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There is a new nurse at mom's SNF. He seems overly interested in getting morphine on board and Xanax and calls me every time mom is struggling. It's a fairly straightforward matter of draining the fluid off her lung and then she's comfortable and can breath. But each time the fluid builds up, instead of getting it drained he talks about her need for morphine. I thought it was just me that found him overly pressuring about it but when my son met him tonite he said he wanted him off my mom's care. Hes very nice but I feel he's either new or possibly a problem..

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Stressed, is mom on Hospice? Is Hospice on board with getting fluid drained frequently?

We went through this with my mom about a year ago. After her chest had been tapped several times ( including one situation where, as mom's lung reinflated, a pocket of bacteria " bloomed", sending her into septic shock) we sat down with her pulmonologist, who said to me " stop poking holes in your mother. The next time this happens, call in Hospice, get her on morphine and let her down gently".

That is what I'll do.
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Thank you for answering Babalou. Her doctor wanted a Pleurex drain put in to alleviate all the pokes because mom is in NO pain otherwise and she felt she had months still to live. We had to travel to a different hospital 40 min away to have it done. The Dr put it in the wrong place and now she has a drain that OUR hospital won't touch and she still needs to have the fluid drained. I don't want to drag her down to that hospital again to have it removed! As of last night this whole thing feels like a circus. Her Dr ordered an infusion because her calcium is way high and affecting her mental status. Hospice keeps saying they don't 'hasten' death which is what's making this so hard. I just want her to have the fluid drained so she's comfortable and THEN be let go. Does that make sense? If they would just word it like that I'd be on board. Has your Mom passed? I signed up with the Hospice and all they did was take her off of baby aspirin and vitamin D. Then the fluid built up and she's miserable. I don't want to see her in misery. I want to ask them to just give her enough morphine to let her go but it seems that they just aren't doing that. I know it's time for her to go but we can't seem to get on the same page. I'm just so frustrated. Thanks for listening. I'll give her doc a call and see if we can't move forward in a better way. Thanks
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Stressed how do you know the plurex is in the wrong place? Have they tried to drain it? It is probably beyond the scope of an SNF to drain a Pleurex. Not really difficult but they often won't take it on.
Your nurse may be new or overly aggressive but he probably knows that once fluid keeps recurring it tends to come back very frequently like daily. Are they giving her strong enough diuretics. I had what is called a pigtail when I was in heart failure for a few days and they drained a great deal of fluid through that. they were going to put in a pleural but said there was too much risk of infection with a permanent drain so they just removed the pigtail and stepped up the Lasix IV which worked pretty well. The nurse wants to give Mom the morphine because it will ease her feeling of breathlessness so she is more comfortable. of course the Zane is for anxiety and everyone is anxious when they can't breath.
If you feel Mom is close to death my decision would be to encourage the morphine and although it won't hasten death will certainly keep her a lot more comfortable. By the way a Pleurex is not difficult to remove and can be done by a Dr in the SNF. Much easier to take out than put in. if you think Mom may have some time left it might be worth replacing the pleurex so the fluid can be drained daily. it is a very simple painless procedure. they just put a vacuum bottle attached to the tube and the fluid runs into that. A lot depends on the reason for the fluid build up and how close to death the family and Drs feel rather than what Mom hopes will happen. Repeated thoracentesis can be distressing and exhausting. Hope this all works out for you. You need to question Mom's Drs and get their honest opinion on Mom's prognosis.
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"really struggling" is the phrase they used when my MIL was very close to death. We saw it happening, gasping, kicking, moaning. She could not wake up, we could not feel a pulse. So go there and see it for yourself, it may lead you to OK the roxanol. We did.
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Thanks Veronica, for answering, and with your own experience. To answer and update; Everyone was pretty sure the drain was in the wrong place because it was only dripping a little blood (tbsp daily) and not the 1.2 liters of fluid that normally would come out. Also, it was obvious that she couldn't breath due to the fluid building. Today they finally took her to radiology and confirmed that the drain was in the wrong area and she indeed has a large amount of fluid. (The SNF is attached to the hospital here so it's just down the hall) Because a different hospital put the drain in this hospital won't touch it to put it in the right area OR remove it. The nurse made an appt to take her back to the other hospital again and I said No. No more. I don't like the other hospital, they screwed it up already and it's just too much for Mom to go thru that again. Unfortunately, for whatever reason, the radiologist didn't remove the fluid while he had her in there today, don't ask me why, maybe the order wasn't clear, so it's scheduled for tomorrow morning. Her Dr said she can probably remove the drain herself so we planned on her doing that, plus removal of the fluid and some IV meds to deal with high calcium levels. (The Lasix was working but now it's thrown too much off balance) Dr wants to see how she does after thoracentisis and lowering the calcium and that's fine, but we also agreed that the morphine is there if her quality of life doesn't return. SO, then tonight she was so miserable with all that fluid that I asked Hospice for the Morphine. I thought if this is it then let her be comfortable. It was the exact OPPOSITE of what I expected. Who knew? It did not comfort her, did not ease her breathing, did not relax her! She was just as distressed but now it was LOUD. Like an unruly drunk :-/ Well that was a cherry on top huh? Here all this time I've worried about them overmedicating her with the morphine and it turns out to be party drug of choice for my 96 yr old mother! She went from laying in bed with her eyes closed struggling and miserable, to sitting in a chair wide eyed and yelling and miserable still struggling to breath. I asked for some Xanax to get her to sleep. Tomorrow is another day and hopefully the thoracentisis will help, and then we can put together a different strategy for comfort. I'm sure they have other drugs besides morphine. I hope I am able to help someone else with this knowledge that morphine affects some people differently. And I'm super glad I wasn't doing this at home on my own. Now it's time to find out what DOES work when she needs it. Thanks again 😘
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Thank you Pam. I did in fact see my mom really struggle and it did push me. Seeing it and hearing about it are two different things aren't they? Thanks again
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Oh, Stressed, I'm so sorry that this isn't going well!
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Hang in there stressed - I believe some folks are also allergic to morphine - I believe my mom is so I pray she will never need it

