Palliative sedation position paper

prostreetrig · Mar 23, 2007

Hello there. I am a nurse with Hospice and we just got done doing terminal sedation on one of our patients. I will start by saying this gentleman had lung ca with bone mets. He was in excruciating pain, all day, every day. We had him on Roxy 4ml Q2H, Ativan 1mg QH, Fentanyl 300mcg Q72H, Methadone, etc. This mans legs were contracted right to his chest all day. We could never even move him to change him without hurting him. I will never forget when it happened. It was a Wednesday morning and this PT looked at me and said "I dont care what you do but I don't want to be awake to feel the pain, and I don't want to know what's going on, I can't do this anymore". Now mind you, two days prior to this he had started in with severe agitation and very delusional. He would tell the nurses to leave because we weren't who we said we were. He would spit on the walls, pee in his bed, all of these things on purpose. We sent the order to doc and it was made. Ativan 1mg QH, Roxy 4ml QH, Demerol injections, shortly after the first seven hours he was finally lightly sedated but enough to not have the pain, not know what was going on. That afternoon sadly he took his last breath, it was his adrenaline that was keeping him alive. This man had been ready to die emotionally but his body was doing nothing but hurting him. So, do I think it's justified, depending on the situation on hand, absolutely. The family was so thankful for what we had done. The best thing was it was his wishes. He was able to tell us what to do. Our first and most important issue is the PT pain and symptom management. We did tell the family it wasn't the drugs we gave him that killed him, we gave him drugs to be lightly sedated and once his body could stop fighting the pain he was able to let go. I hope this helps and I would hope for more answers to this age old conflict. Take care now.

Sabby_NC · Mar 23, 2007

hi

i am a hospice nurse and totally agree that there is a place for palliative sedation.

if any of our home patients require this then they go to a palliative care ward somewhere. we cannot monitor them safely in the home.

there is nothing worse than watch some one suffer the horrendous pain that some cancers and conditions can cause.

this cannot be called euthanasia as you are not ending the persons life, you are easing their symptoms.

palliative sedation means just what it says, you assist the pt to go into a sedated state so they are not aware of their pain/condition. you are still treating their pain even when sedated of course.

it is something that needs to be well discussed with the pt (if possible) and family members along with the dr, counselor, bereavement counselor, rn involved in the pts care. hopefully this has been discussed well before it gets to that stage in the pts goals for care if the pain gets unmanageble etc what his/her goals for treatment would be.

severe bone mets cause horrendous pain and sometimes no matter what you give the actual pain medication is going to cause palliative sedation in a sense, depressing the respiratory center etc.

so yes there is a need for it in hospice care, it is ethical, that is what our job is about isn't it? controlling pts symptoms no matter what they are, in the manner that the pt chooses.

if i worked in a hospice ward, home etc i would have no problem looking after anyone with palliative sedation. i would treat them as well as i would treat anyone else with dignity and love. they deserve nothing but the best at the end of their lives. god bless them all.

IDidIt2007 · Mar 23, 2007

Thanks so much for the above replies. PS only makes sense to me, I don't understand why there is an ethical debate over this.... who are the people that debate this issue and why do they feel it is not appropriate?

river1951 · Mar 23, 2007

There are those black and white thinkers who cannot flex.

For ethical principles, I have always been taught it is the desired end of the treatment that makes a difference- If we sedate to relieve suffering and physical death occurs- there was nothing that was going to prevent the physical body from dying anyway, but why should the patient be tortured?

We have gone through this with families who insist on feeding by extraordinary means to prolong life, while they are truly only prolonging the patient suffering IMHO.

Good luck on your paper.

River

mpingo · Mar 29, 2007

I'm hoping that you can agree that, as in any profession, good, well-intentioned protocols can be abused. I recently took care of a patient in hospice who was not terminally ill, only chronically ill. In my opinion, she died from being over-medicated by hospice, which, in my opinion, caused or exacerbated her depression, which led to her deciding that life was too hard for her (she was in little to no physical pain, other than possibly some arthritis pain), and she decided to end it by refusing to eat. This experience has left me with a rather bad taste in my mouth regarding medication policies by this hospice care agency.

Since talking about this experience on another nursing forum, I've read a post from another member on that board, who told of her experience of having a patient in hospice who wasn't terminally ill, but only chronically ill. She was a brittle diabetic, and since she was admitted to hospice her diabetis was no longer monitored adequately, as part of their policy of not prolonging life, and she died unnecessarily of improperly controlled diabetis.

I think that it's time that our hospice agencies undergo a massive re-evaluation of some of their policies. If the agencies or their regulatory authorities can't or won't do that, then I think that governmental agencies should investigate and assess what is going on in these hospice agencies, and perhaps create some kind of watchdog organization, to make sure that some patients are not being moved into hospice in error, and to make sure that some patients are not being enabled to die that want to die for all the wrong reasons.

river1951 · Mar 29, 2007

Over medicated? If she had no symptoms. I don't understand why any hospice nurse would medicate. So you will have to tell me more so I can understand what you mean.

Hospice doesn't mean medicating patients to oblivion; palliative sedation is only considered for those patients whose suffering (i.e. symptoms) cannot be relieved by routine medications.

Not that all hospices do everything correctly, broad sweeping statements can't be made. If you don't think we aren't already evaluated to death by joint commission and the government, you are not aware of what is happening in our field. Abd we do regulate ourselves as well-

I will tell you this story, I got a patient some number of years ago who had a gangrenous foot and was refusing amputation. We hated to see anyone die needlessly, so we found out the reason she refused the amputation- her surgeon refused to give her adequate pain medication during her previous surgery. We worked to get her pain under control and got her an antidepressant. She then made a decision to have the surgery (from a different MD) and we happily discharged her. I visited her last year and she is still with us.

So, though I can understand you believing a specific patient was overmedicated, I think your sweeping statements about hospice needing more regulation is ....

I can't even state my feelings about how bad I think that would be- We can barely get folks' pain under control now.

Sincerely,

river

EmptytheBoat · Apr 1, 2007

I'm not sure I buy into the palliative sedation concept, and I believe that

such a concept may be misused and misconceived. My hospice experience,

both personally and professionally, has demystified the concept for me.

As a caregiver and a hospice nurse, my goal is comfort and awareness to

allow the transition. If medication is the means to allow the comfort and

awareness, so be it, medication is utilized. In death, my experience has

been, the individual slips into sedation, medicated or not, for a period of

time. The timeframe varies, from minutes to weeks, and during this time,

I wonder, pray for God's mercy, and provide presence. Any medication

administered during this phase of transition is symptom related, usually

dyspnea, fever or secretions, and administered equally for the caregiver

and my peace of mind.

EmptytheBoat · Apr 1, 2007

mpingo: I'm a hospice nurse, I've worked with/for several different hospice

organizations, and I've not been made aware of any specific protocols concerning medication. Each pateint is assessed and evaluated and an

individual plan of care is established and adjusted on-goingly.

The hospice organization may have established standing orders, not all do, from the medical director for medication, the standing orders are not considered protocol for every patient, but are used to allow hospice nurses

to react quickly and efficiently to manage individual patient's symptom(s).

You mentioned that you recently took care of a patient that was chronically

ill but not terminally ill. Hospice is for the terminally ill, terminal illness being

that two physician's have diagnosed and determined that the patient has

less than 6 months to live. Hospice already has government regulations

concerning hospice-appropriateness, and hospice agencies are bound to

follow specific guidelines.