End of life questions

[nursemike, ASN, RN]

Just lately, I've had an odd run of "comfort care" patients (end-of-life, palliative care) and I've run into a couple of issues that concern me. In particular, a dying patient's family told me that their doctor had urged them to have the trach removed because it was only prolonging the dying process. This patient was already off O2, but breathing steadily on room air through his tracheostomy. I thought perhaps the family had misunderstood, but later, as the doctor was pronouncing him, he mentioned to me that it was only the trach that had kept him going so long (at least 8 days).

Is it regular and customary to remove a dying patient's artificial airway? To me, it seems a bit like saying only my nostrils have kept me going this long. If I were terminal, putting a pillow over my face would not be medically ethical.

My other concern is that this patient was more severely dehydrated than I would have thought possible. His eyes were sunken about 2cm ib their sockets. By the time I got him, it was probably too late to matter, but I wonder if he should have been on maintenance fluids, despite his DNR status.

I'm opposed to euthanasia on moral grounds, but I have no objection to measures to improve pt comfort, even when they may hasten death. Some of the aides I work with believe turning a dying patient will cause them to die sooner, but I think if I were in that position, I would rather go a few hours sooner in a clean bed. I have been instructed in school and in CEU's that we shouldn't be afraid to give adequate pain relief to dying patients.

I feel pretty comfortable with all that. But it seems to me, also, that a patent airway and adequate hydration would also contribute to patient comfort, even though they might also tend to delay death.

I'd certainly appreciate any feedback on these concerns.

[kranken_schwester]

I've heard that dehydration induces a kind of euphoria in dying patients and that it can be preferable to administering fluids.

[JBirdAngel]

I am not a nurse, and i cant say that i agree with being comfortable but dying sooner is better, than not being comfortable and living longer, someone can think that smoking makes them comfortable, and they will die sooner, this is ane example where this would not be correct to do.

I think that the patient should be taken care of fully, so I agree that if he can breath with the tube leave it in, if he needs fluids, give him fluids!

Someone dying isnt a reason to stop caring, i agree with the analogy to nostrils keeping someone alive, if you cant breath out your mouth that doesnt mean you plug your nose too, to do so would be wrong and would be to kill yourself.

and a monetary value should never compare to life, yes the person should be helped as much as possible.

He that receiveth a prophet in the name of a prophet shall receive a prophet's reward; and he that receiveth a righteous man in the name of a righteous man shall receive a righteous man's reward. And whosoever shall give to drink unto one of these little ones a cup of cold water only in the name of a disciple, verily I say unto you, he shall in no wise lose his reward.

(Mat 10:41-42 KJVR)

For whosoever shall give you a cup of water to drink in my name, because ye belong to Christ, verily I say unto you, he shall not lose his reward. And whosoever shall offend one of these little ones that believe in me, it is better for him that a millstone were hanged about his neck, and he were cast into the sea.

(Mar 9:41-42 KJVR)

- jason

[puresass]

i'm not a nurse yet (so take this with a grain of salt), but i volunteer for hospice & they told us that giving a dying patient food & fluids can actually cause MORE pain since their organs are shutting down & aren't able to process anything. it may seem counter-intuitive & cruel, but actually you're helping to keep the patient from unnecessary pain.

[TazziRN, RN]

As for the trach, no it wasn't keeping him alive if he wasn't on the vent. Your analogy is correct.

[nursemike, ASN, RN]

I am not a nurse, and i cant say that i agree with being comfortable but dying sooner is better, than not being comfortable and living longer, someone can think that smoking makes them comfortable, and they will die sooner, this is ane example where this would not be correct to do.

- jason

It's a bit more complicated than that, from a nursing perspective. Particularly, opiates to relieve pain may tend to suppress respiration, but it's still desireable to relieve the pain. Actually, it's usually possible to balance these effects, since sedation occurs before respiratory suppression. But, at the end, respiratory suppression can relieve respiratory distress and the anxiety that accompanies it, so you give the patient enough pain meds to be comfortable, even if they don't live quite as long.

