Hospice Patients Alliance – When It is Inappropriate to Have PRN Medical

#end stage copd hospice

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Allowing PRN Orders for Morphine
May Result in Untimely Death
For COPD Patients

Morphine is an opioid medication often used to relieve severe pain in cancer and some other diseases. When prescribed by a physician appropriately for relief of pain, it is a blessing to those whose symptoms are relieved, and to the families of those patients who had suffered watching their loved one in agony. When the patient has severe pain, hospices aim at achieving good pain control as one of their top priorities.

Because morphine is regularly prescribed in hospices for relief of pain and suffering, physicians and nurses come to rely on its power to relieve pain and promote a death without suffering. A death with symptoms well-managed is one important aspect of what is called a “death with dignity.”

Patients in hospice who have diseases without severe pain may not need morphine for comfort. Some take other analgesics and some take none. But patients who have Chronic Obstructive Pulmonary Disease or “COPD” may especially be sensitive to the adverse effects of morphine. COPD patients have breathing difficulties and anxiety which can sometimes be lessened by very small dosages of a sedative and/or a very small dosage of morphine. However, given in too high a dose, morphine can seriously interfere with a patient’s ability to breathe. In fact, anyone who is given a dosage of morphine which is much higher than they are accustomed to, may stop breathing.

One of morphine’s main adverse effects is slowing down the respiratory rate, i.e. respiratory depression. If the dosage of morphine is too high for what the patient is accustomed to, the respiratory depression can become severe and actually stop the breathing periodically for a few seconds or many seconds. This pattern of breathing where the patient stops breathing (skipping breaths) and then starts breathing again is termed “apnea.” Apnea commonly occurs as a result of the terminal illness and the dying process, when certain metabolic changes occur in the patient’s body. If the breathing is stopped completely without restarting, the patient dies. Because COPD patients have compromised breathing already. very inefficient breathing, overly high doses of morphine can quickly cause these patients to stop breathing.

Hospice Patients Alliance has received many, many reports from families about patients with COPD who were given morphine in dosages higher than they were accustomed to receiving. who died shortly after getting those morphine dosages. Most of these patients were given these dosages of morphine by nurses in the hospice setting. In all the cases reported, the physician had ordered that the morphine might be given “as needed” or “PRN” within a certain range and at a certain frequency of time intervals between doses given.

Giving a medication “as needed” requires a careful assessment of the patient’s vital signs, pain level and need for the medication being considered. When a physician writes a PRN order for morphine, most nurses are very dedicated to assessing the patient’s actual needs and doing everything possible to meet those needs by administering the medication as needed. But in the case of COPD patients, the need for extra vigilance in determining the appropriate dosage is very urgent. Pharmacy and drug references, such as the Physicians Desk Reference and morphine package inserts warn about the dangers of giving too high dosages of morphine to COPD patients. The package inserts and the Physicians Desk Reference even write that morphine is “contraindicated” in general for COPD patients. However, when a patient is truly terminal, some of the rules of prescribing medications are adjusted to meet the needs of the patient. In the terminal COPD patient, morphine is sometimes ordered by the physician to be given in very small dosages.

If the physician orders the morphine to be given on a PRN or “as needed” basis, when the patient has COPD, and allows a shorter frequency of administration than that needed for the previous dosage to “wear off” or be metabolized, the concentration of morphine actually in the patient’s blood may increase beyond a therapeutic level, causing severe adverse effects, even respiratory shutdown. If you have a loved one with COPD in a hospice care setting and if you are concerned that he may be euthanized before his natural time of passing on, then it is wise to request that the physician NOT write a PRN order for morphine. If the morphine is actually helping your loved one to breathe better, and is comforting, then you may wish to request the physician to consider ordering the morphine on a fixed dosage and schedule, determined by the physician only, not the nurse.

