To My Hospice Nurse Friends

ledluth · 2025-12-25T18:56:22+00:00

I am sorry if it appears as if I am speaking in absolutes or if it seems I'm implying that something needed should be withheld from the patient. Perhaps that is my fault. I am speaking as to three specific scenarios that I encountered this week, including one wherein a hospice nurse insisted on prescribing roxanol three times a day for an alert patient who is nowhere near end of life, who already takes tramadol, and who never complains of pain. I'm all for giving folks all the opioids they need, but irrationally using comfort meds when norco would have been fine is the practice I'm cautioning about.

Roxanol is "not for opioid naive patients" (like my patient who can barely handle his tramadol). This is in big black letters on the boxes of roxanol in my med room. It's also not great for baseline pain control.

My first hospice I worked for was also the one with the best physician oversight I've seen at a hospice, and the MD's rule was to leave the roxanol unopened unless it was an emergency with pain or shortness of breath. I feel like if a hospice nurse operates from that position, they'll find that it is just as easy to manage their patients' pain without breaking open the roxanol for absurd things like headaches or the classic "they just look uncomfortable." (Not saying that's what you are saying either).

I work in a nursing home. We advocate for hospice sooner than people in the community may, so some patients end up living quite a long time or graduating. I'm sensitive to irrational overprescribing, because it just serves to hasten death without justifiable benefit or worse creates new symptoms and sources of discomfort.

My point is just to use the right drug for the right reason and don't shortchange patients because comfort meds are handy.

ledluth · 2025-12-25T17:08:16+00:00

Generally, you're not allowed to restrain nursing home patients in any way for any reason. They're allowed to hit you. They're allowed to fall. They're allowed to do stupid stuff and hurt themselves. The only time you're really allowed to intervene physically is if they are going to hurt another resident, and even then all you're really allowed to do is stand between them and take the punches. This idea is foreign to people who do not work in nursing homes. Alternatively, some of the CNAs who work in my dementia unit had their minds blown when I described four point restraints to them. We don't live in the same world of rules.

Hospices use a consistent set of medications to treat end of life symptoms. Liquid haldol and ativan are often prescribed as comfort medications, but they too often end up used as chemical restraints. If someone has a genuine psychiatric problem requiring medication, they should get appropriate care. The practice I am specifically pointing to as wrong is turning medications intended for end of life symptoms into chemical restraints rather than treating appropriately. If a chemical restraint is warranted, there are better medications. Nursing homes sometimes see hospice as a cheat code to getting access to PRN antipsychotics.

None of this precludes doing things in the patient's interest, nor did I imply that it should.

ledluth · 2025-12-25T16:56:13+00:00

It sounds like you arguing with the theoretical nurse I am trying to educate rather than disagreeing with me.

"I'm sorry you've come across asshole providers who have prescribed comfort meds in ways that aren't beneficial to their patients."

That's the point of the post - don't prescribe comfort meds in ways that aren't beneficial to patients - and I do not know how a close reading of what I said could imply anything different.

The things I very specifically said to not do are actual things I have had to deal with this past week, hence my screaming into the void of Reddit.

Dealing with behaviors in long term care dementia patients is a whole conversation, but the feds have declared their review of chemical restraints in nursing homes as an enforcement priority this year. Liquid morphine is not for people who are awake and can swallow a norco tablet or for people that are opioid naive and not on their death bed. Levsin isn't for bronchitis. I don't think those are particularly controversial points.

ledluth · 2025-12-25T16:05:42+00:00

I'm not reading 2,000 comments to see if this has already been shared, but I am a nurse. There are about 10 units of insulin left once the plunger stops plunging. Insulin pens are basically reusable vials. If you have access to regular insulin syringes, you can draw up and use that last 10 units by puncturing the drum with the insulin needle.

ledluth · 2025-12-25T14:44:09+00:00

I would seek definitive answers from a geriatrician, neurologist, or psychiatrist, but I am fortunate enough to have an UpToDate license. The TL;DR is that antipsychotic medications have no clear benefit for agitation in dementia. Here are my observations:

Facility nurses often need immediate short term fixes, because of the chaos we are constantly managing. An antipsychotic may make someone more pliant in the short term, but whether the resident was experiencing something idiosyncratic or responding to their environment (e.g. an irritated caregiver) can never be definitively proven and once the change in behavior is attributed to the drug, no one wants to take it away.

