Managing symptoms for a �good death�

[NRSKarenRN, BSN, RN]

found at nursing 2006:

november 2006

volume 36 number 11

pages 58 - 63

managing symptoms for a "good death"

marylou kouch aprn, bc, msn

contact hours: 2.5* expires: 11/30/2008

What's a good death? Most patients facing the end of life say it means freedom from pain and other distressing symptoms. 1 as nurses, we can play a major role in easing their way to a good death.

Managing symptoms in the last phase of life is especially challenging because you probably won't have the benefit of diagnostic studies to help you assess signs and symptoms. But as a nurse, you bring unique qualities to the table: assessment skills, a partnership with the patient and her family, and the determination to bring comfort.

In this article, I'll present a case study to illustrate the most common end-of-life symptoms, including pain, fatigue, dyspnea, and gastrointestinal problems. Whether your patient has all of these symptoms or only a few, you'll learn how to keep her as comfortable as possible.

[lesrn2005]

Thanks, I needed to read that article.

[clemmm78, RN]

Thanks for posting that. I had a quick skim and will read it a bit better later. We often give scopolomine or rubinal, but we don't have the scopo patches. I am going to look into if we have them available.

I work in a 9 bed palliative care residence with patients EOL from cancer, we rarely have any other EOL patients.

[EmptytheBoat]

Thank you for the link!

[leslie :-D]

good article.

for copious secretions, i've mostly used levsin gtts but normally have to convince the md that more is needed than the recommended amt.

leslie

[suzy253, RN]

Very timely post. Thanks for sharing.

[river1951]

Thank you, it is always great to read more good articles on such inportant subjects.

[msnicola27]

Thanks for posting that. I had a quick skim and will read it a bit better later. We often give scopolomine or rubinal, but we don't have the scopo patches. I am going to look into if we have them available.

I work in a 9 bed palliative care residence with patients EOL from cancer, we rarely have any other EOL patients.

I love using the scop patches, they work pretty good. I find them better when we can get the 72h ones. When our pharmacy runs out, we are having to deliver scopolamine gel out in a syringe with patches for families to "make their own" but those ones have to be changed out q12h.

Nicola

[cookie102]

not sure if this is the right thread to post this or not, so i apologize if it isn't, i happened to come across some documentation that a nurse had left lying around on her end stage cardiac patient, ( chf)stating that the family was concerned about the increased swelling the pt had and wanted to increase the lasix, the nurse told the family she didn't want to increase the lasix because she was concerned about the pts K+, and the increased voiding would make her uncomfortable, now i am def not a hospice expert but don't you all think the lasix should of been increased even if it was short term to let the pt be more comfortable and then if needed decrease it, put a foley in the patient, again short term if needed.......let me end it by saying the patient passed away that same night.!!!, i wish i had know this before hand, i feel terrible, i just hope that little lady didn't suffer. thanks for letting me vent

[req_read]

The article is typical of academic journals. It portrays dying process as a series of biological or pathophysiologic phenomena with interventions being overwhelmingly pharmacological in nature. Reading it one might logically assume that hospice nurses could well be replaced by pharmacists. In many areas the article is elementary and redundant to the point of tedious. I would recommend it for first year nursing students.

The article begins with the question: “WHAT'S A GOOD DEATH?” Then answers that question with, “Most patients facing the end of life say it means freedom from pain and other distressing symptoms.” The author then proceeds on the assumption that this simplistic view has merit.

The assumption that a “good death” is dying “free of pain and other distressing symptoms” is the equivalent of the philosophical point of view that a “good life” is one “free of pain and other distressing symptoms.” This is sheer and utter nonsense.

Good symptom control in dying process is NOT the goal, it is a means to the goal. The ultimate goal in dying is the same as the ultimate goal in living; i.e. to do it consciously.

When your son asks if he can play football do you say, “Oh goodness gracious sakes alive! No, no, no Sweetheart. You can’t do that. You might feel some pain or other distressing symptom… and of course that would not constitute a good life.”

Dying consciously seems to be a concept that lies beyond the capacity of hospice’s academic elite to grasp… which is incredibly disheartening. They seem to think there is a fundamental difference between living and dying, which I assume stems from their definition that death “ends” life.

One endures some pain and distress in life because it is widely recognized that some form of learning may result. But when one assumes that death ends life, nothing results… so there is no point to dying. And if that is true, then there is no point to living either.

The current philosophy endorsed by hospice hierarchy is the same as that expressed in Aldous Huxley’s, Brave New World. (Perhaps that would be an appropriate book in the “recommended reading” thread.)

It is not that symptom control is not important… it IS important. But I repeat, it’s importance is measured by the degree to which it accomplishes the real goal.

There may even be times (banish the thought) when feeling pain is appropriate and beneficial. Of course that could only happen if death does not end life and the individual continues to learn and grow beyond the grave.

For hospice to assume that death ends life is a religious doctrine in itself. Hospice bends so far over backwards trying to avoid endorsing a religious doctrine that it adopts a religious doctrine in reverse. In so doing it seriously damages its own credibility in being the public’s guardian or guide to dying process. Not to mention the fact that it is out of step with roughly 90% of the world’s population, all of history’s great spiritual teachers and now with leading thinkers in the fields of quantum physics and the study of consciousness.

Other than that, it was a pretty good article… rather self-congratulatory in tone and the author completely missed the point of Mrs. Brown’s question about how she would die (she sent in a social worker to address a medical question.) But all in all it wasn’t bad… for first year nursing students.

[EmptytheBoat]

I disagree with you on this one req read. This is an excellent article

and much needed for Hospice nurses. They don't teach this in

nursing school. I believe the goal of the Hospice nurse is to manage

symptoms and allow the patient to peacefully and comfortably work

through the transition from this life to the next.

[leslie :-D]

perhaps i misinterpreted req's position, but i got the impression that he was stating that spiritual/emotional/mental pain is necessary, to successfully transition from here to there.

the article clearly focused on pathophysiologic palliation; much more concrete interventions.

i agree that it is important to address physical pain before one can address the other types of pain.

and i do not believe that pharmacologic intervention should be the sole means of abating any mental stressors the pt is experiencing.

taking the edge off is one thing.

totally blunting someone, to the point where all (mental) pain is repressed, is not synonymous with a good death.

revelation is the journey to truth, even if it entails pain.

truth is the journey to a deeper, spiritual awareness, with a resultant enlightenment and peace.

i do understand why req referenced the article as nsg 101, although the information was helpful and valuable.

yet, there is just so much more to dying.

i do think this is what req was talking about.

leslie

leslie