Death With Dignity?

JillR · Jun 26, 2000

This is a great topic. I may be getting off the topic here but what do you think about the terminally ill patient who is not recieving adequate pain control because the doc thinks the morphine (or whatever) may depress the patients respirations?

I am not talking about the patient who may die six months from now, but the patients who are actively dying, in days, maybe hours.

I see this often in the facility I work at and its driving me crazy.

Now I don't think that we should give a patient something to assist them in their deaths in order to make the inevitable come faster. But I do believe that we have a responsibility to make sure that the patient is as comfortable as possible during the dying process.

I get very frustrated when I see docs giving out pain meds like candy to the drug seekers. But refuse to medicate the patients who really need it. It seems that the patients that get the meds are the ones who can stick up for themselves and the ones who cant suffer in silence.

What ever happened to doing no harm? It seems to me that witholding pain meds from terminally ill patients is causing harm, if this person is forced to die in terrible pain. I feel that these actions prevent the patients from dying with dignity. What do the rest of you think? Am I way off base here?

Anyway, thanks for letting me vent.

JillR

bunky, BSN, RN · Jun 27, 2000

I am working on a hard one right now and it makes me sick. On top of all his other problems they've just discovered via and EGD a large duodenal mass. I am going to be quite interested to see what the plan is from here.

leslie :-D · Jul 1, 2000

Bunky,

I totally agree with you. It is so invasive and many times, arrogant on the part of the MD's whose egos will not let their pts. die, nevermind with dignity. Personally, when I administer a narcotic, I don't acknowledge the repercussions of causing their last breath. As long as the parameters are followed, i.e., hold for rr

snickers · Jul 1, 2000

Do you think that one reason certain physicians insist on aggressive treatment, for people who are terminally ill with invasive procedures etc. is that they themselves have not come to terms with their own mortality?

Do you think that the public in general want everything done because illness and death have been hidden away in institutions...for about the past 5 decades.....therefore people are unfamiliar with the process, (other than what they watch on E.R.)

Used to be people were taken care of in the homes, and they died in the home. Children became familiar with illness of some form or another, and with death of grandparents, aunts and uncles etc. so death was a normal natural thing that happened, generally, nature took its course with no heroics.

It has now become something foreign and unnatural to die for goodness sake!!!

Sometimes I wonder how many people even contemplate their deaths...many are unwilling to even discuss it.(maybe if I don't talk about it, it'll never happen to me!)

Had a 94 year old patient, full of cancer, a "fullcode", who told me he wanted "to live forever!!

Go figure!

sj.

bunky, BSN, RN · Jul 1, 2000

Earle, I saw a good show on TV about morphine the other night, and learned something interesting about that. A doctor who specialized in paliative care said that people build a tolerence to it so quickly that on the first dose it may decrease RR but that on the second dose it usually doesn't and he was saying that physicians who are opposed to physician assisted suicide avoid prescribing Morphine because they don't realize this fact, and so their patients suffer more. This other palliative care neurologist said that you can easily tell a physician assisted suicide from a doctor who is trying to provide adequate pain control because of the dose, and this is the part that shicked me! Pain control dose can be up to 100mg! But suicide dosage would be like 1000mg! Gee, I think I'd question THAT order of 100mg even! Damn!

And Sncikers, I agree with you on the issue of mortality and coming to terms with it, but if anything you'd think that a doctor would know better. The worst scenario though is when the patient themselves can't talk and so you are reliant upon family and MD. In a small town place where I worked, I used to be able to speak a lot more openly and bluntly to the MD's, (they were a lot friendlier!) and sometimes I was able to convince them NOT to do things, or at least have them approach the family and tell them the entire story and see what they say. Sometimes this led to a new outlook for all of them.

The worst case of this never say never that I ever saw, was on a very frail little lady who had severe CAD, and the poor thing coded 3 times in 2 days, and still the family begged them to save her. Finally on the third code the doctor and the nurses were the begging the family to please allow her to go. All of her ribs were broken, and mentally she had been gone since the first code. It was heart breaking!

leslie :-D · Jul 1, 2000

bunky,

100 mg. of morphine does sound shocking BUT I recently cared for an end-stage ca pt. who was on 100 mcg. of duragesic (go figure that conversion factor into morphine); 80 mg. of oxycontin bid and 40 mg. of percocet q2h prn for breakthrough pain. He was a very challenging pt. in terms of pain control because in spite of the scheduled meds he was getting, he still scaled his pain a 6-7. I am told your body will take what it needs, no matter what the amount. Anyway, once he came to terms with all the 'mistakes' he had made, and actually reunited with some of his children, he died very peacefully... which leads me to remind us as nurses, we need to monitor for emotional and spiritual pain/distress and that pain takes all forms. Just a little 1:1 with your pt. and making them feel loved and deserving is sometimes worth more than all the pain medication in the world. Feeling emotionally at peace is just as vital to dying with dignity.

LaurieCRNP2002, MSN, RN, APRN · Jul 2, 2000

Hello

I recently started a new job doing home hospice and found this topic very interesting. First, I have done a lot of reading and there seems to a consensus that physicians are not educated properly or fully on end of life care. Another problem that I have heard my new colleagues mention is the problem of referring patients to a hospice service when they are actively dying. Although my agency is primarily a home hospice agency, we do provide care for hospital inpatients at times. Several of the intake nurses have mentioned the problem of admitting a patient to hospice only to have them die 6, 8, 12 or even 24 hours later. Our hospice team is interdisciplinary in nature and when we get patients that die shortly after being admitted to the service, it hampers the team's ability to provide effective care and support for the patient and the family.

