Comfort care measures. - page 2

by Forever Sunshine | 7,618 Views | 16 Comments

A few days ago an issue arose and I'm just wondering if I made the right the decision.. One of my residents is actively dying. He has a DNR/DNH and the family wishes for him to receive comfort care only. His son... Read More


  1. 2
    You didn't do anything wrong at all! Sometimes oxygen doesn't do much to relieve the air hunger in these situations but it's definitely a comfort measure and if the resident wasn't distressed by the cannula, why on earth not? Morphine often helps too.

    Sometimes the resident finds having something on their face irritating or uncomfortable or they get more restless or try to pull at the tubing - in those situations I'll often sit a mask near their face so they get a bit of blow by, like Esme said.

    We generally don't check O2 sats on people who are dying but rather treat any distress we see.

    Unless the cannula was distressing the resident, I'm finding it really hard to imagine why the son was opposed to the oxygen....... Did he believe you when you explained it was for comfort or did he still think it was keeping his father alive? I've had family ask me why oxygen is being given, but I've never been in your situation, thank heavens.
    JZ_RN and amoLucia like this.
  2. 1
    I don't think he believed me at all. He just kinda huffed and puffed it off and then I ducked out of the room.

    I kept the cannula very loose. It was not distressing the resident in any way. Only reason I checked his O2 sats was to have my ducks aligned.
    CompleteUnknown likes this.
  3. 0
    I've heard 2 arguments. One is that O2 is for the onlooker's comfort and not for the patient's comfort. I have also heard that O2 provides improved comfort for air hunger. I have worked with physicians from both backgrounds. Morphine can alleviate air hunger too and some patients may become restless or uncomfortable with the face-mask or nasal cannula. So really, as long as the patient appears comfortable, and the family is satisfied then I am as well.
  4. 0
    Responding late to this but no the resident did not have morphine. He appeared to be comfortable so we didn't get it ordered. The family agreed.

    Weeks later I can say this is no longer an issue but I'm glad I posted this. I honestly thought the family was going to take this matter further.
  5. 0
    First of all I want to say, nursing is not an easy profession and many times you have decisions to make that aren't very easy.

    My dad's experience - O2 just may prolong the dying process.

    From the family perspective...My dad had advanced directives - DNR/DNI, as well as wishing not to return to the hospital. My dad's health was declining over a 1-1/2 period of time that we really recognized. But anyway, he got to the point where he was so week that he had fallen a number of times. He finally went into the hospital, and three days later into a NH. Over the course of a month and one-half he went back into the hospital a couple times. After my mom shared the advanced directives with me it was clear that she need to talk further with my dad to find out how he felt about any more trips to the hospital. He didn't want any measures to keep him alive.

    He had very explicit directives, including not wanting to die in a hospital and not wanting to go into a NH. Although, my mom couldn't take care of him - he had to go to the NH. His directives explicity stated that if he had a terminal condition he didn't want any medical treatment that would prolong his dying, he didn't want to be in pain and wanted "medicine to control my pain even if that will hasten my death."

    During his 3 months at the NH he developed bed sores, eventually worsening to stage IV and I believe he developed sepsis although no one ever said. Anyway, during his last 2-3 weeks of life he was put on 02 via nasal cannula. He was placed on hospice at the NH 12 days before he died. He was constantly removing his oxygen and we as well as the staff were encouraging him and assisting to put it back on. I began to research whether of not the O2 would prolong his life (my gut told me it was) and found websites stating it may actually prolong the dying process. So, when the doctor came for his regular visit (5 days before my dad died), and after inspecting the wounds and making recommendations, my mom asked him about the oxygen. Of course he said it was keeping him comfortable, that without it my dad "may experience heart pain." My dad had atrial fibrillation and congestive heart failure with an EF between 50-60% and an occasional PVC.

    Fast forward 5 days to my dads regularly scheduled care conference. Nursing home staff, hospice staff, as well as my mom, brother and myself were there. (Dad was basically in a coma at that time and had been for 2-1/2 days) We asked, "Is the oxygen prolonging the dying process." The answer was no, "It's keeping him comfortable." (I was trying to think of what to say next because I really felt that the oxygen was indeed prolonging his life). While I was thinking one of the hospice nurses said, "Well, he was always trying to take it off." So, we decided that the oxygen would be removed, and stay off, even if dad started having respiratory distress, the oxygen would not go back on. The oxygen would come off, so nature could take its course and leave it all up to God.

