Comfort Care -- End of Life

[pinky22786]

What do you do when a pt becomes comfort care.

Heres my situation:

Doctor ordered pain and anxiety medication q2 prn. Pt was not showing s/s of distress and family was not asking for the pt to be medicated. My issue is a social worker kept pushing me to medicate q2 weather it was needed or not as that is what the hospice nurse suggested. Ok I am not a hospice nurse and have never experienced hospice care so I dont know if that is standard for their care. This is my first pt to go through the process of dying with for more than a hour. My understanding of comfort care is to keep the pt comfortable as well as the family, not to medicate the pt to hurry the process(resp were

I was glad I left 4 hours early as previously schedule but I dont know if I would have followed the orders. I documented well but still dont feel right about this for two reasons: we are not here to make the decisions to help the pts along that is for the family and pts wishes, then what should I do if I dont agree with the order yet my director does not support me. I was put on call today but I was going to refuse to take that pt today but what to do when your in the middle of a shift and dont agree with orders?

[sunnycalifRN]

you did the right thing. Comfort care is just that . . . alleviate pain and discomfort . . . if the patient did not appear to be in pain, short of breath, agitated . . . then, you don't need to medicate.

Sometimes, things get a little fuzzy . . . for example, if pt's resp rate is already low but endorses or appears to be in pain . . . then, you can give medication, even though it might further suppress the resp drive . . . but the key point, is, you're trying to keep the patient comfortable . . . not accelerate the dying process.

[FLArn]

As mentioned above the resp. rate is not a reason to withhold pain meds in palliative care if there are signs of pain or resp distress. I have had patients who received pain meds who had RR

[Virgo_RN, BSN, RN]

I would medicate based upon my clinical judgment of whether or not the patient was in any distress. Now, having said that, signs of distress might be subtle. It might be as subtle as a wrinkled brow, a slight frown, accessory muscle use, muscle tension, etc. If the patient appears comfortable, the family appears calm, and there is no indication to administer the medication, then the social worker needs to butt out.

[ShayRN]

What is up with a social worker telling you to medicate? That is a nursing judgement, yeesh! That being said, I would not have medicated with what you have told us. I have been a hospice nurse for 3+ years and am aggressive with symptom management, but would never medicate if I didn't feel a patient needed it. That being said, a nurse is expected to use her assessment skills and clinical judgement when giving any medication. Just becaue it is ordered around the clock doesn't mean you HAVE to give it. I have held many medications because I felt they weren't needed.

[pinky22786]

Yes I understand respirations are not a reason to hold medication during comfort care. And I was ready to medicate at any request of the family or signs of discomfort. So now my issue is how would you handle disagreeing with a order in the middle of a shift, hold the medication then have the doctor be upset with you and know that your director also wants you to medicate so they may not back you up in your decision to hold the medication. Is it proper to ask to switch a pt with another RN that was willing to, yet that feels like you are abandoning the pt and the proper care they deserve.

[sunnycalifRN]

Pinky,

I don't know what more to say . . . you are the RN caring for your patient . . . the social worker, director and the MD's are not at the bedside . . . you are. If you are not comfortable with an order . . . you can refuse to implement it . . . document and inform your charge nurse. There have been times when I have felt that an order was not in the patient's best interest, and I did not implement it, but I informed the doc and documented. But, be ready to stand your ground.

[Virgo_RN, BSN, RN]

If you can defend your rationale, then you stand your ground.

[tencat]

Hmmm.....I think it would be appropriate to find out WHY they felt the need to order it q2 around the clock....there could be a mighty good reason for it that you don't know about. It is important to remember that you are not 'accelerating' anything by giving appropriate doses of medications. You are making the patient comfortable. And when someone looks comfortable, sometimes they are anything but and the only way you can tell is through blood pressure or heart rate elevations that are inconsistent with the visual presentation of the patient. I have seen people on ungodly amounts of medications and still they were very uncomfortable. If someone is dying why not err on the side of caution and be sure they are comfortable?

Personally, I have seen too many cases where a nurse did not understand comfort care and let the patient suffer needlessly. I am not saying that you did that; I don't believe you did. But you might want to find out more about hospice care and what it entails so that in the future you will know why you are being asked to do something you don't understand.

[txspadequeenRN, BSN, RN]

comfort care is what it is..for comfort...if your patient was comfortable then there is no reason to medicate.... what medications are we talking about here...sometimes we medicate more routinely if the patient has a issue with seizures and we have her on ivp ativan to control those seizures because she no longer can have any po intake.....bottom line if your patent is comfortable and your assessment is that patient has no anxiety or signs of pain then no medication is necessary.especially if the family agrees...i would have taken that social worker in the room and ask during her nursing assessment what made her think the patient needed medication....sorry i just have a problem with non- nursing people over stepping their boundaries and questioning my ability to care for my patients...

as for the prn turning to a routine order..i would have found out what the rational was...i probably still wouldn't give it if the patient did not show signs of pain or anxiety....

[leslie :-D]

Now, having said that, signs of distress might be subtle. It might be as subtle as a wrinkled brow, a slight frown, accessory muscle use, muscle tension, etc. If the patient appears comfortable, the family appears calm, and there is no indication to administer the medication, then the social worker needs to butt out.

this is what scares me...

that subtle signs may be overlooked...

or, the pt may be stoic and continue to deny pain.

also, you need to be careful re family input, for they may have their own agenda.

regardless, it is ultimately the nurse's call.

op, if you are 100% certain the pt is comfortable, then hold your ground by remaining respectful but confident.

IF you have any reservations as to whether pt is TOTALLY comfortable and you feel a more experienced (with pain assessment, comfort care) nurse may better serve your pt, then by all means, ask to be reassigned.

i think you may feel better if you personally asked the social worker, what she's seeing as signs of distress.

after yrs of working hospice, a pt denying pain makes me raise an eyebrow, as there are all types of pain, and all types of reasons to deny pain.

wishing you the very best,

leslie

[tencat]

The OP said herself that the patient was showing signs of being 'slightly' agitated, but she still didn't want to give meds....that's what worries me, as well. There is no need for ANY agitation, and I think people tend to overlook subtle signs and think all is well with the patient, especially if they do not have hospice experience or training. As to others 'questioning' the nurse's decisions, it depends whether or not he/she has hospice experience, and why he/she felt the patient was needing a dose of medication. The patient's comfort is the bottom line, not the nurse's ego, especially when the nurse is not familiar with a discipline. I can't make sound judgements and decisions for ER, or ICU, or Telemetry, etc. because I do not have the expertise or the experience at this point and know little to nothing about these disciplines. Hospice is as much of a discipline as the rest of these, and people need to know what it is and how to practice it, regardless of whether or not you've been a nurse for 100 years or 6 months. We can make educated guesses as to how to practice, but unless we are willing to learn, we won't be effective.