how much comfort is comfort?

rokidog · Sep 30, 2008 07:19 AM

I work agency usually in PCU/med-surg ( previous ICU experience as well) Last night I was asked to care for an at home hospice patient and I agreed, although I have never done it before. I have always like the ideals of hospice nursing , allowing people to die at home in comfort and dignity.

The patient was just starting "continuous nursing"- so at rare moments he was somewhat cognizant and orientedx2, . He wasn't quite close to dying ( at least not on my shift) but my discomfort comes from --- did I do enough to keep him comfortable? I hope so , but coming from a hospital perspective where I want to keep people pain free, but not entirely "snowed" (unless they are ventilated, of course, different idea) I am not so sure. I did give ativan and morphine as ordered, and he would alternate between sleeping/snoring for awhile then become slightly wakeful with moaning and shifting around a bit.

I felt kind of bad because the oncoming nurse had a lot of experience and immediately said he looked very uncomfortable. He was in the wakeful stage, moaning a bit and shifting a little. She showed me a "comfort box" which had suppositories of haldol/ ativan / ? and I helped her insert one before I left.

How do I know the patient is comfortable enough without me assisting in his death by over medicating so he stops breathing?
Any resources I can find for guidelines? Lawsuits from being overmedicated? Does it vary from family to family or does nearly every family want to see their loved one absolutely still, unresponsive and "peaceful" looking ?

Thanks for any help and my future patients/families thank you as well...
Tammy

*marachne* · Sep 30, 2008, 12:53 PM

Coming from your background, it is understandable that you'd be worried about over medication, but a couple of things:

1) Most current evidence does not support the concept that providing adequate levels of comfort truly hastens death -- at least not by any appreciable amount.

2) If someone has had a long disease course, they may well be at levels of analgesia/anxiolytics that would make the typical hospital-based nurse blanch. If he is on continuous nursing, it probably means either his symptoms are very difficult to control and/or he is actively dying -- it's not the time to be worrying about BPM

3) I've never heard of any suits for over medication for a hospice pt. but that's me personally. I doubt it though.

4) Every patient and family is different -- some want to be able to interact as long as possible, and put up with the symptoms -- some don't have symptoms that need a high level of sedation, and some people say "I don't care how alert I am, I just want to be out of pain."

5) One thing that can happen, and needs to be watched for is hyperalgesia -- the system becomes hyper excited and more (of the same) analgesic can make pain worse. Myoclonic jerks are a common sign of this. http://www.eperc.mcw.edu/fastFact/ff_57.htm can explain it better.

And in general, the Fast Facts, are a great resource http://www.eperc.mcw.edu/ff_index.htm

hope that helps

rokidog · Oct 01, 2008, 04:00 AM

It does help, thank you for the info. I am trying to read different articles in case I decide to try another shift. It really is rewarding in a way... And the people, patients and families seem so much more at peace that they have already made the hard decisions. I just would like to be as educated as I can be for the next time. ( it just goes to show how different specialities can be!!)

Tammy

*marachne* · Oct 01, 2008, 11:03 AM

If you use a PDA or Blackberry or other devise that allows you to download data, there is even a pda version of fast facts. They're really a great tool. I can't remember where I found mine, but this might get you there:

EPERC Fast Facts on your PDA
You will need to download the free Infigo reader, then scroll down to Download the Hospice information file, which contains "Information about hospice and other topics, including "Fast Facts" on over 100 issues in end of life care from EPERC".

Pocket PC users: You must install the reader in the default location. The data files (.pdb) can be placed on a storage card, and the location of those files set in the Settings section of the main program. bullet Pocket Guideline: End of Life Care for Hospitalized Adults (Palm OS only)

The site looks like it has a lot of great stuff: http://www.jasonprogram.org/tools.htm

RyanSofie · Oct 01, 2008, 01:47 PM

It seems he was experiencing terminal restlessness. Continuous care is for those who have symptoms that are out of control or difficult for family to manage. I hope you have another opportunity for a Hospice experience.His moaning was indicative of discomfort and comfort medications were needed.

*NurseAlwaysNForever* · Oct 02, 2008, 08:43 PM

For me, if I see symptoms of discomfort, restlessness, pain, anxiety, SOB, etc. I medicate as little as possible to reach the desired effect. Most meds are titrated according to need at my facility. Our comfort meds have ranges. 0.25-1 ml for example. We start with the lowest, and work our way up to what works. This tends to help with over sedation. In the last few days of a persons life, oversedation is not such a worry, but you don't want a pt so out of it that he can't communicate with his family. I have had pts that hurt so badly that they didn't care if they slept their last days or not. It all depends on the situation. Simply, if you see discomfort, treat it. It always works for me. When a pt can't tell you if they hurt, how they hurt, or where they hurt you almost have to look at them like you would a new born baby. Watch facial expressions, are they moving in the bed a lot, moaning, things like that.

I tend to ramble, sorry for that, but hope this was of some help. I hope you get more chances to do this. Just the fact that you were concerned enough about his comfort to seek answers leads me to believe that you may have a heart for hospice.

how much comfort is comfort?

how much comfort is comfort?

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