Withholding food and fluid in a dying patient

webblarsk · Dec 13, 2004

I didn't think in LTC you could withhold feeding, even if the patient has hospice services. I agree with you and think a order for "diet as tolerated" would be a good way to go.

delta32 · Dec 13, 2004

I believe its an option as a part of hospice, this has been done in my hospital and i believe it's a common practice. if you search through this site you should be able to find many topics on it.

Jamie

KMSRN · Dec 13, 2004

OK...here's the story....the patient has end stage Alzheimers disease and has lost the ability to safely swallow. The speech therapist has recommended she be NPO because the risk of aspiration is so high. The family agrees and doesn't want us to feed her and they DON'T want a GTube or IV fluids. The woman is on hospice services in my facility.
I have no problem with end of life...the woman has no quality of life at all, but is is legal to have an order to withhold food and fluids?? Wouldn't it be better to write an order "diet as tolerated"? Any legal eagles out there?

I agree with everyone not to place a PEG or give IV fluids but I am with you Mermaid on the NPO order - it should be "Diet as Tolerated". I believe it is unethical to deny someone in that condition food or fluids. She will probably not eat or drink much anyway - just a couple of sips. It is cruel to deny someone who says they are hungry or thirsty. And if she aspirates at this point, so what?

GingerSue · Dec 13, 2004

yes - "diet as tolerated"

CapeCodMermaid, RN · Dec 18, 2004

Happy (and sad) to say that the patient in question passed quietly with her family at her side - she wasn't in any distress at the time.

Antikigirl, ASN, RN · Dec 19, 2004

I am happy that she passed with her family there, and quietly...and yet even though I don't know your patient, I still feel the loss and feel the sadness at the loss of someone you care for. I can picture so many that I have cared for when I read this posting...and how this issue was brought up in different degrees...and the emotions come back as if it were today...I don't think I will ever forget, they taught me so much.

I too am a big stickler for the 'diet as tolerated' because I too have gone rounds on this issue with other Nurses/Doctors/Family. In my facility (assisted living) the deal is we have CNA's and unlicensed care givers that do patients medications, and all direct care...so many hospice nurses do not want a CNA determining what a patient can or can't swollow so they automatically put NPO. What they forget is that we do have a Licensed Nurse 24/7 and we can be called upon to either do feedings, or evaluate and give the okay. Word is getting out that we do have this...so it is getting better :).

Yes, I prefer the "diet as tolerated", and I have them also put 'fluids as tolerated (parameters on thickness if needed' as well because of the many feelings about hydration on end of life issues (boy that one can be a hot button topic in our field huh!?!?!? So I like specific parameters to follow). That puts the power back into the hands of the nurses on location that deal with these patients day to day...and that really should be considered :).

I love my hospice RN's..they really are very flexiable and really listen to us at my facility..and whenever there is a probelm like this..they are so open and friendly to work with (and get this..call back in 5-10 minutes every time!!! YEAH!!!!!!). I guess I am very blessed with three great hospice organizations in my area..they really make the difference :) They are sympathetic towards the need for 'diet as tolerated' being comfort for patients in their last moments on this earth...

stbernardclub · Dec 19, 2004

no...npo is correct. If the s.t. said the pt cannot swallow safely, you cannot write as tolorated because it seems more humane. The pt is a dnr, the family does not want any invasive means of feeding or hydration, that is their rite. You can mouth swab the pt, and do many things to comfort the pt.

I agree with everyone not to place a PEG or give IV fluids but I am with you Mermaid on the NPO order - it should be "Diet as Tolerated". I believe it is unethical to deny someone in that condition food or fluids. She will probably not eat or drink much anyway - just a couple of sips. It is cruel to deny someone who says they are hungry or thirsty. And if she aspirates at this point, so what?

Antikigirl, ASN, RN · Dec 19, 2004

"The pt is a dnr, the family does not want any invasive means of feeding or hydration, that is their rite."

Here we go again...oh man I am the worse lecture gal on this!!!!!!

OKAY...DNR is ONLY followed if a patient is NOT breathing or has NO pulse..then and only then is that followed! That has NOTHING to do with feeding or hydration before being pulseless and apnec! A DNR is not Do Nothing Regardless....

Why we get that one wrong all the time is beyond me! It only deals with death..do not bring back..not the journey there! A doctor...a Doctor under their license can determine an NPO by his clinical choice and his license..so we obey that...only then can we withhold what is considered reasonable humaine treatment...

A DNR doesn't EVER mean..stop..let them die...actually it is considered neglect and in some courts murder...tread carefully there...I have seen WAY too many lawsuits win for NOT doing something rather than honoring the DNR correctly!

DNR only involves death...that is it period. If you disagree...then I emplore you to look deeper into your state/provence laws.

Oh and yes..the family..it is NOT within their right to choose for a patient UNLESS they are a SPOUSE or POA! AND the only way they can resend a DNR is to say yes to treatment...but never NO! The reason behind that is simple..a family member or spouce may have THEIR best interests in mind...therefore their word on NO treatment holds no validity..but saying "do CPR NOW!" does...that is a win win...well according to law and liablity....makes sense if you think about it logically....

I had a daughter of a patient who...well he abused her thoughout life..sexually and physically...but he was very fiancially rich! She wouldn't do ANYTHING that wasn't covered by medicare...and he went into acute CHF..she screamed at me not to treat..he was breathing and had a pulse, jsut had some SOB and PAO2 of 70! I had her escorted out, got him to a hospital..and he was fine...thank goodness...he has many years in front of him..this was just a probelm increased by a flu! The daughter was investigated and they recented the POA! Sad for her...he hurt her thoughout life, but not fair to illicit murder with my license on the line! I was found beyond right...and accomidated by the EMS system in my state for my role in helping hold the correct meaning of the POLST (Oregon's state's DNR order or :Physicians Order for Life Sustaining Treatment..which is an ACTUAL MD order! WHEW!)....It was CYA for us nurses..and it worked!

Be very careful throwing the old DNR phrase around...9 times out of 10 I find the one throwing has no idea of the ramifications or rules behind it...and not by their ingnorance...but by the fact is it not taught!!!!!!!! It is the grey..but has disipline that is very black and white!

laurakoko · Dec 19, 2004

ok, beyond the legal issue, and the humane issue.... my feelings, if I knew I was going to die, and I was in hospice, damn, I want to eat, and drink some red wine.... and I really can't think of anyone in their right, or not- right mind wanting to not have comfort, with food or drink...the MD and the nurses might HAVE to do the legal thing, but the family can do what they think, and the thing that they feel might make their loved one the most comfortable. Who is to choose whether it is wrong or right to feed this person who WILL eventually aspirate, who IS going to die???????????????? BIG ETHICAL QUESTION.

nursedawn67, LPN · Dec 19, 2004

Keep in mind if the patient is unable to swallow, then we have a little something called aspiration pnuemonia to worry about...nothing worse then listening to a patient drown in their own fluids. Imagine suffocating. As I agree if the patient is able to ask for something, then find a safe way to give them something, but aspiration is a real risk and awful for the patient to suffer with.

caroladybelle, BSN, RN · Dec 19, 2004

Many dying cancer patients do not want large amounts of food/water because it is physically uncomfortable for them. And TPN requires many blood draws, IVs and throws them into CHF.

Yet the family practically force feeds them (causing nausea/vomiting and diarrhea/constipation) or requires TPN.

If the patient wants to eat or drink, why not let them to their tolerance but not force the issue.

Was the patient requesting foods/fluids?