticosteriods for bone pain. A trial of dexamethasone is always worth considering. If it works, the results are immediate and dramatic. I hope that this is helpful and that you will share it with your Medical Director. Sincerely, Terri Terri Maxwell, PhD, APRN Vice President, Clinical Initiatives excelleRx, Inc., an Omnicare company [OUR MISSION] To advance public health and well-being through a passionate commitment to the appropriate use of medication **Please contact submitter directly via email to obtain. [Submitted on: 1/17/2011 by: Terri Maxwell, PhD, APRN [TMaxwell@excelleRx.com]]

181. Bone Metastasis Pain Management. I don't have a protocol, however have used decadon (po and/or IV) or short term toradol IV with good results. [Submitted on: 1/17/2011 by: [kmcg14@verizon.net]]

181. Bone Metastasis Pain Management. We use Decadron 4 mg 4 x daily and also use Neurotonin with good success. B.J. [Submitted on: 1/17/2011 by: Bettye Rollins [rollinsbettye@hotmail.com]]

181. Bone Metastasis Pain Management. Bisphosphonates can be helpful, as can radiation tx. [Submitted on: 1/17/2011 by: Keane,Mary Anne [MKeane@skylakes.org]]


181. Bone Metastasis Pain Management. Might want to use the decadron earlier in the day as it can keep people up at night and contribute to delirium. NSAID if it is not end of life and con tolerate is better also. [Submitted on: 1/17/2011 by: Barry Ress [barry.ress@yahoo.com]]

181. Bone Metastasis Pain Management. I've tried a one-time dose of IV toradol and solumedrol in a patient with bone mets. He was on high doses of morphine and ketamine and we still couldn't even lift his hand without him grimacing in pain. The results were remarkable; within 15 minutes we were able to move him without any pain. Good luck! Stephanie M. Horanic, RN, BSN, CHPN Compassionate care for children, adults, and families since 1985 http://www.angelahospice.org/ [Submitted on: 1/17/2011 by: Stephanie M. Horanic, RN, BSN, CHPN [shoranicrn@hotmail.com]]

181. Bone Metastasis Pain Management. You may also find something helpful to use with your medical director in the NCCN Guidelines: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp Debbie Monaghan RN, MSN Ed, CHPN Palliative Care Sr. Specialist Sharp Memorial Hospital 858-939-3809 [Submitted on: 1/18/2011 by: Debbie Monaghan RN, MSN Ed, CHPN [Debbie.Monaghan@sharp.com]]

181. Bone Metastasis Pain Management. One of the best ways to assist your medical director to think â&#x20AC;&#x153;outside of the boxâ&#x20AC;? is to show him the other boxes which are available. I agree with Terri and Debbie that the best way to do this is to show him the evidence by speaking from the literature. **Please see attached article. Ginger Marshall Virginia Marshall, ACNP-BC, ACHPN Nurse Practitioner University of Utah Palliative Care Program Director SOM Room 4B120 50 N. Medical Drive Salt Lake City, UT 84132 801-581-5338 ginger.marshall@hsc.utah.edu **Please contact submitter directly via email to obtain. [Submitted on: 1/18/2011 by: Virginia Marshall, ACNP-BC, ACHPN [ginger.marshall@hsc.utah.edu]]


Question 182. SL Concentrated Morphine. Hello, all, I am an NP at an inpatient extended care center that includes a hospice program. We have a current controversy about use of SL Morphine at end of life: as to if it is not absorbed SL, (but rather subtly swallowed- going thru the GI route instead). Reportedly SQ is what is being used as standard of care. Would some of you be so kind as to respond briefly, in the next day or two, if you are routinely using Roxanol (or its equivalent), PRN, &, if so, SQ or SL? Thank you, Debbie Frederick, NP, ACHPN For direct emails: [debbie.frederick@va.gov] [Submitted on: 1/17/2011 by: Debbie Frederick, NP, ACHPN [debbie.frederick@va.gov] ] Answers 182. SL Concentrated Morphine. From the ELNEC course: â&#x20AC;˘ When liquid medications are placed under the tongue (sublingually), very little drug is absorbed through the oral mucosa. The majority of the drug is trickling back along throat into the gastrointestinal tract. Therefore, despite early teaching, sublingual opioids do not have faster onset, but rather provide convenience for those patients with difficulty swallowing larger volumes (Gordon & Weissman, 2005; Reisfield & Wilson, 2007). [Submitted on: 1/18/2011 by: Sue Noll [suenoll@sbcglobal.net]]

