Is turning dying patients comfort care or not?

wooh, BSN, RN · Mar 30, 2012

I turn as much as they can tolerate. But if they're obviously in pain with turning, I'm going to do it as minimally as possible, and if even very small repositioning is causing them pain, then I'm not going to turn.

merlee · Mar 30, 2012

I sleep in a recliner. Sometimes for 5-6 hours without waking or turning. I can tolerate being on my sides only 1-1 1/2 hours, then my back and hips begin to ache big time.

So if I am dying, please please please get me into a recliner and keep me there.

Thanks!

And as for body temp - my dad didn't register on the electronic thermometer the day before he passed. I am glad no one tried to warm him.

AtlantaRN, RN · Mar 30, 2012

i know when patients have agonal breathing, or long periods of apnea, we are fearful if we turn them, it will send them on to meet Jesus. you have to turn patients to clean them. also, I know it is painful to stay in one position. I am not opposed to turning patients.

Psychtrish39, BSN, RN · Apr 4, 2012

I totally agree Twinkletoes.. that made me cry.... so much of nursing is actually just human kindness to another and I dont understand why anymore people question what comfort care is.

TheOldestNurseOnUnit · Apr 4, 2012

On our oncology floor where most comfort care and inpatient hospice patients are placed, we have a standard turn q2h rule. That of course is if 1) the patient allows it & frequently during the night, if our hospice patient is alert & oriented, they will ask us NOT to turn them q2 but perhaps q4h 2) if the family allows it--they have seen that it may cause the patient pain & even with medication for pain & anxiety, if they are staying the night, they frequently do not allow us to turn the patient or 3) if we have a patient that we have worked on getting comfortable--adjusting pain drips, keeping clean & dry; giving medications for restlessness and they are finally sleeping as comfortably as possible, I have sometimes told my CNAs and my charge RN that we're going to let so & so sleep for a couple of extra hours before turning so they can get some rest.

I have no problem turning these patients as many of them come to us with pressure ulcers or vascular wounds that really require good care and turning. And yes, there have been a few times where pre-medicating a patient for comfort and then turning them has given them the permission and comfort they need to go to heaven. The first time it happened I was more than a little upset (kinda felt like the Angel of Death) but then a very wise RN told me "what you did was make them comfortable enough to know they could go" and that really made me feel better. Of course, in the situations where family is refusing turns or vital signs; I let them know that we need a baseline for the shift and that I need to check on any wounds, flexiseals, foley caths, etc., just once; that I would ensure the patient was medicated before we do anything (if they're not on a drip) and then we will just check on them during the night to ensure that they remain comfortable. Both the CNA & I will chart what was done and that the family at bedside is refusing any additional turns, vitals, etc.

I agree with a previous poster's statement that comfort care doesn't mean lack of care (or something similar--sorry if I misquoted!). It was beautifully put & I wish we could put a sign up stating as much in rooms and nurses' stations for others to see. I would also include DNR doesn't mean DO NOT TREAT!

HazeKomp, BSN, RN · Apr 4, 2012

My father was on a Med-Surg floor for two weeks, with terminal lung cancer. By the time I was able to get off work and fly to his location, he had fallen twice trying to get out of bed to the bathroom and had developed pressure ulcers on his sacrum and lateral ankles. My father was a very quiet man, who would never complain, never want to bother anyone. I found the staff's attitude was pretty much the "he's gonna die, so if he doesn't ask for anything he must not need anything." Needless to say, he was moved to a hospice care shortly thereafter where he was kept clean, comfortable, and pain-free until his death a week later.

I do not see a terminal diagnosis as an acceptable excuse for patient neglect.

I am a Labor & Delivery nurse of 30 years. When I have babies born that have "incompatible with sustained life" diagnosis, my babies are bathed, dressed, kept warm, held, and loved until they die. They are not left lying in a crib in a corner waiting for the inevitable.

A terminal diagnosis is not permission to neglect basic human needs and the right to high quality nursing care.

Wishinonastar, BSN · Apr 4, 2012

If the patient is on a mattress that alternates pressure sometimes it is easier and more comfortable to minimize turning, but I would hate to assume. A decubitus is certainly painful as is not turning. Think about your own sleep habits. I turn every ten minutes or so in bed. Two hours would be an eternity and that is the typical schedule we do in a facility.

When my mom was dying the nurses hesitated to turn her, but it bothered me a lot and after so long I finally asked them to do it. She did die about 1/2 hour after being cleaned, turned and made comfortable. I never thought of it as hastening, because I felt better knowing her skin was clean and dry and she was in a comfortable position when she died. She had been having irregular breathing for hours before I asked them to turn her so it was not unexpected. I would have felt terrible if she was laying there uncomfortable and wet, unable to speak. I am glad she was turned.

Vespertinas · Apr 5, 2012

That does remind me.. you're right. It does seem I've had a bunch of patients pass away just after we've stepped back and smiled at them and each other for a hard job well done on freshening up and repositioning the dying patient. I hope part of it's because they felt more comfortable and relaxed.

tewdles, RN · Apr 5, 2012

Opioids can provide wonderful pain relief and may or may not affect a persons response to the pain.

I have been bedridden with significant pain issues, morphine worked but made me sick. Dilaudid eliminated my pain and allowed me to rest and move in bed without nausea. My response to pain was not hampered by the opioids, I was well aware of noxious stimulation. I continued to utilize various types of opioids as I recovered and became more active and my pain was resolved. Without opioids many, many patients would not be able to tolerate ANY type of movement in the bed, much less repositioning.

The use of opioids is a cornerstone of comfort care for hospice patients, and they are effective.

beachmom · Apr 5, 2012

In ICU there was a pt. that was dying. She was hooked up to the monitor. Every time she was turned, her HR, Resp and BP all decreased about 20%. Then over the next half hour the VS increased to normal. Two hours later, we turned her, and VS all decreased about 50%, then returned to normal. The third time we turned her, VS decreased, and kept decreasing until she was gone. I think it made her more comfortable to turn her, but it was hard on her. Since then I always turned dying pts carefully, just enough to promote comfort.

thepita68 · Apr 5, 2012

Thank you for sharing this heart touching story of the baby !

And yes, I agree that comfort measures should be practiced until the very end.

We as nurses, as it has already been mentioned are advocates, and should act accordingly to provide whatever is necessary for our patients whether it be pain meds, repositioning, and just knowing that we care. Each human being alive today has a right to die with human dignity.

jbluehorseh · Apr 5, 2012

we as nurses should not follow a dogma routine of turningpatients. i say this because all patients are different; when he or she is oncomfort care or dnr we need to make the patient as comfortable as possible.even with pain medication, pain cannot be eliminated, so if i means we onlyturn patients every three hours or when it is time to clean patients to helpreduce pain so be it. it not a lack a care, i have had many family members sayplease do not move him or her because of amount of pain. at this point we are no longer trying to cure anything;the body is trying to shut down, the risk of skin break down is even greaterwith these patients i believe if thepatient is responsive then he or she should be asked. if the patient conditionis stable then yes, he or she needs be turned. i like to call it nursing judgment.