Just lately, I've had an odd run of "comfort care" patients (end-of-life, palliative care) and I've run into a couple of issues that concern me. In particular, a dying patient's family told me that their doctor had urged them to have the trach removed because it was only prolonging the dying process. This patient was already off O2, but breathing steadily on room air through his tracheostomy. I thought perhaps the family had misunderstood, but later, as the doctor was pronouncing him, he mentioned to me that it was only the trach that had kept him going so long (at least 8 days).
Is it regular and customary to remove a dying patient's artificial airway? To me, it seems a bit like saying only my nostrils have kept me going this long. If I were terminal, putting a pillow over my face would not be medically ethical.
My other concern is that this patient was more severely dehydrated than I would have thought possible. His eyes were sunken about 2cm ib their sockets. By the time I got him, it was probably too late to matter, but I wonder if he should have been on maintenance fluids, despite his DNR status.
I'm opposed to euthanasia on moral grounds, but I have no objection to measures to improve pt comfort, even when they may hasten death. Some of the aides I work with believe turning a dying patient will cause them to die sooner, but I think if I were in that position, I would rather go a few hours sooner in a clean bed. I have been instructed in school and in CEU's that we shouldn't be afraid to give adequate pain relief to dying patients.
I feel pretty comfortable with all that. But it seems to me, also, that a patent airway and adequate hydration would also contribute to patient comfort, even though they might also tend to delay death.
I'd certainly appreciate any feedback on these concerns.