182. SL Concentrated Morphine. I agree with Sue and she recapped the pharmacokinetics for you. Having worked in hospice and palliative care for now 7 years, I can say I have never seen SQ morphine. Rather, PO/SL liquid concentrate. PO/SL is the standard of care. Hope this helps, Kris Kristopher Young, MSN, NP-C, RN-BC, CHPN AZ HPNA State Ambassador [Submitted on: 1/18/2011 by: Kristopher Young, MSN, NP-C, RN-BC, CHPN [kyoungfnp@gmail.com]]

182. SL Concentrated Morphine. Wonder if the SQ drug is actually hydromorphone? We used that SQ for a patient with an allergy to morphine. Christine Johnson RN CHPN LMFT [Submitted on: 1/18/2011 by: Christine Johnson [Christine_in_Van_Alstyne@BrianAndChristine.com]]


182. SL Concentrated Morphine. Our home hospice organization uses PO/SL primarily also, unless caregivers are unable to give ATC. Or, if the patient has lots of excessive secretions (unrelieved with Atropine or Scopolamine) and the SL does not seem to get absorbed, we would switch to SQ. Hope this helps! [Submitted on: 1/18/2011 by: Christina Chiu [tinachiu22@gmail.com]]

182. SL Concentrated Morphine. I've had Pts on SQ Morphine, Oxycodone, and Dilaudid. If you can keep the concentration on the high side (to avoid infusing too much fluid) the SQ route can be very effective and maintained for quite some time (with regular site rotation). [Submitted on: 1/18/2011 by: Christina Chiu [tinachiu22@gmail.com]]

182. SL Concentrated Morphine. Good morning, we use PO/SL morphine all the time, but when there is excessive secretions (unrelieved by scope patches or atropine drops) we use SC morphine or deluded q 2-4 hours and have used a SC infusion is all else fails. Ellyn Schreiner MPH, RN-BC, CHPN Clinical Educator/Supervisor Adventist St. Thomas Hospice 630-856-6983 630-856-6999 (fax) ellyn.schreiner@ahss.org [Submitted on: 1/18/2011 by: Ellyn Schreiner MPH, RN-BC, CHPN [Ellyn.Schreiner@AHSS.ORG]]

182. SL Concentrated Morphine. Remember, too, that in order to have an equivalent effect when using po vs parenteral morphine, you must triple the dose. If you do that it should be just as effective as IV/IM, just slower onset. [Submitted on: 1/18/2011 by: Polly Hawkes [polly.hawkes@hopva.org]]

182. SL Concentrated Morphine. Any of the opioids (except Demerol-and we do not use that anyway) can be given SQ. In fact you can and we have done subcutaneous drips/PCAs. SQ onset is pretty close to IV. I do have literature on SQ route but don’t have time to look it up. Recently had a 94 year old gentleman who went from living by himself on a Thursday had a fall off his three wheeled motorized trike. H bruised his ribs but didn’t break anything. Day 2 He was dehydrated and orthostatic. In rehydrating him he went into fluid overload and began developing pneumonia. Night of day 3 into day 4 he had a major MI. Day 4 he was made comfort measure. Prior to being made CM we couldn’t keep an IV in him so I got the


morphine ordered SQ. The doctor wanted to order the morphine and lorazepam SL the way outpatient Hospice suggests. As it has a much longer onset and we were giving the MS for both breathing and pain I needed to get it back to the SQ and appropriate doses (she wanted 0.5 mg). Pretty soon she said to just write it-I’ll sign it and we were able to give him some good quality time with family and friends before he died at 1800 that night. The faster onset with SQ makes it more appropriate in an inpatient setting sometimes. I have one Palliative Care drug book which does say you can give lorazepam SQ but never have. I would worry because it is awfully viscous (I’ll send the name of the book later as it is in my car and currently snowing). Janice [Submitted on: 1/18/2011 by: Janice Reynolds [jkrrnocn@comcast.net]]

