Last days of life

Sour Lemon · Oct 19, 2016

I would have absolutely no problem giving the pain medication. At this point, being "careful" doesn't matter. He's dying either way ...better than it's a peaceful death than an excruciatingly painful one.

llg, PhD, RN · Oct 19, 2016

I get scared about each dose I give him that it will be his last breath.
Just need some other thoughts about this situation because I am at home and I keep thinking about this patient and nervous that he may pass away. Is this normal?

I would be hoping that it would be his last breath. ... And I would be hoping that he would pass away soon and peacefully.

Your job is not to keep this man alive for as many minutes as you can. Your job is to help him have a peacefully, minimally painful death.

Why are you so afraid of his passing? Do be so afraid of it that you fail to meet his needs for a good nurse to help him die well.

MrNurse(x2), ADN · Oct 19, 2016

I always ask the family of my end of life patients if they prefer them comfortable asleep or awake, then do a true pain assessment when they awake, if that is the family's desire. Dilaudid 3mg q3 really isn't a hefty dose, I have seen patients with 140mg over 24 hours who have remained awake. Our concern during active dying, as stated by PP, is to give the patient what he desires to be, be that obtunded or awake. Make sure that report focuses on his wishes, it really should be the main focus, as most EOL nursing focuses on ADL's and comfort.

NightNerd, MSN, RN · Oct 19, 2016

Every patient will have a last dose of pain medication, regardless of whether it's fine minutes or five days after that they pass. Please do not withhold his medicine if comfort is his goal. I am sorry; it is hard to witness patients slowly decline.

HouTx, BSN, MSN, EdD · Oct 19, 2016

Do you have access to an Ethics consultation? These folks can really help you clarify all of the issues you're dealing with. My organization automatically involves them as part of the care team for Palliative Care & Hospice. As nurses, we're trained to be focused on extension of life - and it can be very unsettling to deal with this type of care, especially in an acute care setting.

As far as the issue of pain medication hastening death ... it's the intent that matters. You are administering it to relieve pain. If possible when the patient is lucid, be sure to assess the effectiveness of the pain management regimen - and work with the physician to modify it as needed. Patients who suffer intractable pain can become extremely resistant and require much higher dosages than normal.

llg, PhD, RN · Oct 19, 2016

Do be so afraid of it that you fail to meet his needs for a good nurse to help him die well.

I meant to write ... "Don't be so afraid of it ...."

Sorry

Sour Lemon · Oct 19, 2016

I meant to write ... "Don't be so afraid of it ...."
Sorry

I think our minds automatically correct small typos, because I didn't even notice it said "do" until you pointed it out. I read it as "don't".

CelticGoddess, BSN, RN · Oct 19, 2016

Just need to vent a little bit. There is a patient I have grown close with throughout his stay at the hospital. I was there when he first got admitted when he was somewhat functional and able to help himself and now two months later he has gotten worse. He has cancer with mets and he is hooked up to all these tube feedings, trach and catheters. He is a witty, sarcastic patient who busts my chops but that is the bittersweet part of mine and his friendship. I have seen him decline and it is starting to really break my heart. The doctors have increased his pain medication and although I dont want him to be in pain, I get scared about each dose I give him that it will be his last breath. He gets 3mg dilaudid every 3 hours, he is dnr dni and getting palliative treatment. His breathing becomes very shallow when he is on these medications I would say about 8 to 10 but he appears comfortable. My issue is if a patient is dnr dni and they have pain meds as stated above, do you go forth willingly and comfortably by giving all of the pain medication? I feel the 3mg is alot and when I give it I feel I will be the one pulling the trigger to making this patient pass away. He also was crying to me the other night because he is becoming very forgetful and he told me he just feels different and doesnt feel right and that he hopes he is not being a pest to any of the nurses and apologizes for his behavior. Just need some other thoughts about this situation because I am at home and I keep thinking about this patient and nervous that he may pass away. Is this normal?

