Comfort Care Only should be used for terminally ill patients only and only at the point that there is nothing else that can be done for them.  Of course the comfort part should be the fact that we keep them as comfortable as possible.  I refuse to give the pain med if their respirations are less than 10-12.  I don't want to be mean to them, it's just that I don't want to decrease respirations to the point that they quit breathing on me.  We stop all routine meds but not insulin.  We also stop taking their vital signs and anything that causes them pain.  I think that in a lot of cases they need to be dismissed from the hospital and sent home with Hospice if they and the family want that. Have taken care of many patients on comfort care only and they have lasted only a short time.  I think that once the patient has made up their mind that they are not going to make it, they aren't.  I think that this is used a lot of times for the family.  They know the family member is not going to make it but they are unable to take care of the patient themselves and it is easier for the medical personnel to take care of them.  I think that the best that you can do is to support the family, and more importantly keep the patient comfortable and support them the best that you can. 

This is a prime example of why we need

Exactly, I would never had posted this any where else. I still worried about putting it here. I have no problem what so ever about comfort care, it's just occuring to much at this place. I don't feel it is appropriate, but the nurse doing this is managements favorite. They give her whatever she wants. My husband thinks I should leave. Maybe I'm making more out of this than it really is.

I would def go to upper management and get tis issue resolved.The comfort care only should only be used in terminal, dnr patients only.How could something like this occur w/o an assesment made by other staff involved, the family, the patient etc.It sems so odd the Dr's would just give those kinds of orders.Something HAS to be done.Have you spoken w/ anyone  in management regarding this since the post?Keep us informed....

As a nurse you are legally and morally obligated as a patient care advocate to question any and all orders, discontinued or new.  You must go to your manager and bring up these issues.  dmazment

Well two more people have passed. "It's what the family wanted." The only state I know this is legal is Oregan.  To me comfort care is to be there for the person and make them comfortable while they make the transition and pass. Not push them over the edge.

This sounds like an awful situation.. I would be questioning these practices, bring it up with management, if you have a patient whose orders have been d/c'ed and you feel like they shouldn't have been, question the doc.  Doesn't seem like that many people should be on comfort care only or dying when there for rehab.  You've stumbled upon one of those times when we need to be serious patient advocates, even though it's not going to be easy by any means.  Good luck!

wow~~ i have to jump all over this topic! first of all the doctor is a complete moron!!!!!! second of all are these things being discussed with the family members so that they truly understand what is happening?!?!?! if they truly want this i dont understand why they would want their loved one to go under the knife to hae a surgery to go to rehab to be killed off by some roxanol. sorry that may have sounded a bit harsh but that is exactly what is going on. if the quality of life isnt there for the patient then by all means i am for comfort care and other things. but not in this situation. one of the biggest joys in my nursing career was working on a rehab unit for a year and a half. and knowing that you can admit somone in for rehab s/p knee replacement and 6 weeks later do their discharge paperwork..... that is the ultimate feeling because you know that truly helped that person out! thats what a rehab unit is supposed to be like! ok back to the topic at hand.... in my book that nurse is being neglectful on her patients part and should not have her license..... one of the biggest things for me as a nurse is to be a wonderful patient advocate.... and this nuse is taking it to the extreme!! it makes me sick to think there is practicing nurses out there that are like that!! ok enough out of me for now!!! great topic!

abs

ps can you tell rehab nursing is my forte?!?! hehe

Just curious, whatever happened with this situation?

I have seen this many times at various LTC facilities. A patient who is a poor candidate for surgery gets railroaded in to it anyway, then dumped in to a bed to die. No wonder the numbers are so poor for hip surgeries - many die within 6 months of pneumonia.

I think doctors get to the point that they just give up. They know the patient is not going to rehab, and is dying a slow death, so they go the route of Roxinol ATC and basically kill them. It is horrible and wrong, and shows how screwed up the health care systems is.