But, to go with the smoking analogy a moment, would you forbid someone to smoke who was dying of malignant melanoma? Or, for that matter, lung cancer? As healthcare workers, most of our energy is geared toward preserving life, but priorities change when death is imminent. When we speak of interventions that may shorten life, we're talking hours, or even minutes. It's true in a sense that all of us are moving toward death, and some of us do things that aren't good for us, but the situation is different for someone in the actual dying process. "No pain, no gain" may make sense for someone with years ahead of them, but it seems needlessly cruel with minutes left.

In my recent experiences, the matter has been complicated in that my patients have been unable to speak for themselves, so I have to use my nursing judgement to determine whether they are comfortable. My problem is that I'm not entirely confident of that judgement, yet. So I'm more concerned, here, with the relative comfort of the actively dying patient.

Just to clarify, I have no doubt at all about the doctor in question caring. I don't know whether he was the one who suggested removing the trach or simply agreed with the one who did, but I've worked with these guys enough to trust their motives. For that matter I have lots of confidence in their judgement--but that doesn't relieve me from using my judgement.

[Antikigirl, ASN, RN]

I have seen so much of these types of situations, and I am not a hospice nurse! When it comes to end of life, it differs in each individual...and very differently in the family or friends that are involved!

The sence of touch is powerful, and I feel that turning a patient or light massages in the arms and legs from a loved one is comforting to the dying pt, and should be done if not contraindicated. Talking as well...does it matter if they hear you...not really, voice does have a vibration and can be felt as well if they can't hear you...and it helps the living to talk and help the healing process of death.

Hydration...wow, I so use to think I would want all my pts and myself to be hydrated. I changed my mind quickly when I saw that pts can continue longer in their suffering just because they are hydrated! We are talking days to even weeks! I didn't know how powerful hydration was in death...it prolongs suffering more than it comforts in most cases, and I typically vote not to have hydration...but for the mouth, toothettes moistened and swab the mouth as well as lip balm and lotion for the skin.

Artificial airways...that gets a bit more vague. Depends on the wishes of the patient. Sometimes artifical airways cause inablity to control secretions and the need for frequent suction. Deeper suction is very uncomfortable, and is typically a no no in dying pts because it is so traumatic. Simple cheek suction may be necessary to get out secretions just from the mouth, but still uncomfortable so is typically voted out. An art. airway also causes inflamation and additional secretions as well just by its presence...so again...the catch 22...suction or not? AND, it also has to do with a patients idea on artifical life support...an artificial airway is artifical life support even if only supportive for airway. (remember, artifical is something not of self helping you to stay alive...and well, a cleared airway from a plastic tube is certainly not naturally present in humans).

I still tend to give O2 though for comfort, apnea is not comfortable and leads to restlessness and increased pain. Just a low O2 via a nasal cannula (even if you have to place it near the mouth) is helpful but will not prolong life or suffering. Just enough O's to stop severe hypoxia and the anxiety that creates.

And pain meds! This one gets wierd fast with lots of families! Some want lots, some want none, and way to many people and medics are afraid of causing death by them. If you know your meds well...this isn't a probelm and you can tread that fine line between comfort and oversedation. Typically it is a lack of education that causes the tensions on this subject, and I will tell you how much hospice helps with this and other areas of end of life!

I just lost my grandma Dec 22, and my mother and her sister were there...massaged her, sang to her, talked to her, put her in comfortable clothes, turned her, did her hair and nails so she would look good (grandma always had to look good...LOL!)...and told her it was okay to go to heaven and that they would be okay. Once she passed they cleaned her body as a last goodbye and loving jesture...all the while she had been comforted with the help of roxinal and ativan and a little O2. My mom and aunt thanked me for suggesting all these things and it made her passing so much better, and closure so much more fulfilling! I had educated them about roxinal and ativan and all the other things..and well, once they knew...it made things so much better for all!

