I am new to blogging, actually this is my first attempt and I write with trepidation. So, thank you, Alex, for the encouragement and wriggle room to write with imperfection.
Like yours, my academic and clinical background is in both geriatrics and palliative care. Prior to my work as a nurse practitioner in an inpatient in hospice and palliative care unit, I worked for eight years as a hospice case manager in the community. I work integrally with the outpatient hospice community and I am worried. I am worried about the care of the elderly in hospice. I am worried because I know so much more than I did as a hospice RN. I know more about the pathophysiology of end stage diseases, how tricky it is to balance appropriate medication management of elders with multiple co-morbidities, what medications to use and what to avoid in the elderly. I look back on all my years as an RN advising, recommending, and instructing home care patients about medications I didn’t know enough about. I wonder how often I did more harm than good. Let me exaggerate (a bit) and say that I worked in the “morphine and lorazepam” fix most everything era; give everyone the same compounded pill/suppository for nausea and vomiting; NSAIDS for bony pain. I didn’t know what I didn’t know. I didn’t inquire about renal function, history of gastritis or GI bleed, or targeting receptors for nausea treatment. Now I know that lorazepam is more likely to cause delirium in the elderly than benefit from anxiety. Now I know that giving morphine to my patients with renal failure could result in distressful symptoms from toxic metabolites. There was no physician or nurse practitioner (at that time) available to teach and oversee medication management. I was caring and ‘well intended.’ But that’s not enough.
I recently admitted a patient to our inpatient hospice unit who was served at home by a community hospice agency. (To protect patient confidentiality, details of the story have been altered, but the essential story remains the same.) She was in her 80’s, diagnosed a year prior with progressive supranuclear palsy (PSP) and dementia. Her daughter was afraid she would choke to death at home as she could no longer swallow. She felt safer having her in an inpatient setting. Upon admission she appeared to be in a deep sleep, non-responsive, stiff. Her daughter was very pleased with how caring the hospice staff was and with her mother’s relaxed state. I, on the other hand, worried. At home, she was receiving 5mg of po morphine (20mg/ml) along with 1 mg po haldol (2mg/ml) every 4 hours around the clock. “The nurse said I could give him up to 20mg every 4 hours”, the daughter remarked. “Why the haldol?", I asked. “The nurse told me it would be smoother for her”, she replied. The patient was never agitated, confused, or hallucinating. I wondered if the hospice staff thought about how the decrease in dopamine levels would affect this elderly woman with PSP. I wondered if the haldol was part of a ‘comfort care packet’ some hospices give to all patients/families to have on hand. I wondered if the medications and their dose ranges were generically signed off by a physician.
I stopped the haldol and decreased her morphine dose. The next morning she was able to sit up, open her eyes, move her limbs, recognize others, weakly communicate. Was her deep sleep and stiffness related to her exhaustion from the move? Was her one day of semi-alertness just an energy ‘boost’ before her death? We’ll never know. But I wondered and I worried about medical and nursing care of this particular elderly woman with her particular end stage disease.
Hospice agencies compassionately care for newborns through centenarians. Because the vast majority of patients served are elderly with multiple co-morbidities, I wonder, as palliative care providers, if our responsibility to understand geriatrics isn’t as important as understanding palliative care.