Quick Question about comfort measures

Jay-Jay, RN · Oct 16, 2003

Originally posted by sjoe
"parenteral fluids will prevent the comfortable dehydration that helps dying patients achieve a peaceful comfort from endorphin release."

Right. Exiting due to dehydration is MUCH faster (often 3 days or so) and less uncomfortable than exiting due to starvation (often over 30 days). Which would you choose?

Sjoe, I'm guessing you've never worked in palliative care? This isn't the same situation as pulling a feeding tube on someone who's in a vegetative state, but otherwise has no active disease process. Terminal patients (usually Ca. patients) do NOT die from starvation or dehydration, but from the disease itself. The body goes through a very natural shutting down process, where the person does not WANT to eat or drink. Food and fluids should NOT be forced on them, as they serve no purpose. One sign that never fails to signal the end is near is a drop in urine output as the kidneys shut down. You want to give someone whose kidneys aren't working I.V. fluids??

I did have it happen once. The palliative doctor didn't realize just how end-stage this person was, so I carried out her order to start an IV on this poor guy. The lab paged the doctor in the middle of the night to tell her the patient's creatinine was through the roof, and she, in turn, called the patinent's home, and told his wife to turn off the IV pump, STAT!

The patient died the next day. My one regret was that I didn't question the doctor's order.

MoJoeRN,C · Oct 16, 2003

I agree with Jay Jay, I attended a work shop for Doctors, Pharmasists and Nurses on End Stage management and care. It lasted from Friday evening through Sunday afternoon. And they stressed how the body shuts down during the end stage and hydration and nutrition are not problematic. Also stressed that parenteral fluids did hasten death due to the kidneys shutting down. Drowning is a terrible way to exit this earth.

Hellllllo Nurse, BSN, RN · Oct 16, 2003

Originally posted by skrainbow
i'm a hospice nurse, is the pt able to make a decision? What we tell our families is that, as the body is dying, things start to shut down, to help with this process. It causes an antesthetic effect in the brain stem, a numbing effect. Adding fluids at this point can actually cause more problems. Fluid in the lungs, edema, ascites, more discomfort. Hope this helps

I was an inpt hospice nurse for four years, and I agree with the above statement.

Often, a dying pt's albumin levels are too low to allow the pt to comfortabley receive fluids, resulting in anasarca, increased respiratory distress, etc. Sometimes, we were unable to make families of pts understand this.

So, we would run an IV at TKO, just enough to calm the families fears. We would keep the amount infused low enough to minimize any discomfort the fluids would cause the pt, but just seeing the IV in the pt's arm often eased the families fears. We called this "hydrating the family."

stressednurse · Oct 16, 2003

Hellllllo Nurse I agree with you, past experience has shown me that comforting the family is just as important. Educate them and give them something to do. Sitting and watching death happen is very hard for anyone.

flowerchild · Oct 16, 2003

If a dying patient is asking for a drink, give it to them. JMO.

Does the patient have a LW? Is IV hydration specified?

I would not consider IV hydration a comfort measure in most cases.

Hellllllo Nurse, BSN, RN · Oct 16, 2003

Most people who we had in our hospice did not have a living will, and made their own decisions until unable. Then, whomever the pt has designated as their DPOA would make the decisions. Most of the time, this person has little, if any medical knowledge and is under pressure from themselves and other family members to "do the right thing" by the pt.

However, they often do not know what "the right thing" is. Or, are feeling so much guilt, anxiety, etc. over their loved one's impending death, they are in no shape to learn.

Also, many times, pts retain their primary doc when they enter hospice, and it's the doc who is clueless.

And...we all know how open docs are to being educated by nurses. In that case, we have a TKO IV to "hydrate the doc."

Tweety, BSN, RN · Oct 16, 2003

Hellllllo Nurse, that's exactly how I would describe this family. We're trying to help them out, but the terminal comfort measures of mom's illness is new. Before that it was treatment. But only last week were they told of mom's impending death. They need time. They also need nurses to help support and educate.

Damned doctor ordered hospice the other day without discussing it with husband. So poor hospice nurse comes in and the husband freaks and refuses to talk to her/him. I know he'll come around, but it's a process isn't it, and everyone is different.

I'm not good at this stuff. The kids are great, get all teary, and then I get all teary. Having elderly parents who just made a new living will bypassing my older non-nurse brother and favoring me as health care surrogate I know I'll have some issues soon.

Jay-Jay, I've never heard of sl ativan. What is the does, is it pill or elixir. I might make this suggestion.

Thanks again to all who helped.

Jay-Jay, RN · Oct 17, 2003

Ativan=lorazepam. It's a benzodiazepine tranquilizer. The SL pills are really tiny, so they work well with someone who cannot swallow. The usual dose is 1 mg., or .5 mg. I take it myself when I'm having trouble sleeping at night after a rough day

Tweety, BSN, RN · Oct 17, 2003

Thanks Jay-Jay. We give p.o. Ativan all the time. Is the subling the same pills, they are tiny. Or are they even smaller and specific for sl use?