From: email@example.com(Steven B. Harris)
Subject: Re: Morphine in US hospices
Date: Thu, 07 Aug 1997
firstname.lastname@example.org (C.J. Fuller) writes:
>In article <email@example.com>, firstname.lastname@example.org
>(Jay Mann) wrote:
>>Just a query here. When I left the States over two decades ago, one was
>>left to die in pain without enough access to pain-killing drugs like
>>morphine and heroin. Here in NZ we have hospices that provide a
>>dignified pain-free death without paranoid worries about the dying person
>>becoming addicted. What's the current situation now in the U.S.?
>>Jay D Mann <email@example.com>
>>Christchurch, New Zealand
>Jay-Things are getting better, but are still not optimum. Some hospices
>allow patients to control their own morphine dosage instead of the old
>prn order, which often translates as whenever the staff gets around to
>administering it. (This was not a slam at nurses, it was a slam at the
>system that forces people in pain to be dependent on others for even a
>modicum of relief.) Unfortunately, several states are clamping down on
>MD's who appear to be writing too many prescriptions for morphine and
>other controlled substances. Much depends on where you choose to be ill.
>Cindy Fuller, PhD, RD
Most hospice these days, BTW, is "home hospice." Medicare pays for
it, having figured out that it's cheaper than paying for
hospitalization. In this case, compassion and frugality go hand in
hand, and it only took Medicare 20 years or so to get it.
Of course in home hospice, almost by definition, almost all narcotic
use is patient-controlled (or at least, family controlled). Home
nurses are not there most of the time. You generally only have to have
the really stiff security on these drugs when you're administering them
in institutions, so home hospice has been enormously helpful in that
regard. You can do things, like, for instance, put bottles of morphine
elixer out on tables. And concentrated morphine-filled reservoirs for
pumps are generally simply sent to patients by parcel-post, Fedex, or
UPI. No security required, because nobody knows what they are.
Steve Harris, M.D.
From: "Steve Harris" <sbharris@ix.RETICULATEDOBJECTcom.com>
Subject: Medicine and Hospice(WAS Re: AND furthermore)
Date: Tue, 6 Nov 2001 10:54:32 -0800
>firstname.lastname@example.org wrote in message <email@example.com>...
>In article <firstname.lastname@example.org>,
> "Steve Harris" <sbharris@ix.RETICULATEDOBJECTcom.com> wrote:
>>>>>Date: 11/4/01 4:48 AM Eastern Standard Time
>>>>>Heh. That's not what I encountered. The nursing home
>>>>>doctor didn't want JMF to get addicted...this was two
>>>>>weeks before he died.
>>And his doctor was supposed to know he was 2 weeks away from death...how?
>>If he was terminally ill, had a recurrent cancer, was bedbound and losing
>>weight and clearly the battle, why didn't you get him signed into hospice,
>There aren't any. I had hospice nurses visiting once/week.
>Unfortunately, I was also dying and couldn't take care of him
>by myself. That's how he ended up in a nursing home.
Babs, "hospice" isn't a place, it's program. It's everywhere, and was
everywhere a decade ago (AIDS basically got it universally available). What
place and what year are you talking about? Hospice can be done at home (so
long as the patient doens't live alone), in the hospital, in assisted
residential living, or in a skilled care facility. If you had hospice nurses
visiting, he should have been able to get all the narcotics he wanted, just
by asking. In fact, I cannot imagine how you got hospice nurses without a
hospice program. Your story is extremely confused. The hospice doc, not the
facility doc, controls the pain med orders, and in effect it is actually the
hospice nurses who do it, since they have very wide latitude.
Hospice is also a state of mind. It switches labels on a patient and says
"Okay, our primary goal now is comfort for this person, NOT long term
recovery." So narcotics and also antianxiety drugs run like water. If you
can get the primary care doc to agree that the patient even reasonably MIGHT
have less than 6 months to live, you can get a hospice program anywhere in
the country, and medicare/medicaid will pay for it. I've seen these patients
go for 2 or three repeat signups, too-- there is no demand that you die on
schedule. And it's no problem for a guy who's had a laryngectomy for throat
cancer (see what smoking does to you?) and is in a nursing home, failing.
There's no penalty if the patient outlives the 6 months.
You might have thought YOU were dying. But if you had enough presense of
mind and knowledge to think he wasn't getting good pain control, you also
had enough to get him signed up for hospice. Perhaps you didn't know enough
to do so. However, the resources are out there. I'm surprised the attending
at the nursing home didn't suggest it.