There are no checks and balances in the system. I think the surgeon should have to actually see the patient at s/p 30 days, 60 days, 90 days. Actually have to come to where ever the patient is s/p surgery and SEE them and be involved in their rehab. As it is now, they take the money and run and literally wash their hands of the patient post-op.

So what to do in that situation? Do the best you can to advocate for the patient. Medicair has a fraud hotline. Every state has a hotline to report patient abuse. Make the calls and get somebody in there. Even if they can't do anything directly, they can get things moving.

Great post! This happens far more than anyone realizes. Time to blow the whistle, LOUD.

To the previous post. If your mother had a stroke there are so many other ways that could have happened. Are you sure this is what took her?

 To the one asking me if I am sure that my mother's stroke is what killed her:

No.  The stroke did not kill her.  The rehab center did.  She was unable to feed herself without assistance, yet if we were not there to feed her, she did not eat.  She could not drink ice water because it was too cold, yet there was ice always in her pitcher.  Yes, I asked for regular water.  I told her nurse that she could not reach her food because the tray was always out of reach and that she needed help.  She complained of pain during urination.  My sister went RIGHT TO the nurses station and told her nurse.  His reply?  Oh, she has a yeast infection and that is probably what hurts.

2 weeks later, she was admitted to the MICU with severe dehydration, malnutrition, and UTI.  Her systems shut down, she got sepsis and died.  No one can tell me it wasn't that rehab center.  

I can't bring her back, but I sure as heck can change someone elses outcome for the better.

Anonymous says ...

If I were in this situation I would be an advocate for the patient, especially if they do not have any family/visitors to act as an advocate on their behalf. Your motives are pure, you are there for the patient !

Advocating for the patient is so much of what nursing is all about. I used to work in hospice and if we received a referral from a physician for hospice or palliative care, we'd still check the patient to determine for ourselves if that was the case. Oftentimes, AND THIS WAS MOST OF THE TIME, we received referrals just a few days or HOURS before a terminally ill patient died.

Clearly, that was too late for the patient to be beneffiting from the doctor's patient advocacy and the patient should have been evaluated for "Comfor Care" much sooner. It could have been that this nurse believed in "Comfort Care" much sooner than later and she saw accuchecks being ordered ever 4 hours on a patient with a terminal diagnosis of end-stage diabetes. No matter how her insulin was adjusted, the patient was refractory to insulin control of her diabetes;  however, this is a huge judgement call. Was the family involved, did the  patient need a POA?

"Comfort Care" should  NEVER be taken to mean NO CARE; rather, it should be taken to mean that MORE care  may be required to keep the patient comfortable. I guess also to make a decision, most  people would need more information; for example, is she able to sign legal forms for herself?

