I’ve been doing hospice now for over 6 months. As I did in CCU, I only work weekends and some holidays, so 6 months for someone like me doesn’t really equal 6 months for someone who does this full time. I still struggle with remembering everything I need to remember, but I’m getting better. There is more to remember than you’d think!
I’m realizing how much I depended on constantly being around other nurses to learn. My hospice orientation included some different scenarios where I was able to watch my preceptor deal with what was happening, and I learned from that. But it was still only the tip of the iceberg compared to what can really happen.
In the hospital, you’re usually surrounded by other nurses. You’re at the desk with them talking about patient care, you’re at the bedside helping with patient care, you have several around at any given time to bounce problems off of and get advice. I learned how to teach patients by watching other nurses teach patients. I learned how best to say things (and how not to say things!) by watching other nurses talk to patients. I learned how to titrate medications by watching other nurses. You get the point. Throughout my entire career, I was constantly watching other nurses so that I could be a better nurse.
Now I’m on my own. If I’m really in a pickle I can call another nurse who’s on for advice, and I have done that once or twice with a good result. But when you just can’t get that foley in, there is no one else to ask to try. You just have to leave it out and hope someone on days can come do it, which can be 16 hours later.
I went to a house late one night to help symptom manage a patient that was having pain. When I arrived, the patient was asleep but had to be woken up for some medications. Despite having severe pain all day, apparently the pain was gone when she awoke. But the patient was delusional. Although she had no dementia, she didn’t recognize her husband of almost 20 years. She kept asking about a cat that she needed to take care of, but the couple had no pets. She was very very concerned about this cat. Although she was not belligerent (as some confused people can be) and didn’t seem overly agitated about not recognizing anyone in the house with her, she was very insistent that we find this cat and make sure it was okay.
The husband and I did the best we could to reorient her, and she would look at us thoughtfully and then you could just see her mind reject what we were saying outright. But again, there was no agitation, no real distress involved. It was as if one part of her mind had no idea what was going on, but somewhere in there she knew she was safe regardless. The husband kept asking me what we should do about this, but I had no real ideas. We were already reorienting her, she wasn’t distressed, everyone was calm. I asked him a few more questions (has she done this before, has she recently started any new medications, etc.) and could determine no cause for her behavior. So I just said, “We’re already doing what we should be doing.” I just wanted to give her a little more time after waking up to clear her head.
She asked her husband for some ID, he produced his license, and she questioned him further. Finally it was decided that we would call her sister and talk to her about the cat and what was going on. The husband dialed the number and brought the sister up to speed on what was happening, and I heard him say, “I think she’s having a psychotic break and the hospice nurse doesn’t know what to do about it!”
I wasn’t too offended by that statement and decided that from his point of view, I really hadn’t provided much in the way of advice. To me, she was a patient who was disoriented and having delusions, and I’ve seen hundreds of patients in that state. What did I do in those cases? I medicated them. Because usually they were agitated, pulling at things, obviously distressed. This patient was not. I just didn’t feel the need to call the MD right at that moment. Even if the MD would have ordered something (Haldol I assume), it’s not like I could go to a med station and get it. We’d have to figure out where the nearest 24 hour pharmacy was and have someone pick it up. And if the patient had been even the tiniest bit distressed, I would have been all for that plan.
The sister decided to come over, the patient recognized her immediately and eventually become more reoriented. She still wasn’t sure about the guy sitting at the table with us, but took her sister’s word that she did indeed know him very well. She still asked about the cat, but her sister assured her that there was no cat. I believe her behavior may have been caused by disease progression, but who knows. By the time I left, she was fairly reoriented, in no pain, in no distress.
But the “she doesn’t know what to do” comment has really stuck in my head. People always say that CCU nurses have “autonomy.” And they do. But you really don’t know what autonomy feels like until you’re the only medical person there and everyone is looking at you for answers.