End of Life

papawjohn · Aug 7, 2005

Hey Wakinglife

If you are paying attention to the silence, you might notice that most ICU Nurses don't much like 'CMO'. It's mostly about puffing and fluffing and dealing with families and their issues. (I once told the dayshift nurse who was giving me report 'don't tell me their feelings, tell me the numbers!'--I'm a better person than that now but its kind of the 'ICU Attitude'.)

Frankly, I've learned to like it. It's a challenge.

The goal is to have the pt at the balanced point of greatest possible alertness and greatest possible comfort. Propofol is usually for deep sedation; in my unit it is almost always used with vented Pts only. We want our CMO pt to be able to interact and communicate with his family--so I would expect him to be off the Vent.

Sometimes the family becomes a problem, too many of them--too demanding.

If you're lucky there will be a 'gatekeeper' or family leader you can enlist in helping you with this kind of issue. More commonly-you have to deal with them yourself. Answer the same questions, explain the monitors dozens of times, that kind of thing, explain the alarms, yadda yadda. Most folks will work with you if you give them the impression of competence and compassion.

The surprising thing to most families (and sometimes to Nurses) is the length of time that some Pts linger. Usually and reasonably--the machinery that was keeping Gramps alive being removed--we expect the old gentleman to go meet God quickly. Often it don't happen like that. You need to help the familly deal with (sometimes) days of lingering and nights of vigil.

Calls for the best you can give 'em.

Yer Papaw John

bellehill, RN · Aug 7, 2005

Our doctors will usually order Morphine and Ativan qhr for comfort. I usually turn off all my monitor alarms, I am going to be in the room anyhow and the family doesn't need the added stress. I try to prepare people that we don't know how long it will take. Family members can be overbearing but I recently had a death where the family members didn't want to watch the patient die so they left. That seemed more difficult to me so myself and another nurse stayed with the patient until the end.

vikkilclar · Aug 7, 2005

As a pre-nursing student, your experience has enlightened and touched my innermost emotions. You have also taught me how to respond and react if I shall ever be placed in that or similiar situations. Thank you for being thoughtful and compassionate.

Our doctors will usually order Morphine and Ativan qhr for comfort. I usually turn off all my monitor alarms, I am going to be in the room anyhow and the family doesn't need the added stress. I try to prepare people that we don't know how long it will take. Family members can be overbearing but I recently had a death where the family members didn't want to watch the patient die so they left. That seemed more difficult to me so myself and another nurse stayed with the patient until the end.

pricklypear · Aug 8, 2005

Most common order we get for comfort care is morphine. Most, if not all of our patients are beyond ever being alert again by the point that "care" is withdrawn, so it's not an issue. The need to reduce symptoms like air hunger and pain overrides the need to maintain alertness.

Some people go quickly, some don't. It's impossible to predict. We had a 80y/o lady linger for 24 hours with sats in the 40s and BPs 60s/30s. We were amazed. Some families want the monitors kept on, others don't. I just take my cues from them and do whatever they want.

And just for the record, I'm an ICU nurse, and I see caring for someone and their family at the end of life as more that puffing and fluffing and dealing with family. I see it as an opportunity to make a difficult but unavoidable situation as comfortable as possible for everyone involved. As I hope that someone would do for me or my family.

WakingLife · Aug 13, 2005

Thanks for the responses. I was just curious how others dealt with the issue. I worked in ER for a few years and I am fairly new to ICU. Honestly, I have never had to deal with withdrawl of care issues, but I had a "comfort care" case the other day and was taken off guard. I was not sure what was normal. I find it odd that I had a whole 3 month orientation period complete with class and we never talked about it!!

TamaraRN · Aug 14, 2005

I feel like in ICU we deal with this issue frequently but I don't see very much about it on the discussion board...Just curious about end of life issues. When family decides to withdraw care, what are the common orders that you see for comfort care? Morpine? Propofol? Do you feel that everything usually works out and the patients are not in pain? After extubation is end of life pretty quick? What are your feelings on "comfort care"?

With 5 years in ICU I've dealt with the withdrawal of care many times. It can be a really awesome & humbling experience.

Medication wise, the best tip I can pass on is to place 2 Scopolamine patches on the pt when you extubate in addition to the MS gtt. It's a drug used for motion sickness & a side effect is to dry up respiratory secretions. This is an incredible courtesy to the patient & the family. It saves the patient the extreme discomfort of NT suctioning when they become unable to handle their secretions. It also saves the family the discomfort of hearing that "death rattle".

