Hurrying death?

somenurse · Dec 13, 2012

Your patient is going to die regardless and it is much better for him to be comfortable than to have a miserable death. It is a catch 22 because we know the medicine may help speed up the dying process but I think it is cruel to expect someone to suffer when they dying. He will die regardless...you should give him the medicine as ordered and if that is not enough to keep him comfortable speak with the MD. they can order combinations some of which are non narcotic...dont forget turning and positioning and keeping him clean and dry with good oral care too.

You might be interested to read what the Hospice and Palliative Nurses Association says on pain meds for the dying, in reply #9. Of course, you are right, it can vary widely from one patient to another. There's no reason to fear giving a dying person narcotics, though.

Re: the turning and mouth care,

believe it or not,

for some patients,

towards the last stages of their lives,

this is not a comfort, but, instead, induces annoyance, aggitation, discomfort, even pain or nausea can be triggered. More pain than it's worth for some patients on last day or so.

Not "all" patients feel better after being put on their side. Mouths can be very very tender for some patients.

Caring for the dying occasionally follows a whole other routine, for some patients,

than caring for those who will need their sacrum and their mouth to be in great health next week.

My point is, sometimes, care we all think is "helpful" might have to be re-thought and re-considered from one dying person to another, and from one stage of dying, to another stage of dying.

gettingbsn2msn, MSN, RN · Dec 13, 2012

I lost my mother a few months ago in hospice. Believe me, if the nurse had a problem with giving pain medicine or forcing mouth care I would have asked for a new nurse. I knew that my mother did not want to suffer. We had this conversation many times. I was blessed to have had a nurse who understood and did not have moral problems with giving medicines due to the fear of "hastening death". In fact I am quite sure that the doctor and nurse quickened her death by a few days. Thank God for them.

somenurse · Dec 13, 2012

I lost my mother a few months ago in hospice. Believe me, if the nurse had a problem with giving pain medicine or forcing mouth care I would have asked for a new nurse. I knew that my mother did not want to suffer. We had this conversation many times. I was blessed to have had a nurse who understood and did not have moral problems with giving medicines due to the fear of "hastening death". In fact I am quite sure that the doctor and nurse quickened her death by a few days. Thank God for them.

I am so so sorry for your loss. Your post is great example of how, like i said above, the care being given has to be personalized, tweaked,

from one dying patient and their family,

to the next,

and from one stage of dying

to the next.

I also lost my mother, and had mom at home,

and had hospice involved,

and in the last 3 days of her life, it seemed almost a sacred time, we did not turn her, as back in the days when she was more alert, she would have moaned or grimaced if she was touched (she was wracked with metastatic bone pain, which we did medicate very well--even when she was not anywhere near "alert" at all, even a gasp or a frown got medicated, we did not want to risk 'breakthrough" pain)

She had a foley, and hadn't eaten in a long time, so even peri care was also reduced to only prn.

Her final days, she was in a coma then.

We did check to make sure the sheets were smooth, wrinkle free, but, didn't change them, only prn,

and it wasn't necessary in final days to change her sheets. We'd occasionally change her pillow case, or turn her pillow to the cool side, as that was something we'd knew she would have liked. We may have added and removed pillows from her extremities, every now and then,

but, we didn't turn her. it was known, she most comfy on her back.

and her mouth, was far too sore to touch on her final days, and i did not see the point of 'forcing' mouth care at that stage. I think all i did then, was to moisten her mouth every once in a while, fairly infrequently, actually, cuz, when she was more awake in previous times, she'd complain of oral pain.

Although earlier months, when she DID have time left, we did work to reduce and avoid all mouth and skin troubles,

but,

towards the end, we simply sat and held her hand and talked to her, and occasionally played HER song on the record player,

and of course, medicated even the slightest of signs of distress of ANY kind, whether it was gasping or even a grimace. Her death was very peaceful, and this type of care worked for us, to feel we were doing best we could to keep her comfortable.

What is a comfort measure

can vary,

from one patient to another.

lalalulu · Dec 14, 2012

These are all such thoughtful responses. I really do appreciate! You guys are awesome!

