How much do we tx?

la_chica_suerte85, BSN, RN · Feb 6, 2017

Keeping in mind that I work hemonc in a pediatric population, we get kids who come back who are about to or have already starting the process of actively dying. Many are due to brain tumors so there are some issues with swallowing and they may be getting NG tube feeds. Depending on how far along they were in the process of dying is where we intervene and there is a steady progression. Usually, because they are getting massive amounts of pain medication, constipation is an issue, as is the slowing/cessation of digestion, so TPN is started and tube feeds are stopped (enteral feedings are extremely uncomfortable when the body's metabolism no longer requires it). Then, because they are getting all their hydration and nutrition in a fluid base, fluid overload becomes a concern (especially as the kidneys begin to slow down). So, while TPN may or may not be stopped, the recommendation is to start palliative sedation (vecuronium, usually).

In short, you treat for comfort as things progress - hospice can still be practiced in the hospital (some patients aren't able to be adequately cared for at home and hospice facilities sometimes might not have room in time). If the patient comes in w/o a central line, advocate for one (double lumen PICC, please!!!) before things get out of hand. I had to learn that lesson the hard way. If palliative sedation is an option, you may find it helpful in the very final days, especially when the death rattle is too much for families holding vigil at the bedside. Also, remember to provide comfort care for them as well. Death from cancer, while generally a relief for the patient, remains feeling like a "battle lost" for families -- a lot of time, money, effort spent on what? Even if it is expected, it's still just as disorienting for them as well, especially because the progression to death is fairly unpredictable. So, take the opportunity to help them make this their last stand for the comfort and care of their loved one.

If it is your facility's practice to not monitor DNR patients, please resist the temptation to monitor (maybe allow a pulse ox at a maximum) at the family's request because it is torture for families to watch the monitor instead of spending meaningful time comforting their loved one. It's more helpful to you if they can offer insight as to how comfortable their loved one is instead of relying on monitoring (especially if they are on PCA pump + continuous and it's a "nurse push" or "family push" order). It empowers them to be involved more in the process and gives them something more meaningful to do instead of staring at the monitor for days watching a pulse ox or HR dip lower and lower (only to temporarily rebound when a some new intervention is implemented). And, if your facility has good spiritual support, use them as frequently as you see fit. They work wonders.

RN1485, BSN · Feb 10, 2017

Thanks for your response. Even though you work peds, it's definitely applicable to my situation. Sometimes (I've noticed) that many of these pts don't have a central line. The physician doesn't want to have one put in so no TPN. No tube feeding. Still getting IV fluids. Fluid volume overload. No foley for comfort care. I just feel like there has to be a better way for our unit to take care of these patients.

la_chica_suerte85, BSN, RN · Feb 10, 2017

What is the palliative care situation at your facility?

RN1485, BSN · Feb 10, 2017

Palliative gets consulted and usually sends pts home or to inpatient hospice but doesn't always write new orders to make the patient more comfortable and a lot of them don't make it by the time hospice is ready.

db2xs · Feb 15, 2017

RN1485, unfortunately this is fairly common for a lot of patients who are nearing end of life. You should always advocate for your patient. Keep in mind that it's not always the doctors who are driving the over-care. Many times it's the family/loved ones who are having a hard time letting go. It is our duty to try and teach when we can.

Case in point, I was taking care of a patient yesterday who is at the end of life. Her family was quite resistant to sending her to hospice and withholding certain medications while continuing to allow other types of (unnecessary) medications (for this stage of her disease). The weight of the situation finally hit them the day before yesterday and they finally relented to hospice eval, but the patient was too fragile at this point to be transported. No one wanted to put the patient on a PCA pump because of some past instances of the patient's being effected in a certain way but by this time, the patient had become unresponsive. She was comfortable but in my opinion not receiving the proper care. When I felt the timing was right, I approached the family and asked how they felt if we changed things up. At this point, they were amenable.

I work on an adult heme/onc unit.

KelRN215, BSN, RN · Feb 18, 2017

If we're talking about patients who are actively dying- no tube feedings, no IV fluid, no TPN. Sometimes a Foley could be a comfort care measure if the patient is uncomfortable/unable to void.

My background is pediatrics as well. I started in neuro-oncology, then did general pediatrics/mostly heme-onc and now do general pediatrics for home infusion where my primary populations are oncology and CF patients.

For patients who are actively dying, meds for comfort were usually all we did. Even for patients with brain tumors who were previously tube fed, those would usually be stopped. I have never seen TPN started on a dying patient. If the patients is actively dying/comfort care only TPN isn't going to do anything for them. I sent a TPN dependent patient (mitochondrial disease) home to die last year. Once he was made comfort measures only/started on a morphine drip, his parents decided to stop the TPN/tube feedings and just focus on comfort.