DNR-Comfort measures

DutchgirlRN, ASN, RN · Feb 28, 2006

I get a little confused about this two..no, actually just the "comfort measure"...I find it hard to just do that...I know the family consented to it as well but seeing the patient and the family suffer makes my heart melt..can someone tell me the best way to care for this patient without feeling like I'm slowly killing this person........

When we have a patient on comfort measures they always have IV pain meds, usually Morphine, ordered on a very frequent PRN basis. I would find it very difficult to care for a dying patient who was gasping or moaning in pain. I can't fathom the doctor who would let this happen. Either do everything or nothing and make the patient comfortable. No in-betweens.

Legal Myths May Prevent Comfort Measures to Dying Patients

The panel was convened in 1997 to offer recommendations on how to improve care of the dying.

The authors describe seven myths about end-of-life care that may prevent appropriate treatment of the dying patient:

Myth 1: It is necessary for a comatose patient to have previously made known his wishes that, if faced with a terminal illness, he would refuse life-sustaining treatment. According to the consensus panel, most states would allow life-sustaining treatment to be stopped if the family perceives that to be the patient?s wish ? even if the patient never expressed it himself. Only four states -- New York, Missouri, Michigan, and Wisconsin -- need proof of the patient?s wishes.

Myth 2: It is illegal to stop or withhold intravenous fluids, or to withhold feeding through a tube for an unconscious patient. Once again, if the family thinks this is the patient?s wish, fluids and nutrition can be withheld. Most courts have ruled this is legal with a few exceptions. This can be a problem in nursing homes, where administrators require written statements, such as a living will, to avoid being a target of government investigation.

Myth 3: The hospital?s risk management department must be informed if life-sustaining treatment is stopped. Telling the risk manager is usually unnecessary, but some hospital officials worry about legal liability. This may cause problems because some doctors may be too cautious and continue to use ventilators or artificial nutrition and fluids, even when it disagrees with a patient?s wishes.

Myth 4: Advance directives like living wills or health care power-of-attorney must be written on specific forms authorized by the state and cannot be transferred to another state. This is not true, according to the authors of the article. They say the content is more important than the form and is almost always recognized, even across states, as the best evidence of the patient?s wishes. But official-looking documents may carry more weight especially with doctors who are not familiar with the patient.

Myth 5: A doctor can be criminally prosecuted if he or she causes a patient?s death by giving high doses of medication to relieve pain. As long as the doctor was only trying to relieve the pain and not end the patient?s life, he or she is usually safe from prosecution, according to the authors. This can be a problem because it is often hard for doctors to prove their intent. Until there is laws are passed in more states to protect doctors in this situation, some will take the legally safest course and undertreat patients.

Myth 6: There is no legally permissible way to ease the suffering of a terminal patient when the pain medications are not sufficient. Even the Supreme Court accepts the notion of "terminal sedation" where a patient is given enough sedatives to make him unconscious, or life-sustaining nutrition and fluids are withheld. Even if these measures hasten death, it is acceptable as long as they are done to relieve suffering.

Myth 7: Physician-assisted suicide is illegal. In 1997, the Supreme Court ruled to leave the decision on physician-assisted suicide to each state. In 1994, Oregon voters approved the Death with Dignity Act, which allows a doctor to prescribe a lethal dose of medication requested by a competent, terminally ill person. The medication must be self-administered. Although it is an "open secret" that physician-assisted suicide does occur outside Oregon without criminal prosecution, it remains legal only in that state, according to the authors of the JAMA article.

Ira Byock, MD, a member of the panel and past president of the American Academy of Hospice and Palliative Medicine, says these myths keep patients from getting effective pain control. "Even though few physicians can articulate these myths, they exist below the surface. Physicians are often unsure of the law concerning the point at which intensive pain control ends and euthanasia begins," he says. "Doctors need to focus on doing the right thing, doing it with well-considered reasons, documenting what is done, and having conversations with the patient and family."