[JBirdAngel]

I am replying because you seemed to specifically ask me a question, but i dont know that i really have anything more to say then i have, for me I am a Christian and I want to do the Lord's will, i feel what i say is true, but I've never been faced with this issue and I dont feel i can for certain say what exactly is the right thing to do, if faced with the issue I would do my best to listen to what Jesus wants me to do, but since i havnt been faced with this issue i can't say that He has given me special insight into exactly the right thing to do, i can just say what i did as my general observation, but i can't say for certain that i am certainly right not having special insight on the issue. To me this is similiar to some Bible verses and topics, on some things He has given me a better understanding of some verses, there are others that I cant say I have been given insight so I cant know what is meant by them at this time.

I am also not a nurse so i dont know if the smoking question plays into that differently for a nurse, but i dont think i can or am supposed to force people to do anything, i dont think smoking is right or healthy, but i cant and dont think i should force that on people, i could gently explain to them the harm of it, but i dont think it is for me to do more than that.

also i dont know if my examples are always correct or appropriate, while the example of the smoker is true, i dont really know if that properly relates to this issue, again i dont know much about this actual issue, i know that for some things pain can make things better, like a surgery can cause pain that in the end will help and cause less pain, what i know about this issue is that we are to love others and that money doesnt matter. But, as ive said, i dont know exacts on this.

- jason

[nursemike, ASN, RN]

Thanks, guys. I have to say, I have been thoroughly disabused that these patients are in any way easier to care for. At first, an evil little voice would say I was getting this patient because it didn't matter if I killed them. (I'd have hoped I would have run out of ways to undermine my own confidence, by now, but apparently not.) Now I tell myself that a.) it's just the luck of the draw and b.) I do seem to do pretty well with the families. I guess that was a big part of my concern r/t hydration--he looked so bad, it had to be tougher on his loved ones, but if it's better for him, that can be explained. The point about organ failure would be a useful one, there.

I suspect these are some more of those "character-building" experiences that will make me a better nurse, over time. Lord, but I could learn to dread building character!

[nursemike, ASN, RN]

I am replying because you seemed to specifically ask me a question, but i dont know that i really have anything more to say then i have, for me I am a Christian and I want to do the Lord's will, i feel what i say is true, but I've never been faced with this issue and I dont feel i can for certain say what exactly is the right thing to do, if faced with the issue I would do my best to listen to what Jesus wants me to do, but since i havnt been faced with this issue i can't say that He has given me special insight into exactly the right thing to do, i can just say what i did as my general observation, but i can't say for certain that i am certainly right not having special insight on the issue. To me this is similiar to some Bible verses and topics, on some things He has given me a better understanding of some verses, there are others that I cant say I have been given insight so I cant know what is meant by them at this time.

I am also not a nurse so i dont know if the smoking question plays into that differently for a nurse, but i dont think i can or am supposed to force people to do anything, i dont think smoking is right or healthy, but i cant and dont think i should force that on people, i could gently explain to them the harm of it, but i dont think it is for me to do more than that.

also i dont know if my examples are always correct or appropriate, while the example of the smoker is true, i dont really know if that properly relates to this issue, again i dont know much about this actual issue, i know that for some things pain can make things better, like a surgery can cause pain that in the end will help and cause less pain, what i know about this issue is that we are to love others and that money doesnt matter. But, as ive said, i dont know exacts on this.

- jason

No criticism intended, and you're certainly welcome to learn with me. If I had all the answers, I'd have fewer questions.

[JBirdAngel]

I didnt take anything as criticism, i was just trying to answer your question and further explain what i said. thanks for welcoming me to learning with you :)

[leslie :-D]

hi mike,

the trach question really depends of what the pt wants, or it should.

i've seen trachs removed and i've seen them kept in.

we (the hospice nurses i've worked with) try and avoid suctioning as it is an invasive intervention.

scopalamine is used often and has many rtes of administration.

as for hydrating an actively dying person.

it really should be contraindicated.

if you could see what hydration does to a dying pt, everyone would think twice.

since there circulation is shutting down, their lungs fill up, and their entire bodys just get soft tissue swelling as well as dependent edema.

the body does indeed release endorphins in a semi-starved and dehydrated state.

i imagine your pt was well medicated also.

i'm sure he wasn't aware of how awful he looks. (:) )

if you ever want to pm me, i'd be glad to share with you, what is normal in the dying process.

you sound like a wonderful, wonderful nurse.

leslie