Honoring the Moral Concerns of Caregivers Afraid of Giving Morphine

Joan’s breathing relaxes as the morphine starts working. Her son Travis, on the other hand, is clearly upset as we sit at her bedside where she is dying. Despite his mother’s intense respiratory distress before he gave her the morphine, he’s convinced that he’s just made a big mistake. “I’m sorry, mama,” he whispers.

He turns his head my way. “I wish you hospice folks had never brought that morphine out here,” he says. “Now she’s dead for sure and it’s my fault.”

A sometimes essential medication.

For caregivers with this level of fear about morphine, it’s a painful dilemma. If you don’t use the best, sometimes the only, medication we have for getting acute respiratory distress in terminally ill patients under control, both patient and caregiver suffer. But if giving morphine is freighted, as it is for Travis, with a belief that it causes death and/or signifies giving up on, even betraying, a loved one, it can intensify a caregiver’s distress.

The hospice nurse had already given the standard education, assuring Travis that in patients near the end of life morphine is safe and effective when used as prescribed. We had given him written information debunking some of the common myths about morphine—“it kills you”; “makes you crazy”; “it’s addictive”—when used appropriately with hospice patients who have active symptoms. We had promised to […]

2018-01-22T10:19:38+00:00 January 22nd, 2018|Ethics, family caregiving, Nursing, pain management|0 Comments

There from the Start: A Hospice Nurse Looks Back

A painting of Dianne Puzycki, RN, hangs in Connecticut Hospice in New Haven.

At age 82, Dianne Puzycki has yet to retire from nursing—she still works the night shift once a week at Connecticut Hospice in Branford, where she’s been employed since the organization’s inception in the 1970s. Founded by Florence Wald, it was the first hospice in the United States.

Puzycki started her career in 1955 at Memorial Hospital in New York City, caring for patients with cancer at a time when death and dying wasn’t openly discussed. “We weren’t allowed to talk about that. It really haunted me for years,” she told AJN in a July profile. Several years later, she encountered two influential women: Dame Cicely Saunders, who founded the first modern hospice, and Elisabeth Kübler-Ross, who introduced the concept of the five stages of grief in her groundbreaking 1969 book On Death and Dying. Seeing them speak piqued her interest in the hospice movement, and she began volunteering for Connecticut Hospice, which eventually led to a full-time job.

Throughout the decades, says Puzycki, she’s witnessed hospice care constantly change and improve. She recalls that in the past, more patients used to stay up at night, afraid, spending time in a family room near the nurses’ station—but now, “most […]

2017-07-26T09:35:44+00:00 July 26th, 2017|Nursing, nursing career|1 Comment

PTSD and Falls: For the Elderly, a Lost Sense of Safety and Control

Jack lowers his head and presses his temples with his thumbs. He whispers, “Am I going crazy?”

In the weeks after his fall and trip to the emergency department, something has gone painfully awry. He’s been having episodes of anxiety when transferring from bed to chair as well as difficulty sleeping. His once unflappable optimism has been blunted by intrusive memories and ruminations about the fall and a sense of foreboding about the future.

Psychological Aftereffects of a Fall

Though he sustained no serious injury and had been quickly returned to the assisted living facility where he lives, the fall has left him with symptoms of posttraumatic stress disorder (PTSD). Most health care professionals are unaware that falls in the elderly can cause posttraumatic stress symptomatology, acute stress disorder, even PTSD. Indeed, in some settings falls occur frequently enough to insulate nurses and other medical staff from the awareness of how terrifying such an event can be or how it can undermine one’s sense of safety and control, particularly when it results in injury and/or invasive medical treatment.

Although Jack was under hospice care at the time of his fall, the facility sent him to the hospital because of its policy on ruling out head injury. Most hospices and facilities have protocols governing their response to falls. These typically include timely […]

2017-07-19T07:34:30+00:00 July 19th, 2017|Nursing|2 Comments

The Challenge of Caring for a Graying Prison Population

Photo by Ackerman + Gruber An elderly prisoner in hospice care. Photo by Ackerman + Gruber

Inmates 54 or older are the fastest growing age demographic in U.S. prisons. According to the U.S. Bureau of Justice Statistics, the percentage of inmates who are 54 or older jumped from 3% to 8% in two decades (1991–2011). Criminal justice experts say the increase is probably an effect of the longer sentences of 1980s antidrug laws.

A 2014 report by the Vera Institute of Justice asserts that “prisons and jails are generally ill-equipped to meet the needs of elderly patients who may require intensive services” for their medical conditions. Correctional staff often lack training for treating age-related illnesses and prisons typically don’t have the ability to monitor chronic health issues or employ preventative measures. Inmates are often sent off-site for medical treatment beyond what prisons can provide.

Older adults with physical disabilities or cognitive impairments are also more vulnerable to injury, abuse, and psychological decompensation in the prison setting. “ [T]he prison environment is, by design, an extremely poor place to house and care for people as they age or become increasingly ill or disabled,” said a 2013 American Civil Liberties Union report. Even reliance on devices like wheelchairs, walkers, or breathing aids can present logistical hardships for inmates in facilities that were designed to accommodate a younger population.

This month’s […]

2016-11-21T13:01:23+00:00 March 15th, 2016|Nursing, nursing perspective|0 Comments

The Balancing Act: A Dying Patient and a Spouse Who Can’t Let Go

Illustration by McClain Moore Illustration by McClain Moore

The Reflections essay in the March issue of AJN is called “The Balancing Act.” The author describes a situation she faced as an ICU nurse in which her efforts to keep a dying patient comfortable were complicated by a spouse’s reluctance to accept the inevitable. It’s often hard to advocate for a patient while honoring the emotional struggle of a close family member. Here’s the start of the essay.

I have just arrived to work in the ICU and am assigned a patient in respiratory distress. Her name is Darlene and her husband Tom is pacing the room. Within 10 minutes, he drinks three cups of coffee, ignoring the cot provided by the previous nurse so he could sleep next to Darlene. His wife has more than one cancer and both are growing. She left the hospital a week ago for hospice care, but has been readmitted after a decision by her husband to reattempt curative treatment.

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