Hospice patient and vitals

smf0903 · Jun 12, 2017

When we have hospice/actively dying patients on our floor (I work in a hospital) and family is at the bedside, we ask the family if they want vitals taken, the patient turned, etc. Most times they don't want either and we chart as such, making a note of the family's wishes. I always still take and chart a RR and HR as I can listen for them without bothering the patient.

Personally I would approach it something like "your mom (whatever the relationship) seems comfortable as she is right now. Would you still like me to get vitals on her? I don't want to disturb her if you feel that she's comfortable..." That kind of throws it out there as to why you may not be taking vitals but still allows the family to play a role in the patient's care.

Don't take it to heart...the family is probably trying to maintain some control over an uncontrollable situation and is probably working through a lot of feelings.

I wouldn't mind getting a set of vitals once a shift in such a case (if the family insists on vitals) but no way am I bugging an actively dying patient for vitals q2h or q4h. My number 1 goal is comfort, comfort, comfort for that patient.

snowflower2016 · Jun 12, 2017

I'm also in a hospital. For our hospice/comfort care patients there is an order set that includes no scheduled vitals, no blood glucose checks, no blood draws, etc. Our primary goal is comfort.

NightNerd, MSN, RN · Jun 12, 2017

When I worked in hospice, we took vitals once daily, with any medications that would require it, and per family request. When families asked how often it would occur, I explained that it's less frequently than at the hospital to allow for the patient to get more rest, but that I'd be happy to take a new set if they'd like. I do find it helpful to have at least a daily set, because BP trending down, HR up, fever, etc., can indicate some things about where the patient is in the dying process, but usually it isn't necessary to do it any more frequently. Most people accept that.

Lisacar130 · Jun 12, 2017

Some of the families are used to an intense ICU situation and don't understand how hospice works. I always asked family if they wanted vitals though, but the purpose is pretty much to let the family know of any changes so they can mentally prepare for how soon the end might be. Although even that can be very deceving, as some people linger forever and others go quickly despite the vitals.

Same thing with suctioning... I would tell family we're usually less aggressive now (if they were used to ICU and frequent suctioning) as we're focused on comfort... but to let me know if they think their loved one would want to be suctioned. Same with turning... I would ask if their loved one was comforted by frequent turns when they were more alert and if so I would continue that, for example. But otherwise would explain that we are less aggressive with turning now as our focus is on comfort. Different families have different views on the care so I always asked them first.

Here.I.Stand, BSN, RN · Jun 12, 2017

I would have said that as we are not intervening with abnormal VS -- e.g. we don't need to check a BP/HR prior to a beta blocker, because we are not giving the beta blocker -- and because a thermometer or BP cuff can be uncomfortable, checking VS is not typical for someone actively dying. Also, you are constantly noting the pt's respiratory rate and effort, which DOES give valuable information about the pt's comfort. Your assessment just isn't as visible to the family, as it would if you were checking a temp.

I get that you were probably caught off guard, but the "I haven't gotten around to it yet" response tells her that it is a priority, and you are in fact not providing the care the pt needs. A bit of education about the goals of comfort care may have helped her feel better. Now if the family wants to know and it doesn't seem to bother the pt, you could offer to check.

When my Grandpa was on comfort care in LTC, the nurses would periodically do a spot check with the oximeter. It was quick and non-invasive, and it gave us an idea when he was entering into the activity dying phase. (Actually they called my mom at home to tell her his pulse was in the 20s, so we should come.) But a full set like you would get in the hospital? Unnecessary.

blondy2061h, MSN, RN · Jun 13, 2017

A lot of taking care of end up life patients on comfort care is doting on the family and understanding what their expectations are and what they want done. Usually when I had these patients on the floor I would start the night by introducing myself and seeing who they were and what the relationships were. Then I would say something like "I understand you have decided to focus your mother's care on keeping her comfortable and pain free now. Since we're doing that, we don't need to bother her to do things like check her blood pressure throughout the night. Doing so will not alter the care I provide, but may give you some sense of how much more time you have left with her. Do you want me to check her blood pressure throughout the night?" I'd also offer them snacks, drinks, blankets, and extra chairs.

amzyRN · Jun 13, 2017

You're not wrong. I might have asked the family if they wanted vitals taken and done as you had done and said you hadn't gotten to it yet. I think it's hard for families to let go. I try to take things too personal when dealing with end of life situations.

annabanana2 · Jun 13, 2017

I probably would inform the family kindly that our goals at the moment are for comfort and that taking a set of vitals that the patient might find uncomfortable or disturbing probably wouldn't yield us any useful information. I would ALSO, though, explain that just because we're not taking vitals doesn't mean I'm not assessing the patient frequently, and fill them in on things they might not have noticed me looking at like RR, CWMS, whatever. It sounds like the family was maybe less concerned about the actual vitals and more concerned that their loved one is getting the care they need and deserve.

KelRN215, BSN, RN · Jun 14, 2017

A lot of taking care of end up life patients on comfort care is doting on the family and understanding what their expectations are and what they want done. Usually when I had these patients on the floor I would start the night by introducing myself and seeing who they were and what the relationships were. Then I would say something like "I understand you have decided to focus your mother's care on keeping her comfortable and pain free now. Since we're doing that, we don't need to bother her to do things like check her blood pressure throughout the night. Doing so will not alter the care I provide, but may give you some sense of how much more time you have left with her. Do you want me to check her blood pressure throughout the night?" I'd also offer them snacks, drinks, blankets, and extra chairs.

When my grandfather was dying in the ICU, I was a junior in college in my first semester of clinicals. When they called us in because they didn't think he'd make it through the night, the nurse asked if we wanted to take him off the monitor. I wanted to see it because I wanted to know what was coming. My mom and uncle didn't care. Had I not been there they probably would have just said to turn it off. Because the alarm went off when he went into Vtach, it woke them up (I stayed up all night) and they were able to say their final goodbyes.

When I worked in the hospital (pediatrics), we encouraged parents to allow us to turn off the monitors when children were actively dying/on comfort care but we ultimately did whatever they wanted. Some agreed that their children had been connected to monitors for far too long and it was time to turn them off. Others wanted to keep just the pulse ox but turn all the alarms on it off.

Taking vitals or not isn't going to change the patient's management or outcome but it might make a difference to the family.

nuangel1, BSN, RN · Jun 14, 2017

my husband was recently inpatient at a large teaching hospital.he had terminal cancer .he made himself DNR/DNI/CMO. They started a dilaudid drip .I and my family were with him for hours.they offered us chairs blankets food coffee.The nurses would come in ask me if I wanted vitals turning etc to be done.If we thought he was uncomfortable they went up on drip and gave prns.no vitals needed.He passed away may 14th after a 2 1/2 year battle radiation and chemo .he had 41 treatments .

blondy2061h, MSN, RN · Jun 14, 2017

my husband was recently inpatient at a large teaching hospital.he had terminal cancer .he made himself DNR/DNI/CMO. They started a dilaudid drip .I and my family were with him for hours.they offered us chairs blankets food coffee.The nurses would come in ask me if I wanted vitals turning etc to be done.If we thought he was uncomfortable they went up on drip and gave prns.no vitals needed.He passed away may 14th after a 2 1/2 year battle radiation and chemo .he had 41 treatments .

I'm so sorry for your loss