I am absolutely amazed that no one is investigating this nurse! First of all, this isn't Hospice where you expect people to die, this is a Rehab Unit, where you expect SOME people to go home much improved, and if rehabilitation is not possible for the patient, one would think that they were at least medically stable otherwise they would never have been sent to Rehab in the first place. Secondly how is this nurse getting away with dc'ing a patients insulin ? Into what orifice do the doctors there have their heads inserted? I assume the patients in Rehab are not there for Palliative/End of Life Care, and I assume that most are not No Code's, so why the heavy use of Roxinol and why so many deaths? Someone suggested earlier that you should call the State Nursing Board AND the police. I agree! Unfortunately having an RN behind your name doesn't mean that you are of good, moral character or even sane. There have been a number of nurses (and doctors too) who went about quietly euthanizing patients, but sad to say these sociopaths practiced many years before they were caught. Everyone the sociopathic nurse or doctor worked with thought that they were "odd", and they knew that medically stable patients seemed to die ONLY when they were on duty, but  their colleagues just shrugged it off, didn't want to get involved, or thought that this doctor or nurse couldn't POSSIBLY be murdering patients.Something is "rotten in Denmark" as they say and I urge you to get in touch with the Nursing Board and the police. If you didn't know already, you can report this nurse anonymously both to the Board (anonymous reporting happens all the time with the Board) and also to the police. You may even want to call the FBI and ask them what they think. If you are worried about your safety or reputation, and wish to remain anonymous and yet report, you can do it from any public pay phone (don't use your land line or cell phone as these can be traced). One thing that hasn't been mentioned was the possibility that this nurse is addicted to Roxinol. That would seem to me to be a somewhat plausable explanation for a nurse to get all of the patients under her care onto the same drug, i.e... the drug that she is addicted to. I've worked with  a couple of addicted RN's and MD's  (I didn't know at the time that they were using narcotics from the hospital), and looking back now I realize that there were many signs of their addiction, but at the time I was a brand new RN and I never thought that a nurse or a doctor could ever be an alcoholic or a drug addict! Now being much older, in the profession a long time,  and after working a number of years in addiction medicine, I know that ANYONE can be an addict or an alcoholic. In fact it is thought that 1 out of every 7 doctors, nurses, and pharmacists (they think the number is probably closer to 1 in 6)  are addicted to drugs, alcohol or both. I really hope that you do report this person; if this nurse is euthanizing patients, or taking Roxinol for her own use, then you have saved an untold number of people from an untimely death, or from the clutches of an incompetent, drug addicted nurse who may be making fatal errors in judgement. If this nurse is innocent of any wrong doing, then her name will be cleared and no harm is done. I live in Oregon and even though Oregon legalized assisted suicide, the patients have to go through lengthy examinations, psychological evaluation by a psychiatrist, and they must be terminal and have 6 or less months left to live. Nurses are not allowed to administer or prescribe the medications used for assisted suicide. That is strictly in the hands of the doctors. Good luck in this situation, i will keep you in my thoughts and prayers.

Anonymous says ...

I did Hospice for a very short time.  Mostly because I was tired of seeing patients go on Hospice care only hours before they would have passed.  I admit I was really bad at it.  Hospice Nurses are very special people, but it wasn't for me.  Too many sleepless nights wondering if I did the right thing.  I wonder if the nurse you speak of was a Hospice nurse or an employee of the facility.  I ask this because when patients went on Hopsice when I worked for one, we had a whole team of Social Workers and Chaplains that worked closely with the families and the facility to make sure that EVERYONE was on the same page.  Then and only then did the medicare paperwork get signed and the meds started to get D/C'd, with the primary docs approval.  We also had a Medical Director, an MD who would get involved with the Docs.  I found that most of the docs did not want Hospice for their patient and were very uncomfortable with D/Cing meds.

I am surprised at how easy it seems to be for this nurse to make all of these judgement calls and the docs to just blindly go along with her.  I was taught to D/C finger sticks because they were painful to a patient who wanted no more intervention, but had a really hard time with that, I tried to keep at least one per week.  To me that seemed to be care.

So anyway, a patient can revoke the Hospice benefit and return to curative care at any time.  I would call the state board, of Nursing or Nursing Home Administrators, and advise them of the situation, you can do it anonymously.  Also you could call in a Social Worker, of course you'd have to go through channels and there goes your anonymity, but I've had the pleasure to work with really good Social Workers.  I wonder if we have any Hospice Nurse to join in on this.

What ended up happening.,  Are you still there, is that nurse still there?  What's happening.  It's been 4 months since the original post.

The only thing that I can think for justifying this kind of behavior was that if the nurse in question was the nurse from the hospice facility and she can take orders from the doctor. HOWEVER, the nurses on the REHAB unit would know if she was a  hopice patient who wished nothing but comfort care. It seems a stretch of the imagination that a hospice patient would be on a rehab unit, but I've seen it in working  hospice. Again, if this was a staff nurse and the patient was NOT hosipice, i'd look into it, speak with management and document per protocol: i don't think that would be in regular progress notes, sort of like an incident report. Also, when the nurse DC the insulin and accuchecks did she write an order in the  chart "Discontinue insulin." Verbal order. Doctor 'x'?

I'd be really concerned and  you shouldn't have to check all your other patients to make sure Dorothy Death isn't discontinuing their ofders.I think I'd speak with the nurse, herself and if you don't get satisfaction, go up the chain. Annie