Dying, unresponsive patient and assessing pain

RN403, BSN, RN · Sep 20, 2015

I believe you did the right thing. Don't be so hard on yourself.

Moaning, agitation, facial grimacing, all can indicate pain and would warrant the PRN pain medication if safe to give.

Even though you are no longer assigned a mentor there must be a supervisor or fellow nurse you can reach out to on your shift for questions, no?

Best wishes.

quiltynurse56, LPN, LVN · Sep 20, 2015

I believe you did the right thing. Don't be so hard on yourself.
Moaning, agitation, facial grimacing, all can indicate pain and would warrant the PRN pain medication if safe to give.
Even though you are no longer assigned a mentor there must be a supervisor or fellow nurse you can reach out to on your shift for questions, no?
Best wishes.

I agree. I have a resident who went on hospice Friday. Has not eaten for a few days. Will she wasn't saying much, you could see her face grimace, she was crying and moaning. Since she had just been admitted on hospice, I was the one to start her Roxanal. I gave her first PRN dose, then her second an hour later. About 2 hours later I gave her her scheduled dose. The next time I stopped in to check on her, she was sleeping so I chose not to give her another dose of PRN. If she would have woken during my shift and started some of the nonverbal pain cues, I would have gone ahead and given her a PRN does. Want to keep on top of the pain.

I agree, talk to your supervisor or another nurse you have learned to trust to get their opinion on what you should do. We don't want them to be in pain, but we don't want to give them the pain med when they don't need it either.

tsm007 · Sep 20, 2015

I am an agency nurse so technically not an employee there. I'm by myself at night. Although there is another nurse I can call in the other building if I need to. At the time I was confident with my decision, but made a note to myself that I wanted to read up more on assessing nonverbal responses to pain. I just wanted to make sure I didn't miss something. I find that I often second guess my decisions and trying hard to build my knowledge base so I'm not so insecure. I have found a couple people I can ask questions too, and when they are there I soak up everything I can.

Jensmom7, BSN, RN · Sep 20, 2015

Ugh, I hate this first year of nursing. I really wish I had a mentor, but for now AN is it.
Okay, onto my question. I was taking care of a hospice patient that was actively dying, unresponsive and had been NPO for 8-9 days. He had an order for Roxanol q 2hrs prn for pain. The nurse before me said she had been giving it every 2 hours for pain because he had some moaning and that his respirations were 4 and she expected him to die my shift. She recommended just giving him the Roxanol q 2 hrs. So I gave him Roxanol right when I came on shift due to her reports of moaning and pain and saying he was due for another dose. I talked to the family, did my assessment. Respirations were now 10. Every time I walked down the hall I sort of poked my head in to check on him. Two am went in to see how he was doing because I was going to give him another dose, but he wasn't moaning and didn't seem to be in pain that I could tell. The daughter was sleeping at bedside so I just kind of left them be. I repeated the same thing checking on him throughout and at 4 am he still didn't seem to be moaning and I couldn't really see anything that indicated he was in pain so I talked to the daughter who was now awake. I explained to her that I had checked on him at 2am and 3am and they were both sleeping and he didn't really seem to be in pain at that time so I let him be for now. I told her I could give him another dose if she'd like, but he wasn't showing any signs of pain. She said she kind of thought the same thing that he wasn't moaning like he was earlier and didn't seem like he was pain and honestly I think she was just looking for me to reassure her that he wasn't in pain.
Now, I am sitting here feeling bad because truth be told I am not 100% sure if I made the right decision. I sort of felt like the previous shift might have been trying to hasten death by giving it q2 hr instead of q2 hr prn, but I don't know. I wasn't there to assess him then. I don't feel like I was "holding" medication from him. It was ordered prn. Of course, at the same time I am not very good at assessing pain in unresponsive people yet. He didn't seem restless. He wasn't moaning. Can some of you give me some ideas on what things to look for to determine pain in unresponsive people? Do you think I made the right call on this? This is nursing judgement stuff is hard.

Ok, Hospice Nurse here. You did it right, and so did the Nurse ahead of you.

She gave the med based on non-verbal cues (the moaning). So it was still being given as a prn, he just needed it every 2 hours.

Your assessment determined that he was not showing any non-verbal signs of pain, he was comfortable, with no restlessness or respiratory distress. You quite rightly let him be, and checked on him frequently.

You discussed it with the daughter when she woke up, and she agreed with you. Again, you did the right thing.

Always remember, if you aren't sure about how to handle a Hospice patient (we ARE a specialty, even though we aren't acute or critical care, and there is specialized knowledge we don't expect non-Hospice Nurses to have at their fingertips) you can always call the Hospice agency. During working hours, you can talk to the patient's Case Manager, after hours there is always someone available, either on call or triage.

