end of life care.. how could I have done better?

Laurie52 · Mar 8, 2013

new grad here, I recently had a pt with pulmonary fibrosis, not doing so well, and family just agreed for pt to go to hospice. He was going to transfer to hospice the next morning and not yet on comfort measure. Last ABG showed that he's hypoxic, he was on BiPAP 99% throughout the day until the afternoon they switched him to 100% non-rebreather to prepare him for transferring to hospice because hospice doesn't take BiPAP.
At beginning of my shift (7pm), family and friends were all in the room, talking with him, saying goodbye, pt was still AAO x4.. 1 hour into the shift, just as I went in to the room again to made my round, I noticed he start to get restless, very confused, trying to take off his non-rebreather.. I know it's due to the lack of oxygen, but I can't really do anything such as putting him back on BiPAP or call an RRT, so what I did at the time was place the mask back on him, talked to him, was about to go get morphine IV asap for him that's what has been keeping him comfortable, and then call the doc. before I walked out, he had an episode 10 second seizure, body stiffening, tremor, staring to the left.
I stayed in the room, had someone to call the charge, we gave him ativan x 1, morphine x1. called MD, gave another ativan x1. and started him on morphine drip and comfort measure.
before the drip, his RR was 36, restless, seem uncomfortable. after on the drip, he's RR was 26 on 1mg, eyes closed/resting besides using accessory muscle to breath. He's non-responsive now. after one hour, I titrated to 1.5mg, and RR = 22-24, still using accessory muscle breathing.
at this point, I talked to my charge, I don't know if up the dose would help more or would it depress his respiratory even more and cause him to have to work harder breathing? at the same time, I don't want to overdose him.. this is my first pt on comfort measure, I don't really what to expect..
I had also asked my other co-worker too, and asked if we should keep their breathing between 12-20? or as long as patient seem comfortable..
our conclusion, pt seems comfortable, family also think patient seems comfortable, so leave it as it.
when giving report, morning RN came and saw the pt, she said - no no no, pt's not comfortable, when they are on morphine drip, you titrate it until they no longer using accessory muscle breathing, and appear as if they are just breathing normally..
I'm confused.. what should I have done here?
also, throughout the care, I feel really bad because I don't know what to say to the family. I let them know that i was there for them if they had any questions or anything I can help. I explained everything I do with the family, made sure tissue, water, and blankets are available for those that are visiting/staying. kept the room quiet and neat, called the priest per family request to say the last word..
I left work that day feeling like I could have done better.. I guess the feeling of I didn't know what to say so I really didn't say much to comfort the family made me feel really bad.. I felt I did everything i could "tasks" wise but didn't offer them emotional support.. how can I do better next time?

I think you did a great job. This patient has been using accessory muscles for a long time. The morphine is titrated to patient comfort. If both you and the family thought he was comfortable, I'm sure he was comfortable. He has end stage lung disease--he will never have a "normal" respiratory rate.

I would love to tell you that this gets easier but it doesn't . As nurses, we are privileged to walk this final journey with our patients and their families. We make a difference in people's lives. Take care and know that you have helped.

MunoRN, RN · Mar 8, 2013

When you've got a patient for whom death is expected, it's hard to feel like it ever goes perfectly. Nurses find themselves in the position of being the MC of someone's death and hold themselves to a high expectation about how much they can control the process, after all, it's not something we get a second chance on if we mess up the first time, so it can be very stressful. You do the best you can with a process that can be difficult to control and remember that you helped make a potentially uncomfortable situation for the patient and family a little more comfortable.

You'll find different procedures and practices out there in terms of how patients transition to comfort care or hospice, so I'm not really familiar with how it went in your case. My local hospice doesn't typically take patients who are in the Hospital and are expected to die within a few days once treatment is withheld, including BiPAP dependent patients. We usually start morphine gtt's while still on the BiPAP if they are uncomfortable off of BiPAP and titrate down the pressures while we titrate the gtt until we can take off the BiPAP and have the patient be comfortable. One thing to remember with BiPAP in a patient with end stage pulmonary fibrosis is that the BiPAP is at least as much for clearing CO2 as it is for getting O2 in. Switching to a NRB might keep their O2 levels up, but CO2 levels can still rise rapidly.

I think you did very well given a less than optimal situation from the start, it sounds as though a transfer to hospice might have been overly optimistic. The use of accessory muscles to breath is typical of cheyne-stokes breathing and other respiratory patterns that occur at the end of life and may not necessarily be a sign of discomfort, we have a detailed protocol and that alone doesn't indicate more morphine, but it might if other factors are present.

Keep_Calm · Mar 8, 2013

I think you did a great job too. You did what any good nurse would do. You cared for your patient to the best of your ability, you consulted other nurses and the charge nurse, and you did everything you could for the family. With end stage respiratory disease, the patient would have to use accessory muscles to breathe until he, well, stopped....right?

netglow, ASN, RN · Mar 8, 2013

Op, you did good and reacted fast. So glad for CC, aren't you - not a moment too soon.

