my patient started going down hill yesterday. labored breathing, unresponsive to verbal and tactile stimuli, etc.... patient on nrb mask. she has g-tube and used to be on continuous feeding but patient did well on swallowing test and the diet was advanced to chopped diet and the tube feeding was dc'd 2 months ago. patient was dnr/dni/dnh. i came to my shift today and counted rr 40/min.
i called md and requested roxanol order because patient is actively dying. family came to unit and remained with patient. patient stopped eating since yesterday and son asked me about giving tube feeding via g-tube. son was concerned about blood sugar since patient has dm. i told him i will ask the md.
so i called the md and asked about giving tube feeding. he started screaming at me on the phone and said who gave the family an idea about tube feeding and said there was no point of giving tube feeding and that patient is dying already and that he already ordered roxanol for comfort. he asked me if i told the patient's family the risk of giving tube feeding at this stage of the dying process. he said patient would be at risk for aspiration now. i told him i didn't explain the risk to the patient. i raised my voice because i got tired of him screaming at me and told him "you do not have to give me the order for the tube feeding if you don't want to. i am just relaying the family's concern to you." i also told him i told the supervisor (who is also the adon, working ot today) about tube feeding and supervisor agreed about giving tube feeding and told me to just elevate hob during feeding. md said he would only give the order after i call the family and explain to them the risk of starting the tube feeding now and if they agreed, write t.o. as "poa request".
i called family and they agreed not to start the tube feeding. so i did not write order for the tube feeding. so i gave two doses of roxanol during my shift. i went to her room at 10:30pm and just stayed with her until she passed at 11pm.
i do not have much experience with hospice or the dying process and feels like a dummy that i did not know the risk of starting/giving tube feeding at this stage of the dying process. i thought i could just follow the protocol about checking residual every few hours and elevate hob 45 degrees. that is why i consulted with my supervisor and she agreed about giving tube feeding.
wouldn't these patients be in pain or discomfort due to starvation? did i deserve to be yelled at?
You did not deserve to be yelled at, no one does. In the future know that in the actively dying pt their systems including the gastric system is slowing down and stopping. This is one of the reasons that they stop eating. By putting down a feeding tube and starting feeding at this point you would be causing discomfort with the insertion. The tube feed itself could cause discomfort and possible pain, as it more than likely will just stay and expand the stomach and not be digested. As muscles are not working optimally during this time there is also an increased risk of aspiration from the tube feed in the stomach when you have to lay the pt flat in order to wash and change the linen. Part of our comfort care protocol is stopping tube feeding and the removal of feeding tubes.
With that said a lot of families want things done for their family members that are actively dying which will not help the pt but will help the family members feel better. You did nothing wrong with relaying the concerns and ideas of the family members to the doc. Doctors want it both ways, we are not to give out medical advice (what medical orders are needed for a pt) to family members/pt's unless it is convenient for them.
just posted and saw that they had a GT.
Last edit by ukstudent on Aug 8, '11
: Reason: added