182. SL Concentrated Morphine. We have used SQ morphine via SQ button using injection or PCA routinely in our inpatient and also our field hospice patients. I also like to use liquid ativan PO/SL for restlessness (2 mg/ml) as it is better tolerated and easier to administer to patients who are having difficulty swallowing. We also use SQ atopine via SQ button for patients who have extreme terminal congestion. Of course, we must have a separate SQ button for each medication which needs to be changed Q3days. Hope this helps. Lynn S.V. Walls, RN, BSN, CHPN [Submitted on: 1/18/2011 by: Lynn S.V. Walls, RN, BSN, CHPN [lwalls7777@aol.com]]

182. SL Concentrated Morphine. I have read that SL meds do trickle down into GI tract and not much is absorbed by the oral mucosa. Still, in the outpt setting that is what we primarily see. I work in the acute care setting and if IV is not available and the pt can’t take oral meds, we will use the SQ route frequently. Debbie Monaghan RN, MSN Ed, CHPN Palliative Care Sr. Specialist Sharp Memorial Hospital 858-939-3809 [Submitted on: 1/18/2011 by: Debbie Monaghan RN, MSN Ed, CHPN [Debbie.Monaghan@sharp.com]]

182. SL Concentrated Morphine. We use PO/SL morphine 20mg/mL and typically get excellent symptom management. We do on occasion use SQ Morphine Infusions. However, as long as the patient can tolerate the oral/SL route and the patient is well managed, we stick with the oral/SL Roxanol. Melissa Summerlin, RN, CHPN Nurse Clinician/Educator Hospice of Northeast Georgia Medical Center 2150 Limestone Parkway, Suite 222 Gainesville, GA 30501 (770) 219-8500 [Submitted on: 1/18/2011 by: Melissa Summerlin, RN, CHPN


[Melissa.Summerlin@nghs.com]]

182. SL Concentrated Morphine. Debbie, The concentrated morphine gtts do indeed go through the GI tract like any other oral medication. We regularly use Roxanol 100 mg/5 ml concentration prn for our patients who are having trouble swallowing as their disease progresses. We do not use SQ injections with our patients. (On rare occasions, we have used a PCA pump with a SQ route.) We have found that our patients die very comfortably with the Roxanol prn. Opioid dose and frequency needs often change during the dying process as the liver stops metabolizing the drug effectively and the kidneys are not eliminating the drug as efficiently (i.e. lower dose and/or increase time between doses of the opioid.) Hope this helps. Marsha Farrell, BSN, RN-BC, CHPN Hospice Family Care [Submitted on: 1/18/2011 by: Marsha Farrell, BSN, RN-BC, CHPN [mfarrell@hospicefamilycare.org]]

182. SL Concentrated Morphine. Good morning, we do use lorazepam SC and have had no problem, have used up to 2cc at a time. Ellyn Schreiner MPH, RN-BC, CHPN Clinical Educator/Supervisor Adventist St. Thomas Hospice 630-856-6983 630-856-6999 (fax) ellyn.schreiner@ahss.org [Submitted on: 1/18/2011 by: Ellyn Schreiner MPH, RN-BC, CHPN [Ellyn.Schreiner@AHSS.ORG]]

182. SL Concentrated Morphine. Also, if I know or even suspect that my patients have renal insufficiency, I use oxyfast (liquid oxycodone 20 mg/ml) instead of Roxanol. Dosage is basically equivalent to Roxanol, it is pretty cheap, and can avoid or delay some of the neurotoxic side effects that occasionally happen with morphine. Anecdotally, when a patient on Roxanol DOES develop twitching that is causing the patient (or family) concern, I have found that switching to oxycodone has eliminated the twitch. I have not found "best evidence" for this occurrence, just experience. [Submitted on: 1/18/2011 by: Polly Hawkes [polly.hawkes@hopva.org]]

