Best environment to die in....hospice opinion needed.

[coolpeach]

Hi .... I am in pre nursing, and taking the last of my pre reqs while waiting for acceptance. I am taking End of life issues, and must give a oral presentation on "The best environment for dying including care giver behaviors".

I started thinking that the best person to ask was a hospice nurse. What do you think? This is something you see daily so I was hoping you could give me some ideas on what you have seen. Are there really good deaths and bad deaths? What makes the difference? How do you behave to insure you do your part to make it a good death?

For those of you who have worked both in a hosptial ,and hospice what are the differences in dying in the two different places.

If you were to die having seen what you have where would you chose to die?

Please tell me your stories....take as much space as you need. I am really interested, and need the help.

[Ariesbsn]

Hi Coolpeach,

I have never worked hospice, however I watched both of my parents die from cancer. My father died in a hospital when I was 10. My mother died in a hospice facility 8 years ago. I have also worked in ICU.

I think the best place to die is somewhere that makes sure your pain is managed and that encourages your family to be as involved as you, and they, want to be. Sometimes that can happen in the hospital. It just depends on the nurses:nurse: .

When my father died in 1977, my access to him was restricted because of my age. I was allowed 15 minutes a day with him until the last week of his life. At that point someone decided he was too sick and I wasn't allowed to visit him any more. I didn't get to say good bye or tell him one last time that I loved him.

When my mother died in 1999, she was in a hospice. The experience was very different. The energy was different. It felt like you were walking into a giant hug. It was also very comforting to have people around who specialized in end of life issues. My mother had a much more peaceful and pain free death than my father.

When I was working in ICU, I had a 55 year old patient who was a DNR. He was approaching his celestial transfer on my shift. His wife had been sitting in the chair next to the bed all day. People had come and gone and at around 0200 she asked me if she could put down the side rail because it was hard for her to hold his hand with the rail up. I said sure, not a problem.

I told her that if she would like, I could reposition her husband in the bed and she could get in the bed and snuggle with him. She took me up on my offer. I pointed the video camera in the room at the ceiling (for privacy), repositioned her husband, got her comfortable in the bed with him, pulled the curtain and left. He died in his wife's arms at 0337. As she was leaving she thanked me for allowing her to have one last cuddle.

I guess in my mind, it isn't so much the place, as it is the people who are caring for you. I don't care where I die. I just hope that it is sudden and that there isn't a lot of pain.

[tencat]

Hi. I've been a hospice nurse for 5 months, and a nurse in general for a little over a year. It really is an individual choice as to where one wants to die. The hospital death is often messy in the fact that there are a lot of invasive tubes and wires involved usually because the emphasis in hospital care is to treat and save an individual. I have seen individuals 'live' a lot longer than they would otherwise because they are on life support. Sometimes I've seen patients who begin to have necrotic periphery tissues (hands turn black, feet turn black) but still are 'alive' because they are hooked to ventillators and being given drugs to regulate their blood pressure, heart rate, etc. At this point the patient is at this stage because there is a loved one who cannot give in to the fact that the patient is dying, or there is a loved one coming in from far away who wants to see the patient before he/she passes. Plus doctors are very reluctant to 'give in' if the family is adamantly demanding very aggressive treatment, as lawsuits are rampant.

Deaths at home lack the monitors, tubes (for the most part), wires, and life sustaining drugs. The emphasis on home death (ie: hospice) is comfort. Pain medications and antianxiolytics are given, as are drugs to reduce symptoms such as nausea, vomiting, shortness of breath, excessive sectretions, and agitation. Oxygen is used as well. Death at home offers the family a chance to actively be involved in care for the patient in a familiar and comfortable setting. A majority of the time I've seen that this environment is beneficial to the whole family by allowing the patient more control over how he/she is treated. The disadvantage to the home death is that the family is often 'lost', and they are often afraid of heavy-duty drugs such as Roxanol and Lorazepam. Thus, they sometimes don't medicate the patient as often or as 'well' as they should. It's hard to overcome the family fear/denial at times and it becomes frustrating at times because the patient can be in a lot of pain etc. and the family withholds drugs because they are afraid they'll send the patient into death more quickly, or they will make the patient too sleepy and disoriented to participate in the daily activities that are going on around them. When the family is not able to adequately care for the patient and give the comfort drugs that need to be given, the hospital or an inpatient 'respite' or inpatient hospice becomes a better alternative for the patient.

Which death is better? I know I'd prefer to die at home. I suppose it depends on cultural preferences as well. Navajo people, for example, have several strict taboos about death and dead people. Many of the Navajo feel that they cannot touch the dead or have the dead in the home as then that home will have to be destroyed because it is 'tainted' beyond repair due to the presence of a dead person, or the family will be forced to move due to the death in the home. Navajo people will use hospice, but they prefer to take their loved one to the hospital when death is eminent to avoid the person dying in the home, or being declared dead in the home. (Anyone feel free to correct me if I'm wrong as I'm not Navajo).

