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- by lalalulu Dec 11, '12I really need some opinions please. I have a patient who is on hospice and did have some pain issues where roxanol was effective for them. However today it appears as if the doctor and family have decided its time to put him out of his misery. I have no problem keepin pt comfortable But I really feel like I'm forcing pt to die. Roxanol and Ativan ordered q2h routine even if pt sleeping, they want me to squirt meds in mouth. And made npo even though he was requesting drink just yesterday. The pt is elderly, and was miserable but I guess I feel like I'm putting a dog down or something. Other hospice pts I haven't had routine orders like this.
I just feel morally and legally weird about this issue. Does anyone else ever have an issue with doctors orders for end of life pts?
- Dec 11, '12 by somenurseOH no, why is the patient NPO? Imo, small sips at the least, should be given, as a comfort measure, but, it's not clear to me, why this patient is NPO. I am well versed on the reasoning that dehydration is thought to alleviate some discomfort and symptoms as death approaches, but, if the patient is A and O, and complaining of thirst, that is a whole other matter.
If he was too groggy, i'd at least moisten his mouth, or do a swabbie or something, if my patient complained of dry mouth.
I can understand your concern, on a patient who is A and O as baseline(?) being given Roxanol round the clock. It seems to me, you have the right to circle the med as not given, "pt asleep" if you choose to. I can not imagine you getting in trouble for not following this order, if the patient is asleep!!!
but, this is a sticky area, and different nurses have different feelings, on this. One person's situation is not always just like another. I don't know this exact situation, but,
I could do this in many cases, if the patient was actively dying, and in pain, etc, yes, i could. I hope someone will do this for me when the time comes.
Other nurses can't. Some will be horrified at this post. Other nurses are more horrified at long, horrible, painful deaths in those who are actively dying already.
Me, i DO feel humans deserve the same care we give to dying dogs in pain. but, that's just me. This is a very individual decision, and you have to do what is right for you. doesn't matter what anyone else says, if YOU are not comfortable slipping Roxanol under the tongue of a dying person who is not fully awake, then you should NOT do it then, even if it is ordered that way.
We used to chart, "signs of labored breathing" or "respiratory distress/facial grimaicing" or whatever patient was doing, as reason to give the dose on time. Once the patient is in coma, many to most nurses began skipping doses then, unless there was some sign of discomfort of any type--however slight.
If you do NOT feel comfortable doing this order, then you should have the right to circle the meds/not given, patient asleep. You do NOT have to participate in anything YOU do not feel comfortable with.Last edit by somenurse on Dec 12, '12
- Dec 12, '12 by lalaluluYes I agree with u I would want someone to give it to me to make me comfortable. I have absolutely no problem giving it to him every hour IF he needed it, but he's asleep??? Im actualy all for euthanasia as a pt right, althougj i wont be the one euthanzing. he has No signs of distress. And yesterday I was talking to him and although not eating was very thirsty. I don't know why npo but I think doc and family want him to die quicker.
It just seems very much like actin like god and deciding he's done. I appreciate ur response! Thanks so much
- Dec 12, '12 by somenurseThanks for your reply back, too. I like that you are thinking aobut this, and this is something that no one else can really decide for you, what is right for you,
is right for you.
What is wrong for you,
is wrong for you. some might point out, it's not so much about us, it's about the patient. Still, since this is such a sensitive matter, it's important you do not go against your own strongly held beliefs. but, if it's just gathering various opinions, to weigh out and decide for yourself, go for it. but, it has to feel right to you.
My opinion is only my opinion. What feels right and kind in my heart, might not match what you feel in your heart. You have to follow your own heart on this. Your opinion and concerns and feelings about this, however they will shake out over time, are equally valid.
Many others would most vehemently disagree with my feelings on that, and that is fine, i don't think any nurse ought to do what s/he is not comfortable with, in every way. sooner or later, someone else will spot this thread, and write their ideas, too, it's good if you hear all sides, imo.
"acting like god"??
I don't see giving morphine as someone is dying, any more "acting like god" than i view removing a funky gallbladder (that apparently god wanted in there).
I don't see helping a dying person avoid a few days of suffering, going against the gods,
any more than i view delivering a baby from the womb a bit early for whatever health reasons that decision is being made. Apparently, the gods would have the baby stay in the womb another week,
yet, the doctors got that baby out of there. No one seems to question if that is going against the gods (who seem to want the baby to not be born yet).
I don't see helping someone who IS most definitely dying, avoid a few days of extra suffering,
any less worthy of a goal,
than when i medicate the guy getting stitches avoid useless suffering, either. some folks, like my parents, see a spiritual value in suffering. I don't.