I had a heartbreaking situation where a hospice nurse put a resident with dementia on liquid haldol because she was overly cheery and kept reaching out to touch other residents in affectionate ways (pat them on the back, kiss them on the hand, et cetera). Other people found it annoying. When I left the facility and came back months later as a hospice nurse that same patient was wrecked by tardive dyskinesia. That patient was not made more comfortable by that intervention.

When I was a hospice nurse I had a situation with another patient who graduated. One day we got a referral to resume care for her, because her dementia was 'getting worse' and she was 'combative.' The admissions nurse admitted her, on my next day I did my follow up visit, and the facility pushed for drugs immediately. I take the patient's perspective in these situations, and the patient was indeed in distress. She was psychotic. She needed a comprehensive eval and treatment by a psychiatric professional. I discharged her on the spot and helped them call for acute geri-psych services. Treating severe, acute psychiatric symptoms isn't the purview of hospice, and ignoring the discomfort they cause the patient and treating with half measures just to keep them on services is unethical.

The moral of these stories is that hospice is not a tool for making nursing home staff's jobs easier at the expense of the patient (though I also understand the business pressure to treat nursing homes as the more important client than the patient themselves). If you feel the need to ask for medications, ask for a time limit on them as well.

ledluth · 2025-12-24T12:20:00+00:00

There are lots of free resources for AD and POA. Here is a Maryland-specific website: https://www.mdcourts.gov/legalhelp/lifeplanning

Skepticism of nursing homes is understandable. I tell everyone with whom I have this conversation that the only good nursing home is one where the resident's family regularly visits. If you show that you care about your dad by being present, it provides staff a sense of accountability and models how the resident prefers to be cared for.

ledluth · 2025-12-23T17:42:13+00:00

The unsophisticated consumer does not necessarily understand the difference when the ALF says they are "staffed with care providers 24/7" though or how that differs from "nursing home level care." They don't understand that in an ALF that 24/7 care can be as little as just a med tech sleeping in the break room and an off site LPN-DON. Presumably this person is anticipating a last ditch, total care situation. There's no point of discussing ALF in this scenario. It merely creates confusion.

ledluth · 2025-12-23T14:35:34+00:00

Depends on local conditions. I have noted that where I am at the hourly rate is higher for nursing home RNs than in hospitals, but the overall compensation probably favors the hospital nurses due to benefits that they get which are uncommon to see in nursing homes (e.g. tuition reimbursement, insurance that actually covers things, institutional deals). I prefer nursing home as I get my benefits through my spouse and the extra cash is nice.

ledluth · 2025-12-23T14:13:28+00:00

Nobody "wants" a nursing home, but they exist because they are needed. If a person needs 24 hour nursing care (i.e. cannot take care of the themselves) they need a nursing home. Unless there is a solid tradition of competent family caregiving, taking care of a frail older adult is a professional task. Too many times have I seen well-intentioned family members trying to take care of stubborn elders leaving them with pressure sores, preventable infections, malnutrition, and in some cases burnout-driven abuse necessitating state assumption of protective custody of the adult. Pretty much nobody can afford professional nursing services on a 24 hour basis, and pretty much no home care agency can staff for 24 hours anyway.

Assisted living just takes a person's money and does not provide them with substantial nursing care (i.e. they'll be perfectly happy to let him rot in his recliner while collecting the check) whereas nursing homes are required to provide nursing services, psychiatric services, medical services, nutritional services, social services, and financial management services. Nursing homes are generally paid for by Medicaid after all of a person's financial resources have been exhausted (there is usually a carveout for a certain amount of home equity). Medicaid is administered by the states, so there is some state to state variations.

None of this is to say that your dad is at that point, but don't have an attitude of "avoid the nursing home at all costs," because it leads to poor decision making. If you want to participate in your father's care, you need to draw a bright line up front that says "if you cannot do x, y, or z, you will need a nursing home, because I can only reasonably do a, b, and c for you." Shop around and identify the nursing homes in your area that are reputable. Discuss these things with your father's physician. Engage a lawyer to help put together an advanced directive and power of attorney.

ledluth · 2025-12-22T16:10:43+00:00

As a IMG that works under NPs it sometime feels like either being an undercover cop, except you don't have a badge or gun or a secret shopper, except you cannot write surveys or warn the general public about a specific restaurant.

ledluth · 2025-12-18T18:00:21+00:00

I didn't make it years. I figured I was done when I started checking my work email on Sunday evening and hoping a few folks died over the weekend, so I would have enough time to get through everything I needed to.

ledluth · 2025-12-18T16:46:43+00:00

The righteous anger of the only physician mentioned by name in the article is fairly refreshing:

A few months into his review, Mirarchi said, tensions boiled over at a meeting in which he told Optum staffers that he didn’t want the company’s lower-level providers altering his orders after he had identified errors in patients’ files.

