Impaction question

loving2024, BSN, RN · Apr 29, 2016

One thing you need to know is that Hospice patients have the right to refuse treatment, food and water. if this patient is AO*3 and refused treatment, then the nurse can acknowledge that by telling the family to stop feeding.

Also, the purpose of Hospice is to provide comfort by letting them enjoy the little time they have left. So if the patient is not in any distress, there is no need to intervene, also the patient wont be constipated because nothing is going in because she stops tolerating tube feed.

Goodluck

Scenario: Patient is total care with no s/s of actively dying. NPO with tube feed. No BM for 7 days. Stops tolerating tube feed. Hospice nurse instructs family to stop feeding. Constipation/impaction not addressed. Rationale: Patient is in hospice.
Your input please?

chopwood carrywater · Apr 29, 2016

Scenario: Patient is total care with no s/s of actively dying. NPO with tube feed. No BM for 7 days. Stops tolerating tube feed. Hospice nurse instructs family to stop feeding. Constipation/impaction not addressed. Rationale: Patient is in hospice.
Your input please?

What do you mean by "stops tolerating"?

So if there was nausea or vomiting, then there's a real risk for aspiration. And the GI tract may be in the process of shutting down if it's not getting adequate blood flow.

What do you mean by constipation and impaction not being addressed? Was a rectal assessment done? Were any bowel meds given?

nutella, MSN, RN · Apr 29, 2016

Scenario: Patient is total care with no s/s of actively dying. NPO with tube feed. No BM for 7 days. Stops tolerating tube feed. Hospice nurse instructs family to stop feeding. Constipation/impaction not addressed. Rationale: Patient is in hospice.
Your input please?

Generally speaking patients who are under hospice still need to be monitored for BMs and should have a bowel regimen. Usually there are standing orders for hospice care that address that specific issue.

I am surprised that the pat is receiving tubefeeds while on hospice. Some hospices will agree to do tubefeeds but in my area most of them do not support that.

Of course - when a pat does not tolerate TF is is stopped but if constipation is the problem you need to address that as well...

Pbrown1414 · Apr 30, 2016

Oh my God! this is terrible hospice nursing! Comfort first. What is comfortable about constipation and impaction? Has the nurse even checked? Is the patient active? There are only a few reasons not to treat, but at least you check to see if that is the issue. In the preactive, active stage of dying, I don't try to treat constipation or impaction unless pt and family really want me to. I explain it, and the potential trauma and pain involved, as well as the relief, and let them make the decision. Almost all other situations call for treating the constipation/impaction.

Pbrown1414 · Apr 30, 2016

of course, if the patient refuses treatment. But would they? Are they able? Do they have a POA that can make that "informed" decision? The nurse does not have the authority to tell the family to stop the feeding. That is a physicians order. Period. So is treatment of constipation and impaction, I might add. The bottom line, (no pun intended) is that the family and patient should be educated on the possibility of this complication at the beginning of their hospice journey. They should be well informed that just because a pt has stopped eating, does not mean they will have no waste or no bm. Where did you get your nursing license? Not tolerating tube feeding is the first indication of constipation and impaction. If the patient and family chose to insert and utilize tube feeding, they were more than likely informed of the pros and cons. People who come to us for care deserve to know the truth, and to be educated on complications and contraindications. No BM for 7 days is the first indication that the nurse is not paying attention to one of the most common, if not THE most common complication of a hospice patient. We know what to do about it. Every hospice I know has a bowel protocol, and the nurse in this scenario would know that. Sounds to me like avoidance on the part of the nurse, if not laziness, but it is absolutely negligence. And could be prosecuted as such, if the family knew their rights.

Pbrown1414 · Apr 30, 2016

I have never known a hospice to refuse a patient that is on tube feeding. We have an obligation to allow pts and families to direct their own care to the extent that they understand palliative versus curative. In most cases, tube feeding is considered palliative. It certainly is not curative. I have seen hospices discharge a patient who has decided to have one inserted, as that is not a procedure that a hospice would cover, and it is usually disease-related. However, the patient who has a tube feeding inserted and it is their only form of nutrition, has the right to be on hospice if they so choose, and hospice would have the responsibility to cover the feedings and supplies including DME tp provide that comfort. It doesn't matter that we don't personally agree with a pts decision, it matters that we allow them to make it. Just like a DNR. We are restricted from requiring one, and must admit a patient to hospice if they qualify, even though they are a full-code.