If you have concerns that your loved one may be medically killed or euthanized in a hospice setting, you should discuss these concerns with the physician and request that PRN orders for morphine not be used. If the physician refuses to do so, you may be able to determine whether the physician is sympathetic to your concerns about euthanasia or not. If you believe the physician is determined to euthanize your loved one, involuntarily, or without your knowledge, then you always have the right to change physicians or to change hospices. Any time that you have concrete evidence that a nurse or physician is acting to euthanize your loved one, the patient, or the patient’s representative may act to change the physician and hospice to a setting that will provide true hospice care.

Real hospice care is NOT about hastening the death of a patient. It is about providing relief from distressing symptoms, supporting the patient and letting them know that they are valued and loved. Hospice patients necessarily choose not to try to cure the terminal illness, because all efforts to cure the disease are believed to have failed and further efforts are believed to be of no use in curing the disease, i.e. the physician has determined that no efforts would succeed in any case. That does NOT mean that treatment for a urinary or respiratory infection is to be withheld, or that food and water are to be withheld if the patient can absorb them. Withholding food and water is a form of euthanasia for the patient who is not already actively dying! Withholding appropriate treatment for an infection when the patient is not actively dying is also a form of euthanasia!

Giving overly high dosages of morphine to a COPD patient, or a patient with another terminal illness, is a form of euthanasia. By being alert, discussing your concerns with the physician and hospice staff and acting promptly to prevent overly high dosages of morphine from being administered, you can save your loved one from an untimely death. Removing your loved one from a setting that is bent on euthanizing your loved one may be the only way to save them from being medical killed.

There are many nurses and physicians who would never even think of doing such a thing, but unfortunately, there are many who would. Surveys and research into the attitudes and practices of physicians and nurses reveals that a significant percentage of nurses and physicians believe that euthanasia is acceptable. If you don’t agree, then you must act to protect your loved one. The best protection is to know what medications are being given, what effect the medications have, what dosages are being given (by being there if possible when they are given) and knowing why the medications are being given. If your instincts tell you that something is not right, act promptly to check with someone you trust who is a nurse, pharmacist or physician who can give you some feedback and further information.

PRN orders for morphine may be totally inappropriate for COPD patients who do NOT have severe pain!

Permission is granted to share these articles with others, to print them, or post them on other websites so long as credit
is given to the author and Hospice Patients Alliance with a link to this original page.





Foundation Repair #foundation #repair, #foundation #contractor, #house #leveling, #foundation #repairs, #anchor #bolts,


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Why We re the Best

Experience like no other. Repairing and constructing over 7,000+ foundations. We know homes.

There are a lot of companies offering foundation repair in the Los Angeles area. How do you know which one is best? We believe experience should be the deciding factor. Julian Construction was formed in 1994, and our focus has always been on building foundations, doing repair, replacement, earthquake retrofitting and house leveling. We have inspected over 16,500 foundations .

If you also talk to another foundation contractor, ask how long they have been doing foundation repair. Not how long they have been in business. But how long they have been doing foundation work. There are some contractors in the LA area who have been doing foundation work for a year or less. Would you trust the safety of your home to them?

When the safety of your home and family are at stake, we think you ll want to go with Julian, the company that has been working under homes for nearly 20 years.

Best value. Our affordability comes from the efficiency of expertise and smooth-running crews. All equipment and vehicles are company owned. Julian Construction also offers 0% financing .

100% expert oversight. From start to finish, licensed and expert managers oversee all projects, ensuring perfection, timeliness and safety.


Which Schools Have Online Physical Therapy Assistant Degree Programs? #physical #therapy #online


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Which Schools Have Online Physical Therapy Assistant Degree Programs?

Offered at the associate’s degree level, physical therapy assistant programs train students to successfully administer physical therapy treatments under the supervision of licensed physical therapists. Due to the clinical requirements, completely online physical therapy assistant degree programs do not exist. Schools offering Physical Therapy degrees can also be found in these popular choices.

