More frustrations dealing with end of life oncology patients...

[mama_d, BSN, RN]

So I've taken a few days to think about this, and it's still bothering me. I'm looking for input as to how to handle if a similar situation comes up again, and possibly resources to reference from anyone who cares to throw something out there.

Let me add on at the beginning here that we have recently started inpatient hospice but have had no additional training as of yet, which I think is a significant portion of the problem lies.

We had a patient who was not expected to live for much longer, a day or so at most. She had terminal restlessness and anxiety accompanied by SOB; sats were routinely in the 60-70's b/c she would not leave O2 on. The attending physician ordered comfort care only, including Ativan solution po for anxiety/SOB and Roxanol for pain. Gave Ativan po for the terminal restlessness, which another nurse that night said afterwards was not a good idea b/c it can cause further respiratory issues and recommended giving the Roxanol instead.

My opinion was that since patient was comfort care, and was obviously not comfortable due to terminal restlessness, the Ativan was the way to go. Even after I stated my POV, the other nurse still stated that she would have given the Roxanol instead.

Since we're likely going to be getting more of these kinds of patients, I'd love some words of wisdom, and any kind of evidence based practice info that anyone can give me. I'm hoping to bring up this issue of lack of training at a staff meeting next month, and hope that some of the difference of opinions can get cleared up once adequate training is done, if it ever happens.

[Blee O'Myacin, BSN, RN]

I think that the answer here is both meds. The Roxanol will help with the air hunger and the restlessness that comes along with hypoxia, ease any pain, etc. The ativan will help with the additional anxiety. If the patient is "comfort care", then we should be medicating to comfort.

So what did you wind up giving? Did it work?

Blee

[DeepFriedRN]

I think that the answer here is both meds. The Roxanol will help with the air hunger and the restlessness that comes along with hypoxia, ease any pain, etc. The ativan will help with the additional anxiety. If the patient is "comfort care", then we should be medicating to comfort.

Blee

:yeahthat:

[nursemary9, BSN, RN]

As an Oncology nurse for over 25 yrs. I agree with Blee.

As a matter of fact, My Mom passed away 3 wks ago & was under Home Hospice Care.

She was on that exact regimen and believe me, she was really or appeared to be really comfortable this way. She was not an oncology pt.; she was end stage CHF. She also, for a short time, kept pulling off the O2. Once we got her settled with these drugs, she was much better.

I agree that some In-Service would be a gooid thing.

Mary Ann

[tencat]

Blee's got it right. Both drugs should have been used, not just one, though it's not 'wrong' to use one or the other, rather better to use both.

[mama_d, BSN, RN]

We just gave that one dose of Ativan, which helped for some time. It was not my patient, unfortunately, she belonged to a new grad who after the conversation regarding further respiratory issues became too frightened to give him any more meds. Better anxious and in pain than dead was pretty much the attitude. Personally, I'd have medicated him until he was comfortable, regardless...if my patient is only going to be around for a day or so longer and is comfort care, shouldn't the goal be comfort?

[brighella]

yeah it sounds like you need training and a palliative care resource available to help with the end of life patients. In-patient hospice has much different goals of care than most oncology floors I've been exposed to, requiring related but different focus and knowledge. Id be asking for a palliative expert to be available for questions like that.

[Mollypita]

I work on a floor with some palliative beds and absolutely, there's no reason to be stingy with drugs at that point. WHY should that person be at all aware of resp distress, pain, or the inevitable end?! I give what the doctor ordered as liberally as needed, and if it doesn't seem to be doing the trick, I WILL bother the doctor in the middle of the night for a new order. Most family members accompanying the patients on my floor feel the same way. I feel very strongly about this...

[Spidey's mom, ADN, BSN, RN]

I agree with all the responses regarding MORE education about palliative and hospice care.

I routinely give Ativan and Morphine.

steph

[leslie :-D]

i strongly encourage looking through eperc (eol-palliative-education-resource-ctr) and esp its fast facts.

wonderful, wonderful resource.

http://www.eperc.mcw.edu/ff_index.htm

believe it or not, benzos are not the first line drug to use for terminal confusion.

they tend to cause paradoxical agitation and/or worsening of symptoms.

if in fact, it is truly terminal confusion (people use that term rather loosely).

haldol is given in escalating doses to desired effect.

but since it is ativan, yes, GIVE THEM TOGETHER.

they work synergistically and potentiate ea other's effects.

the goal is to keep your pt comfortable, which will necessitate giving mso4/ativan atc.

you really want to stay ahead of her symptoms.

i can't believe you've opened hospice beds w/o any inservicing.

check out the eperc website.

it is a hospice nurse's best friend.

leslie

[leslie :-D]

oh.

and that thing about ativan causing resp depression?

bull.

unless a pt is taking large doses of narcs/benzos, or has pulm comorbids, ativan is not known for causing resp...

no more than any other benzo or opioid.

this is not a good time to start acting paranoid.

dying pts need us and our expertise.

definitely, get that inservice.

leslie

[debblynn13]

I agree with everyone else.

Also are you required to get sats? Those numbers will make everyone upset but they are normal for a dying person. We have taken the mask off people if it really irritates them and just medicated with the roxanol and ativan to keep them comfortable. Oh and use a fan to keep the air circulating and cool cloth on the forehead. Sometimes you have to play with things to find out what works the best for THAT patient.

One other thought....we have admitted people to hospice and left them in the hospital as hospice inpatient esp if they are terminal. Is there a hospice that could come in and do that? If your floor doesn't want to have a hospice involved in care maybe they could have a hospice come do an inservice on end of life medications. A hospice nurse mindset is different than a floor nurse....goals are different.

Good luck,

Debblynn