Dealing with Family and feeding issues

[nkochrn, RN]

I have a patient who's dying of colon cancer. Social Services has spoke with the family and she's basically comfort care now. However one of her sons does NOT seem to get it. EVERY night he comes in and tries to force EVERY bite of food down here. He seriously sounds like he's coaching a whole football team, yelling, "Come on, Open UP, C'Mon, Let's Go!" I can't take it!

This is the first night I've heard him do it, but I've been told it's this way EVERY night. I'm not sure if it's just that he doesn't understand what's going on or if he thinks feeding her is gonna help miraculously cure her. I CAN NOT take it anymore though. She's sick, dying, and DOES NOT want to eat. I'm not sure what else to do other than just have Social Services and the Doctor try to explain things to him a little more tomorrow b/c he's obviously not getting something here. I'm not sure how to approach him about myself without causing a major blow up. She was previously in a bigger hospital and he himself told me he pretty much raised hell with them there about everything. It's to the point that I feel like he's abusing her in a way by forcing her to eat.

[Batman25]

I would gently tell him that she is comfort care and define what that is. Be nice and gentle but also firm. Let him know you know this is hard for him and sympathize with the loss that is to come. Ask if he'd like to speak to someone. Also, give him ways he can comfort her so he doesn't feel useless...rub her feet, wipe her mouth with a wet cloth, etc. Sometimes replacing one activity with another works. It will also give him the control he is so craving right now.

[nkochrn, RN]

I know this is TOTALLY unprofessional and I wouldn't really do it, BUT I'd really like to tell her tonight after he's gone that tomorrow when he's trying to force food down her throat to spit it in his face.

[Batman25]

Yeah, I would advise you to steer clear of that. lol I do however think forcing food down her throat could cause her to choke especially if she is starting to have swallowing difficulty. Bring that up to him too. Document.

[fiveofpeep]

I read an article once during my gero rotation that the act of anorexia during end of life is a protective effect of the body. It discussed how forcing food or even dextrose containing fluids can cause the patient incredible pain and discomfort because the body cannot function to eliminate it. The state of starvation helps to reduce pain and discomfort according to the article.

Have you heard of this too? I wish I kept the article so I could give it to you to print out.

Maybe if you told him this he would better understand how his actions arent helping her. Then you could redirect him to ways he can help her be more comfortable so he doesnt feel useless or guilty. Ill look for that article

[PostOpPrincess, BSN, RN]

He's in major denial.

Whatever you may try and do may not work.

Good luck....

[nkochrn, RN]

Yes I realize that not wanting to eat is natural and important for many reasons, but she is also alert and not having swallowing problems. I'm pretty sure the whole problem is his MAJOR denial.

ETA: She is alert at times, she kinda goes in and out of a lethargic state.

[heron, ASN, RN]

If she's alert and able to say no, then it's between her and her son, IMHO. At best, I could approach him about yelling at her ... verges on abuse ... but if he offers food and she takes it and swallows it with no aspiration or subsequent vomiting or abd pain, then I don't see how we can ethically stop it.

I would also make it a point to speak to the patient alone... ask her if she feels forced to eat and if she would want you to speak to her son about it. Document what she says.

If she is not oriented enough to be considered legally competent, then a chat with the POA or next of kin ... whoever is empowered to make her medical decisions ... would be in order, expressing your concerns and asking for direction.

In short: If a competent patient chooses to eat, we can't starve them. If a competent patient doesn't want to eat but can't say no to family, then maybe the pt will allow us to say no for her/him. If a pt is incompetent, then we need to follow the direction of the POA. Only if feeding is causing aspiration, gi symptoms or pain are we able to go against those expressed wishes.

It's a very hard one in comfort care. I once had a pt who was going through this. She had had quite enough of medical professionals and would barely speak to us ... turned her head away when we entered her room. As near as we could figure out, she was competent. She accepted food from her family until the day she aspirated so badly that she became obtunded, congested and hypoxic over the next few hours and died within 2 days. Imagine how that family feels now.

[tewdles, RN]

this is a common occurrence in hospice care...family members who are not accepting of the terminal nature of their loved one's illness.

There are wonderful resources that are most likely available through your social workers which will help this man take the next step in his grieving process. Please ask your MSWs and pastoral care for some assistance with this family.

[heron, ASN, RN]

this is a common occurrence in hospice care...family members who are not accepting of the terminal nature of their loved one's illness.

There are wonderful resources that are most likely available through your social workers which will help this man take the next step in his grieving process. Please ask your MSWs and pastoral care for some assistance with this family.

What she said! Excellent suggestion.

Just bear in mind that real people don't always grieve in neat little steps like in the books ... and we don't get to decide when it's time for him to move on from denial.

If the son is ready, those resources could be just what is needed to trigger the change. If he's not ready, pushing on his denial could trigger more of the same resistance and upset, aggravating rather than helping the problem.

No way to predict, IMHO ... the only way to find out is to try, but not push him to go through it if he's not ready.

He's losing his mom ... and we don't get to dictate how he deals with it.

[leslie :-D]

He's losing his mom ... and we don't get to dictate how he deals with it.

true...

and so, the pt is the one who suffers because her son can't deal?

sorry, but i have told those in denial, that their actions are only contributing to pt's distress and suffering.

typically, they'll become even more upset and demand to see the dr.

enter the doctor, who vindicates every word i've said.

and then we elicit more support for family member.

everyone on the hospice team, should be on the same page and present a united front.

i refuse to placate a family member by sacrificing any part of the pt's comfort and well-being.

leslie

[nkochrn, RN]

true...

and so, the pt is the one who suffers because her son can't deal?

sorry, but i have told those in denial, that their actions are only contributing to pt's distress and suffering.

typically, they'll become even more upset and demand to see the dr.

enter the doctor, who vindicates every word i've said.

and then we elicit more support for family member.

everyone on the hospice team, should be on the same page and present a united front.

i refuse to placate a family member by sacrificing any part of the pt's comfort and well-being.

leslie

This is EXACTLY what I was thinking!!!

I did try to ask her about not wanting to eat tonight when he was out of the room while we were turning her. I asked if she ate and she said yes, so I asked her if she wanted to and she shook her head no and then clamped her mouth shut. I'm thinking that not opening your mouth when someone puts a spoon to it and you're alert and somewhat oriented is a pretty good sign you DO NOT want to eat!