Let us know how the procedure goes tomorrow
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Both my parents would have extreme hallucinations on morphine- so we avoided it. However, towards the end, when my father was on hospice, suffering from CHF and his lungs were filling with fluid, I agreed to morphine as they told me it would help his breathing. Daddy was also given Ativan with the morphine and that seemed to help with the hallucinations- who knows, perhaps he was still having them but with the Ativan he didn't care? I am also sorry you're having to go through this. Seeing a loved one struggle for breath is gut wrenchingly heart breaking.
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Just wanted to say I'm so sorry things have got so complicated medically. Don't let them fob you off, but don't drive yourself nuts trying to find certainty when in the nature of the situation there may not be any to find. All the same, I hope her team will be able to untangle what's going on and make your mother comfortable.

If the new nurse is young and enthusiastic that's probably what his problem is - youthful enthusiasm and a gung-ho spirit aren't really what you want in hospice. Maybe suggest he be guided by calmer and more experienced older colleagues? If you think he's jumping the gun, don't hesitate to tell him so frankly but not angrily.
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You need to report him immediately!
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You need to be suspicious! Any care giver who suggests narcotics or any strong drugs that have street value is probably an addict or a pusher. I would report it anonymously to the director of nursing.
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Hi, stressed.. I hope today's procedure goes well - it seems horrible that this hospital will not remove the incorrectly placed one - what if she came in during an emergency, would they refuse to treat, because something had been done elsewhere?? But it sounds as if you've said, she can remove it herself (I hate those legal ass-preserving distinctions) - but if that's the case, maybe you can get the better placement started, and work to find ways to make sure that the self-removal option is carefully attended, to minimize any risk of infection.

I'm an oddball, but I believe we can rush in fear to adding drugs - one cannot wait forever, but surely one can see through the next procedure, when it sounds as if it may correct an error - and comfort by companionship and minimal sedation and pain meds, keep telling your mom that this next intervention will make things better, whether she looks as if she can hear or not - pray and trust and help her hope through this attempt to rectify, and revisit the issue of drugs another time. Sometimes the drugs can ease anxiety and mask symptoms.