I work on a palliative care unit. 3mg Dilaudid Q3h is not a lot. I have given 4mg QH before. You do what you have to do to keep the patient comfortable. The disease is going to cause his death, not your making him comfortable.

I recently had a patient who was literally drowning. Nothing we did pulled the fluid off her lungs fast enough. She was getting 4mg Dilaudid QH to keep her as calm as possible. She struggle the last s24 hours of her life and only the dilaudid made it halfway possible for her to breathe. When the meds wore off, she would be breathing 35 to 40 breaths per minute. On the dilaudid, it went down to 8 to 10. It was worth it.

The thing about palliative care is that you want to make the patient as comfortable as possible. By all means, if the patient isn't in distress, don't medicate them. But if they are, don't worry about them dying. As I said, the disease process is going to cause her death not your medicating him/her.

You are NOT pulling the trigger. The disease already did that. You just need to worry about his comfort.

nutella, MSN, RN · Oct 20, 2016

OP - it sounds that your patient is already dying - slowly and perhaps not actively yet but he started the last part of his journey I would say.

The patient will die - but so will every person on this earth when the time has come.

I would not have any objections to giving pain medication. If the patient is DNR/DNI but not CMO there might be holding parameters for narcotics and it is often less than 8 / minute. Having said that - if the patient situation changes and the pain or/and SOB requires more narcotics and it becomes clear that there is some imminence, the MD/NP usually have a discussion about CMO status.

If you give the ordered narcotics and the patient dies after it, you did not cause the patient to die. In this scenario, the patient could die anytime. It is the illness that kills the patient.

Dying has become such an "abnormal" event and people have somehow adopted the idea in the US that "dying is optional".

As a nurse you are way better off by adopting a view that is based on common sense and reality - which is that dying is a normal part of life. Granted, it is sad when people die early in life or when they die of a disease that leads to suffering. But it still is normal to die. All the technology and advances in medicine help a lot of people in the developed world to live longer but nobody can live forever. There is a trade off. Before it became "normal" to die in a hospital or nursing home, people would die at home. It was a normal part of life and people grew up with this knowledge. But now we do not have extended families living close together anymore , women are working nowadays, and a lot of folks feel that they are only "allowed to die" after they have "tried real hard" all kind of treatments, even the ones that do not benefit them much. There is all this pressure about "not giving up hope" - but what does that really mean??? When your time has come your time has come and you die. Having hope does not equal frantic attempts to engage in futile treatments or treatments that will extent life for one week but take away all quality of life. Hope for what? Cure? There is illness that can't be cured. If a person "hopes" for a miracle - when G-d wants to perform a miracle it will happen one way or another - no suffering needed.

freckles23 · Oct 20, 2016

Thank you all for the wonderful insight. I really wasnt looking at it that the patient would die naturally of the disease process over dying because of the pain meds. You have opened my view of this and now I know the information for my next patient. I appreciate all the responses and can use this knowledge in my further practice!

jdub6 · Oct 26, 2016

Thank you all for the wonderful insight. I really wasnt looking at it that the patient would die naturally of the disease process over dying because of the pain meds. You have opened my view of this and now I know the information for my next patient. I appreciate all the responses and can use this knowledge in my further practice!

I was going to mention something very similar but it looks like others have beat me to it! It's amazing how, despite working with very sick patients, we sometimes really don't realize when someone is close to death (and it isn't just nurses, sometimes docs are leading the charge insisting the patient will live).

Not only will you help this patient by understanding that he is dying and providing him with the care he needs to be as comfortable as posdible, but being able to make the critical distinction that you made in your post will be helpful to future patients. Many patients and especially their loved ones have the same concerns you did at first and need a lot of teaching and support to accept pain relief at the end of life and to understand what are signs of dying/ natural end of the disease process vs signs of overmedication. (Also for reference highest palliatove dose of dilaudid i have given IV was 20mg and no that is not a typo, that was qhour-started much lower and worked up obviously-and the patient lived months on that dose walking/ talking- so it really is patient dependent and can be much harder to overdose some patients than you might think! )