As far as monitors, I find that families often stare at the rhythm & the numbers rather than looking at their loved one & interacting with each other. I like to turn the brightness all the way down on the monitor in the room so that the screen is black, but I can still see it at the desk, & the alarms are on to alert staff of changes. If I'm unable to remain in the room because I have another patient to care for, I find the family is reassured by my paying attention & knowing when something happens.

Emotionally, anything the family needs goes. I try very hard to allow large groups of visitors, bring in chairs, put several boxes of Kleenex around the room, bring in water, & find out if any of the visitors is diabetic or has any special needs that we can help with. I always encourage the family to bring in their spiritual advisor, or offer our chaplain or a priest. Gently feeling out the issue will tell you what are the spiritual needs without pressing.

Preparing the family for what will come... Tough subject. The doctor will probably tell the family, & you can reinforce, that there is no way to predict how long it will take. It could be minutes or days. Obviously, we can't keep a unit bed occupied for comfort care for very long. Many hospitals have a beautiful oncology unit, where the patient & family can wait in comfort. The oncology nurses have a great deal more experience with comfort care. It's really great to prepare the family by telling them that if their loved one makes it until morning (or whatever cutoff is appropriate) they can anticipate transfer out of the unit. It's also a good time to let the house supervisor know that you may be requesting a private room for transfer in the morning.

Withdrawal of care is an opportunity to make more of a difference in peoples lives than many of the heroic & exciting things that we do. I've cried & prayed with many families. It's a chance to connect with people and be a part of one of the most important and memorable things that will happen in their entire lives.

Bekahlynn · Aug 28, 2005

Our end of life protocol consists of orders for MS and ativan IVP PRN and MS and ativan gtts if needed, and Robinul for secretion management. Our food services provide a cart with cookies, tea and coffee for the family. We have nice handouts that were developed by our unit's care committee that explain to the family what the might expect such as skin discoloration, etc, and why we do some of the things we do, such as continuing to turn the patient q 2 hours, performing oral care, etc. Some go quickly on our unit, some do not and go to the small hospice unit within our hospital.

The families are the hardest for me. With some families, Nothing that I can say or do will be of any comfort to them, and that bothers me. I am a new nurse, and thankfully not had to deal with too much.

ZASHAGALKA, RN · Aug 28, 2005

If you are interested, this is the society of critical care medicine's guideline for 'end of care in the icu':

http://www.sccm.org/professional_resources/guidelines/table_of_contents/Documents/EndofLife.pdf

It's long but thorough.

A telling exerpt:

"A clinical team needs to be mulitdisciplinary and committed to cooperation and clear communication. A recent survey by Asch pointed to difficulities in this area, with critical care nurses reportedly needing to engage in many covert practices that were in conflict with physician orders. These included administering more opioid then ordered and concealing the action by falsifying the amount "wasted", increasing doses of opioid when patients were already comatose, or only pretending to administer life-sustaining treatments that were ordered, such as substituting saline for vasopressor infusion.'

~faith,

Timothy.

christianRN · Aug 30, 2005

I've appreciated hearing the input of all! THis is a very challenging aspect of our profession. Each patient is so different.

As many have said, we use the MS gtt often if PRN MS doesn't make them comfortable enough. I hadn't ever heard of using the scopolamine (sp?) patch - that sounds like a great idea. Usually turn off the monitor in the room. I try my best to share all the info I have with the family and keep communications wide open, so they know what to expect. It's so difficult for them. We have a "comfort cart," that we can order from dietary that has chex mix, cookies, sandwiches, cola, coffee, fruit, etc. that can be taken directly to the pt's room so the family won't have to leave for refreshments if they don't want to.

pricklypear · Aug 30, 2005

We have a "comfort cart," that we can order from dietary that has chex mix, cookies, sandwiches, cola, coffee, fruit, etc. that can be taken directly to the pt's room so the family won't have to leave for refreshments if they don't want to.

What a wonderful thing for your institution to provide. I think that's absolutely fantastic!:) :)

christianRN · Sep 2, 2005

Thanks, Prickly Pear.

I don't know who originally came up with the idea, but families really appreciate it.

And, it's a very cheap, easy way to make the patient and family happier if they don't want to leave the bedside.