I know how challenging all these choices, conversations can be, when the risks seem so high. I saw morphine help a lady with a severe cancer, and had to be somewhat convinced - yet I've also seen times when compassionate extra company, hand holding, resting together, can help an elder calm down, and if you have the alternative procedure planned, this seems good to try, for when things turn around, small signals grow into recovery, and that's amazing too.
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Aside form the very stressful medical situation your mother is experiencing, I too feel that another nurse should be caring for your mother. No one is a " standard" when it comes to end of life. You both need the caring, respect and experience of a more seasoned nurse. Her physician should change the med ( morphine ) if it is not having desired effect and you should speak with the nursing supervisor or director of Nursing to have another hands on caregiver.
The supervisor of Nursing should also observe this over zealous nurse to see what he is doing both with and away from patients.
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why don't you just take her home and you take care of her since you know best what to do.
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I know this does not apply to your situation but I just wanted to share.
My mom had a brain bleed near the end of her life. The neurosurgeon at the hospital told us he could fix the problem with surgery. My moms neurologist heard this conversation and pulled me aside and told me he wanted me to think about what he was going to say. He said to me the surgeons could operate but should they? would this operation really better her quality of life? This was a heart wrenching decision to make but the best advice I was ever given. Good luck and God Bless.
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i think the most important thing for your mom is that she is not in pain. i would do everything in my power to make sure she's not suffering silently.
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Hello, I can feel how worried and stressed and concerned you are for your mom. I am sorry you feel you can't trust this nurse because it makes a difficult situation so much worse. I will share with you that I am a nurse practitioner and in a case where a patient is struggling to breathe due to excess lung fluid it is classic protocol to use Lasix (a diuretic) and morphine. The Lasix helps the body get rid of the fluid via the kidneys and morphine dilates the blood vessels in the lungs which assists in this process and also decreases anxiety due to breathlessness (usually). I don't believe this nurse is doing anything but trying to help your mom at a critical point when she is in need of quick relief. Your mother obviously experiences an idiosyncratic reaction to morphine when she is given that drug and may need a benzodiazepime (antianxiety agent) in addition to the morphine to help keep her from becoming agitated. My best to you and I hope your mom gets some relief.
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When my sister-in-law was losing her battle with metastic cancer some years ago, her daughter called my husband and their sister (we live some distance away)and told them they needed to come as her mom had fluid on the lungs and they were refusing to drain the fluid and wanting to give her morphine, which they said would not only make her comfortable but depress her breathing and....
My SIL went and convinced the doctors to drain the fluid and hold the morphine--she lived several more months in relative comfort.
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Is she on Furosemide/Lasix? That drug increases urinat
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that drug increases urination; draining excess fluid out of the body.
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I agree that it's worth asking about her diuretic px and whether it can be adjusted. But I also wouldn't be too hopeful: if the dose hasn't already been adjusted to clear the excess fluid there will probably be strong medical reasons for that - such as that her kidneys can't cope. Still, no harm in asking.
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Stressed I hope by now Mom's situation has changed and she has a properly placed tube that can be drained regularly. Placing a tube is not too stressful and does bring a lot of comfort so I would not be against the proceedure as it is certainly a comfort measure.
As far as the medications are concerned the side effects of many drugs are totally unpredicable especially in the elderly so it is often necessary to experiment to find what works best.
I hope the Dr that said the tube could be removed meant herself not Mom. it would be dangerous to do that ones self. It is a simple process but should be done with safeguards in place in case it is actually in the lung rather than the two layers of pleura surrounding the lung. Reinsertion has to be done under expert X-ray control so the radiologist can see exactly where it is being placed and there is sufficient fluid in the pleura for the two layers to be separated enough to safely introduce the tube. It is possible that the closest hospital does not have the necessary equipment or trained staff to do the procedure. What you have heard is a refusal to do it but they may mean they can't do it because they lack the equipment and expertise. When you are so stressed it is often confusing to really hear what you are being told especially if it is conveyed through a third party.
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As a healthcare provider, I think there is a BIG PROBLEM when the hospital won't remove a drain that is not in the correct position to place a new one. It doesn't matter who put the drain in. If she is a resident of the SNF attached to another hospital, it is their duty to take care of her the right way. I would have a major problem with that if it were my loved one. If she is unstable (which it sounds like she is), she is not fit for transfer to another hospital just to have a drain pulled out----especially when there is a hospital right next door!!