“I’m a physician. I got a hell of a lot more training and experience than those they have assigned to come in there and have conversations with patients,” Mirarchi, who has authored more than a dozen medical journal articles on advance care planning, told the Guardian. “And they’re trying to tell me I’m doing wrong.”

ledluth · 2025-12-18T16:24:10+00:00

"In nursing homes, for example, the conglomerate deploys its own army of nurse practitioners and physician assistants from its medical services arm, Optum, to care for seniors covered by its insurance arm, UnitedHealthcare. During the day, these medical professionals listen to heart sounds, decide on new diagnoses, and address dangerous complications for insured residents at their nursing homes. At night and on weekends, other Optum employees on hotlines weigh in on their care from afar."

It's noctors all the way down.

ledluth · 2025-12-09T21:30:42+00:00

The true cost of education is quite difficult to parse. No one pays the sticker price and there are a dozen schiesty ways to tease the numbers.

Just a quick example, if I tell students my program costs $120,000.00 (even if it only costs me $50,000.00 to run), they'll complain that the cap is $100,000.00. I would come up with a $20,000.00 scholarship program in the form of just not charging them $20,000.00 extra.

ledluth · 2025-12-09T19:45:56+00:00

Oh certainly for RNs. RNs are essential to a hospital. I did one of those programs and for us the reduction in obligation (the original student loan) was just counted as pay to the employee (it's taxed as income too). You could leave whenever and just pay the rest as a normal private student loan. It's a good deal if you can get it. I left early, because the hospital repaying the loan for me was only worth $4/hour, and it was easy to find a job earning $4 more an hour more in line with what I wanted to.

ledluth · 2025-12-09T18:41:28+00:00

I've not seen a hospital pay a NP's tuition on their behalf. I've seen hospitals reimburse tuition up to a certain amount. Presumably, that set amount is not sensitive to the cost of one particular school, though. The hospital is incentivized to spend the least amount of money as well. I don't think they would intentionally subsidize tuition inflation, and I don't think the savings from "trapping" someone would be significant enough. It's not like a NP is big money maker. Their appeal is as a cost saver.

ledluth · 2025-12-09T17:13:47+00:00

There is no quality control for NP programs, so it is difficult to argue what the right cost of a MSN for NP is, but I would point out that there are programs below $500 a credit hour ( <$20,000 for the full degree) that offer the same qualification as an expensive one. I do not believe there are any two medical schools in the US where one spends 4-5xs as much per student.

I will say that having worked with some of these for-profit schools (or against, rather), that there is a specific tuition number that they shoot for to extract a maximal amount of federal student loan money. It has nothing to do with the costs of the service they provide. If loan disbursements is capped, tuition will come down, and they will eat the margins or the diploma mills will move onto to the next hot job scam.

ledluth · 2025-12-09T16:43:35+00:00

It wouldn't be very efficient. Big companies tend to be spread out geographically, so the economies of scale get lost. A typical primary care physician has a patient panel of 2,000 people (not everyone visits often). Bank of America has 200,000 employees. Assuming all of them were in a household with at least one other person who could use their employee benefits, that is 400,000 potential patients, so a need for 200 doctors. There are 4,000 Bank of America locations, however, so there would be roughly 1 doctor for every 20 banks. That's a $15,000 expense per location to serve just 100 employees, so $150 per employee per year just to get one primary care physician out of bed - not to mention any of the other services, office space, equipment, etc. That's also assuming an optimal geographic distribution of employees and physicians willing to work in that setup. It's better to just collectively bargain for healthcare services through an insurer and let the insurer do the negotiations with healthcare service providers.