Hope this helps. Sorry it's so long.

[aimeee, BSN, RN]

The "best" environment to die in is the one of your choosing. I think a "good" death is easier to achieve at home, but it can happen anything because "good" has a lot more to do with state of mind and control of symptoms than it does with physical location.

[Elvish, BSN, DNP, RN, NP]

I told her that if she would like, I could reposition her husband in the bed and she could get in the bed and snuggle with him. She took me up on my offer. I pointed the video camera in the room at the ceiling (for privacy), repositioned her husband, got her comfortable in the bed with him, pulled the curtain and left. He died in his wife's arms at 0337. As she was leaving she thanked me for allowing her to have one last cuddle.

Thank you so much, Aries. If my husband goes before I do, that's how I'd like ours last hours to be. Thank you for giving that gift to that couple.

[loricatus]

The "best" environment to die in is the one of your choosing. I think a "good" death is easier to achieve at home, but it can happen anything because "good" has a lot more to do with state of mind and control of symptoms than it does with physical location.

I think that aimeee has it right. Ever person is different and what one would consider the 'best' environment may not be good for another. There are some people that prefer having pain and view it in a spiritual way called 'redemptive suffering'. Others will do anything to avoid even the thought of pain and would consider euthanasia. So, what would constitute a good death is a matter of individual choice. A good death would result from respecting the individual's choice(s) they have made for end of life care (understanding that choices can change along the way).

[leslie :-D]

it has been my experience there is no best place to die.

there is only a best way to die.

in the final hours, very few will have a preference as to where they are.

i've spoken with many pts, who prefer to die at the inpt facility.

they do not want their homes being remembered as the place where they died.

too much of a burden for the family.

ultimately, it indeed boils down to being with those who love you.

leslie

[shrinky]

I guess, as others have said, that it depends on the person's preferred place to die. My experience of 7 years in Hospice and many more as a nurse is dependent on the ability of the care givers to be able to deal with dying in the home. I have seen many patients make the choice whent they know the options, even if they are unresponsive. My own mother was to go home with hospice and made the choice to die in the hospital just as I arrived in her room. One patient passed just hours before he was to go to a SNF from the hospital. If the nurses in the hospital subscribe to the philosophy and are willing to medicate when needed then that may be an alternative to a home death, but I have had not so good experiences with my inpatients when the nurses would not give SL meds because they feared aspiration. I would choose to die in a hospice house, if possible so that my grands would not associate death and my room together.

[kerrioutlaw]

Hi Cool Peach I have been a Hospice nurse for 8 years and there definately good and bad deaths. Some depend strictly on the type of disease process and the nurse's ability to control symptoms. Others depend on the nurse's ability to care for the "Whole" patient which with most hospice patients include their families. I focus on education with my patients and their family about disease process and what to expect. we don't preach dying from the get go but keeping a family and patient informed about theri advancing disease makes the whole process easier to handle. Most patients and families actually handle the dying part very gracefully. To watch someone die a little everyday is very difficult and by the time these patients die their families are ready, just wanting them to be at ease. The deaths that tend to be difficult are the ones where we are only in the home a very short time and don't have the opportunity to bond with our patients and families. there are worse things than death, sometimes dying really is the best thing for the patient. That dosen't mean I want my patients to die but I understand that my job is to make that transition somewhat easier for both the patient and the family.

[Allow Mystery]

My opinion is that the best place to die is the place that it was best

to live.

[eternalsunshine]

My opinion is that the best place to die is the place that it was best

to live.

that's beautiful Allow Mystery

There are definatley good and bad deaths, and as someone said, sometimes it can just be the nature of the disease which can make it bad, (i.e. SVCO).

I have worked in Hospital and Hospice (and continue to do both) here is a list which I hope will help:

Hospital: (from my experience)

staff shortages lead to nurses being unable to give the quality of care that they would like to give

Lack of beds means patients lack privacy and are sometimes in a bay with 5 other patients

lack of emotional and spiritual support for patient and family

Futile treatments continued

Discussions about dying tend to be avoided

Lack of specialised knowledge can lead to poor symptom control

Hospice:

The care is holisitic and completely patient centered

all spiritual and emotional needs are addressed

Death is spoken about openenly and is considered as a natural and normal part of life

better quality of care (better staff:patient ratio)

less sterile environment and more homely with own rooms to respect privacy

symptoms are much better managed and addressed

Home:

Personal choice, some patients prefer it, where as some have requested to go to the Hospice where they feel safe

Hope that helps