182. SL Concentrated Morphine. Thought you all might be interested in a pharmacist report of absorption of meds when they are used sublingual. This is from the pharmacist I work


with in end of life care. I find it helpful to review pharmacokinetics once in awhile! “Sublingual absorption of opioids follows pharmacokinetic and biochemistry principles including lipophilicity, solubility, pH, and pKa---but mostly lipophilicity. The most lipophilic opioids will have the best ability to cross the lipid mucosal membrane and thus have some direct mucosal absorption. Even this is not very good with the far majority of the administered sublingual dose indeed being consciously or unconsciously swallowed. The literature I use is from Weinberg (Clin Pharmacol Ther 1988 Sep;44(3):335-42-----yes it is old because this is how long we have known about this) and shows the following absorption for sublingually administered opioids: Fentanyl 51% (most lipophilic opioid therefore the best “true” absorption)” Methadone 34% Morphine 22% Oxycodone <20% Judy Bartel, MSN, ACHPN, CHPCA Director of Clinical Programs Hospice of the Western Reserve 19201 Villaview Road Cleveland, Ohio 44119 jbartel@hospicewr.org 216-486-6024 fax- 216 4814940 [Submitted on: 1/18/2011 by: Judy Bartel, MSN, ACHPN, CHPCA [JBartel@HospiceWR.org]]

182. SL Concentrated Morphine. Great discussion. We too, use the concentrates - Roxanol or oxycodone most of the time - have used subq opioids also at times....we are fortunate to have a compounding pharmacy - someone mentioned the lorazepam - we often use that in a compounded cream which is handy if they can't take the pills or concentrate. We have never used actiq (the fentanyl oral for breakthrough ca pain) - does anyone have experience with that? [Submitted on: 1/18/2011 by: Sue Noll [suenoll@sbcglobal.net]]

182. SL Concentrated Morphine. All: **With the permission I received a short time ago from The Thomas Massey Cancer Center, I am attaching some algorithms that may add to this discussion. Especially pertinent is the algorithm on page 4 on "alternative routes". Those of us who worked or work now in hospices where finances is a concern as well as comfort, remember that the rectal route was always something we would discuss with the patient/family. Inserting the long acting opioid was the norm, before we opted for the pumps and the sc route. Consider also, a few "out of the box" ideas on these algorithms, such as the injectable fentanyl being used sublingually. Dr. Perry Fine recently stated recently at the Capital Hospice seminar on dyspnea "...lack of research does not necessarily mean lack of efficacy". The topic at that time in the panel discussion was the use of nebulized fentanyl for dyspnea, which is also one of VCU's first line meds for the patients in the inpatient unit, and they have 10 years of experience with that medication and patient reports of fast relief. Another "out of the box" use for fentanyl, the sublinqual route for the injectable form, was from the experience of a physician in Jordan, published in the Journal


of Palliative Medicine. That's all he had to work with to help his patients and by using it, he comforted the patients in his care. Research is extremely important, no doubt. But it is not easy to complete good studies in hospice and palliative care settings! Remember that the use of sl morphine was passed down to us from nuns that were under the observation of Cicely Saunders, MD. We are still giving that medication all these years later. Many studies were generated using morphine as a result of its success. And now we know how much absorption occurs in the oral mucosa with morphine compared to other meds that have a higher rate, as mentioned by another member on this group. With some other meds, we are just at the starting point of proving their value via research. Meantime, I think we need to pay attention to good information shared with us by valued and dedicated professionals, just in case we encounter a patient who can benefit from the knowledge. Regards to all, Judy Dobson, MSN, CHPN PESI speaker on hospice and palliative care interventions **Please contact submitter directly via email to obtain. [Submitted on: 1/18/2011 by: Judy Dobson, MSN, CHPN [pcnurse@verizon.net]]

182. SL Concentrated Morphine. **Here is the letter from Dr Milhem reporting the use of injectable fentanyl given SL for pain. He works here at U of Iowa. Our pharmacy is reluctant to use as there is no 'research'. Regards, Cheryl Vahl MSN ARNP AOCN ACHPN University of Iowa Cheryl-vahl@uiowa.edu **Please contact submitter directly via email to obtain. [Submitted on: 1/20/2011 by: Cheryl Vahl MSN ARNP AOCN ACHPN [cherylvahl@uiowa.edu]]

