Having a bit of a disagreement among our clients care team - some input would be nice, having a hard time finding any literature on the topic.
I have a patient who is on comfort care only, has had a trach for years and is not on a ventilator.
Patient's pain and air hunger is well controlled with MSIR and Ativan and is "brain dead" according to doc's.
I personally don't feel that a deep trach suction is compatible with comfort cares if the patient appears comfortable. I don't think the pain and discomfort of a deep suction will improve the patients comfort level for how invasive it is.
If the patient was brain dead, none of this would be an issue as brain death is determinant of death. He's obviously not, as he's breathing on is own. The brain is what controls breathing, if it's dead, the patient doesn't breathe.
Does the patient appear to be uncomfortable when suctioned? Does his DNR specify anything about suctioning? In peds, DNRs tend to be VERY specific and would outline whether or not the parents wanted suctioning.
Agree with the other "brain dead" comments; he's not. GCS of 4, spontaneous respirations=not brain dead. One of the determinants even before the official brain death testing even happens is the pt cannot be overbreathing the vent AT ALL. So if the rate is set at 12, and we happen to see "13" as the total rate, we wouldn't even call MDs to do the testing.
But anyway, that wasn't your question. :) I agree with you 100%.
First off, a pt can have crackles on auscultation and not having discomfort. Have you ever had pneumonia? I've had it a few times; I've had crackles on auscultation, but zero air hunger. Miserable and coughing, yes; but 1) not coughing continuously, and 2) not needing mechanical help to clear secretions. In fact, when I was 8 y/o I had it badly enough to need a 3-week hospitalization after many weeks of treating it at home w/ various PO antibiotics. I don't remember ever "having a hard time breathing." I know my parents and MDs asked me all the time, and I always said "no."
So anyway, my point is crackles heard w/ a stethoscope don't mean that a pt is having discomfort that warrants suctioning.
This is a comfort care pt; like Big Al said, deep suctioning would increase secretions, and is very uncomfortable. Second, since he's not showing distress from secretions, he wouldn't need suctioning at all. Now if he's audibly rattling and the family is distressed I might do a little superficial suctioning, and also administering SL atropine and/or TD scopalomine to decrease the secretions.
The use of any sort of suctioning in a patient on comfort care depends on the patient's wishes in balancing distress and avoiding artificially prolonging death, but the default position for comfort care is usually that you are no longer trying to reverse or alter their natural course, which means no suctioning. If the decision to suction is based on the need to treat severe distress it's one thing, but I often find that people feel the need to suction because they're worried the patient will die due to lack of suctioning, which sort of misses the point.
Specializes in Vents, Telemetry, Home Care, Home infusion.
So anyway, my point is crackles heard w/ a stethoscope don't mean that a pt is having discomfort that warrants suctioning.
This is a comfort care pt; like Big Al said, deep suctioning would increase secretions, and is very uncomfortable. Second, since he's not showing distress from secretions, he wouldn't need suctioning at all. Now if he's audibly rattling and the family is distressed I might do a little superficial suctioning, and also administering SL atropine and/or TD scopalomine to decrease the secretions.
Agree 100%: Comfort care= keep patient clean and comfortable with least intervention and tons of family/ caregiver education.
Little crackles on auscultation with no signs struggling to breathe, not coughing, no thick secretions in trach tube on cleaning -leave alone. Audible rattles not improved with turning to side position + family distressed, light suction, use SL atropine and/or TD scopalomine
Specializes in Psych, Addictions, SOL (Student of Life).
Wait....what?!
I had the same thought - is patient brain dead or in persistent Vegetative state - In any case if patient appears comfortable and not exhibiting air hunger and sounds that they are drowning in their secretions I agree that deep suctioning should be avoided.
We use atropine opthalmic drops 1-2 drops SL as needed, or hyoscyamine 0.125 mg SL as needed. It may or may not make a difference, but the appearance of concern and treatment comforts the family. Suctioning would not be appropriate in this case.
We use atropine opthalmic drops 1-2 drops SL as needed, or hyoscyamine 0.125 mg SL as needed. It may or may not make a difference, but the appearance of concern and treatment comforts the family. Suctioning would not be appropriate in this case.
I am so glad you posted this! Just today at clinicals I was working with a fairly new LPN who was caring for her first hospice patient. I am a pretty experienced hospice CNA and knew atropine is used to help reduce secretions but had no idea ophthalmic drops could be used SL. She seemed fairly flummoxed by the order, but we determined together that there wasn't anything in the drops that would be harmful taken orally, so she went ahead and gave it according to the order.
Frankly, it's not going to make any difference. Based on my experience, the lady is going to pass in the next 12-24 hours. But at least now I know, for next time, that the practice isn't completely out of left field.
Specializes in Mental Health, Gerontology, Palliative.
The idea of comfort cares as I understand is that it involves care designed to make a patient comfortable in that end of life stage.
As others have said, deep suctioning may well stimulate secretions and if the patient is comfortable without the suctioning, it would seem rather daft to introduce something that by its very nature would be invasive and distressing.
KelRN215, BSN, RN
1 Article; 7,349 Posts
If the patient was brain dead, none of this would be an issue as brain death is determinant of death. He's obviously not, as he's breathing on is own. The brain is what controls breathing, if it's dead, the patient doesn't breathe.
Does the patient appear to be uncomfortable when suctioned? Does his DNR specify anything about suctioning? In peds, DNRs tend to be VERY specific and would outline whether or not the parents wanted suctioning.