Degree Program Information

Associate’s degree programs for physical therapy assistants are often available through vocational schools or community colleges. These programs usually take two years of study and include general education courses in addition to those in physical therapy. Because of the hands-on, clinical nature of the profession, fully online physical therapy assistant programs do not exist. Below are some of the schools that offer on-campus physical therapy assistant degree programs.

Important Information About Physical Therapy Assistant Programs

High school diploma or equivalent

Applied anatomy, tests measurements, pathophysiology

Physical therapist assistant, medical assistant (may require further education)

Bachelor’s programs are available; licensed physical therapy assistants may be required to complete continuing education coursework for licensure renewal

Whatcom Community College

Whatcom Community College offers a full-time program at their campus in Bellingham, WA, but students who cannot attend on-campus classes can opt for the part-time online/hybrid option. The program leads to an Associate in Science (A.S.) in Physical Therapy Assisting. This PTA degree features required prerequisite courses in general education topics such as math and English, and after completing these courses, students can study kinesiology, physical therapy, and PTA procedures.

Milwaukee Area Technical College

Milwaukee Area Technical College in Wisconsin awards an Associate in Applied Science (A.A.S.) in Physical Therapist Assisting. This program emphasizes effective communication with patients and is designed to prepare students to secure jobs in nursing homes, rehabilitation centers and other health care facilities. Students are encouraged to fulfill their roles with sensitivity and respect. The program examines ways in which the delivery of physical therapy services may be properly documented.

Jefferson State Community College

An Associate of Applied Science (A.A.S.) degree in Physical Therapy Assisting is available through the program at Jefferson State Community College. The degree requires two years of study, with one year devoted to prerequisite coursework and the second year focusing on professional coursework. Once the student graduated program, he or she will be qualified to take the National Board Exam and receive professional state licensure.

Job Duties

Physical therapy assistants play an important role in the delivery of physical therapy services to patients trying to regain movement after illness or injury. They perform many of the same tasks as physical therapists, such as patient preparation, hydrotherapy, massage and heat pack application. Every state requires that physical therapy assistants be licensed and hold an associate’s degree from an accredited college program as well as pass a licensing exam.

To continue researching, browse degree options below for course curriculum, prerequisites and financial aid information. Or, learn more about the subject by reading the related articles below:

The schools below may include sponsored listings but are popular choices among our users.


Finding out you have advanced cancer #alive #hospice #nashville

#terminal cancer

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Finding out you have advanced cancer

When cancer is advanced it means that it can’t be cured and is likely to cause death within a limited period of time. The amount of time is difficult to predict but it could be weeks to several months. Doctors might also say that the illness is terminal. This distressing news can affect you and the people close to you in different ways. This page is about how you may feel and what can help you cope. There is information about

Your first reactions

There is no right or wrong way to react when you are told your cancer is too advanced to cure. Everyone responds in their own way. For most of us of course, this is very shocking news. Even if you thought it may happen, hearing it from your doctor can still be very upsetting.

Some people become silent. They can’t believe what they are hearing and don’t know what to say or do. Some start to cry and feel as though they won’t be able to stop. Others may become very angry and scared. Some people feel numb and as though they have no emotions. These are all very common reactions.

You might find that many questions come into your mind, such as

  • Why me?
  • Do I deserve this?
  • Why can’t you find a treatment to help me?
  • There must be something that will stop this cancer – can’t you just try anything?

It is natural to feel desperate, upset, angry, or that you don’t believe the news. Be sure to give yourself the time and space to take in what is happening. You might want to be on your own. Or you may need to spend time with your partner, family or friends to help you deal with the news. Of course they may also be very upset and feel that they don’t know what to say. Even if all you can do at first is get upset together, that can be a huge help.

If you don’t feel like talking straight away, you don’t have to. Just let the people around you know that. As hard as it can be, try not to push your emotions aside completely. If you can manage it, it is better to express how you feel and allow your emotions to come to the surface – even if that is uncomfortable and hard to cope with.

