bad bad deaths

loriangel14, RN · Jan 14, 2014

Pretty much 100% of our palliative patients are on PCA pumps subcutaneously with both a basal dose and a bolus dose.Scapolomine is used to treat extra fluid build up.Sometimes it is still not a good death. We also use Versed a lot.

BerryHappy · Jan 16, 2014

Yup, my worst have been hepatic related. Lung has been pretty bad too, but for some reason the hepatic encaphaly makes all palliative measures pretty much moot. Either we knock them out so they just sleep until the end, or they are tormented (as well as the family) until they finally go.

NC29mom, ASN, LPN, RN · Jan 18, 2014

Pretty much 100% of our palliative patients are on PCA pumps subcutaneously with both a basal dose and a bolus dose.Scapolomine is used to treat extra fluid build up.Sometimes it is still not a good death. We also use Versed a lot.

We have the option of using the pca's also, but not every pt is appropriate to use. As a matter of fact, we rarely use. Generally we are able to allow the pt a comfortable death using po/pr routes.

I wish I had done a pca on the particular death I was referring to. However, unfortunately the pt had different nurses doing visits with no real case manager, which is a shame. By the time I was involved, the pt was hours away from death. It takes a good 24h to get orders and a pca set up. We used to use an outstanding infusion company. When our company was bought out by another, we were forced into using an infusion company over 2h away.....making setting up a pca even more time consuming.

PomMom65 · Jun 21, 2014

We use Robinul for secretions / congestion. I think it works better than Atropine and Scop patches. That is a very distressing sound for families.

TammyG · Jul 4, 2014

I find the worst deaths are esophageal cancers because of the pain, and patients with intestinal blockages because of the intractable nausea. Often those patients need to go to hospice house because you can't keep things under control at home.

I have had several patients receiving so much SL meds that they pool up in the throat. This happens sometimes when the MD has not changed from liquid dilaudid to something more concentrated. I am not sure it really bothers the patient, however, and I am not sure that the medications are not absorbed in the buccal membrane, so I generally tell families that it is not bothersome to the patient. We can get a PCA out in 6-7 hours but it is a huge effort with lots of paperwork and people involved and orders -- it is often not worth it.

BTW -- A recent study found that atropine, scopalamine and hyoscyamine all work equally poorly. We do not use robinul at our hospice (doesn't it have to be given IV)?

toomuchbaloney · Jul 7, 2014

I pronounced a COPD patient who died in the night. Family discovered patient in early a.m. and called hospice. I discovered the patient in hospital bed with arms and legs outside of the rails. She had clearly struggled to get up or out of bed at some point considering the position she was in at time of death. She had a bug eyed and distressed appearance in death. There was foam and vomit on her face and bed clothing. Rigor mortis was present and getting the body disengaged from the bed was difficult.

This death occured in an area that required notification of local LEO's so they came to examine the scene and status of the body.

Family apparently drank liquour and slept through the event. Several of them were quite upset and wanted reassurances from me that the death was peaceful/comfortable.

TammyG · Jul 7, 2014

That's an interesting scenario? What did you tell them? I would tell them, absolutely, she died comfortably. We don't know how she died, why cause the family to be upset. I was not aware that there were places where the cops have to come out to examine a dead hospice patient.

toomuchbaloney · Jul 10, 2014

That's an interesting scenario? What did you tell them? I would tell them, absolutely, she died comfortably. We don't know how she died, why cause the family to be upset. I was not aware that there were places where the cops have to come out to examine a dead hospice patient.

YUP...some large cities with high death rates...Detroit would be an example.

I didn't tell them she died comfortably because I had no reassurances that she had, in fact, her appearance and positioning suggested just the opposite. I simply told them I had no way of knowing whether or not she was comfortable although if they followed the hospice plan for symptom management then the chances were good that she was comfortable.

When you take the medical examiner's course for pronouncing death you pick up a number of useful skills in determining things about the circumstances surrounding a death.

Amy'sGrandbaby, BSN, RN · Sep 13, 2014

Hey toomuchbaloney-

What is the criteria for taking the medical examiner's for pronouncing course and are Hospice nurses required to take it?

Thanks

toomuchbaloney · Sep 13, 2014

In some states, like Michigan you must take the course if you are going to practice/pronounce in the counties that require ME exam for deaths in the field.

In some of the counties the local PD will defer attendance if you can provide an ME case number for their records, otherwise they respond to the scene for their paperwork/legal requirements. Not all counties require that.

ShesanRN · Oct 29, 2014

We've used Robinul 2mg tabs SL very successfully in patients with really excessive secretions. We make sure to do/teach oral care every hour, though, as it can be that drying. I agree, liver deaths are some of the worst...

We too have maintained most patients' comfort with Roxanol and not have not needed to initiate pumps often.