Jensmom7, BSN, RN · Apr 30, 2016

of course, if the patient refuses treatment. But would they? Are they able? Do they have a POA that can make that "informed" decision? The nurse does not have the authority to tell the family to stop the feeding. That is a physicians order. Period. So is treatment of constipation and impaction, I might add. The bottom line, (no pun intended) is that the family and patient should be educated on the possibility of this complication at the beginning of their hospice journey. They should be well informed that just because a pt has stopped eating, does not mean they will have no waste or no bm. Where did you get your nursing license? Not tolerating tube feeding is the first indication of constipation and impaction. If the patient and family chose to insert and utilize tube feeding, they were more than likely informed of the pros and cons. People who come to us for care deserve to know the truth, and to be educated on complications and contraindications. No BM for 7 days is the first indication that the nurse is not paying attention to one of the most common, if not THE most common complication of a hospice patient. We know what to do about it. Every hospice I know has a bowel protocol, and the nurse in this scenario would know that. Sounds to me like avoidance on the part of the nurse, if not laziness, but it is absolutely negligence. And could be prosecuted as such, if the family knew their rights.

Back the truck up for just a minute.

OP said the patient was imminent. Patients who are actively dying are not in a position to make decisions.

Remember that Hospice treats symptoms. Any of my patients who are at this stage and are asymptomatic (no non verbal signs of pain or discomfort), I give the family the choice of whether or not to administer a Dulcolax suppository, while reminding them (because the actual teaching needs to be done before they stop eating and drinking) that as the gut starts to slow down, there could be very little, if any, stool passed.

Most of the time, as long as they see there is no discomfort, they don't want their loved one to be disturbed. Your logic error is caused by thinking that this is a complication during the process of actively dying.

Personally, when it comes time for me to make the journey, I will straight up come back and haunt anyone who sticks something up my butt just so I'll pass stool until I die. And yes, I have so informed my family...AND my doctor.

Also, asking "where did you get your nursing license" is just plain rude. The physician, nurse and family may have already discussed this, with the Doctor instructing to stop the tube feed if a, b, or c happens. And, throwing around the "n" word (negligence) and saying someone deserves to be prosecuted is simply childish and unprofessional, especially when you didn't experience this situation first hand.

When someone is dying, if they are comfortable and peaceful, sometimes the best thing to do is to do nothing. In a situation like that, I provide emotional support to the family.

P. S. The reason patients are discharged from Hospice is because g-tube insertion is NOT part of a Hospice plan of care, and the Medicare Hospice benefit would not pay for the hospitalization or the surgery. They are more than welcome to elect the Medicate Hospice benefit once they are discharged back home, should they so desire. It still wouldn't be part of the Hospice POC, and psych/soc would be heavily involved in discussions with the family (and patient if they are able).

ktwlpn, LPN · May 1, 2016

Back the truck up for just a minute.
OP said the patient was imminent. Patients who are actively dying are not in a position to make decisions.

Actually the OP stated there were NO signs or symptoms of actively dying.In that case a bowel regimen needs to be ordered.We need more information here,if the patient is "not tolerating the tube feeding" is it because they are transitioning or full of stool ? If the patient is moving into end of life then at least check recreation and take action if they are full of feces.

toomuchbaloney · May 2, 2016

Too many unanswered questions about the scenario you presented to provide a good answer.

Yes, hospice will take measures to correct impaction and constipation if that is what the patient needs and wants.

feelix, RN · Jun 12, 2016

Update: I wrote the original post on April 28. Today is June 11.

The patient is alive and well today. We had to hatch an elaborate plot to extricate her from the 'care home' she was dumped into by her family and left by hospice to die.

She had cared for her 4 kids and hubby till she herself became disabled. The moment she became disabled herself, everybody dumped her.

Suffices to say, when she arrived at the hospital they said her kidneys were shutting down. After two days of hydration kidneys started producing urine, she is tolerating tube feeds after a bowel program was initiated. She was transferred to an LTACH, from where she would be sent to a nursing home.

ktwlpn, LPN · Jun 12, 2016

Update: I wrote the original post on April 28. Today is June 11.
The patient is alive and well today. We had to hatch an elaborate plot to extricate her from the 'care home' she was dumped into by her family and left by hospice to die.
She had cared for her 4 kids and hubby till she herself became disabled. The moment she became disabled herself, everybody dumped her.
Suffices to say, when she arrived at the hospital they said her kidneys were shutting down. After two days of hydration kidneys started producing urine, she is tolerating tube feeds after a bowel program was initiated. She was transferred to an LTACH, from where she would be sent to a nursing home.

Poor soul.