You know, when you are at full DNR/CC you just look at comfort. Discussion is, that if making comfortable eg morphine needs titrating, and that stalls respiratory drive, then it just does. Yours and the MDs is to be clear to family "what is and shall never be"

leslie :-D · Mar 8, 2013

i agree, that your heart was clearly in the right place.

as a longtime hospice nurse, i am with the a.m. nurse who said pt wasn't comfortable...

or, he didn't achieve his maximum level of comfort.

it doesn't matter whether he has used accessory muscles as his baseline.

morphine is to be given until a resp rate of 12-14 is achieved, with no accessory muscles being used is ideal...

not always achievable but sometimes it is.

also, for resp pts, a circulating fan (pointed at their face) is a Godsend to many of these pt.

please, do not worry about hastening death or suppressing resp drive.

as long as your intent is to alleviate suffering, then you haven't done anything wrong/illegal.

please be persistent and consistent with the morphine and ativan.

there is nothing worse than a suffocating death.

leslie

eta: many nurses remain reluctant in giving mso4, having same fears as you with resp depression and/or hastening death.

because of that, you will often see they have noted "pt resting comfortably"....and that is just not the case.

there really is an art in assessing pain.

PLEASE do not hesitate in titrating up.

morphine is one of the best agents out there for dyspnea.

and, there is no ceiling to amount given.

again, you will get a lot of different opinions but not all of them are truly in the pt's best interest.

i do appreciate your efforts and concerns.

Sun0408, ASN, RN · Mar 8, 2013

Without seeing the pt myself I can't comment on "how comfortable" he was. I know with end of life it is hard sometimes to find the right things to say. I tend to educate the family on what to expect, I also talk to them like I am having a conversation with an old friend. If they want to talk about how dad used to be, I listen...I do as much as I can. I think you did well. You will continue to learn and grow as you navigate this topic first hand.

As far as the morphine gtt, 1mg or 1.5 and hour is a very very low dose. I have given up to 10mg an hour at times. No, that dose did not "kill" them. A dear friend of mine passed not to long ago in the ICU from end stage COPD and other lung complications; he was on a morphine gtt at 8mg an hour. He lasted 4 days before passing away peacefully. Bipap was removed several days prior. Resp rate and effort will vary from pt to pt.

wanderlust99 · Mar 9, 2013

Great thread. We provide end of life care so frequently in the ICU, usually without ever consulting hospice or having the time to do so. It's helpful getting some comments from hospice nurses. Leslie, I would have thought that abnormal respiratory patterns were normal, so I wouldn't have necessarily increased the Morphine either, if the patient was with their eyes closed and looked comfortable and the respiratory rate was normal. Now I will think differently about it. Thanks for your comments.

leslie :-D · Mar 9, 2013

Dyspnea at End of Life

# 027 Dyspnea at End of Life, 2nd ed

leslie

s0ad · Mar 10, 2013

I work on an oncology/hospice floor, and it does take working with a few dying pts to really learn what to do. I probably would have titrated up the dose if it looked like there was some labored breathing, or I would have given breakthrough medicine if available (like roxanol). I have given some hospice patients 20mg roxanol q2 hours in addition to ativan if they looked uncomfortable. If my patient is breathing shallow with 10RR and no signs of discomfort (grimacing, restlessness, etc) then no I would not give them anything. Unfortunately often times its a lot of gasping or accessory muscle use, restlessness, grimacing when repositioned, etc so they get meds, even if that may mean I speed up their death (which I really don't think we do - a study I saw showed hospice patients often live longer than those who opt for all the treatments and no comfort care).

It can certainly be awkward with families at times. I usually offer the family snacks or coffee, or assure them I will watch over the pt. if they would like to go eat. I also usually explain the dying process - most people have no idea, especially if family is concerned about their loved one becoming dehydrated, etc. I explain my assessments, how their breathing looks, how sometimes pts get "gurgly" at the end of life, what we can do to help it, explain mottling, cooling down, etc (its surprising how many family members seem very interested in these things because they see the changes themselves, but don't really know what they mean or if its normal). I can almost tell now (in the short 6 months of being on my own) if a patient will pass within 24hours and I will usually tell family that there is no way to tell when someone will pass, but in my experience this pt. looks like they will go soon, and to be safe you may want to call in additional family. I also like learning about who these pts were (as we get most of them unresponsive or close to it) and get to hear some nice stories, and it seems to help the family.

Also to add in with my own personal experience, my grandfather recently passed and was unresponsive, was extubated, and looked as if he had labored breathing. I asked the ICU nurse to give some morphine, and eventually asked for a drip. I would have rather my grandfather live a day less and more peacefully, than to have the nurse worried about his RR and being hesitant about medication administration.