I don't think he's going to like this one...
If you need to catch up....
How hospice and others made things worse
The new hospice nurse and her preceptor were just getting the day started when a call came in from their clinical manager. The preceptor listened intently for several minutes, then put her phone away.
"Change of plans," the preceptor said. "We need to get over to Alcott Hospital. We might have to screen a patient for GIP." (pdf) "This will be a good experience for you."
When they walked onto the unit designated for hospice intensive care, the charge nurse gestured to a small group huddled in a corner.
Somewhere down the hall, a man screamed loudly. He was the subject of the small group's conversation.
The small group consisted of:
- the unit's nurse manager;
- an oncologist;
- the vice president of nursing;
- a nurse named 'Sheila' who had been at Alcott since anyone could remember, was variously estimated as being somewhere between her late 60's to early 80's, wore a lab coat over expensive clothes, and seemed to just randomly appear in small group discussions or larger meetings, but was never either consulted or challenged.
"Not our patient yet," the preceptor said.
"But aren't we supposed to screen somebody for GIP?" the new hospice nurse asked.
"Not our patient yet," the preceptor repeated.
The new hospice nurse could still hear the small group's discussion from where she stood with the preceptor's hand on her elbow, holding her back.
Somewhere down the hall, a man kept screaming.
"We can't use propofol," the nurse manager said. "He needs to go to ICU if you want to use propofol."
"We'll do Just in Time Nursing Education," the vice president of nursing replied enthusiastically. "I've been waiting for a chance like this."
"I'm not sure if propofol works for pain," the oncologist said. "Shouldn't we ask the pharmacy?"
"What's going on?" the new hospice nurse asked the preceptor. "What else do you know about this case?"
The preceptor replied, "The patient you hear screaming is someone who's been on hospice, but not our agency. He was with East Cupcake Home Care and Hospice."
The new hospice nurse had never heard of East Cupcake.
"They're a small outfit twenty miles away," the preceptor continued. "They mostly do home care visits - wounds, new babies, teaching people how to inject their insulin, that sort of thing. Every once and a while they admit someone for hospice, and the same nurses do those visits, too. Their census is usually less than five, and anything complicated really throws them for a loop."
"Yikes," was all the new hospice nurse could say.
The preceptor went on, "This guy came into the ER this morning. His wife brought him in. He has metastatic cancer and lots of pain. He was on a CADD pump with morphine but it didn't relieve his pain, so the nurses from East Cupcake kept calling the oncologist, who kept increasing the basal rate and the breakthrough dose, and on it went until the wife brought him to the ER. Now here we are."
"But shouldn't we step forward?" asked the new hospice nurse. "Don't you think we can help?"
"Not our patient yet," the preceptor replied. "His wife revoked hospice and he's been admitted here. He's an oncology patient, and they haven't asked us to join them, and we'd have to get the wife's consent to admit him back to hospice first, so we just have to wait."
"Then why are we here?" asked the new hospice nurse.
Somewhere down the hall, a man kept screaming.
Why indeed?
Thanks for reading. See you next time.
