Research Results are in: To Suction or Not To Suction, End of Life & Hospice Patients
"To Suction or Not To Suction, End-of-Life & Hospice Patients" is an article I recently published in allnurses.com and the responses were very conflicting. As of today Sept. 13, 2018, there are over 16,000 views of the article and 3 pages of clinician comments arguing their points! So the results are in:
"To Suction or Not To Suction, End-of-Life & Hospice Patients" is an article I recently published in allnurses.com and the responses were very conflicting. As of today Sept. 13, 2018, there are over 16,000 views of the article and 3 pages of clinician comments! So the results are in:
"To Suction" = 20 votes vs. "Not to Suction" = 13 votes and 6 people voted that they were impartial.
On one hand there is a clinical group that thinks, "Not To Suction".
Some clinicians believe suctioning of the dying patient is actually more harm than good. They believe it is uncomfortable and goes against the comfort care principles. They feel suctioning is unnecessary because it is not a curative treatment of the dying patient, but only symptom management. Some think it makes the family feel better but does nothing for the patient.
On the other hand, there is a clinical group that thinks, "To Suction".
Some nurses believe they are not only dealing with the patient but also the whole entire family, therefore treating both is of most importance. They think it only seems reasonable to suction a person who is in need, even if it is only considered symptom management. They want to give patients a dignified death, not one where they sounded like they were drowning in secretions as the family looks on.
Since we did not receive enough votes from the previous article to form a strong opinion, I started to review the research that has been done on family members' perceptions during hospice and palliative care.
What Does Current Research Say?
A research study at 95 Palliative Care Units of 360 family members that witnessed their loved one's death: [Shimuzu, et al. "Journal of Pain and Symptom Management" Vol. 48 No. 1, July 2014].
- 46% experienced the "Death Rattle"
- 66% reported High Distress Levels
- 53% perceived A Strong Need for Improvement of "Death Rattle" care.
- 64% thought the patient was drowning
- 57% felt as if they themselves were suffocating
- 98.3% reported that Nasopharyngeal & Oropharyngeal Suctioning helped improve the "Death Rattle'.
PROBLEM: 62% reported patient discomfort with suctioning and 12% reported rough suction technique.
Although I completely understand trying to avoid and not performing excessive suctioning on a dying patient, some suctioning may be necessary. I would not consider any suctioning comfortable, but there are techniques and methods of suctioning that make it much more comfortable such as No-Bite V suctioning with the use of a red rubber catheter. Red rubber suction catheters are much softer and minimize any insertion trauma. And the No-Bite V allows you to introduce a catheter orally and avoid the nose altogether. I think everybody basically considers nasal suctioning an act of torture at this point, especially repetitive nasal suctioning. But if suctioning can be done in a minimally invasive manner, it increases the patient's comfort level once suctioned properly. And I definitely think suctioning a dying patient brings a calmness to the room, as well as the family. I would never want a family to take away that their loved one suffered or went through some difficulty breathing, in that they actually heard the patient's breathing difficulties in the form of the death rattle. This is something a family would never forget. A nurse's goal is to minimize any degree of suffering, physically and mentally, to both the patient and the families.
One nurse's comment really sums it up:
"I don't want a patient to die on my watch because of poor nursing care instead of their underlying disease. The patient should not die from a plugged trachea, they should die because their body gives out from their disease."
Now that the above research has given insight into family members' perceptions of a dying loved one...
What side do you agree with:To Suction or Not To Suction?Last edit by Joe V on Sep 19
About NickICU-RN, RN
ICU RN- 15 years exp
Joined: Jan '18; Posts: 6; Likes: 20
from NY , US
Specialty: 15 year(s) of experienceSep 18Joined: Jul '08; Posts: 520; Likes: 703I think it depends on the situation. Suctioning can help clear the airway. But, sometimes the patient gets too distressed from it. It is a balancing act to have the patient suffer the least.Sep 18Joined: Apr '04; Posts: 287; Likes: 692The answer to a family's perception that their loved one is suffering isn't necessarily suctioning. Often it's education. If the respiratory effort and rate don't increase and it's just a matter of the patient no longer being responsive enough to clear oral secretions by swallowing or tracheal secretions by coughing, suctioning isn't indicated in my opinion even if it can be made more comfortable with specific devices. Calling the family's attention to the fact their person doesn't appear distressed by the noise often helps family accept it.
