Requesting assistance with End of life care

[DatMurse]

So I havent had an active dying patient until yesterday. I knew turning caused him pain, I also know that oral care caused him discomfort, I never charted a full assessment due to the fact I wanted him to rest and touching him in certain areas cause him pain. I am well aware that people say "turn for comfort", but if it causes him pain. Is it still necessary? I am always kind of lost with this. Is charting ecchymotic skin necessary?

I know people throw around "end of life protocol", but I never ever see any paper that actually says protocol.

People use the "protocol" word for everything, but there is no paper or policies/procedures anywhere -_-

[duskyjewel]

Can you premedicate for pain before turning? That's what the nurses I work with do. (I'm a hospice CNA.)

[DatMurse]

Can you premedicate for pain before turning? That's what the nurses I work with do. (I'm a hospice CNA.)

I can premedicate him, but I guess it is ok to cause slight pain to turn him?

I guess I need to start re-evaluating how I was treating the patient. I need to remember that any pain meds wont accelerate the death along with to utilize everything that I have including ativan, etc.

[DatMurse]

Can you premedicate for pain before turning? That's what the nurses I work with do. (I'm a hospice CNA.)

ty btw

[ktwlpn, LPN]

We pre-medicate and in the last days we will minimize re-positioning if it clearly continues to cause discomfort and the family understands the risks and is on board. Just small and subtle changes in position can be all that is necessary.

[amoLucia]

Just small and subtle changes in position can be all that is necessary.

Sometimes I considered that just pulling out a prop/positioning pillow could be thought of as a change of position as it can change the points of pressure significantly.

I figured not a lot of movement for a change of pressure points. A lot of pain? I hoped not.

[toomuchbaloney]

The problem in the OP is not the repositioning but the fact that the patient is experiencing pain with ADLs. In the hospice world that reflects a poorly functional POC. Symptom management is the core of hospice medication plans.

There are two possibilities;

1) the medication POC relative to pain is ineffective and needs to be adjusted ASAP, or

2) the nurse is not implementing the medication POC as available to optimize comfort and quality of life.

If you are not premedicating a painful patient before ADLs then this falls into the second category.

Position changes at end of life are often subtle and are designed to maintain comfort while changing pressure points.

[duskyjewel]

So, DatMurse, how is it/did it end up going?

[DatMurse]

So, DatMurse, how is it/did it end up going?

I didn't have him the next day. HOWEVER I did have another Code 3 that was an unresponsive stroke patient who had all nutritional withheld. He had reflexes and reactions, but could not talk. It actually blew my mind. I feel that the family wanted to sedate him with morphine to relieve any discomfort from the nutritional withdrawal.

They wanted us to limit moving due to decrease stimuli. I do plan on pre-medicating to turn unless I get a full refusal.

[Veronica Cheney]

The palliative care MD that basically taught me everything I know about end-of-life care would tell me that if the patient was experiencing any symptoms of pain while the staff performed care to call to increase the pain medication dose itself.

Sure we cannot and probably wont eliminate all pain but reducing it significantly is key. We also stopped doing the Q2 hour turn and usually the MD would order us to reduce the full turns to Q6 and then Q12 hours. However, in between those times, movement of a pillow here and there does count as repositioning.

[ktwlpn, LPN]

The problem in the OP is not the repositioning but the fact that the patient is experiencing pain with ADLs. In the hospice world that reflects a poorly functional POC. Symptom management is the core of hospice medication plans.

There are two possibilities;

1) the medication POC relative to pain is ineffective and needs to be adjusted ASAP, or

2) the nurse is not implementing the medication POC as available to optimize comfort and quality of life.

If you are not premedicating a painful patient before ADLs then this falls into the second category.

Position changes at end of life are often subtle and are designed to maintain comfort while changing pressure points.

Isn't it appropriate in an actively dying end of life patient to curtail those ADL's? That's my experience, I have had more then one family member ask us to stop turning, mouth care ,etc in the last hours.