182. SL Concentrated Morphine. This reminds me of a physician who sat next to me on a plane on the last leg to the AAHPM/HPNA conference in Salt Lake City. We were discussing pain management and wound care. I have been frustrated in my efforts to use morphine gel (which does have some literature to back it up) and he said, "I always just drip IV morphine into the wound; doesn't everyone?" Janice [Submitted on: 1/27/2011 by: Janice Reynolds [jkrrnocn@comcast.net]]

Question 183. Withdrawing Ventilator. A question has come up regarding taking our patients off ventilators; can the RN do this without a physician in attendance, and does the patient have to be officially “comfort care”? If any of you have insight(s) or policy, I would so appreciate hearing from you. We do not have policy but RN’s have been w/d our patients with MD order. We now are meeting resistance from some of the ICU RN’s feeling they are killing or


hastening the patient’s death. When on comfort care, many of our patient’s are not breathing on their own, this is causing a lot of discomfort amongst some of our nurses. Again, insights or policy would be so helpful for us. Thank you, Lee Lee Mayer, NP Palliative Care Service (408) 947-4723 O'Connor Hospital 2105 Forest Ave. San Jose, CA 95128-1471 Email LeeMayer@dochs.org [Submitted on: 1/19/2011 by: Lee Mayer, NP [LeeMayer@dochs.org]] Answers 183. Withdrawing Ventilator. We have a team approach to ventilator removal in our hospice inpatient unit. The physician, nurse practitioner, or respiratory therapist actually disconnects the ventilator tube. The nurse is also at the bedside and is focused on medication administration for patient comfort. The chaplain and social worker are present as needed for emotional and spiritual support. Linda Freda RN, MSN, CHPN Director of Education Hospice of the Comforter 407-379-0198 lindafreda@hospiceofthecomforter.org [Submitted on: 1/19/2011 by: Linda Freda RN, MSN, CHPN [lindafreda@hospiceofthecomforter.org]]

183. Withdrawing Ventilator. Interesting, Our RN's and a resp therapist do the terminal extubations with an order from the physician. Our RN's are very on board with end of life. I do follow up with the RN that has been caring for that patient to help them work through their feelings, and deal with their stress of attachment that at times can play a role in resistance from an RN. We teach death and dying classes with a focus on quality of life, pt wishes , end of life. HPNA APN SIG - Remember Reply goes to all! Sandra Kelly RN BSN, ELNEC Trainer Palliative Care Battle Creek Health System Phone: 269-966-8446 Pager: 269410-0110 "Never stop believing in dreaming, and never stop dreaming of believing. That is what gives us hope, and what keeps us alive." ( unknown author) [Submitted on: 1/19/2011 by: Sandra Kelly RN BSN, ELNEC Trainer [kellys@trinityhealth.org]]

183. Withdrawing Ventilator. EPERC (Fast FACTS) provides excellent info/resources for policy development. Nurses and RTs need support/education. If they are not comfortable w/process, that should be addressed. We just updated our policy to include removal of non – invasive ventilation (BIPAP) in the dying patient (in addition to invasive vent removal). We do not require MD attendance (but do require MD orders as guided by our order set). Code Status is Comfort Care. The RN and RT are always in attendance, & very often a member of the Palliative Care team and Chaplain or other person for spiritual support, if desired. Our


orders/protocol guide care providers in regard to communications with loved ones and use of meds (allowing aggressive escalation as needed) to prevent/treat any signs of resp distress. If the patient survives more than 2 hours and/or is transferred out of the CCU comfort care orders replace vent removal orders. [Submitted on: 1/19/2011 by: Kathleen Fahey [kathleen_fahey@sbcglobal.net]]