In my opinion, making the room more peaceful isn't an indication for putting a patient through the discomfort of suctioning. After watching literally hundreds of people die in a hospice inpatient setting I can say that I have never seen a person die of a plugged trachea. Perhaps this happens frequently in non-hospice settings. Almost always, positioning someone at a 45 and high on their side allows postural drainage of oral secretions. Anticholinergics like atropine and Levsin dry up tracheal secretions. And in end of life cases, suctioning for pulmonary edema unnecessarily and distressingly prolongs the dying process.Sep 18Joined: Sep '18; Posts: 1; Likes: 5I think stating to "never suction" is ridiculous, of course we have to suction sometimes even though we don't like to and try not to.Sep 18Joined: Oct '06; Posts: 2,617; Likes: 3,981If the patient isn't uncomfortable secondary to the rattle, then leave it be, as I feel suctioning would cause them discomfort!
I think people think of the families and their distress and forget they aren't the ones lying in the bed feeling the pain/discomfort, the patient is.
AnnieSep 18Occupation: Critical Care Specialty: 10 year(s) of experience ; From: US ; Joined: Nov '10; Posts: 9,503; Likes: 26,482One nurse's comment really sums it up:
"I don't want a patient to die on my watch because of poor nursing care instead of their underlying disease. The patient should not die from a plugged trachea, they should die because their body gives out from their disease."Sep 18Joined: Dec '12; Posts: 848; Likes: 2,802I think gasping for a breath or struggling to breathe is an indication for suctioning. A patient struggling for that next breath is not the way any of us want to go. Give me the pain of suctioning. If the patient is medicated adequately, then suctioning shouldn't be an issue during end of life care. It relieves the fear of the family, and hopefully provides a peaceful passing.Sep 18Occupation: Critical Care Specialty: 10 year(s) of experience ; From: US ; Joined: Nov '10; Posts: 9,503; Likes: 26,482Quote from missmollieIf the patient is medicated adequately then there is no need for suctioning. Subjecting the patient to the torture suctioning involves to "relieve the family" is inappropriate, and fails the patient who is your first priority.I think gasping for a breath or struggling to breathe is an indication for suctioning. A patient struggling for that next breath is not the way any of us want to go. Give me the pain of suctioning. If the patient is medicated adequately, then suctioning shouldn't be an issue during end of life care. It relieves the fear of the family, and hopefully provides a peaceful passing.Sep 18Specialty: 2 year(s) of experience in hospice, LTC, public health, occupational health ; From: AZ, US ; Joined: Dec '16; Posts: 267; Likes: 1,151Quote from MunoRNImpaired airway protection is one of the ways that people die as a result of their disease, that's like saying someone who has a flaccid airway due to a neurological injury and who is comfort measures only, should have an endotracheal tube inserted so that they don't die from an obstructed airway but instead from their terminal condition, even though an obstructed airway is how someone dies from that terminal condition. The purpose of comfort measures only isn't to keep the patient alive, particular using extremely unpleasant means.Quote from MunoRNIf the patient is medicated adequately then there is no need for suctioning. Subjecting the patient to the torture suctioning involves to "relieve the family" is inappropriate, and fails the patient who is your first priority.
From this former hospice nurseLast edit by Aunt Slappy on Sep 18Sep 19Joined: Dec '03; Posts: 1,532; Likes: 3,826First of all, the cited study Shimuzu et al from 2014 took place in Japan. Secondly, the article has a lot of more information about perception of "death rattle" - as always, perceptions need to be seen and interpreted within cultural context. I think everybody would agree that Japanese culture is very different from USA culture - perhaps USA family perception is similar but one cannot just assume...
I am a certified hospice and palliative nurse (CHPN) with experience in acute care and community care - I have taken care and consulted on many patients who are in the stage of actively dying. In addition, I am a member of a professional nursing organization dedicated to palliative and hospice care (HPNA).
Anybody who takes the time to review some literature on this topic "death rattle" and professional recommendations will find that naso-pharyngeal sunctioning or "deep suctioning" is NOT recommended because it does not remove the pooled secretions that result in the rattling noise. It does lead to discomfort and can result in injury and even bleeding in patients while absolutely not doing anything for the rattling. It seems that nurses in ICUs have the hardest time to resist the urge to stick a suction catheter in - nurses on medical surgical floors who are more familiar with this natural phenomenon in the dying patient usually do not attempt.
Since the rattling noise that one hears close to the throat comes from seecretions that pool (patients cannot swallow close to death) in that area there is actually a simple nursing action that removes the secretions, can be integrated while providing care, and is effective:
You simply turn the patient fully onto the side until the head is the lowest point - take the pillow out - place a washcloth under and simply wait few minutes with patient in this position. Secretions run out because of gravity. After that, reposition in 30 degree side and place pillow under the head again. I often see that the head is overextended, which results in the mouth being wide open and it looks uncomfortable. Make sure you have enough pillows...
Secondly nurses need to educate the family and each other that "rattling" is a normal phenomenon, which does not disturb the patient.