So my feeling is that there needs to be more education on the concept of hospice and what a hospice agency can do for a patient in their last months of life. I would venture to say that most nurses DO NOT want to see any patient they are caring for die in pain or be uncomfortable in any way during the last hours of life. The reasons for pursuing aggressive care inappropriately are many---physician arrogance, unwillingness to admit they can't help a patient, denial on the part of the patient and/or family...the list goes on and on. With all the technology available in this day and age, it is very hard for the healthcare team (doctors, RN's, etc) to acknowledge that in some cases, a patient's disease cannot be cured.

I think Jill hit the nail on the head with her comment about doing no harm. Patients deserve to die peacefully, without pain or other discomfort. I have learned a tremendous amount about palliative care in a short time and look forward to learning more about this very important specialty of nursing.

Laurie

bunky, BSN, RN · Jul 5, 2000

Earle what you are saying is so true! When I care for a patient who is dying and the family and the patient KNOW and ACCEPT it, a type of peace seems to settle on them all and it's infectious. I look upon these families as having such courage and the patient as being so loved, and to me, I feel privileged to be of service to them during their time of need. It's no less sad when the person dies, but it remains a peaceful event. Even when it's your own family, when you have a doctor simply be truthful and caring, and he/she tells you the prognosis even with intervention, it makes all the difference in the world! It is hard to find this anymore though. When the family is left with options for interventions which I don't feel they fully understand the outcomes of, they grasp at these. I am all for explaining options in full, but I don't think that the idea of palliative treatment is presented in the same light as the idea of medical intervention. I think that most doctors fall short in this area. Yes, we can call in a priest or a minister, but if the family is left believing that a patient will live after a tube is inserted, spiritual influence is not going to tell them any differently. As a nurse, we CAN'T tell them any different either as it is the physician who has to provide the info for "informed consent". If the physican has told them the risks, and that the insertion of a tube or a surgical procedure will prevent the patients immediate death, then we have to accept that as informed consent even though we know that what is being done is only a measure to prolong death. Do you see what I am saying?

JenMarie · Jul 6, 2000

I have a new job on a ward that has the 3 specialties: Oncology, Haematology and Palliative Care. I great range and I am enjoying the challenge if the new job. On the Palliative care side....I think it is done really well. When it is decided that not more can be done medically for the patient, they are handed under the care of the Palliative Care team.

The team works holistically and beautifully. The patient is given all the information straight and the patient is made as comfortable as possible. The family is given support and together the patient and family are able to make informed decisions.

I think that Palliative care is all about making the patient comfortable , without speeding up the process or slowing it down.

leslie :-D · Jul 10, 2000

Bunky-

I don't know what to tell you. When families authorize any intervention to 'save' their loved one and also the MD's who play God, without getting into it too much, sometimes there are ways around it. And speaking of informed consent, I had to readmit one pt. who returned with an ng tube who had acutely deteriorated in the hospital. She had developed severe dysphagia but was also gagging on the feeding via the ngt because it was not securely placed in her stomach. Anyway, it came out...the family and MD ordered me to put it back in. Knowing this was only a short term solution, I informed the parties I was unable to; that the tube kept on coming out her mouth. The doctor then ordered ME to discuss the option of a g-tube or if they declined, comfort measures. I don't know if this was even legal. After I discussed in depth their options, they then spoke with the MD who only said I was correct in everything I had told them. This 98 y.o. woman ended up getting a g-tube who had a primary dx of depression & anxiety, who also was begging for God to take her. But since she wasn't deemed competent, it was her nephew who acted as the guardian. Many times I tactfully pointed out to the nephew to distinguish between life and mere existence. The doctor, however, authorized 'pleasure foods as tolerated' which she ended up aspirating and dying a most invasive and tormented death. That whole scenario almost led me to leave nursing. Many times I think it is nurses who should continue with their education and become doctors. I shouldn't even be responding to this topic right now. There's one doctor, as we speak, that I would like to personally castrate right now, which leads me to a new topic. Bunky, be alerted for I would like your input.

Blue11RN · Jul 11, 2000

I think the topic "Death with Dignity" includes pain control for the dying. Nothing makes me more upset is when MD's done want to order pain meds except Tylenol because "the pt may become addicted". HELLO, the pt is dying and is on comfort care!!!! I actually begged on MD for a MSO4 order for my dying pt. She was on comfort care and only had a few days. I had her as a pt everyday she was on our floor. She couldn't eat, speak or move, but could blink answers. She told me she was in pain, but the MD only would give me Tylenol po. I begged him that she couldn't take it and the MSO4 might help her breathe and make her comfortable. And, maybe make her way out of this world alittle easier. Still no. The third day I couldn't take it anymore!! I screamed at him in the hall and told him he wouldn't do this to his mother, why do it to this poor lady. He just walked away with no answer. She died in pain. And, the way I see it, without dignity!! But, then again this is the same MD who screamed at us for calling a code on a lady who had no pulse or resp. He stated that we jumped the gun and didn't know what we were doing. Oh, I am sorry that we brought her back before you got there, but I don't ever want you touching me if you think no pulse or resp does not call for a code!!!!!! What a jerk. So, basically my point is the MD can make or break the chance of dying with dignity. Nurses can only scream and yell for the pt so much.