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?

[pinky22786]

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.

I was reluctant to medicate per the standing order but when I went to give the medication and seen the state of the pt I was fine giving it. Pts arm was starting to twitch was the only sign of agitation. When I spoke with the doctor and asked the rational for changing the order to standing her response was we want the pt comfortable. I guess she did not want to miss the little signs of discomfort. Is this a normal practice for hospice care?

I cant put a finger on why I am so hung up on medicating around the clock for a pt in the dying process. It's not the fear of causing them to pass or being legally responsible. Its more medicating when not necessary, yet now reading the responses giving pain medication to a dying pt is like giving nausea medication to a pt prior to them eating or taking medication that has been nauseous. Its anticipating the discomfort and medicating so they do not experience any. I understand this with the help of the responses. But who is to say they will experience discomfort? Better comfortable than not. I look for the s/s of discomfort on a large scale, not the small such as they eyebrow movement. I hope I can take these lessons learned and apply them to the next comfort care pt I have and feel comfortable medicating when s/s are not there.

Thanks!!!

[leslie :-D]

i was reluctant to medicate per the standing order but when i went to give the medication and seen the state of the pt i was fine giving it. pts arm was starting to twitch was the only sign of agitation. when i spoke with the doctor and asked the rational for changing the order to standing her response was we want the pt comfortable. i guess she did not want to miss the little signs of discomfort. is this a normal practice for hospice care?

yes, atc dosing is the norm.

and it's too easy, to miss "the little signs of discomfort".

that's why we err on the side of caution.

i cant put a finger on why i am so hung up on medicating around the clock for a pt in the dying process. it's not the fear of causing them to pass or being legally responsible. its more medicating when not necessary, yet now reading the responses giving pain medication to a dying pt is like giving nausea medication to a pt prior to them eating or taking medication that has been nauseous. its anticipating the discomfort and medicating so they do not experience any. i understand this with the help of the responses. but who is to say they will experience discomfort? better comfortable than not. i look for the s/s of discomfort on a large scale, not the small such as they eyebrow movement. i hope i can take these lessons learned and apply them to the next comfort care pt i have and feel comfortable medicating when s/s are not there.

thanks!!!

you were spot on, when saying it's about anticipating the discomfort.

we need to stay ahead of it.

and of course, there are folks who die peacefully, and never experience discomfort.

but those folks are the exceptions.

i am not talking about physical pain only, but the psychological anxiety/fear that one inevitably experiences, r/t the dying process.

circulation is shutting down, as are the organs.

muscles may be atrophying r/t immobility and cachexia.

do you honestly think this process happens without any type of discomfort?

remember that homeostasis is the prototype of what the ideal is.

in its absence, would naturally follow that any imbalances = discomfort.

please (yes, i'm near begging:)), treat all of your comfort care pts with the consideration they warrant.

as long as your intent is to relieve or avoid further distress, you will never be in trouble.

best of everything.

leslie

[dmc_rrt]

Sounds like you did the right thing, I like how you included the family, as I feel they are just about as important to keep comforted at this time. Just an idea...Sometimes an order for glyco or scopolamine will reduce the need for suctioning and will reduce the resp. rattles. Maybe you already know that though.

[OldnurseRN]

After years of hospice (inpt and home care) plus oncology, I must say it IS about staying ahead of the pain. Maybe your patient IS comfortable at that 2 hour check but then it escalates. Keeping ahead is so much easier than trying to catch up.