183. Withdrawing Ventilator. I think adding non-invasive ventilatory support such as BiPap is much needed. We recently sedated a patient in our hospice house and removed the BiPap. The decision was made by the patient. We put on a NRB mask and eventually at the family's request removed this as well. He died peacefully surrounded by his family. I was the nurse on the floor that day and it was quite an experience even for me despite 20+ years in hospice and Palliative nursing. I believe this is a situation we will be encountering more often. Nanci Tansey, APRN, GNP Tidelands Community Hospice Georgetown, SC Areas first Hospice House 843-520-7700 [Submitted on: 1/20/2011 by: Nanci Tansey, APRN, GNP [tanseyprn@yahoo.com]]

183. Withdrawing Ventilator. We have a similar system. The RN and RT perform the withdrawal. If it happens during business hours, we offer SW and chaplain support, and if palliative care involved, we are frequently there to support the family as well. The orders are for withdrawal with comfort measures and the pt is a DNR. If the pt is relatively stable after a few hrs, they are transferred out of ICU to the palliative care unit, and if they still donâ&#x20AC;&#x2122;t look imminent, we call hospice. We do not require physician presence, but there needs to be documentation that the physician has had discussions with the family and physician orders. When palliative care is involved we also document clearly what discussions were held, and options presented after physician gave prognosis. I believe CAPC has examples or templates of discussion points that need to be documented in these cases, as well as standardized order sets for withdrawals. We always invite the bedside RN to participate in any family meetings, and this frequently helps when they hear the discussions and see the process of decision making. If staff are still struggling with this then they need more education and support. And, sometimes the person who continues to struggle with these issues may need to try not to take assignments that look as though there may be decisions made for withdrawal. Unfortunately, that is hard to avoid when you work in the ICU, kind of the nature of the beastâ&#x20AC;Ś Debbie Monaghan RN, MSN Ed, CHPN Palliative Care Sr. Specialist Sharp Memorial Hospital 858-939-3809 [Submitted on: 1/20/2011 by: Debbie Monaghan RN, MSN Ed, CHPN [Debbie.Monaghan@sharp.com]]


183. Withdrawing Ventilator. At our hospital nurses and respiratory therapists are the ones at the bedside when ventilators are withdrawn and patient's goal and orders are focused on comfort. Some physicians choose to be at the bedside, there is always a physician in the unit to respond to symptoms which cannot be managed with current orders and additional orders are required. We also have a policy on conscientious objection which allows a staff member to request not to participate in activities around withdrawal or withholding or life sustaining treatments, there needs to be timely notification of the manager, must continue care until an alternative staff can be placed. It also sounds like some of the nurses are experiencing moral distress associated with these patients--the AACN has a program to identify and talk about moral distress--the 4 a's--it is useful in getting the topic out in the open and allow dialogue to happen. I am wondering if nurses are objecting to all incidents of withdrawal of a ventilator or is there a specific patient population or populations or circumstances that are raising the most concerns by the some members of the nursing staff. Sounds like it is a wonderful opportunity to start a discussion with the staff and figure out the underlying issues and develop a plan--education, staffing, communication, policy needs, for some nurses it might be a strongly held values of sanctity of life and then the question is how to or if it possible to accommodate their moral values within the structure of the unit. The stress of providing end of life care in the ICU setting is well documented, what can be done to create a supportive environment for staff and patients is a key question. Thanks for raising a question/concern that many nurses face in the practice on a daily basis Marydenise [Submitted on: 1/20/2011 by: Mary Denise Smith [smithm@ohsu.edu]]

Question 184. Fentanyl Infusion and Nalazone Policies. 1) Does anyone have a nursing or hospital policy supporting the use of IV fentanyl infusions (alone or as part of IV PCA) on regular medical floors? A concern has been voiced at our hospital that infusions of fentanyl are more dangerous than morphine and that their use should be restricted to the ICUs or step-down units. 2) Does anyone have a nursing or hospital policy supporting the gradual titration of naloxone in cases of suspected opioid overdose? We have good articles and have looked at the new edition of Pain Assessment and Pharmacologic Management by Pasero and McCaffery, but would like to see how other hospitals have dealt with this in their formal policies. Thanks, Jay Jay R. Horton, ACHPN, FNP-BC, MPH Clinical Program Manager The Lilian and Benjamin Hertzberg Palliative Care Institute The Brookdale Department of Geriatrics and Palliative Medicine Mount Sinai School of Medicine One Gustave L. Levy Place, Box 1070 New York, NY 10029 (212) 241-5178 jay.horton@mssm.edu [Submitted on: 1/20/2011 by: Jay R. Horton, ACHPN, FNP-BC, MPH [jay.horton@mssm.edu]] Answers