BUT BUT BUT, each and every case can be different. Each and every paient and family involved have different needs. I recall a case, (hospice) where we were all trying hard to keep the man going a few more days til his daughter could arrive.
Maybe that was cruel to the patient, but, we all felt exact same way in that situation, that getting that last goodbye, was a VIP goal for that family.
What seems kindness to do for Mr Brown, might not feel right for Mrs Smith.
I don't have as much trouble with the "deciding he is done" part, in most cases. Usually, (not always, but usually) the patient himself is often eager for relief and peace and an end to the suffering. When a person reaches that stage, it can be detected. Many of them say it out loud, over and over.
Other patients can be confused/not very interactive/ by this point, too.
The signs of impending death, get more and more obvious to notice, and the signs the person is suffering too too much, is also hard to miss.
I've never ever seen "snowing" a patient ordered when death was not obviously approaching. Not a once.
I do not view striving for the most peaceful, least painful death possible,
as an unworthy goal, going against the gods, etc.
but, that's just me. sooner or later,
others will spot your thread, and put in their two cents.Last edit by somenurse on Dec 12, '12
- Dec 12, '12 by somenurseto lalalulu,
If my hospice patient wanted a sip of water, and he was ordered NPO, and i did not understand why (sips are not prolonging life, i can't imagine that is reason)
i'd either ask whatever nurse was that patients primary hospice nurse, or the nurse most interacting with the doctor if she knew,
i'd ask doctor if the patient couldn't have some sips, even if they have to be thickened sips, that is IF IF IF the patient can swallow, and has normal throat, etc, (again, i don't know what is going on).
- Dec 12, '12 by MunoRNThere's a couple things to consider with the NPO order. The first is just whether it's appropriate for end of life hospice care, which may be up for debate, although I'd argue they can have whatever they want.
The other is not really up for debate, which is that patients can refuse an NPO order. This was actually a big "awareness" campaign in my state mainly in relation to fluid restrictions but applies to NPO in general. If a patient is able to refuse, they have the right to refuse an NPO or restricted diet/fluids order. And while you don't have to provide a patient with their favorite soda, you do have to provide water as requested if they do not want to follow an NPO order if they are unable to get water for themselves, failing to do so is considered abuse of a dependent adult and is a felony (at least in my state).
- Dec 13, '12 by lalaluluThanks everyone for ur responses. It gave me a lot to think about. The pt did already die, and never woke up which I suppose was the whole point of this order. But If pt would have awakened and asked me for a drink I would've given it.
I did end up givin meds as ordered q2h to keep pt out of pain. I ended up feeling it was the right thing at this point in time. Pt went very peacefully.
- Dec 13, '12 by KelRN215With end of life patients, high doses of medications that may hasten death are often given but it's seen as acceptable because the purpose is to relieve pain not to kill the patient.
I once had an 8 year old who weighed something like 24 kg on 100 mg of morphine AN HOUR with 10 mg bolus doses available PRN. The typical dose of morphine for a child this size would be 2.4 mg q 2 hrs PRN... so in an hour this child was getting almost 50x his q 2hr PRN dose. In addition to this, he was on continuous ketamine and 5 mg of Ativan (double the dose for his weight) scheduled q 4 hr. He lived for days on these meds and, because he was end of life and the doses were escalated per the end of life/comfort measures protocol, these were viewed as acceptable doses. This child wasn't awake or moaning in pain for the last several days of his life but he had been before we got him to these doses. He was comfortable and simply stopped breathing and slipped away one evening. There was no struggle.
- Dec 13, '12 by somenurseOn another thread, someone posted this link, from the Hospice and Palliative Nurses Association, on giving pain meds to terminal patients.
from the link above:
//"Although there is agreement that the goals of palliative care must focus on the prevention and relief of pain and suffering, clinicians, patients, and families may be reluctant to use opioids to achieve this goal in patients who are dying.7, 8 This hesitancy may stem from the fear that administering opioids depresses respirations, thereby hastening death. However, there is no convincing scientific evidence that administering opioids, even in very high doses, accelerates death.9-13 In fact, numerous clinical studies demonstrate no significant association among opioid use, respiratory depression, and shortened survival.10, 12, 14-20 Respiratory depression and other changes in breathing are part of the dying process and are more likely to be from disease and multi-system organ failure than from opioids.16, 21
Despite the lack of evidence that opioids hasten death, some clinicians continue to believe that administering opioids can accelerate the dying process; for this reason, they seek moral justification for providing aggressive pain management."//