For the record, I have no problem "snowing" someone at the end. I would want that for me or my family. I guess what bothered me most was the doctors decision it was the end and I sorta disagreed??? I dont wanna get too into detail cuz hippa, so hard to explain my hesitation.

I dunno. He's at peace, family's at peace, so I guess all is well.

MedChica · Dec 14, 2012

I really need some opinions please. I have a patient who is on hospice and did have some pain issues where roxanol was effective for them. However today it appears as if the doctor and family have decided its time to put him out of his misery. I have no problem keepin pt comfortable But I really feel like I'm forcing pt to die. Roxanol and Ativan ordered q2h routine even if pt sleeping, they want me to squirt meds in mouth. And made npo even though he was requesting drink just yesterday. The pt is elderly, and was miserable but I guess I feel like I'm putting a dog down or something. Other hospice pts I haven't had routine orders like this.
I just feel morally and legally weird about this issue. Does anyone else ever have an issue with doctors orders for end of life pts?

I had this sort of situation on my second (and last) hospice pt. The family was forcing my hand. I understood. I just felt uncomfortable giving him the Roxanol to that extent.

I gave him 10 (his ordered was changed to 20mL prn b/c the pain wasnt being touched, BUT the pain wasn't being touched because the nurse was administering it PRN...q3-4....and to treat someone actively dying and in pain...shouldn't pain relief be administered more often?).

So, I gave 10ml...but q1 hr...with the intent to increase the dose per doc order IF he could handle it.

I consulted the triage nurse and she told me that it was ok.

And it was ok for a time. He was in and out of consciousness.

The family began to feel that the pain wasn't being managed. Every movement. Every cough and they wanted me to increase.

My dilemma was: I wanted to manage pain but I was afraid to give too much because I think that depressing the breathing to such an extent would hurt the pt and cause a worse death.

It's like suffocating them, to me. His respirations were ALREADY decreasing...and triage was telling me to NOT push the roxanol. So, I gave ativan with the dropper to calm him and that was difficult b/c he WAS npo, too, and choked on even 0.5 ml. sigh So, that backfired slightly.

Monitored his resp. It came up some. No s/s of pain at the moment.

Resumed 10ml roxanol, the next round.

He wasn't screaming in pain, but I'm thinking that I probably did things wrong.

Eventually, towards the end of my shift, there was some breakthrough pain (facial grimacing, fidgeting) and I did end up pushing the Roxanol per family demand.

It felt like I was euthanizing him. Not that it's a bad way to go and I don't see what's so wrong with it. I'd definitely want to take my swan dive high as a kite on Ativan and Morphine. LOL

I'm just not built for hospice, I don't think. That's fine b.c I never want to do it again (beyond the safety of LTC). I find myself trying to keep them alive.

somenurse · Dec 14, 2012

These are all such thoughtful responses. I really do appreciate! You guys are awesome!
For the record, I have no problem "snowing" someone at the end. I would want that for me or my family. I guess what bothered me most was the doctors decision it was the end and I sorta disagreed??? I dont wanna get too into detail cuz hippa, so hard to explain my hesitation.
I dunno. He's at peace, family's at peace, so I guess all is well.

Are you a new nurse, new at this? Or you've been doing hospice for quite a while, and have attended many deaths by now?

It might be, you didn't realize the death was approaching? Sometimes i have gotten so used to a declining patient's status, especially if they decline slowly, sometimes it takes me a while to realize "OH, this is the end coming now. Ohhhh."

Or, perhaps your view, that this patient still had some quality time left, is valid. Did the other hospice staff going into that home feel like you did, or were you only staff person going into that home? I'm sorry you feel that way, is probably not a good feeling to have, sorry.

I am glad this patient is no longer suffering, that is was a peaceful death, and hope that you do realize you were probably a comfort to the patient and his family.

