August 5, 2006, 7:34 am

The Valley of the Shadow


It’s 0610 and I am sitting in a Starbucks blogging!

That was not a misprint.

I work 1500 – 0330, the worst shift in the history of, well, shifts!

The problem? I’m not tired until three or four hours after I get home. Usually I am blogging or reading until I get tired.

Well today my youngest had to be somewhere at 0600.

Ha! I’ll just go to Starbucks and do my “thang” there early today!

Well, I can tell you this, the cushy chairs are all vacant at this hour and I don’t have to stare anyone out of their seat, as is my usual way of obtaining the best seat by the plug.

I could do without the reggae blasting on the speakers.

Not that I have anything against reggae. Just not at 0610 in the am. Where’s Dylan or the Motown sound when you need them?

Oh, you like the statue? I swear it was patterned after me. Except I’d be sitting on that hot water bottle.


Reminder: Change of Shift will be guest hosted at It’s A Nursing Thing on Thursday so be sure to get your post in via Blog Carnival or to Intelinurse at intelinurse2b at aol dot com.


My only experience with Hospice was personal.

Two weeks before she died of lung cancer, my mother-in-law was under the care of a hospice nurse.

The nurse wasn’t there 24 hours a day, but she was there to answer questions and educate the family on what to expect as Monica approached the end of her life journey.

Medications were provided to keep Monica pain and anxiety free, as her hypoxia and hypercalcemia took their toll that last week.

She died with all nine children and the majority of her then-born grandchildren at the house by her side. Peacefully. The hospice nurse was there, quietly in the background, providing support when needed, assisting with the post-mortem care and plans.


I’m not sure what has happened in the last sixteen years since we experienced hospice care.

Patients are being brought into ERs by Code 3 ambulances with “everything” being done when they are hospice patients.

These are patients whose deaths were imminent and expected.

Why are the families, pardon the vernacular, “freaking out” as the end comes and calling the paramedics?

Often, they don’t even have a copy of any DNR papers and so the medics are obliged to do “everything”.

What is the purpose of hospice if you are going to be brought Code 3 to the hospital and subjected to invasive procedures, not the least of which is intubation?

What are hospice nurses teaching families about the death process, about what to expect at the end, about what they can do to lessen suffering or decrease the anxiety the patient may be experiencing?

I know there are good palliative care nurses out there, and some of them must work in the hospice home setting.

Is the teaching being done, but the family unable to accept the concept when the death of their loved one is actually becoming a reality?

Do they feel overwhelmed? Feel obligated to get “help” at that crucial time? Change their minds at the last minute? Are they scared? Unable to accept the inevitable?

I was under the impression that hospice nurses were educated and available to help during the death transition.

So why are so many end-of-life hospice patients showing up in the ER?

What am I missing here?


  • DisappearingJohn

    August 5, 2006 at 5:02 pm

    I think you hit it on the head. The family freaks out, and calls 911.

    We had a patient last night brought in. Had a DNR in place. Daughter revoked it. Patient became coherent, and daughter was crying, “Keep fighting, Mom… You can’t leave me”. Doc talked with Mom and daughter, code status changed to agressive hydration, feedings, medications, no compressions or intubation.

    I don’t know the specifics of their particular hospice situation, but it sounds to me like the family wasn’t prepared.

  • Intelinurse2b

    August 6, 2006 at 5:39 pm

    Interesting question. My mom died two years ago from multiple myeloma. She was under hospice when she died and when the “end” came, she was living w/ my brother and I think he just was struck with the reality of his mom dying in his home and it scared him. So he was one of those who called the ambulance and she was taken to the hospital, to die there. I was disappointed but also understood his decision. The hospice nurses assigned to her care were wonderful, but probably could have done a better job explaining to my brother what to expect. They have such a hard task, to prepare people for something that is so painful. I have considered following that nursing path, but Im just not sure if I could deal with that emotional toll all the time. Great Post-thanks

  • marachne

    August 6, 2006 at 8:30 pm

    I’m a hospice nurse, but not in home hospice. I work for That Big National Health and Benefits organization that takes care of our best and brightest after they’ve served their country. We have a hospice/palliative care unit. Some people come in hospice, others palliative care (maybe getting palliative chemo or radiation). Often, the palliative care folks eventually realize they want to stop torturing their bodies, or the docs say they won’t/cant do anything more. The family is often behind the patient in coming to realize that keeping on fighting is not of any use, that what is important is being as comfortable as possible so that they can enjoy the time they have left, that refusing pain medications to “stay alert” is an exercize in torture, etc.

    That said, the will to live, or the fear of loosing someone is a very strong force. I’ve people with mets to Everything, in terrible pain and with no hope for treatment vacillate back and forth between DNR/DNI and full code. One person finally changed their status back to DRN/DNI/Do not hospitalize hours before they died.

    I know I do a good job with my patients and their families (who are also our patients in hospice). I know a lot of other hospices up here are exemplar. I have, however heard horror stories about some hospices, and for that I am both angry and sad.

    And I think that every state should adopt something like the POLST (, to make things saner for all. Around here, EMTs always ask if there is a POLST before proceeding.

About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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