"There are also other reasons why people fail to get good pain control," Byock adds. "Patients and their families have misconceptions and worries, such as fears about addiction, concern about side effects, and that taking pain medicines too early may prevent them from working later. All these contribute to the avoidance of good pain treatment and affect prescribing on the part of the physician."

http://www.cancer.org/docroot/NWS/content/NWS_2_1x_Legal_Myths_May_Prevent_Comfort_Measures_for_Dying_Patients.asp

FreshRN05 · Feb 28, 2006

Wow! Thank you for this valuable information...........

leslie :-D · Feb 28, 2006

I get a little confused about this two..no, actually just the "comfort measure"...I recently had a patient who was a DNR but the family requested comfort measure (IV therapy and IV antibiotics ok also)....My patient was a 78 years old with pleural effusion, status post chest tube insertion...hx fo CHF and renal failure on top of it....the patient's condition was deteriorating right infront of our eyes....BS went down to 20's (given amp of D50 and IV maintenance of D10), ALOC, his pupils unequal...but patient was still responsive although slow....Anyhoo, one of the nurses at work told me that when a patient is a DNR, there's really nothing else we can do but make him comfortable...but really I find it hard to just do that...I know the family consented to it as well but seeing the patient and the family suffer makes my heart melt..I feel so helpless....especially when I hear the patient moan and trying to catch his breath.......can someone tell me the best way to care for this patient without feeling like I'm slowly killing this person........

i don't think there are any absolutes for what connotes comfort measures. where i worked, comfort measures would have meant no iv's so i think it's per facility policy & procedure. one thing i can tell you for sure is comfort measures will NOT let the pt. suffer in any way, which means there is no reason in the world why he should be moaning and gasping.:stone this is unconsionable!! he should be on atc mso4 with the goal of reducing his air hunger and any associated pain/discomfort. as long as your intent is to dissapate any suffering, then you will never be held liable for wrongdoing if he should ever pass prematurely or earlier than expected. i hope you make it a priority to get him the pain relief he so obviously needs.

leslie

outlierrn · Feb 28, 2006

Although it varies from place to place, the exact meaning varies most importantly from CASE to CASE. Understand that ALL of your pts are going to die, allowing them to pass easily is not killing them. Facilitating a comfortable, peacefull experience for the pt and their family is as real as nursing gets, good luck to you,

Larry

Indy, LPN, LVN · Feb 28, 2006

Although it varies from place to place, the exact meaning varies most importantly from CASE to CASE. Understand that ALL of your pts are going to die, allowing them to pass easily is not killing them. Facilitating a comfortable, peacefull experience for the pt and their family is as real as nursing gets, good luck to you,
Larry

I agree 100%. When you take away the telemetry, the consults, the tests, and they get to the point that they don't take PO meds, what you're left with is your two hands, your narc drawer, hopefully a patent IV, and a person in their most vulnerable state since babyhood. I've seen only a few of my patients in this state and yet I feel drawn to them. I questioned my ability to give out morphine every hour for an increased heart rate and respiratory rate, thinking that I couldn't bear to be one who would hasten death. When the patient came around who decided to die anyhow, in spite of what everyone else wanted for him, and in great pain, I was pretty scared when I called and got the orders for his pain meds, and promptly started administering them. What I found out was that I could not watch this man suffer without doing something.

I do have some questions though. Is air hunger uncomfortable for the patient once they're in a light coma? Does morphine actually help with the large amount of respiratory secretions (I call it gargley breathing... I can not stand that sound... drives me up the wall) or does it just suppress the breathing altogether? Is there anything besides suctioning that helps with the secretions? Does suctioning make it worse for the patient?

Iluvhospice · Feb 28, 2006

I work on an oncology floor, so we spend a lot of time with patients who are comfort measures only.

The "gargly breathing" that usually signals near death can be helped with suctioning (but that's often not very comfortable and can be downright scary) but often the docs order a scopalamine patch to dry the secretions. It is placed behind the ear and is painless and helpful.