somenurse · Dec 14, 2012

I had this sort of situation on my second (and last) hospice pt. The family was forcing my hand. I understood. I just felt uncomfortable giving him the Roxanol to that extent.
I gave him 10 (his ordered was changed to 20mL prn b/c the pain wasnt being touched, BUT the pain wasn't being touched because the nurse was administering it PRN...q3-4....and to treat someone actively dying and in pain...shouldn't pain relief be administered more often?).
So, I gave 10ml...but q1 hr...with the intent to increase the dose per doc order IF he could handle it.
I consulted the triage nurse and she told me that it was ok.
And it was ok for a time. He was in and out of consciousness.
The family began to feel that the pain wasn't being managed. Every movement. Every cough and they wanted me to increase.
My dilemma was: I wanted to manage pain but I was afraid to give too much because I think that depressing the breathing to such an extent would hurt the pt and cause a worse death.
It's like suffocating them, to me. His respirations were ALREADY decreasing...and triage was telling me to NOT push the roxanol. So, I gave ativan with the dropper to calm him and that was difficult b/c he WAS npo, too, and choked on even 0.5 ml. sigh So, that backfired slightly.
Monitored his resp. It came up some. No s/s of pain at the moment.
Resumed 10ml roxanol, the next round.
He wasn't screaming in pain, but I'm thinking that I probably did things wrong.
Eventually, towards the end of my shift, there was some breakthrough pain (facial grimacing, fidgeting) and I did end up pushing the Roxanol per family demand.
It felt like I was euthanizing him. Not that it's a bad way to go and I don't see what's so wrong with it. I'd definitely want to take my swan dive high as a kite on Ativan and Morphine. LOL
I'm just not built for hospice, I don't think. That's fine b.c I never want to do it again (beyond the safety of LTC). I find myself trying to keep them alive.

well, do go back to page 1 of this thread, and read the quote from the Hospice and Palliative Nurses Association, in "Reply #9" about your concerns with

dying patients,

and narcotics,

and respiratory rates,

.......it might comfort you some. I think your medicating this patient sounded like he much needed the pain meds, imo.

The patients i've seen slip into comas, in no way appeared to be suffocating. If i had a patient who did appear to be suffocating, i'd medicate that, as a sign of discomfort, in a heartbeat.

Yes, hospice isn't for everyone, we all have our niche i guess, but, hsopice gets easier with time, i think, to be able to provide comfort measures and focus more on signs the person is now painfree,

as painfree as we can achieve, and at peace, as comfortable as possible,

more than

we focus on the respiratory rate. Did triage ever say WHY you should not be giving the roxanol?

At any rate, i bet you did fine and glad you did find your niche in nursing.

OnceMorewithFeeling · Dec 23, 2012

The only order I see a problem with is the NPO order. If he is a Hospice Pt, and he wants a drink of water or some ice chips, he should have that.

You said that the patient had been miserable. Why not give him the medication he needs to not be miserable?

Medications were ordered to be given even when he was asleep. Perhaps this was to make sure that there was a basal level of medication in his system at all times for comfort. We all know that bodies need sleep, and patients will sleep through pain, only to wake when their pain is out of control. Giving pain meds even while the patient is asleep can alleviate this, and provide them with more steady control.

Hospice care can be very hard on nurses, and it's made so much more difficult when we see ourselves as quickening death.

But you describe a situation where a man is dying, very soon, and there is nothing anyone can do prevent it. The intent of your interventions is not to quicken death, it is to give him and his family comfort and peace during this time.

Rest easy.

jadelpn, LPN, EMT-B · Dec 23, 2012

NPO and the patient could still have ice chips. Mouth swabs in cold water. The last thing that you would want is for the patient to start coughing on liquid.

You have to document why it is you are giving ativan and pain meds. Be mindful if the patient is struggling to breathe, is antsy and appears not comfortable. The goal is peaceful and at ease, and q 2 hours and you may assess that the patient is needing something at that time. If the patient continues to appear comfortable, then a discussion with the MD needs to happen regarding the fact that you can not find reason (that you are legally responsible for) for the patient to have q 2 meds, that if it is PRN that you are going to assess q2, however, will not be medicating if the patient is appearing comfortable, however, at the first sign of the beginings of distress you will medicate accordingly. (and let the family know the same)

Make sure you document well. The family nor the doctor would be in any position I would not think to complain that you did not give meds q 2 if you document the patient was sleeping comfortably. You, however, would have a hard time explaining why you would medicate at that time.

