"Starving to death"

llg, PhD, RN · May 23, 2012

You probably did just fine -- and the daughter simply didn't want to hear what you were saying. I'm don't work in the geriatrics field, but have had a couple of family experiences with the issue. I think the key is to prepare the family in advance, and not wait until that stage of dying occurs to bring up the topic. People often need time to think through these issues, talk to family and friends etc.

You also might want to avoid words and phrases like "starving," "starving to death," "withholding nutrition," etc. that automatically bring up negative images of suffering and cruelty. You can simply say that the patient can't process food right now and doesn't want it --"So we are not going to force feed him/her." (That sounds kind and compassionate, not cruel.) "This is a normal and expected part of the death process" etc. These phrases don't sound so much like you are being cruel to the patient.

allnurses Guide · May 23, 2012

I work caring for hospice patients and this is a conversation I have all the time.

Food is at the center of how we care for each other and it is hard for family members to see their loved ones not eat. It is hard for them to understand the reason too.

You did a good job. :up: You just might have to repeat it. I get additional help from my hospice team members so the family hears the message from different people.

Double-Helix, BSN, RN · May 23, 2012

I'd say something like:

"One of the best things we can do for your mother is give her comfort and dignity during this process. Since she is refusing to eat, and her body isn't processing food, it's her way of letting us know that food is not what is best for her. You may continue to offer her favorite foods, and she may way if she would like to. However, placing a tube through her nose into her stomach and giving tube feedings will cause her discomfort and take away her dignity at this time. Again, our goal is to make her as comfortable and to allow her to direct her own care as much as possible."

tothepointeLVN, LVN · May 23, 2012

A lot of the times when a patient's family is angry at you it's really they are angry at the situation. Being that I do a lot of continuous care usually what I run into is families that want to squirt water into their loved ones mouth regardless of being able to swallow at which point I'll give education regarding aspiration.

On the occasion that the GT comes up I'll mention it may not be a suitable candidate for the surgery and explain that we give what ever the patients needs if they are able to eat / drink but we do not throw nutrition at them when they can no longer process it.

I always empathize with them regarding that to them food is life and their need to be able to do something. Often times thats it. The only thing they can think to do is feed them.

More and more I've been coming across families that seem to be pushing for high tech interventions like IV's cardiac monitors etc in the home. I'm wondering if the admissions reps aren't adequately preparing them. One family even when actively dying was very concerned he was going to miss his dialysis appointment the next day.

tewdles, RN · May 23, 2012

It sounds like you did fine. These are hard questions for hospice professionals and the family asking are occasionally not wanting to hear what we must tell them.

If your agency does not have printed material that can support your verbal explanation you might suggest that. Having written materials gives each of the disciplines a "common thread" of information to which we add our own individual expertise.

Some of these situations get "easier" as you encounter them over and over again in hospice.

Good luck.

Nascar nurse, ASN, RN · May 24, 2012

I always try to help a family visualize what I mean. They can easily see that the "outside visable" muscles don't work as they once did...if we forced them to work it would only cause the patient pain and discomfort (they almost always agree with this part). I then try to explain that the same thing is happening on the inside...if we push food/fluids down into the stomach but the muscles aren't strong enough to move it all along in the digestive tract it causes pain and discomfort as well.

It doesn't work with everyone because honestly, some just don't want to hear it. But sometimes this seems to be a good way to help them understand. I just keep preaching comfort measures. If they want and are willing to try to drink - give it to them. If they close their mouth or turn away just stop.

IEDave, ASN, CNA, LVN · May 24, 2012

That's a toughie - especially for me, 'cause I just love to eat! Having been on both sides of that issue (had to sign the order for my mom - and I currently work with hospice residents at my LTC facility) it's emotionally a tough thing for family members to accept when a loved one is being "denied" anything, but it's also important to educate them on the realities of the end-of-life process.

Personally, had you been been working my mom's case I would've accepted what you had to say, and it sounded like you did just fine. The closest thing to a criticism I'd give is that oftentimes how something is said is as important as what is being said. Since that's going to vary widely between individuals, that really follows more into the "art of nursing" category and I'd have to defer to the more experienced nurses on that one - I ain't there yet.

In any case - my take: you done good! :hug:

----- Dave

jeannepaul, BSN · May 24, 2012

This is what I usually tell a family when the question of feeding and "starving to death" comes up....I'm sure I say it somewhat different each time I talk about it.

I first explain how the body is slowing down and if I do not hear any bowel sounds, it is telling me food is not moving through their system... I explain that we do not withold food to shut the body down, we withold food BECAUSE the body is shutting down and if we continue to put food into the stomach, it will just sit there, the patient will vomit and it will possibly go into the lungs. I also tell them that even when/if the patient had a feeding tube, at a certain point, the feedings would have to be stopped when the bowels have shut down and/or if patient is congested.

I am usually discussing the whole dying process and how we let the body guide us by what we are seeing and hearing. As I do the assessment, I am explaining some things (I don't say anything negative in front of the patient, even if they are unresponsive) but I can tell what I am looking at/for on some things. ie. when I look at the feet, I tell them I am checking color and temperature and that this is something they can also do and it will tell us about their circulation. When we go into another room I will explain what the color of feet will change to, what it means and how the feet will become colder.

A lot of people still remember the Terry Shivo (? on spelling) episode, and I personally believe they stopped feeding her to shut her down. We somethimes talk about that and how it was not hospice that wanted to stop the feeding, it was the husband and the courts.

I also include the discussion of the patient becoming dehydrated and how that actually helps at the end of life to decrease the fluid that goes into the lungs.

It usually takes me a long time to talk about everything to them, but I tell them in a way that they can understand it and most of the time they understand and agree by the time I am finished.

*LadyJane* · May 24, 2012

You might want to give a pamphlet to her called "crossing the creek", which details what is normal in the dying process. I gave one out to a family member of someone going through this process while in nursing school. The woman who received this information was really, really grateful to have all of this demystified, since most people have no idea what is happening, or what is going to happen and are scared of the unknown.

Jane

tothepointeLVN, LVN · May 24, 2012

Gone from my sight is the one I use.

*LadyJane* · May 24, 2012

Yes, excellent also.