[Keepstanding, ASN, 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....

love the quote at the bottom of your post. ! love it.....and lpn's

[imintrouble, BSN, RN]

I was so glad to see this topic this AM. I am so conflicted about COMFORT MEASURES. I'm not referring to pts who are dying and in pain. I have no problem giving those pts morphine. Where I work comfort measures... pain relief is almost always Morphine q 1 hr prn. I have found that families are the ones that request it, and I frequently wonder who the morphine is for. Just this week I had an advanced alzheimers pt who was dying. He was nonresponsive, breathing easy absolutely no s/s of pain. Family wanted morphine given. I was off shift when the requests from the family for morphine started, but I have been faced with this dilemma. I have had families insist their loved ones get morphine. If I would say, "Do you think John looks like he is in pain?" I've had families say, I don't care, the Dr said he could have it and I want you to give it. Most of the nurses I work with have no problem pushing morphine on the dying even if there is no signs of pain. There is subtle, and sometimes not so subtle pressure to comply by my fellow nurses. If I refuse to give the med, another nurse I work with will have to give it, or the house sup. will have to come and give it. Is it okay to give meds to the dying for the comfort of the family?

[tewdles, RN]

okay...I am not in the habit of trying to insult or irritate people so please accept this post with that knowledge.

If you work in LTC you should expect that the comfort orders will be ATC rather than PRN as a general rule. There is a great deal of difference between nursing knowledge and practice from nurse to nurse, shift to shift, and facility to facility...and it can be challenging to overcome some of the barriers to achieving GOOD not just adequate comfort in dying patients in that environment. As a hospice case nurse my objective is to provide the most comfortable and dignified death for the patient as is desired and possible. While I am more than willing to educate staff and family and physicians about the hospice/palliative approach and tools, I cannot be ever present and ATC scheduling makes it more likely that the patient will not be under medicated.

Unfortunately, not all nurses have the same skill level when it comes to interpreting signs and symptoms of pain and discomfort. Even in the acute hospital setting, I have had to make traditionally prn meds ATC to insure that my patients did not awaken in the morning in excrutiating pain, or bounce from sleep to agitation because they had not been medicated during the night. While I hate to admit it, there ARE nurses out there who complete a pain assessment from the doorway, and this is simply not adequate or acceptable in hospice.

Having said all of that, and no doubt really annoyed multitudes of my peers in LTC, I will end with the comment that I work with a number of excellent professionals and paraprofessionals in LTC. I count on them for their outstanding level of care and concern for our patients. I simply understand that my first objective is to insure that the best care is provided for these dying people and that often means that I need to decrease the potential for undermedication.

It is, afterall, easier to not give a PRN than to give it (thinking in terms of time to admin, follow up, and documentation of same) and similarly, it is easier to give an ATC med than not give it for similar reasons. So, I fully expect that if a nurse caring for our mutual patient assesses and determines that a scheduled med is NOT warranted at that time, he will not administer it and will document such. This is fine with me. That is nursing autonomy and professionalism. I am, afterall, not interested in snowing the patient, I only want him optimally comfortable when possible.

I really appreciate your concern about your patient. I would encourage you to ask the hospice nurse about an inservice on comfort care for your unit. Most hospices are thrilled to offer education (sometimes with CEUs) for the staff of facilities caring for their patients in common.

p.s. Hospice MSWs are specifically trained to assess for signs of discomfort (physical, emotional, spiritual) as they are sometimes the hospice professional present when pain is occuring and they need to know what to look for and how to advocate for the patient.

[leslie :-D]

Is it okay to give meds to the dying for the comfort of the family?

while the family's wishes are a major consideration in your nsg care, i absolutely refuse to administer meds when i feel that the atc dosages, will kill the pt before their disease does.

i'm not talking about merely hastening death, but administering enough morphine to kill a horse, hour after hour after hour.

will not do it.

of course i always explain my decisions to the family.

sometimes they're rational, sometimes they're not.

but you need to remember, that hospice is truly a team effort.

and that is because we recognize the lability and precarious nature of what/who we're dealing with.

we could never do this alone, and we all rely on ea other for much needed support.

tlh, i know how aggressive families can get with their demands.

a nurse who is assertive and confident, will not have any problems standing up to them.

we are there to protect the pts, first and foremost.

may that always be your guiding light.

leslie

[imintrouble, BSN, RN]

Thanks Leslie. What you've written is exactly the kind of info I was looking for.