End of Life and Difficult Discussions Part II

This is the second in a series of articles about end of life discussions in the acute and chronic setting. It is geared for APNs who host these discussions and hopefully provides some tips to make these proceed smoothly Nurses Announcements Archive Article

End of Life and Difficult Discussions Part II

This is Part II of the difficult discussions we must often have with our patients and/or families. This never gets easier and in reality, should it?

These discussions should be difficult as they are often the catalyst to pursuing advanced care, resuscitation and/or placing a patient on life support. These are some how to's for discussing these topics. This is a continuation of my last article and these are tips that have worked for me.

Some of my patients are homeless and illiterate and drug or alcohol addicted. They need to know that I value them as humans with a medical problem and that I will do everything in my power to help them. I try to use the language and verbage that they give me. If they say "vomicking" or "I fell out" I know what they mean. Conversely, I have patients who are physicians who want to feel in control of their care as much as possible. I explain everything in medicalese and offer as many choices as possible. In either example, my goal is to work WITH the patient for the common goal of the best health attainable.

We should be talking with our patients about the "what ifs" that could happen. What happens if we can't get your breathing turned around? What happens if we put you on a ventilator and then find that we can't get you weaned off? What happens if the chemotherapy doesn't get rid of the cancer?

And...we should be discussing all of the "what ifs" before they happen if at all possible.

For those of us that care for chronically ill patients, we should make a big effort to determine their care wishes and their goals. Do they have a Power of Attorney (POA)?

Do we have their phone number? Are they willing and able to act as a POA? This should be discussed at least on a yearly basis as phone numbers and general situations change.

Many of our patients use several hospitals. Do the hospitals have shared knowledge or a "bridge" for sharing common information?

Do you have access to it and know how to use it? Depending on the hospital system, sometimes you will need to be credentialed at both facilities, sometimes not if there is an already existing information sharing agreement.

Try to establish a relationship with family members. For me, I find that when I make a concerted effort to meet the spouse, child or friend who is close to my patient, I already have a basis for any difficult talk that may arise. Its all about advanced planning if at all possible.

In addition to asking about POAs on a yearly basis, I also ask about advance directives about every six months and more often if the patient is deteriorating. I realize that I have the advantage of caring for chronically ill patients, thus giving me more time to watch and monitor their overall condition.

I also try to be open about end of life care and involve spiritual advisors also if that is appropriate for the situation. Some of my patients are very spiritual and welcome a frank discussion to include the afterlife (or whatever their belief system entails). Others do not. Its all about balance and knowing your patients.

What tips can you all share with us to make these discussions easier?

Do you have a team that handles this like palliative care. Or are you on your own? Does your physician help out or just give vague details?

Trauma Columnist

14-yr RN experience, ER, ICU, pre-hospital RN, 12+ years experience Nephrology APRN. allnurses Assistant Community Manager. Please let me know how I can help make our site enjoyable.

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Specializes in ICU.

I had to "have the talk" with one of my patients last weekend. We do have a palliative care team, and I can't say enough good things about them, but they are pretty much a Monday-Friday operation, and the family couldn't get together before Monday to talk with them.

This patient's pulmonologist came to see her on Saturday morning and told her (in my presence) that she needed to address her code status as he had no other options to offer her because her pulmonary status was worsening. After he left the room, she was pretty high anxiety for a while, and so we talked about her fears. She told me that above all else, she didn't want to be intubated, but she hadn't told her children this yet. I asked her to talk to them that day, even if it was by phone. She did, and by the end of the day, she wanted to have her doctor change her to a DNR.

When this whole conversation started, as a bedside nurse, I felt a bit like I was overstepping my bounds, but seeing her breathing deteriorate over the course of that day and the next, I'm glad I had the talk with her. It helped ease some of her anxiety, and she and her children were able to focus on spending quality time together. She was transferred to our hospice facility on Monday, and I haven't heard anything since. I think it really did give her some peace of mind to know that we weren't going to be doing chest compressions and "shoving a tube down [her] throat."

Thanks for posting...this is a topic that hits home for me!

Specializes in Nephrology, Cardiology, ER, ICU.

Thanks for your kind comments OneDuckyRN - you are such a wonderful patient advocate.

Thank you so much for posting this article. I am appreciated.

Specializes in Nephrology, Cardiology, ER, ICU.

You are very welcome.

Specializes in Emergency, ICU.

Great article! I really wish more providers had the courage to approach this discussion with their patients. Often, I encounter families who are already dealing with a family member who is transitioning or actively dying and no one has explained the situation to them. I've worked as a hospice nurse and many times have arrived at a patient's home (to admit them to hospice after their physician referred them) and have found that I am the first person to ever mention the reality of the situation to them.

I personally have no trouble having this conversation and am very good at addressing fear and end of life, but it is not ideal to be introduced to hospice by the hospice team. Ideally, these conversations should begin early on in the disease process so patients have time to digest and adjust. Also, so they don't find themselves making really tough decisions all at once -- when they almost have no other option. It's just not fair to anyone. Delaying the conversation robs patients of time they could use to wrap things up in their life -- in whatever way they need to.

Some providers are really good at this, but I do see many who are just scared to bring it up. And my experience has been that most patients are very willing to have someone speak to them frankly so they can make informed choices about their end of life care.

Specializes in ICU.

I wish more providers were like you. More often than not, it is the bedside RNs having the end of life/code status conversations with patients where I work. I can count on one hand the number of times I have seen a provider, be the person a physician, NP, or PA, really have a serious conversation about code status with the patient and family that took longer than 30 seconds. I feel like it is a big responsibility to put on bedside RNs and I wish we had more help with it.

Specializes in Nephrology, Cardiology, ER, ICU.

Great comments.

my primary job is with chronic dialysis pts all of whom are seriously ill. I try to start these conversations before an acute issue develops. It also helps or hurts as the case may be that sudden cardiac death is a reality in my world and unr

fortunately it's witnessed by other pts.