I'm a new nurse (I've only been practicing for 2 months now) and am working at a LTC facility. Today, a resident came back from the hospital, and I was told that they were strictly NPO, and that the only thing they were allowed to have was PRN morphine and ativan?!? No water, no ice chips, etc. The woman had a blood clot to her brain last Thursday (and a seizure as a result) and apparently her family signed an order for a DNR... She's still responsive to pain, will look at you when you say her name, and even tears up on occasion. I feel HORRIBLE about not being able to give her anything but 3cc's of liquid meds on my shift. Is this common practice to starve someone to death? I don't want to go against Dr's orders and give her something to drink, but every fiber in my body says I'm supposed to help her, even if she's dying, and to make her as comfortable as possible.
Any help/similar stories would be appreciated. I'm having a very hard time coping with this.
this woman needs a swallowing eval, stating her capabilities and limitations.
if she had a stroke, then yes, dysphagia would be a major consideration.
and she's a dnr, not comfort measures, correct?
yet, if she is truly unable to swallow, then yes, a decision about fdg tube vs no fdg tubes, would be the next major decision.
if she is mentally competent, it is her right to decide.
if her poa/hcp says no fdg tube, then this would go way beyond a dnr, and should be comfort measures.
you may consider contacting the ombudsmen, whose number should be in public view with the name and contact info.
but before doing so, please get all your facts together.
if she didn't have a swallowing eval in the hospital, get one done asap.
let us know what happens?
leslie
Boy, I can't agree with this enough. My Mom was NPO after her stroke, but was able to understand when she was told that a PEG would be necessary, even though she was really mentally out of it in the first few weeks after her stroke. Through therapy we were able to remove the PEG. She eats a little TOO well now. ;-)
I'm just a pre-nursing student and don't know ANYTHING about this kind of a situation (other than what I've witnessed with my Mother). I'm certainly not in a position to offer advice, but the situation you've outlined really troubles me. Thank you for being an advocate for her! Bless you.
And why wouldn't 'comfort measures' include giving them water/ice chips? Don't their mouths get parched?
As the above posters (who seem to have a great deal of experience in this area) indicate, giving ice chips/water to a client that cannot swallow may result in aspiration of the water and or choking. These do not sound very comfortable.
Yes, yer mouth and lips get parched when yer NPO (I speak from experience here) whether you are at then end of your life or not (I wasnt, but it still was not pleasant). This is why the experienced and compassionate nurses that posted above place great emphasis on timely oral care - the regular swabbing of the mouth and the application of emollient to the lips.
I was impressed by the nurse that takes care to turn her/his client to the window. We would all be lucky to have care like this at the end of our life.
Her body is shutting down and from what I understand, dying people don't have the same needs and drives as a non-terminal person would have. I know it's hard to watch, but I was taught they don't feel what we perceive they would feel.
Why can't she have pain medications? It doesn't have to be PO?
I think the original writer mentioned Morphine and Ativan PRN. Along with the other things mentioned ( good mouth care , talking to them , etc. ) this sounds like compassionate end-of-life care. I have a lot of experience in this area ( LTC for 14 yrs ) , and situations like this tend to be a lot harder on the family and care-givers.
I spoke to some of the other nurses today, and apparently she has a subdural hematoma. I guess that was what caused the seizure last Thursday, and the lethargy. I'm assuming that most people (especially the elderly) don't recover from those?
I always talk to my dying patients while providing care too. I figure since the hearing is the last sense to go, the least I can do is tell them what I'm doing ("I'm going to give you a bath now, I'm just emptying your catheter") and I always thank them for letting me do what I have to do.
I talk to my hospice patients all the time - especially the unresponsive ones - and tell them all the steps of what I am doing,"I am getting the washcloth, now I am wiping your right eye, here I come over to the left eye..."
I don't know what the patients hear, if anything, but it dawned on me recently that the FAMILY is also listening and watching, and they are usually ever so grateful that their dying family member is still being treated with respect and dignity.
They sent her back from the hospital as comfort measures only. I don't understand why. And why wouldn't 'comfort measures' include giving them water/ice chips? Don't their mouths get parched?
If she's only responsive to pain that's fairly far gone and it's doubtful she's thirsty and wanting water. For more alert patients, it's not unheard of to provide fluids and food for comfort, regardless of aspiration risk. But your patient is only responsive to painful stiumuli so fluids/feedings aren't what she needs for comfort at this stage of the game.
By all means continue maticulous oral care, bowel care, positioning and liberal administration of comfort medications.
There's a difference between comfort measures and starving someone to death.
As to why they are providing comfort measures only, it's probably becaues agressive treatment at this point would be futile, as evidenced by her vegetative state. She's dying, it's good that the family accepts that, and you should try to understand and support that. It isn't easy because our society and nursing is gear on getting people well at all cost. It especially isn't easy for someone new, so I completely understand your feelings and it's great you're working through them.
i spoke to some of the other nurses today, and apparently she has a subdural hematoma. i guess that was what caused the seizure last thursday, and the lethargy. i'm assuming that most people (especially the elderly) don't recover from those?
subdural hematomas in the elderly are not uncommon because their brain tissue becomes very fragile. they can have a subdural hematomas and have to s/s for several weeks by which time they have detiorated to the point that they begin to experience seizures followed by permanent brain damage. at this stage there's no point in doing surgery.
A good article (and CE, if I'm not mistaken) on the last hours of living, general principles of palliative care, changes in physiology at end of life, etc. *(you may have to sign up with username and password, but you won't get junk mail from them)* Many nurses use glycerin-based products after mouthcare is given (usually at least q1h) to maintain moisture. Nystatin solution may be indicated, too, in event of thrush (not uncommon for lots of dying folks).
Your care for this patient and her family at this time is priceless and won't be forgotten, by them or you. All you can do is be there, ask questions of your colleagues, learn and keep caring as much as you do! Keep us updated!
Ugh. Its going on 19 days now and she's still alive. I'm actually to the point where I'm praying for her to go in her sleep... I just keep giving her p.o. morphine as much as possible.
She has prn ativan ordered too... does anyone think that I should give that with the morphine? The hospice nurses say she doesn't seem 'agitated', but I'm getting the impression that she is really aware, just unable to express it. (She responds to voices, can track things with her eyes, etc.)
God forgive me, but I want to dope the woman up as much as possible without actually killing her myself.
Penny8611
150 Posts
Boy, I can't agree with this enough. My Mom was NPO after her stroke, but was able to understand when she was told that a PEG would be necessary, even though she was really mentally out of it in the first few weeks after her stroke. Through therapy we were able to remove the PEG. She eats a little TOO well now. ;-)
I'm just a pre-nursing student and don't know ANYTHING about this kind of a situation (other than what I've witnessed with my Mother). I'm certainly not in a position to offer advice, but the situation you've outlined really troubles me. Thank you for being an advocate for her! Bless you.