I am having a trouble understanding the process of one of my residents.
She is 94, alert and of sound mind. She is capable of making her own decisions.
She came to our LTC facility about a month ago after suffering a stroke that left her, for the most part, unable to swallow. She was going to therapy to assist her with this problem.
She is not able to have a feeding tube because of an abdominal aortic aneurysm but, she was seemingly doing just ok with eating and drinking altho it was difficult.
About a week ago, she was admitted to the hospital for aspiration pneumonia. This did not surprise anyone because of her difficulties.
She returned to our LTC very weak. She was once an easy 1 person transfer. Now, she is bed ridden. She is also NPO now. When I asked her nurse how she gets her nutrition if she is NPO the nurse replied she is hospice, she doesn't get nurtrition at all. She will eventually die.
I am having a hard time accepting this! I know it is NOT my decision. It is really none of my business. My only place in this is to provide care for her and keep her comfortable.
She is still alert and of "sound mind". She asks me to give her a small cup of water so she can suck water from a sponge. I CAN'T do this. I remind her that I am not allowed to.
The nurse has been very clear on my not giving her ANYTHING because she can choke and die.
So, instead, I have to watch her literally die of starvation...and I watch her family all day, every day trying to cope with this.
Tell me something about this process to make it easier. I've search the internet trying to learn more about aortic aneurysm, but nothing is helping. I know it is probably a decision she and her family made, but how do you tell someone they can't have a sip of water when you know they've not had any nutrition in about 4 days.
Water should be fine as long as she isn't going to aspirate but TPN or tube feeding would be inappropriate.
Sounds like aspiration is definitely the problem. Her risk of aspirating is just too high to even attempt sips of water. Even aspiration of water can cause much bigger problems if the mouth isn't basically pristine. There is a practice called the Frazier Free Water Protocol, which enables NPO patients and patients on thickened liquids to have sips of plain, thin water at certain times of the day. However, it requires meticulous mouth care before the sips can be given. I think aspiration pneumonia and sepsis would be much more distressing to everyone involved, especially the patient.
Sounds like aspiration is definitely the problem. Her risk of aspirating is just too high to even attempt sips of water. Even aspiration of water can cause much bigger problems if the mouth isn't basically pristine. There is a practice called the Frazier Free Water Protocol which enables NPO patients and patients on thickened liquids to have sips of plain, thin water at certain times of the day. However, it requires [i']meticulous[/i] mouth care before the sips can be given. I think aspiration pneumonia and sepsis would be much more distressing to everyone involved, especially the patient.
I work hospice and have met many patients to whom aspiration pneumonia and its risks were fully explained, and they chose to eat and drink anyway as long as they were able. They decided the comfort and satisfaction of being able to eat and drink was worth what they might suffer later. This woman is A&O, why shouldn't she be allowed to decide which risks she's willing to take?
Any patient has the right to refuse to participate in any part of any plan of care. If this woman does not have a legal guardian because she has been legally declared incompetent (and no, this is not a nursing or medical decision, it's very specifically a LEGAL decision) then she has every right to have whatever the heck she wants. Moreover, it's illegal and immoral to refuse her. As RK says, it's her choice. She can refuse to be NPO. Yes, she can. She CAN.
She's 94, she knows all about death, she's seen her grandparents, parents, siblings, and friends die, she knows she's near the end of her life, and she has ever right to have the end of her life be the way she wants it. She apparently knows about aspiration; if she doesn't, someone can explain it to her, if necessary every time she asks for mercy/succor, and then she can say yes, she understands, and please may she have some water.
Oh, and they don't call pneumonia "the old man's friend" for nothing. It's a lot less distressing than unremitting thirst and cruelty.
Your facility should have an ethics committee or an ethics person on call for this sort of thing. If she is on hospice, the hospice service chaplain and social worker (required elements for hospice) can help explain it. Meanwhile, you go on being merciful with as much as you can.
I agree with a lot of what people have said. Just because one nurse says she cannot have anything doesn't make it so. If she is still legally responsible for herself, she has any and every right to refuse to remain NPO. Are you another nurse or a CNA? Maybe bring it to the DON's attention or someone higher up than this nurse. If she will choke and die from water...and she knows this and still wants it, it is her right.
Water denied to a DNR patient on hospice who is asking for water? That is just cruel. That is a violation of patient rights. She should be able to have water if she wants to after really good mouth care has been done, and the risks of aspiration have been explained to her. I agree with those who said to go over the nurse's head to the manager or someone else who you know will be sympathetic and will okay the water.
Specializes in Mental Health, Gerontology, Palliative.
We have several patients who are a major aspiration risk. We get around this by using thickened fluids, soft and puree diet and having all their meals supervised.
We had one person who was steadily loosing weight, on investigation it turned out this person was so scared of choking on their food they were choosing not to eat. By using thickened fluids a puree diet, and having this person being fed, we have seen a very small weight gain approx 700grams however when compared with the steady loss...