184. Fentanyl Infusion and Nalazone Policies. Hi Jay I have worked in hospitals that have used fentanyl PCAs infusions on general floors since 1996 (four in total). I am not sure where this concern comes from as fentanyl is an 'opioid' just as hydromorphone and morphine. The chest wall syndrome only occurs with rapid infusions of high dose opioids toherwise I have found fentanyl can be actually safer especially in those patients who are elderly and renally compromised. [Submitted on: 1/20/2011 by: Kathleen Broglio [kathleen.broglio@gmail.com]]

184. Fentanyl Infusion and Nalazone Policies. 1. Does anyone have a nursing or hospital policy supporting the use of IV fentanyl infusions (alone or as part of IV PCA) on regular medical floors? We routinely use fentanyl on all floors, not just ICU. Our PCA policy includes all opioids. That being said, our physicians are usually hesitant to order any opioid infusion or PCA w/basal, on M/S floors, unless the pt is opioid tolerant, or on comfort care. Our policy does not restrict any to the ICU. I do not see that fentanyl is any more dangerous than other opioids. It is a matter of education with physicians and staff. 2. Does anyone have a nursing or hospital policy supporting the gradual titration of naloxone in cases of suspected opioid overdose? The following orders are written for all opioid infusions/PCA’s and are part of the pain management policy: 1. Narcan 0.1mg IV/SQ if RR ≤ 10, and unarousable. Call MD and Pain pharmacy immediately. Continue q 2 minutes until awake or RR > 14. 2. Call pain pharmacist prn poor pain control, oversedated, RR ≤14. 3. Check RR prior to each dose of narcotic, hold if RR ≤14. 4. Patients with continuous narcotic infusions: check RR Q1º x 4, then Q3º. Hold if RR ≤ 10 5. Exception: in terminal “comfort care only” patients, respiratory rate pa ameters may vary from protocol and should result from appropriate discussion with physician. Debbie Monaghan RN, MSN Ed, CHPN Palliative Care Sr. Specialist [Submitted on: 1/20/2011 by: Debbie Monaghan RN, MSN Ed, CHPN [Debbie.Monaghan@sharp.com]]

Question 185. Retired Hospice RN and Volunteering Roles. I was recently approached by a retired hospice RN who is interested in volunteering with my palliative care program. Does anyone have experience with this and if so, what are the guidelines and scope of her role…any suggestions would be greatly appreciated…. Thank you! Jo Ann Jo Ann Gottlieb, ARNP-BC, CHPN, PhD Palliative Care Nurse Practitioner Baptist Hospital of Miami Office: 786-596-7067 ASCOM: 786-594-9702 [Submitted on: 1/21/2011 by: Jo Ann Gottlieb, ARNP-BC, CHPN, PhD


[joanng@baptisthealth.net]] Answers 185. Retired Hospice RN and Volunteering Roles. I checked into volunteering in the VNA's hospice program, and told them I was certified, etc., and their response was that volunteers, nurses and otherwise, were not to do nursing tasks. Just my experience.... Christine Johnson [Submitted on: 1/21/2011 by: Christine Johnson [Christine_in_Van_Alstyne@BrianAndChristine.com]]

185. Retired Hospice RN and Volunteering Roles. I actually had several volunteer nurses when I directed 2 separate hospices - 1 in MA and 1 in OR. RN must got through RN orientation, have correct licensing, etc. But it can work well for both sides... Constance Dahlin, ANP, BC, ACHPN Palliative Care Service Massachusetts General Hospital Boston, MA [Submitted on: 1/22/2011 by: Constance Dahlin, ANP, BC, ACHPN [cdahlin@partners.org]]

