Hospice Story: Psychosocial Support & Medications –
Safety & Sleep 

This was just your ordinary Wednesday afternoon, patients were being seen, medication orders were being written, and patients and families were working through tough transitions.

Meet Debbie. Debbie was an elderly woman who had suffered a stroke and had vascular dementia. She was receiving hospice care in her home, as she had multiple hospitalizations for UTIs and aspiration pneumonia and the goal wasn’t to go back to the hospital anymore. Between her stroke and vascular dementia, she didn’t speak much, often communicating with simple eye movements.

It seemed recently that Debbie was really struggling with insomnia. It was reported that she couldn’t fall asleep and would just lay in bed with her eyes wide open. The hospice nurse reported she was concerned that if this continued much longer Debbie would begin to have some delirium. The hospice nurse reported that they had tried the lorazepam already in the home, using varying doses. The medical director ordered some trazodone a couple of nights ago, with repeat and titrating doses, all of which didn’t seem to do anything.

So, the question was what should we try now? There were endless choices it seemed, as ideas were tossed around among the interdisciplinary team. The conversation landed back on me and they said… so what do you think?

I resisted the urge to throw out another option, instead I said something felt off. Debbie hadn’t had any reports of insomnia until these past couple of weeks and it wasn’t happening every night. I think we need to poke around more. What’s Debbie’s home life like and has anything changed? Come to find out Debbie’s husband had passed away years prior and she had no family. She resided in her home and had paid caregivers who stayed with her during the day and at night. Upon inquiring with the caregiver agency, they said Debbie always has the same caregiver at night, up until recently. Bingo! That change corresponded with new onset insomnia. Let’s think about it, if you had a stranger in your house, would you sleep well at night? That explains the up-all-night and eyes-wide-open. This was confirmed by Debbie using eye blinking to let us know she was scared when new caregivers stayed overnight.

So why did the medications not work? Well, the mind is a powerful thing and it’s not uncommon for the mind to overcome medications. The repeat and titrating doses weren’t going to muster enough to get Debbie to sleep- she was resisting. Even if they did work, it’s short ten-minute sleep cycles, leading to exhaustion. So, the resolution required some work between the hospice and the caregiving agency, but stopping the rotation of new caregivers each night and doing some ‘introductions’ between new night caregivers and Debbie helped create more of a team that could rotate through, easing that stress and allowing Debbie to rest.

Sometimes when things don’t make sense it is imperative that we reminder ourselves to pause, remembering that psychosocial and spiritual elements can carry just as much power as medications found in our hospice toolkits.

Note: This is a part 2: Psychosocial Support & Medications – Safety & Sleep