watching my pt. die

  1. i am struggling and even starting to lose sleep over the following. a couple of weeks ago, one of my pts. had a cva and lost her ability to swallow. she was receiving ivf until her niece decided to opt for a fdg. tube or comfort measures. even though this pt. has minimal dementia, she herself had always been making her own decisions. whenever we asked her if she wanted a fdg. tube, it was an impassioned "NO". ivf's have been dc'd. she sits there, eyes open, so alert, just waiting to die. most times she has her hand over her face. there's a prn order for mso4; her vs are stable including respirations. she's afebrile amazingly, as her face is looking skeletal and dehydration has not set in yet. i've consulted with her doctor about a possible ativan order or something, something to make her sleep. the doc states that there is no physical distress, as i do agree. i'm concerned about any mental/emotional distress; i don't know what she's thinking, just sitting there all day and noc, eyes open, non-verbal. but i did tell the doctor that we should assume the worst and give her something for her emotional pain. i've thought about giving her mso4 as often as possible but decided against it because it's probably unethical, as this would be a form of conscious sedation, would it not? my stomach just goes in knots every time i look at her. i am accustomed to helping pts. die, as this is my specialty at an inpt. hospice. but for the 1st time, i feel so very helpless. any input would be most appreciated.
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  2. 21 Comments

  3. by   Dinith88
    Screw the ativan. Give her the morphine. Make her comfortable.
    I'd personally keep her snowed and pain-free...but thats just me.
    Even if this lady isn't experiencing any physical pain, i'd give her the MS.
    Shoot, the ladies in hospice...you're worrying about her being sedated?
  4. by   LesJenRN
    Difficult one isnt it. If there is evidence that you can document suggesting pain than you are justified giving pain medicine, right? Unfortunately these days you have to be sure not to cross any lines that could get you in deep do do legally. If I was in her position, hell yes I'd want MS or something, The other thing that we have to be careful of is that it is not our own discomfort we are treating.... Is the niece realistic? Does she need more help understanding end of life issues? What are her feelings as far as pain/anxiety medications?
    I am sure I didnt help.....I am just thinking it through in my own head. I guess I would be looking for signs of pain or anxiety. Increased heart rate, anything....
  5. by   leslie :-D
    Quote from Dinith88
    Screw the ativan. Give her the morphine. Make her comfortable.
    I'd personally keep her snowed and pain-free...but thats just me.
    Even if this lady isn't experiencing any physical pain, i'd give her the MS.
    Shoot, the ladies in hospice...you're worrying about her being sedated?
    no, i WANT her sedated and that's why i tried to get an ativan order. if other nurses are documenting that her vs are stable and aren't giving the ms, then i don't know how to justify me (the only nurse) giving it to her. i'd love to keep her snowed, trust me.
  6. by   leslie :-D
    Quote from LesJenRN
    Difficult one isnt it. If there is evidence that you can document suggesting pain than you are justified giving pain medicine, right? Unfortunately these days you have to be sure not to cross any lines that could get you in deep do do legally. If I was in her position, hell yes I'd want MS or something, The other thing that we have to be careful of is that it is not our own discomfort we are treating.... Is the niece realistic? Does she need more help understanding end of life issues? What are her feelings as far as pain/anxiety medications?
    I am sure I didnt help.....I am just thinking it through in my own head. I guess I would be looking for signs of pain or anxiety. Increased heart rate, anything....
    excellent point about ascertaining that we are not treating our own discomfort. as a hospice nurse, you need to (1) make peace w/yourself re: end of life issues then (2) that we treat every facet of pain, whether it is physical, emotional or spiritual. the niece has not been involved in the pts' life and is very squeamish about making any decisions since her aunt has always made them for herself. i really just want to see this lady close her eyes and be at peace.
  7. by   Tweety
    That is a difficult point, not all people can handle that. I agree that lots of sedation/morphine or whatever is in order.

    Sounds like a case I was involved in once, a co-worker couldn't take care of her stating she could not participate in the starvation of a patient.

    Best wishes.
  8. by   leslie :-D
    Quote from 3rdShiftGuy
    That is a difficult point, not all people can handle that. I agree that lots of sedation/morphine or whatever is in order.

    Sounds like a case I was involved in once, a co-worker couldn't take care of her stating she could not participate in the starvation of a patient.

    Best wishes.
    God, this is pathetic. it's 5:03 a.m. and i'm due back in work at 7a-scheduled for a double today. i worked 3-11 last night....see what i mean about losing sleep? anyway tweety, i'm not sure if i'm having problems about the 'starvation' aspect of it. God knows, most (like 99%) of my pts. go in a totally starved state; and fyi, dehydration/starvation is not painful. your body releases endorphins in response to its' decompensated status. what i think i'm having problems with is my pt. just sitting there so alert. i'm hoping that since she's been w/o fluids for a few days now, that lethargy, fever and all the rest will start setting in. after that, all the compensatory mechanisms will start taking over, i.e., the increased respirations, which will in good conscience, allow me to give her the mso4. i just cannot ethically or legally snow this lady w/o any indications or rationale for my actions. do you see my dilemma? please, keep the responses/feedback coming and i'll touch base w/everybody either at midnight tonight or on thursday. peace to all of you.
  9. by   emmy
    Hi
    I'm only a student nurse so I am in no position to give advice, I just wanted to say that my thoughts are with you through this trying time.
  10. by   Agnus
    It sounds like no one is helping THE Daughter. This is the source of the problem. Is it not? The daughter I mean.

    If you are a hospice nures as you state then why is the daughter not given the help, education, and support needed to make this discision?

    You are assuming that she is suffering in some way because she is awake. Awake does not = cognition. You assume. Do you really dare do this?

    You "want her snowed" but can't justify it. This should be telling you something.

    You are clearly in emoational distress. Perhaps you need to excuse yourself from this case until you can resolve your own issues. Otherwise start focusing on the daughter's needs and concerns and help her with the decision.
    Last edit by Agnus on Mar 17, '04
  11. by   Hellllllo Nurse
    Shouldn't social services be involved w/ the daughter?

    Since the pt has indicated that she didn't want the feeding tube, can you ask her if she's feeling anxious/fearful/sad, etc?
    If so, ask her if she'd like some medication to help her relax.
    Document her answer and take it to her doc.

    Also, use supportive, therapeutic communication to help her feel understood and validated, and to provide emotional support.

    I prefer valium for pts who are not having behavior or agitation problems.

    I don't think a pt without heavy pain and sx mgmt issues needs to be snowed.
    Last edit by Hellllllo Nurse on Mar 17, '04
  12. by   P_RN
    My DH's mother is in exactly these same circumstances. She became aphasic March of 2000. She is still lying there, tf through gastrostomy, day in day out....four years now. She too holds her hand over her face often.
    She also said no, but her dd had HCPOA and agreed to the tf. but no meds except her routines.
    It just breaks my heart that it is this way.
  13. by   Hellllllo Nurse
    I feel for you P_RN. I've taken care of many pts like this.
    My heart breaks for them with yours.
  14. by   LauraF, RN
    Has anyone tried an augmentitive type of communication with this poor patient. If she is able to put her hand over her mouth, then she should be able to point to a board that says yes and no. Or blinking as communication. The first and foremost is to try and come up with a way for this person who is alert to communicate. How about 1 finger for yes and 2 fingers for no. I had a patient who was alert and suffered from a CVA. She had copious amounts of saliva and mucous that would sit there all day with a tissue under her chin. She received g-tube feedings and would cry when she received them. The last time she had a major problem that required hospitalization, she finally spoke up and said NO more! And we assisted her family to allow her to go peacefully and with as much dignity as possible.

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