Palliative/end of life does not mean no food. I tend to advocate for people to eat what ever they are in the mood for and to not worry about having a full meat and three veg type of meal. We had one patient who passed recently who ate mostly scrambled eggs and ice cream over the last days.
Personally I would be going higher. Sure, it may mean that this lady has to be fed however if she is able to tolerate food and fluids she should have the option if she wishes
Is this lady at risk for aspiration? Yes, of course she is. Is that a good reason to keep her NPO in this case? NO.
A SNF I used to work in had standard LTC, memory care, subacute rehab, and assisted living all under one roof. I worked on the subacute floor, and one of our residents was there from AL. He'd been released from the hospital for aspiration pneumonia and was NPO and being tubefed. His goal was to go back to his AL apartment. He was completely alert and oriented, but no matter how many times we walked him through it, he couldn't get the hang of giving himself his own tubefeeds...and he WANTED to eat. You know what we eventually did after weeks of tubefeed teaching? He made the decision to forget the tubefeeds, go home, and eat whatever he darn well wanted to eat. He made this decision knowing full well that he was going to aspirate and die. But he was 93, and he wanted to be in his own place, with his giant CD collection and a piece of lemon meringue pie. He died two weeks later. But he died listening to his music and having enjoyed that pie. He lived out his life on his own terms and enjoyed it until the end. What made him miserable was being in a single room and being tubefed. That and "feeling stupid" that he couldn't get the technique down.
This woman is 94 and on comfort care. Right now, thirst is causing her significant discomfort. I can't even imagine...I know when I get thirsty, I get nauseated, my heart races, and I feel almost panicky. If she is of sound mind and can understand the risks of aspirating and dying of pneumonia and chooses to take those risks, that is HER right and HER choice. She can have steak and lobster with champagne as far as I'm concerned. I agree that you need to take this higher than the nurse.
Respect for human dignity requires the recognition of specific patient rights, particularly, the right of self-determination. Self-determination, also known as autonomy, is the philosophical basis for informed consent in health care. Patients have the moral and legal right to determine what will be done with their own person; to be given accurate, complete, and understandable information in a manner that facilitates an informed judgment; to be assisted with weighing the benefits, burdens, and available options in their treatment, including the choice of no treatment; to accept, refuse, or terminate treatment without deceit, undue influence, duress, coercion, or penalty; and to be given necessary support throughout the decision-making and treatment process. Such support would include the opportunity to make decisions with family and significant others and the provision of advice and support from knowledgeable nurses and other health professionals. Patients should be involved in planning their own health care to the extent they are able and choose to participate.
Each nurse has an obligation to be knowledgeable about the moral and legal rights of all patients to self-determination. The nurse preserves, protects, and supports those interests by assessing the patient's comprehension of both the information presented and the implications of decisions. In situations in which the patient lacks the capacity to make a decision, a designated surrogate decisionmaker should be consulted. The role of the surrogate is to make decisions as the patient would, based upon the patient's previously expressed wishes and known values. In the absence of a designated surrogate decision-maker, decisions should be made in the best interests of the patient, considering the patient's personal values to the extent that they are known. The nurse supports patient self-determination by participating in discussions with surrogates, providing guidance and referral to other resources as necessary, and identifying and addressing problems in the decision-making process. Support of autonomy in the broadest sense also includes recognition that people of some cultures place less weight on individualism and choose to defer to family or community values in decision-making. Respect not just for the specific decision, but also for the patient's method of decision-making, is consistent with the principle of autonomy.
Individuals are interdependent members of the community. The nurse recognizes that there are situations in which the right to individual self-determination may be outweighed or limited by the rights, health and welfare of others, particularly in relation to public health considerations. Nonetheless, limitation of individual rights must always be considered a serious deviation from the standard of care, justified only when there are no less restrictive means available to preserve the rights of others and the demands of justice.
Patients have the moral and legal right to determine what will be done with their own person; to be given accurate, complete, and understandable information in a manner that facilitates an informed judgment; to be assisted with weighing the benefits, burdens, and available options in their treatment, including the choice of no treatment; to accept, refuse, or terminate treatment without deceit, undue influence, duress, coercion, or penalty; and to be given necessary support throughout the decision-making and treatment process. Such support would include the opportunity to make decisions with family and significant others and the provision of advice and support from knowledgeable nurses and other health professionals.
emphasis mine, and I'm sorry I can't make it bigger and more impressive.
Advice and support... there's nothing in there about "...and make the choice for her, and enforce it."
So, OP, what will you do? (Besides print out Here.I.Stand's excellent excerpt!)
Boog'sCRRN246, RN
784 Posts
Sounds like aspiration is definitely the problem. Her risk of aspirating is just too high to even attempt sips of water. Even aspiration of water can cause much bigger problems if the mouth isn't basically pristine. There is a practice called the Frazier Free Water Protocol, which enables NPO patients and patients on thickened liquids to have sips of plain, thin water at certain times of the day. However, it requires meticulous mouth care before the sips can be given. I think aspiration pneumonia and sepsis would be much more distressing to everyone involved, especially the patient.