185. Retired Hospice RN and Volunteering Roles. Retired nurses are a great help in teaching patient care skills to volunteers that will serve in this role- once you insure they teach what you want them to teach. Mary Wheeler, MSN, RN, ACHPN [Submitted on: 1/22/2011 by: [MWheeler@communityhospices.org]]

Question 186. Request for Information Regarding Composition of Palliative Care Consult Service. Dear Palliative Care Colleagues, I am the PC Program Manager / CNS at Stanford Hospital and Clinics. The number of consults and the need for palliative care is growing. I appeal to those of you in academic settings to share some key information regarding the staffing for your consult service. If you would prefer to talk live, please provide your contact information and I will call. I am interested in the following: • Do you have an inpatient palliative care (PC) consult model? If so, do you have inpatient palliative care beds? How many? Are they designated PC beds or do they change to acute care based on census? • How many palliative care inpatient consults per month? • What is the staffing on the PC consult team? (Number of physicians and FTE, NP or CNS and FTE, social worker FTE, chaplain FTE, etc.) • Do you have an outpatient palliative care service? If so, who staffs those patients? Thank you so much. I appreciate your time and attention. Judy Passaglia RN, MS, ACHPN Palliative Care Program Manager / CNS Department of Quality, Patient Safety & Effectiveness Stanford


Hospital & Clinics (650) 723 3736 jpassaglia@stanfordmed.org [Submitted on: 1/24/2011 by: Judy Passaglia RN, MS, ACHPN [JPassaglia@stanfordmed.org]] Answers 186. Request for Information Regarding Composition of Palliative Care Consult Service. May I ask what to going to be done with this information? Nancy Joyner, RN, MS, APRN-CNS, ACHPN Clinical Nurse Specialist-Palliative Care Altru Health System- Altru Hospital 1200 So Columbia Road Grand Forks, ND 58201 njoyner@altru.org ph 701-780-5442 fax 701-7804296 [Submitted on: 1/24/2011 by: Nancy Joyner, RN, MS, APRN-CNS, ACHPN [njoyner@altru.org]]

186. Request for Information Regarding Composition of Palliative Care Consult Service. Stanford is trying to determine the best staffing metrics and wanted to learn from other programs as we make these decisions. I am happy to answer any further questions. Judy Passaglia RN, MS, ACHPN Palliative Care Program Manager / CNS Department of Quality, Patient Safety & Effectiveness Stanford Hospital & Clinics (650) 723 3736 jpassaglia@stanfordmed.org [Submitted on: 1/24/2011 by: Judy Passaglia RN, MS, ACHPN [JPassaglia@stanfordmed.org]]

186. Request for Information Regarding Composition of Palliative Care Consult Service. Feel free to contact me at the number listed below Belena "Billie" Adkins RN CHPN Community Palliative Consultants Project Manager 904.608.4042 badkins@communityhospice.com [Submitted on: 1/25/2011 by: Belena "Billie" Adkins RN CHPN [BAdkins@communityhospice.com]]

186. Request for Information Regarding Composition of Palliative Care Consult Service. Hi Judy- I'd be glad to talk with you off-line. You can reach me at 303-588-5416. Virginia Gillispie, CNS, APRN, CHPN [Submitted on: 1/25/2011 by: Virginia Gillispie, CNS, APRN, CHPN [2-dogs@earthlink.net]]


186. Request for Information Regarding Composition of Palliative Care Consult Service. Do you have any residents or fellows with the service and when did you start the consult service? Thank you. Judy Passaglia RN, MS, ACHPN Palliative Care Program Manager / CNS Department of Quality, Patient Safety & Effectiveness Stanford Hospital & Clinics (650) 723 3736 jpassaglia@stanfordmed.org [Submitted on: 1/25/2011 by: Judy Passaglia RN, MS, ACHPN [JPassaglia@stanfordmed.org]]

186. Request for Information Regarding Composition of Palliative Care Consult Service. Dear Judy, please call me directly, I think I have previously made contact with you for a presentation you made for the CNS org.? Eve Cruz (323)409-8535 [Submitted on: 1/25/2011 by: Eve Cruz [eacruz2@msn.com]]