Palliative care in the elderly

[redtshirt]

At the moment im working in an acute medical elderly unit. There are a lot of patients who on admission are discussed with family and team and decided how far interventions should go with the patients, eg feeding tubes, recussitation, ventilation etc. I think this is ideal as you never know what hour of the day or night something might happen. I have one patient who is now listed as 'palliative' patient is bed bound with no infection(just cleared), has subcut fluids some days with potassium added depending on bloods. She doesnt take anything orally no food no fluids and is suported solely by those sub cut fluids. The family have decided no feeding tubes but the patient is much better than she was at the time of the decision. I just feel that its wrong that this patient is getting no nutrition via an NG, PEG, or RIG line. A patient without dementia may be able to verbilise hunger. Is she starving to death or am i looking at this in the wrong way? Either way i think the team and famly need to meet again to discuss patietns progress.

[CapeCodMermaid, RN]

zowie...we have used clysis in years and years around here.

OOPS!!! Should have written HAVEN'T used...we use peripheral lines, Mid lines and PICC lines but haven't used clycis for at least 25 years. It seems barbaric.

[heron, ASN, RN]

OOPS!!! Should have written HAVEN'T used...we use peripheral lines, Mid lines and PICC lines but haven't used clycis for at least 25 years. It seems barbaric.

I think it's a really old-fashioned way to give fluids, from before iv's were common.

I'm not sure about the barbaric part ... far fewer possible complications, far less invasive. The needles made for clysis are something like a size 30 and barely a quarter inch long. You can give quite a bit of fluid even if it's slower than an iv. We used to give a liter over 12 hours to our lols ... that's about 75mls per hour ... no swelling at the site, either. Wouldn't want to try fluid resuscitation that way, though.

The drawback is meds ... we use it for opioid drips in hospice and are now using it for gentle hydration. You couldn't use it for abx or other meds, though ... only for things already formulated to give subcu.

[redtshirt]

Sorry it took me so long to get back. We use the subcut fluids in people who we can no longer get IV access to, its a butterfly needle secured as you would with a clear plastic dressing so you can inspect the site. Ive seen it used a lot in palliative care for subcut morphine/cyclizine pumps.

The RIG line i cant remember what it stands for but its like a P.E.G line except the tube is much smaller and the opening is a catheter tip opening.

Thanks for all your thoughts on the subject!

[achot chavi]

The fancy term for subcu fluids is hypodermoclysis ... clysis for short. A short small gauge needle is placed subcutaneously and secured just like an iv. There are needle sets made especially for this or you can use a butterfly. You can give fluids as a continuous drip, albeit more slowly than is possible with an iv, or cap it and use it like a hep lock, only you don't use heparin to flush, just normal saline. You can give any meds you can give subcu via a clysis. In hospice we frequently use them for opioid drips. Much less uncomfortable and persnickety than an iv.

In one hospital where I worked, we had a chronic floor and used an overnight clysis to keep the little old ladies hydrated.

Never heard of a RIG line ... can't even begin to guess!

We ONLY give Normal Saline through Sub-Q (or clysis or whatever) we find it successful in hydrating pts without the need to start an IV.

[ellen 12]

The general impression among hospice clinicians that starvation and dehydration do not contribute to suffering among the dying and might actually contribute to a comfortable passage from life.

taken from this site. http://www.dyingwell.org/prnh.htm

People die from dementia - often by losing the ability or drive to take food and fluid.

To my mind - subcut fluids are prolonging the process of dying - just as tube feeding would prolong the process of dying.

Dying is part and parcel of life and to my mind has become too medicalised.

There comes a point where the goal of care must focus on accepting and easing the dying process - without prolonging.

[morte, LPN, LVN]

Radiologically inserted gastrostomy tube (RIG)

These tubes are gastrostomy tubes which are put directly into the stomach under X-ray guidance. This is done for people who can't have an endoscopy, perhaps because because of a tumour in the oesophagus.

ok guys/girls.....this took me at least 1/2 hour to find, it better be the right thing! lol