Personally, I tend to think that when a person is on hospice, the incentive to treat something is removed because there really is no hope to prolong that person's life. The thinking is that they can just give the person some medications to ease their pain & suffering, and make the road "out" as smooth as possible. Nobody likes to see their loved one having difficulty breathing. In your subsequent posts, you say that your mother is indeed on hospice and 96 years old, routinely draining 1.2 liters of fluid from her chest. Adding that to the equation makes more sense to me for why the hospital is doing what it is doing---your mother is very ill, and a thoracentesis could lead to a hospital admission, which nobody wants to be responsible for primarily due to Medicare rules for reimbursement. The hospital won't get paid for her admission. It is sad, but it's true----admission & re-admission rates are scrutinized by Medicare, and physicians & hospitals don't get paid for them. They don't want to do something, have something go wrong & have to admit a 96 year old woman on hospice that is a SNF resident. So, they figure they'll transfer her to the hospital that misplaced the drain in the first place and let them deal with an admission/re-admission. Have them not get paid for a re-admission of a patient that was previously in their care.

Getting back to the matter at hand----the nurse was probably just trying to make your mother comfortable. And, with orders for morphine & xanax from hospice, that's what he was able to do. Your subsequent posts actually turned into another topic altogether, in which it seems like you are more accepting of your mother's passing rather than torturing her with more thoracenteses, drains, etc.
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Re: the close hospital refusing to remove the incorrectly set drain... I have been in a very similar situation. Medical hardware surgically implanted, was either incorrectly placed, or shifted due to an emergency 12 day hospital stay. The hardware needed to be re-positioned, and I was told I had to go back to the original surgeon. It is a liability issue. Try not to think poorly on a hospital trying to protect themselves.
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Yea, the diruetic rx would be to get the edema build up out of body.
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The hard part is knowing how long to keep fighting a losing battle. If your mother is content and okay with the continual draining, then it's probably okay to continue with it. But as the neurologist told Rosebush (about a different situation but there are similarities), just because they can doesn't mean that they should.

I think the nurse wants to see the pain controlled and likely feels the continual draining isn't in your mom's best interest. This is neither right nor wrong - it's an opinion that has more than one side. His intentions are good but you may not agree with the approach. Talk with the doctor about how long to keep up the draining.

Consider your mom's wishes. How long does she want to continue this treatment. That should be the main consideration. Some people want everything done and others want to quit fighting and simply control the pain. I hope that she is still able to have input.

Take care of yourself, too, during this tough time.
Carol
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Thank you all for help, this is truly miserable. The reason I don't take her home is that I am disabled.i can not take her to the potty, bathe her or change a diaper.
One thing I know is this ; you can't pilot a boat from the shore
Mom is at a stellar SNF, but each decision is only as good as the person making it. The overzealous nurse came from radiology and is not young, just I think, very into exploring his new job, and his closest male buddy is a Hospice guy. He is frustrated with me because I don't seem on board with the heavy drugs to comfort Mom.
So she had the fluid removed and she breathes easier. She gets some anxiety and they use Xanax. The Xanax makes her more sedated and vocal. So they give her some more. She is unable to open her eyes or sit up but now she calls out a lot, cries, and says she wants to go home, but can't answer any questions. She can shake her head yes or no when asked if she wants water or is pain. Never in pain. Always a no.
Now I am left with this horrible thing to watch. Either anxious and unable to be calmed without the Xanax, or unconscious and unable to be calmed with the Xanax. WHERE IS THE COMFORT THEY KEEP TALKING ABOUT??
I'm just at the point of screaming. Now they want to add Vicodin. For what? Narcotics wind her up. I think they just need to be clear about their goals! Either help her to the other side or don't, but this no mans land is misery.
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And thank you for the expert advice, I appreciate this. I no longer want to see her get poked (although she says she doesn't feel a thing and enjoys her trip to do it) but I don't want to see her choke to death gasping. They either need to hasten the end with big drugs or drain the fluid. I just want her to go out at peace. Is that not possible?
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I'm so sorry, Stressed, for both you and your mother.

Where is her own GP in all this? One person - one medically qualified person, that is - taking ownership of adjusting her px and responsibility for her comfort shouldn't seem too much to ask, is it?

I'm not liking the sound of your nurse any better than I did. As my mother used to say "I'm sure he MEANS well..."
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