    My dad died peacefully within about 15 minutes of the oxygen being removed. No death rattle, no gurgling (although he had done a little of that earlier in the week when he had it off), just slipped peacefully away. We were prepared to listen to that, as well as the fish out of water type breathing (the hospice booklet outlined that and I experienced it with another individual that I sat with when she took her last breath), skin color changes and all of that. I still find myself wondering if all of that removing of the oxygen was another way of him telling us he was ready to pass from this earthly world. Will never know. Although, he obviously didn't want it and we didn't honor his wishes.

    Anyway, I just wanted to stop by to give my (our family) experience. Please look at the whole picture and try to view all sides. It wasn't easy seeing my dad get sicker and his wounds deeper and larger or even realize that he wouldn't be with us forever. But, we also wanted to honor his wishes and didn't want him to have to hang around longer than he needed either.
    Last edit by theothersideoffence on Mar 28, '13
  6. 0
    People die at home on hospice every day with no O2 in the home.If a patient is actively dying give them morphine for comfort,educate the family regarding the signs and sx of impending death,support the family and the pt.I think I would have removed the o2 and observed for signs of distress (not by pulse ox) but actual signs of discomfort and then reacted accordingly and obtained morphine.I don't believe that 2L of O2 is going to prolong death.I have not started O2 for the past several deaths I have been involved with but we started fentanyl patches early on,scopalamine and S/L morphine with scheduled doses and PRN and everyone was very comfortable.I believe the most important aspect of our job is providing a comfortable and dignified death to our residents but equally as important is the support we give the family.
  7. 0
    Quote from theothersideoffence
    First of all I want to say, nursing is not an easy profession and many times you have decisions to make that aren't very easy.

    My dad's experience - O2 just may prolong the dying process.

    From the family perspective...My dad had advanced directives - DNR/DNI, as well as wishing not to return to the hospital. My dad's health was declining over a 1-1/2 period of time that we really recognized. But anyway, he got to the point where he was so week that he had fallen a number of times. He finally went into the hospital, and three days later into a NH. Over the course of a month and one-half he went back into the hospital a couple times. After my mom shared the advanced directives with me it was clear that she need to talk further with my dad to find out how he felt about any more trips to the hospital. He didn't want any measures to keep him alive.

    He had very explicit directives, including not wanting to die in a hospital and not wanting to go into a NH. Although, my mom couldn't take care of him - he had to go to the NH. His directives explicity stated that if he had a terminal condition he didn't want any medical treatment that would prolong his dying, he didn't want to be in pain and wanted "medicine to control my pain even if that will hasten my death."

    During his 3 months at the NH he developed bed sores, eventually worsening to stage IV and I believe he developed sepsis although no one ever said. Anyway, during his last 2-3 weeks of life he was put on 02 via nasal cannula. He was placed on hospice at the NH 12 days before he died. He was constantly removing his oxygen and we as well as the staff were encouraging him and assisting to put it back on. I began to research whether of not the O2 would prolong his life (my gut told me it was) and found websites stating it may actually prolong the dying process. So, when the doctor came for his regular visit (5 days before my dad died), and after inspecting the wounds and making recommendations, my mom asked him about the oxygen. Of course he said it was keeping him comfortable, that without it my dad "may experience heart pain." My dad had atrial fibrillation and congestive heart failure with an EF between 50-60% and an occasional PVC.

    Fast forward 5 days to my dads regularly scheduled care conference. Nursing home staff, hospice staff, as well as my mom, brother and myself were there. (Dad was basically in a coma at that time and had been for 2-1/2 days) We asked, "Is the oxygen prolonging the dying process." The answer was no, "It's keeping him comfortable." (I was trying to think of what to say next because I really felt that the oxygen was indeed prolonging his life). While I was thinking one of the hospice nurses said, "Well, he was always trying to take it off." So, we decided that the oxygen would be removed, and stay off, even if dad started having respiratory distress, the oxygen would not go back on. The oxygen would come off, so nature could take its course and leave it all up to God.

    My dad died peacefully within about 15 minutes of the oxygen being removed. No death rattle, no gurgling (although he had done a little of that earlier in the week when he had it off), just slipped peacefully away. We were prepared to listen to that, as well as the fish out of water type breathing (the hospice booklet outlined that and I experienced it with another individual that I sat with when she took her last breath), skin color changes and all of that. I still find myself wondering if all of that removing of the oxygen was another way of him telling us he was ready to pass from this earthly world. Will never know. Although, he obviously didn't want it and we didn't honor his wishes.

    Anyway, I just wanted to stop by to give my (our family) experience. Please look at the whole picture and try to view all sides. It wasn't easy seeing my dad get sicker and his wounds deeper and larger or even realize that he wouldn't be with us forever. But, we also wanted to honor his wishes and didn't want him to have to hang around longer than he needed either.
    Thank you so much for sharing this experience with us.


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