Feelings you may have

Over the first few days, you may go through a range of very strong emotions. The emotions may change very quickly and sometimes you might feel numb or as though everything is happening to someone else. Some people say they feel very calm and detached when they are first told they don’t have long to live.

At times, you will probably feel shock, anger, and sadness. These emotions can feel overwhelming at times. This news will mean that you can’t plan your future in the way you had hoped. Dying may mean leaving behind a partner, children, and other important people in your life. You may wonder how they will cope and won’t want to see them upset.

These thoughts may be too painful to cope with at times. You might be unable to stop crying and worrying. All this is perfectly normal and understandable.

You may find it difficult to look around and see life going on as normal for most people. It can feel very strange to watch people going about their daily lives as usual – shopping, driving and working. Coping with this roller coaster of feelings can be very exhausting. You may feel as if you are stuck under a huge black cloud and that there is no point in doing anything.

Most people will have some or all of these emotions. This usually changes gradually. Many people say that the intensity and distress lessens in time. This doesn’t mean that you stop worrying or feeling upset. But the feelings get more bearable. You will most likely be able to think about your situation a little more calmly and plan what you want to do.

Looking at your options

It can be helpful to find out what support is available. Some people want to make plans about what they would like to do before they die. You may like to ask your doctor about

  • How to control cancer symptoms
  • What is likely to happen
  • Who to talk to about your concerns

Having some idea about what to expect can help you feel less anxious. You might also want to think about where you want to be at the end of your life.

Sharing your feelings

Sharing your fears and sadness with people you love and trust may be a great relief for you.

Many people say that talking about their feelings helps them to cope. It also helps your friends and family to understand more about your situation. In turn, this will help them to help and support you. Other people find sharing their thoughts and emotions too difficult, and would rather keep things to themselves. It is important to do whatever feels best for you.

Don’t let other people pressure you into talking if you don’t feel ready. This is a very personal, emotional time. You can choose how you handle things. If you would like to talk, make sure you choose people you can talk to easily, who will understand how you feel and be able to support you.

If, after some time, you still feel overwhelmed and that you can’t cope, try speaking to someone outside your immediate family and friends.

Our advanced cancer organisations section lists counselling organisations that offer this kind of support. They also have information about coping with grief, terminal illness, and dying with cancer.

If you are by yourself

If you don’t have people nearby to help with practical things, you can ask for help. One of your health care team may be able to arrange volunteers to help out at home, or come to visit you in hospital. Ask your specialist cancer nurse or doctor about this.

If you need help with personal care, such as washing or dressing, social services may be able to help. They can arrange a care package for you.

You might be wary of letting people you don’t know into your life. But most people find that they do need support at some stage from other people or organisations. And the people that you are put in touch with will be understanding and aware of your feelings and need for personal space. They will want to support you in the best possible way they can.

You might find help and support at your religious organisation or through other organisations you are involved with.

Staying hopeful

It is important that people nearing the end of their life, and those close to them, are aware of what is likely to happen. But only if they want to know this. Everyone needs to have some sense of hope for their future. When you are dying, this hope may be that you can visit a place that you love. Or you may hope that you can enjoy being with your family and friends for a time. Some people believe that there is life after death and find that this gives them hope.

It may help you to share your hopes with other people, so they can help you fulfil them. Many people hope for comfort, dignity, friendship and love to surround them in their final days.

For more information

For general information and support

Contact the Cancer Research UK nurses on freephone 0808 800 4040 (open 9am to 5pm, Monday to Friday)

Share experiences on our online forum – Cancer Chat

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Updated: 6 May 2016

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Cancer Research UK is a registered charity in England and Wales (1089464), Scotland (SC041666) and the Isle of Man (1103). A company limited by guarantee. Registered company in England and Wales (4325234) and the Isle of Man (5713F). Registered address: Angel Building, 407 St John Street, London EC1V 4AD.