Hope this helps.

And thank God for IV Morphine and the comfort it brings.

Jess_Missouri_RN · Nov 27, 2011

Had my first DNR pt. die Thanksgiving night. 93 years old and showed no signs of distress at 2200 but when I walked in at 2300 she had only minutes to live, she had gargly breathing and I yelled for a fellow nurse and respiratory that were standing in the hall. They came in, grabbed a pulse ox, asked if DNR, I responded yes, told me to go check the chart for papers and call the daughter, did that and walked in and she had a non rebreather mask on O2 stats of 60's and heart rate in 40's, took her last breath and that was it, it was over.

Personally was horrible but I was glad I could be there for her last few moments, she didn't die alone and I am so glad I got up from the nurses station when I did to walk by her room and hear her gargly breathing.

Iluvhospice · Nov 27, 2011

Since I last posted in this thread, I have worked in hospice for more than 5 years. The increased tracheal secretions are simply the result of no longer being strong enough to swallow the saliva/secretions that you and I are swallowing all day long. It does not impede air flow and is not uncomfortable to the patient, only to those who are listening to it. Atropine drops sublingually or Scopolamine topically are both very good at drying secretions. Scopolamine takes more than 24 hours to take effect, so getting an order for 1% Atropine drops (they are the drops that optometrists use to dilate eyes) is always a great comfort measure. If a patient is tachypneic or dyspneic - then Morphine is your drug of choice - not because it slows respirations but because it loosens up bronchioles/bronchi and assists with blood flow (the same reason it is a primary drug for heart attack - remember MONA - Morphine, Oxygen, Nitro, and Aspirin?) I'm sorry that this patient's death was horrible for you. I hope it helps to know that it may not have been as horrible for her as it was for you. God bless your work!

carolmaccas66, BSN, RN · Dec 4, 2011

I've worked hospice, and we give pain meds of course, and make the patient comfortable - lots of pillows, 02 via NS, they get put on a special air mattress, mouth care x 3, etc.

But I have not had a hospice patient on IV ABX & fluids. There isn't any point. If they are going into total organ failure (TOF) then giving fluids and ABX does not do anything - their body can't process the drugs anyway. The family is in the room also, so you don't want to be turning and prodding them too much - they need peace to slip away with their loved ones by their side. Imaging if you were dying, and someone decided to shove a cannula in you, or prick you constantly to get blood - is that what you would want?

You probably heard a lot of horrible noises too when the person was dying. Death is not like it's portrayed on TV - there is a lot of fluid build up in the heart and lungs, you get Cheyne Stokes breathing just before death which is awful to listen to. Relatives get very distressed at this sound, but it means the end is near.

The best thing you can do is literally keep them comfortable, comfort the relatives and assure them their loved one is not in pain. Our primary goal as nurses for hospice patients is ensuring they do not have pain (or very little) before they die.

You will see a lot of this. If you need to de-brief, find a counsellor or another senior nurse to talk to, because this is part of the job. Also writing a diary after events happen can help alot, as it helps your brain process and sort all the information & conflicting feelings you have.

You did nothing wrong. You just reacted to a bad situation that is going to happen a lot. People die, and it's not always nice. Give yourself a break - you did not 'kill' him. He was dying, and there comes a point as a nurse where you have to say: well there is nothing else I can do to stop him dying, I will just keep him comfortable.

Pediatric Critical Care Columnist · Dec 4, 2011

This is a very old thread. It dates back nearly 6 years. I expect the OP has learned how to deal with the emotional impact of providing comfort care to dying patients.

This thread makes me think of the time I gave a dose of morphine to a baby who had already died, but the parents who were holding the child didn't realize it and wished to continue holding their baby. The baby was on mechanical ventilation and we were waiting for the physician to return and pronounce; the ventilator continued to chug away at a rate of 40 so it felt to the dad that the baby was struggling. Rather than add to their pain, I chose to give the morphine even though I knew the baby wasn't feeling anything any more. I would do it again, too.