Thirdly, there are randomized controled studies about the effectiveness of medication to dry out secretions and other studies - some studies concluded that medication is not more effective compared to placebos. Current practice is that patients receive scopolamin patches or / and levsin to help with drying out secretions, sometimes patients get a dose of lasix if they are fluid overloaded and the rattling is further down / pulmonary edema. I also usually recommend to make sure patients do not receive iv fluids while they are dying because the body can't handle it and it seems to result in more "rattling".
Please fellow nurses - do not stick a suction catheter deep down the throat or through the nose - Yankauer is fine for in the mouth cavity. Instead, position onto the side as described and wait for secretion to run out. If patients build a lot of secretions you might have to do that more regularly but you should repositioning anyways and can integrate it. I have done this numerous times and still do when I see a rattling patient who is dying in acute care. Gravity is your friend....And the best thing is that does not harm the patient.
If the patient appears to be close to death (mottling etc.) make sure the family understands that death is imminent. Families are usually relieved when I educate them about the rattling and repositioning.
Yes - the rattling noise causes distress in families and staff that is not educated. But suctioning does not help and is usually more for the nurse's own comfort. Repositioning takes more time and 2 people - so I can see why suctioning seems more appealing - but it usually does not help and can make it worse. I have seen patient bleed significantly after somebody sunctioning through the nose or "deep suctioning" while patient is dying - that is even worse than rattling.
There are many articles but I am only citing one here:
Jancin, Bruce. "Simple measures for dying patients can limit secretions, death rattle." Internal Medicine News, 1 Aug. 2007, p. 16. Academic OneFile, Off-Campus Login. Accessed 19 Sept. 2018.Sep 19Joined: Aug '14; Posts: 263; Likes: 1,484The OP provided some good information on oral pharyngeal suctioning using a flexible catheter. It is an under-utilized technique, in my experience, and if done well is typically not traumatic.
In general, I think causing a dying patient pain or trauma to relieve family anxiety is a poor choice, so NT suctioning a hospice patient is more often than not a poor trade-off. That said, it's impprtant to treat each patient individually and not just apply the same rule of thumb to everyone. And, as others have said, explain things to a dying patient's loved ones, and dont forget to consider pharmacological options. Glycopyrolate and appropriate pain medications or even sedatives can help.Sep 19Specialty: 15 year(s) of experience ; From: NY, US ; Joined: Jan '18; Posts: 6; Likes: 20The research was done in Japan at 95 different palliative care facilities. My apologies, I could not find anything like it done in the US. But just as once cannot assume that Japanese perceptions of compassionate dying is the same as Americans, one cannot assume it is different.... I personally think compassionate care of a dying loved one is something innate that cannot be swayed by a "No Suction Theory". Compassion is a feeling that comes from the heart that crosses international lines. I've seen various burial rituals, beliefs on death, etc, but I have never heard of a culture letting one choke on their secretions as they are dying. This palliative care "No Suction Theory" is the first I am hearing of this.
Don't get me wrong, I always try to avoid suctioning. I am in no way advocating for suctioning of ALL death rattles, and I am All-In for the medicated patches to help dry up secretions. But I am stating that in some cases a patient may need to be suctioned especially if they had pneumonia previously. For somebody to say secretions do not matter and that is just how patients are supposed to die with impaired airway obstruction, etc.... Then why even use Anticholinergenic patches to dry up secretions.. Are you soon going to be advocating against Anticholinergenic patches because it is only helping the families??? We know these things are not curative, nothing is curative in End-of Life....
Picking one therapy such as Anticholinergic patches and not picking another does not make sense, unless you are terrible at suctioning and always hurt your patient... And if that is the case use a No-Bite suction, it is much easier and more comfortable that pushing a catheter up a patients nose.. To state that Anticholinergenic patches "Always Works" and that is why they do not have to suction.... Or that we "Never" do suctioning no matter what because it goes against a "Do Not Suction Theory", does not make sense.
And I sincerely think you stand by your "No Suction Theory" because this is how you were educated. But if they did research in the US that stated the same results: That families perceive the death rattle as high discomfort and although they felt suctioning is an additional discomfort, they still wanted suctioning done..... Would you change your mind on the "Do Not Suction Theory"?
Also, Are you stating that they families feelings do not matter especially when they fill out HCAHPS?
I know a preemptive education on the death rattle is key, but if somebody needs suctioning and appears in high discomfort, the family is not going to buy your education, they know that their loved one is suffering.Sep 19Joined: May '16; Posts: 402; Likes: 1,243working in an ICU i rarely suction our comfort care patients. Instead i will first give medications such as glyco or atropine to help with secretions.
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