These Cities Have the Cheapest Luxury Hotels in the World #motel #fort

#cheap luxury hotels

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These Cities Have the Cheapest Luxury Hotels in the World

Hotels around the world are getting more expensive. According a recent report by the behemoth booking site Hotels.com, the average price for a room rose about three percent globally from 2013 to 2014, fifth consecutve year of rising rates. Here in the States, the average room was five percent higher than the previous year (though we still haven’t reached the highs of 2007). But for travelers looking for deals, it’s not all bad news: some destinations saw significant drops on room rates—even at luxury hotels :

  • Asia offers some of the biggest savings: bucking the global trend, hotel room rates across the region dropped by two percent overall from 2013 to 2014. Bangkok. in particular, saw steep declines in the cost of a luxury hotel room: a five-star room was $187, down by 11 percent.
  • Other Asian cities that offer good value on luxury hotels: Delhi. where the average room was $177 a night, and Beijing. which had rooms for $210 a night.
  • In Europe, where a falling euro is making things even more affordable for American travelers, Hotels.com found good five-star room rates in Berlin ($211 a night), Brussels ($202), Budapest ($208), Istanbul ($207), Lisbon ($209), and Prague ($216). But the lowest luxury rooms in Europe are in Warsaw. where they go for just $107 a night.
  • It was harder to find great deals in the United States. Five-star rooms in San Francisco jumped by a full 21 percent to an average to $447 a night. In Seattle they rose 15 percent to $347. In Boston they increased 12 percent, reaching $574 a night. The bright spot for the U.S. was Las Vegas. Although rates there rose, the average price of a luxury room was still just $254 a night.





    Have the Conversation Keyword

    #hospice of chattanooga

    #

    Hospice of Chattanooga, Inc. wants to thank you in advance for giving us the opportunity to consider you for employment.

    Following the instructions below, you will be able to use your computer keyboard to complete the application package at your pace, and upload your completed application package to us.

    Please read through the following instructions completely. It is VERY IMPORTANT to follow these instructions in order:

    NOTE: Tablets and smart phones cannot be used to complete and submit this application online.

    1.Complete the Hartman Value Profile. After you have completed it, return here to complete your application. Enter hospicecha in the Username, Password and Client Code fields.
    Click Here for the profile.

    2.Make sure you have the latest version of Adobe Acrobat Reader on your computer – You can download the latest version of Adobe Acrobat Reader here. MAC Users MUST use Adobe Reader

    3. Download and SAVE the application to your computer. Click Here to download the employment application. When the application opens, save it to a secure location on your computer.

    4. After the application is downloaded and saved to your computer, open the application using Adobe Reader. Complete and resave the application. You may open and resave as often as needed to complete the application

    5. Complete the application following the instructions on pages 1 and 2 of the application package. The instructions will direct you to a location to upload your completed application package.

    Signatures are not required for submittal, but physical signatures may be required later.





    Do You Have – The Little Blue Book – in Your House?

    #hospice book on stages of dying

    #

    Do You Have ‘The Little Blue Book’ in Your House?

    If you are wondering what I’m talking about, it is for you that I am writing this blog! Here’s the bottom line: We were all born one moment of one day, and each of us is going to die one moment of another day — we just don’t get to know when that will be. For some of us, that is a major source of anxiety. Furthermore, we live in a society that has kept us in the dark about what to expect when we, or someone we love, dies. This absence of knowledge not only makes us ill-prepared to face death, but it feeds our fear of death, which in turn diminishes our enjoyment of life.

    It is perfectly normal to have some anxiety or fear about death, and in fact, most death-related anxiety is actually about the process of dying rather than about being dead. That’s where the little blue book comes in — this little 14-page blue booklet gently, kindly, and in a matter-of-fact manner explains the dying experience in such a way that it brings its readers great comfort. So why not reach for that comfort sooner rather than later? Why live with death anxiety on autopilot in the background of your mind? Why wait and find yourself called to the bedside of a dying loved one unprepared for what you will encounter and not knowing what to do?