We actually prefer that you call us if you're unsure about something. Part of our job is to provide support to the caregivers, and that includes the facility staff.

Jensmom7, BSN, RN · Sep 20, 2015

I agree, talk to your supervisor or another nurse you have learned to trust to get their opinion on what you should do. We don't want them to be in pain, but we don't want to give them the pain med when they don't need it either.

Yes, you should talk to someone, but it should be the Hospice Case Manager (the Nurse) if you are unsure what you should do.

If necessary, the Hospice Nurse can make a visit and assess the patient's needs.

Please, don't worry about addiction when it comes to Hospice patients, especially when they're transitioning or imminent. They may develop a physical tolerance and require increased doses, but that is NOT addiction, because the med is being given for the purpose intended, not to get high.

Better a Hospice patient get a dose even without obvious signs of pain than to have it withheld "because they don't need it."

tsm007 · Sep 20, 2015

Ok, Hospice Nurse here. You did it right, and so did the Nurse ahead of you.
She gave the med based on non-verbal cues (the moaning). So it was still being given as a prn, he just needed it every 2 hours.
Your assessment determined that he was not showing any non-verbal signs of pain, he was comfortable, with no restlessness or respiratory distress. You quite rightly let him be, and checked on him frequently.
You discussed it with the daughter when she woke up, and she agreed with you. Again, you did the right thing.
Always remember, if you aren't sure about how to handle a Hospice patient (we ARE a specialty, even though we aren't acute or critical care, and there is specialized knowledge we don't expect non-Hospice Nurses to have at their fingertips) you can always call the Hospice agency. During working hours, you can talk to the patient's Case Manager, after hours there is always someone available, either on call or triage.
We actually prefer that you call us if you're unsure about something. Part of our job is to provide support to the caregivers, and that includes the facility staff.

That's terrific advice. The outgoing nurse told me the hospice number, but I didn't realize I could call them for advice. The nurse before me had told me I should just continue giving it around the clock. That is partially what made me question my judgment. She knows I'm a new nurse and is pretty good about giving me tips and such so I wasn't sure if maybe there was an assessment I was missing.

tsm007 · Sep 20, 2015

Yes, you should talk to someone, but it should be the Hospice Case Manager (the Nurse) if you are unsure what you should do.
If necessary, the Hospice Nurse can make a visit and assess the patient's needs.
Please, don't worry about addiction when it comes to Hospice patients, especially when they're transitioning or imminent. They may develop a physical tolerance and require increased doses, but that is NOT addiction, because the med is being given for the purpose intended, not to get high.
Better a Hospice patient get a dose even without obvious signs of pain than to have it withheld "because they don't need it."

I wasn't worried about addiction and I know that in hospice patients sometimes it's necessary to give narcotics even when it is suppressing respiration. I just am not sure besides moaning or facial grimacing, or restlessness if there is anything else that would indicate he was in pain. Thank you for your help.

Jensmom7, BSN, RN · Sep 20, 2015

That's terrific advice. The outgoing nurse told me the hospice number, but I didn't realize I could call them for advice. The nurse before me had told me I should just continue giving it around the clock. That is partially what made me question my judgment. She knows I'm a new nurse and is pretty good about giving me tips and such so I wasn't sure if maybe there was an assessment I was missing.

Sometimes, the most important thing is to know who your best resource is.

With a Hospice patient, you'll never go wrong talking to one of the Hospice nurses when you have a question or concern. Especially if you work an off shift and don't get to see the nurse during the day.

Jensmom7, BSN, RN · Sep 20, 2015

I wasn't worried about addiction and I know that in hospice patients sometimes it's necessary to give narcotics even when it is suppressing respiration. I just am not sure besides moaning or facial grimacing, or restlessness if there is anything else that would indicate he was in pain. Thank you for your help.

Didn't say you were. This was a reply to another poster. I already told you that you did it right!! ðŸ‘

UTHSC_Bound, BSN · Sep 21, 2015

I just am not sure besides moaning or facial grimacing, or restlessness if there is anything else that would indicate he was in pain.

Im not in palliative care, but in my area we often consider pain as a possibility with a spike in blood pressure.

Jensmom7, BSN, RN · Sep 21, 2015

Im not in palliative care, but in my area we often consider pain as a possibility with a spike in blood pressure.

Doesn't always work that way at end of life, though.

Blood pressure is the least reliable vital sign for determining much of anything. I've had patients who had a pretty "normal" blood pressure until they took their last breath, and other patients I couldn't get a reading on 3 days before they died. If someone's getting close, most of the time I don't even bother with BP.

Pulse, respirations, terminal restlessness, fever (not related to infection, temperature control mechanism in the brain goes wonky as the CNS is shutting down) are what we focus on as someone transitions or is imminent.