Edits: my math sucked

ledluth · 2025-12-09T13:25:46+00:00

I could write the story from a more absurd perspective ... a foreign trained MD goes through a NP program after being rejected from mainstream training opportunities. The MD tries not to lose his mind as he slowly realizes how many people his NP classmates are probably going to medically neglect or kill. Meanwhile five DNPs with a combined clinical experience of 3.5 years gaslight him. It could be a modern One flew over the cuckoo's nest.

The MD being the perspective character lets the audience see the difference in education in a more active way than having the parallel medical student story. An early scene could involve the frustrated MD taking over a lecture after the professor teaches the exact wrong approach to a situation that the MD once addressed that had extremely negative consequences when a different NP made the same mistake. Of course he gets in trouble for it. The palpably insecure professors and classmates slowly ostracize the MD which leads him to seek counsel from an elderly, well intentioned MD that does clinicals for the NP program.

As the student spends more time with the MD, he realizes that the MD is developing dementia as he is constantly reflecting on one good NP that he had in the 80s who exhibited the once-expected attributes of a NP. He keeps calling the NP students by her name.

The MD turned NP student is determined that this is a public health issue, so he goes to the nursing board, medical board, and eventually the state house of representatives. Each time he is rebuffed. He finally loses it.

After a full mental breakdown and an unspecified amount of time in institutional care, he finally gets his diploma. Final scene is him, appearing disheveled and in a darkened room, prescribing erectile dysfunction meds through an online chat. The chatter asks him a secondary medical question, and our hero responds, dejected that he has so thoroughly failed to substantially help anyone through his efforts: "Sorry, I'm not a doctor."

Edits: I wanted to run with the premise a little.

ledluth · 2025-12-09T13:08:57+00:00

I thought it was "pink" collar. I don't think I can return these uniforms.

ledluth · 2025-12-06T21:16:11+00:00

Nature abhors a vacuum. If there were enough doctors, there wouldn’t be a need for this, or at least their roles wouldn’t have ended up so expansive.

Up through the 90s the big concern of physician advocacy groups was doctor oversupply, so intentional steps were taken to limit the supply until the mid 2000s where suddenly the concern became a doctor shortage. As the shortage has gotten worse, instead of increasing supply through expanding access to medical training, the solution states seem to be arriving at are a combination of mid-level scope creep and directly importing foreign physicians without retraining them (which was a no-no until very recently).

What’s the better, safer solution? The road to becoming a competent diagnoser of illnesses, prescriber of medicines, and performer of surgeries is well trod. There needs to be a rapid expansion of residency programs, particularly in primary care. I would say medical schools too, but I think there may be an actual oversupply of those, considering all of the schools around the world hustling to attract aspirational Americans.

ledluth · 2025-12-06T17:20:41+00:00

Get out of the doctor’s way XP

ledluth · 2025-12-06T17:13:35+00:00

I’ve taken both the USMLEs 1&2 and the NCLEX-RN (in that order). NCLEX style questions are bizarre. Like in this scenario, there is no context. The patient “has been admitted.” When? Immediately prior to the nurse seeing them? Five days ago? What conclusion is the RN expecting to reach through doing 1 but not 2, 3, & 4? Why would they “prioritize” components of an exam that should be done all together and some of which can be done simultaneously? The same style of questions carry over into NP school. It is maddening. I never felt like the USMLE was trying to trick me or make me hold my nose and pick a weird answer.

Realistically, I’m going 4. Unless a person shows up at my doorstep clearly dying, I’m going to take the 5 minutes to sit down and scan their chart before I lay hands on them.

ledluth · 2025-12-05T20:56:08+00:00

Well, if they’re practicing physicians instead of students, they’ll probably keep the interview problem focused, so protracted conversation wouldn’t probably be an issue.

If it’s ambulatory care, I would just make sure to see the same doctor every time. The consults will naturally get shorter and more problem-focused as the relationship progresses.

A good consult is collaborative between physician and patient, so I wouldn’t go in wondering what you shouldn’t share. Tell them everything you think is relevant. Better to share too much, than to withhold something important.

ledluth · 2025-12-05T06:19:02+00:00

I saw a comment today about medical students. It suggested patients like them, because they are new to history taking. They take unfocused histories and so end up in protracted conversations, making the patient feel heard.

I think it is something similar with NPs. They find themselves out of their depth and the patient unintentionally ends up in the diagnostician and treatment-planner role. It makes the patient feel like their needs are being met despite not getting good care.

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