And this squirting in the mouth thing.....REALLY? I am not sure that this is the way to adequately be able to manage pain and anxiety. Is there another route that can be used? The patient can not have IV access? A sub-q lock? (and ativan IM is not ideal, but perhaps more comfortable for the patient than squirting liquid in their mouth if they are NPO and not swallowing well.)

mazy · Dec 23, 2012

The Roxanol and Ativan would be administered sublingually so should not be squirted into the mouth, but rather the meds should be placed under the tongue where they are absorbed into the system. If it is possible to control pain and respiratory issues that way it is preferable to an IV, which can be very invasive for a dying patient.

At end of life it is common to see Roxanol given Q hour; I have not had the experience of being told it must be given every hour as a scheduled med, usually it is PRN and is given according to nursing judgement.

In my own experience, usually when the dr. orders NPO, the order refers to PO medications, which are d/c because they are not useful to a dying patient, and cannot be swallowed anyway.

I have not had an order to specifically withhold fluids, and use my nursing judgement as far as that is concerned, but other hospice nurses might have a different experience. It can be very uncomfortable for a dying patient to receive liquids and not at all helpful.

However, it does depend on where the patient is in the dying process. I would never withhold liquids from a patient who was alert enough to ask for them, although would probably provide sips or ice chips and good oral care.

MN-Nurse, ASN, RN · Dec 24, 2012

I really need some opinions please. I have a patient who is on hospice and did have some pain issues where roxanol was effective for them. However today it appears as if the doctor and family have decided its time to put him out of his misery. I have no problem keepin pt comfortable But I really feel like I'm forcing pt to die. Roxanol and Ativan ordered q2h routine even if pt sleeping, they want me to squirt meds in mouth. And made npo even though he was requesting drink just yesterday. The pt is elderly, and was miserable but I guess I feel like I'm putting a dog down or something. Other hospice pts I haven't had routine orders like this.
I just feel morally and legally weird about this issue. Does anyone else ever have an issue with doctors orders for end of life pts?

I've had one instance where family member, a son and daughter, kept pushing for the staff to purposefully overdose their father.

The Palliative Care MD and everyone else who they pushed for this entered their request into notes and explained to the family in no uncertain terms that this would NOT be done and that meds would continue to be used appropriately. I had the patient for a few shifts and got to know them a little bit. We ended up talking at length about end of life issues and policies. It turned out they were completely unaware that we don't OD people on purpose. They thought it was a normal part of hospice care and just wanted it to end quickly for him.

I told them, "If I wanted to kill him painlessly and instantly, I wouldn't even use the things we are giving him now, these drugs just don't work that way. You know your dad, he did things his own way and on his own time, correct? Well, this is no different. We will keep him comfortable, but he is still running the show."

They seemed to understand this, and their father passed away on my shift the next evening. They expressed deep gratitude to me for talking with them about the situation.

OCNRN63, RN · Dec 26, 2012

NPO and the patient could still have ice chips. Mouth swabs in cold water. The last thing that you would want is for the patient to start coughing on liquid.
You have to document why it is you are giving ativan and pain meds. Be mindful if the patient is struggling to breathe, is antsy and appears not comfortable. The goal is peaceful and at ease, and q 2 hours and you may assess that the patient is needing something at that time. If the patient continues to appear comfortable, then a discussion with the MD needs to happen regarding the fact that you can not find reason (that you are legally responsible for) for the patient to have q 2 meds, that if it is PRN that you are going to assess q2, however, will not be medicating if the patient is appearing comfortable, however, at the first sign of the beginings of distress you will medicate accordingly. (and let the family know the same)
Make sure you document well. The family nor the doctor would be in any position I would not think to complain that you did not give meds q 2 if you document the patient was sleeping comfortably. You, however, would have a hard time explaining why you would medicate at that time.
And this squirting in the mouth thing.....REALLY? I am not sure that this is the way to adequately be able to manage pain and anxiety. Is there another route that can be used? The patient can not have IV access? A sub-q lock? (and ativan IM is not ideal, but perhaps more comfortable for the patient than squirting liquid in their mouth if they are NPO and not swallowing well.)

Yes, when I worked in hospice we did use highly concentrated liquid forms of morphine and sublingual ativan on our patients who were actively dying. Most of them did not have veins that could support IV access. Besides, why cause a dying patient more pain with repeated sticks (IV, IM or SC)? Absorption/circulation of the drug may not be as efficient as oral mucosal route.