    Most people working in the field of dying, death, and grieving know about “the little blue book,” as it has come to be known. Many hospice and palliative care organizations around the country give this book to their dying patients and their loved ones to ease them through the dying experience. It is entitled Gone From My Sight: The Dying Experience and is written by Barbara Karnes, RN, who was one of the pioneers of the hospice movement in this country in the early 1970s. To learn more about Barbara and her work, visit her website at https://www.bkbooks.com. Barbara’s other three titles are: The Eleventh Hour: A Caring Guideline For The Hours To Minutes Before Death (my personal favorite), My Friend, I Care: The Grief Experience. and A Time to Live: Living with a Life-Threatening Illness. All are available on her website.

    This blog is not meant to be an advertisement for Barbara and her work, but rather I am shouting from the rooftops to spread the word that each and every one of us has the opportunity to prevent the needless suffering that our fundamental ignorance about the dying process brings. Not knowing what is normal and what the signs of the end of life are, we often cling desperately to life, relying on physicians to come up with a pill or procedure that will prolong our lives. Sometimes this is reasonable, but often the dying and their loved ones simply lack the understanding of the dying process that would enable them to consider the relative wisdom of further medical interventions or the timing of opening the door to palliative care.

    Those of us who work in the field of dying, death, and grieving have satchels of stories about the ways people suffer unnecessarily through their own death or at the bedside of a loved one. Not knowing what to expect, what is normal, and how to support and comfort a loved one who is dying makes us ill at ease which detracts from a tranquil environment for the dying.

    As someone who writes often about dying, death, and grieving, I am quite passionate about the need for a basic education of the general public about this topic. That’s why I would go so far as to say that if I were queen of the world, I would make Barbara’s books required reading for everyone and as important as a fire extinguisher to have in your home!

    The vast majority of us will die of old age and/or prolonged illness. Having Barbara’s books on hand when you or a loved one begins the end of life’s journey empowers you all to do your very best to provide a loving, comforting, and supportive sendoff. Rather than worrying about what you should or shouldn’t do, what’s normal and what isn’t, and how to be the greatest comfort to your loved one, empower yourself with some basic education and serve as an example to others. Sitting at your dying mother’s bedside, when you know that what you are observing is normal, you can encourage her and let her know she is doing a great job of dying. In this case, a little knowledge is a very powerful, wise, and comforting thing.

    Please feel free to leave a comment below.

    To learn more about Judith Johnson, visit website .





    These Cities Have the Cheapest Luxury Hotels in the World #seattle #motels

    #cheap luxury hotels

    #

    These Cities Have the Cheapest Luxury Hotels in the World

    Hotels around the world are getting more expensive. According a recent report by the behemoth booking site Hotels.com, the average price for a room rose about three percent globally from 2013 to 2014, fifth consecutve year of rising rates. Here in the States, the average room was five percent higher than the previous year (though we still haven’t reached the highs of 2007). But for travelers looking for deals, it’s not all bad news: some destinations saw significant drops on room rates—even at luxury hotels :

    • Asia offers some of the biggest savings: bucking the global trend, hotel room rates across the region dropped by two percent overall from 2013 to 2014. Bangkok. in particular, saw steep declines in the cost of a luxury hotel room: a five-star room was $187, down by 11 percent.
  • Other Asian cities that offer good value on luxury hotels: Delhi. where the average room was $177 a night, and Beijing. which had rooms for $210 a night.
  • In Europe, where a falling euro is making things even more affordable for American travelers, Hotels.com found good five-star room rates in Berlin ($211 a night), Brussels ($202), Budapest ($208), Istanbul ($207), Lisbon ($209), and Prague ($216). But the lowest luxury rooms in Europe are in Warsaw. where they go for just $107 a night.
  • It was harder to find great deals in the United States. Five-star rooms in San Francisco jumped by a full 21 percent to an average to $447 a night. In Seattle they rose 15 percent to $347. In Boston they increased 12 percent, reaching $574 a night. The bright spot for the U.S. was Las Vegas. Although rates there rose, the average price of a luxury room was still just $254 a night.