Research Results are in: To Suction or Not To Suction, End of Life & Hospice Patients

[NickICU-RN]

"To Suction or Not To Suction, End-of-Life & Hospice Patients" is an article I recently published in allnurses.com and the responses were very conflicting. As of today Sept. 13, 2018, there are over 16,000 views of the article and 3 pages of clinician comments! So the results are in:

"To Suction" = 20 votes vs. "Not to Suction" = 13 votes and 6 people voted that they were impartial.

On one hand there is a clinical group that thinks, "Not To Suction".

Some clinicians believe suctioning of the dying patient is actually more harm than good. They believe it is uncomfortable and goes against the comfort care principles. They feel suctioning is unnecessary because it is not a curative treatment of the dying patient, but only symptom management. Some think it makes the family feel better but does nothing for the patient.

On the other hand, there is a clinical group that thinks, "To Suction".

Some nurses believe they are not only dealing with the patient but also the whole entire family, therefore treating both is of most importance. They think it only seems reasonable to suction a person who is in need, even if it is only considered symptom management. They want to give patients a dignified death, not one where they sounded like they were drowning in secretions as the family looks on.

Since we did not receive enough votes from the previous article to form a strong opinion, I started to review the research that has been done on family members' perceptions during hospice and palliative care.

What Does Current Research Say?

A research study at 95 Palliative Care Units of 360 family members that witnessed their loved one's death: [shimuzu, et al. "Journal of Pain and Symptom Management" Vol. 48 No. 1, July 2014].

• 46% experienced the "Death Rattle"
• 66% reported High Distress Levels
• 53% perceived A Strong Need for Improvement of "Death Rattle" care.
• 64% thought the patient was drowning
• 57% felt as if they themselves were suffocating
• 98.3% reported that Nasopharyngeal & Oropharyngeal Suctioning helped improve the "Death Rattle'.

PROBLEM: 62% reported patient discomfort with suctioning and 12% reported rough suction technique.

Although I completely understand trying to avoid and not performing excessive suctioning on a dying patient, some suctioning may be necessary. I would not consider any suctioning comfortable, but there are techniques and methods of suctioning that make it much more comfortable such as No-Bite V suctioning with the use of a red rubber catheter. Red rubber suction catheters are much softer and minimize any insertion trauma. And the No-Bite V allows you to introduce a catheter orally and avoid the nose altogether. I think everybody basically considers nasal suctioning an act of torture at this point, especially repetitive nasal suctioning. But if suctioning can be done in a minimally invasive manner, it increases the patient's comfort level once suctioned properly. And I definitely think suctioning a dying patient brings a calmness to the room, as well as the family. I would never want a family to take away that their loved one suffered or went through some difficulty breathing, in that they actually heard the patient's breathing difficulties in the form of the death rattle. This is something a family would never forget. A nurse's goal is to minimize any degree of suffering, physically and mentally, to both the patient and the families.

One nurse's comment really sums it up:

"I don't want a patient to die on my watch because of poor nursing care instead of their underlying disease. The patient should not die from a plugged trachea, they should die because their body gives out from their disease."

Now that the above research has given insight into family members' perceptions of a dying loved one...

What side do you agree with:To Suction or Not To Suction?

[BSN16]

working in an ICU i rarely suction our comfort care patients. Instead i will first give medications such as glyco or atropine to help with secretions.

[BeenThere2012, ASN, RN]

I agree with the quoted nurse. I watched my father die with the "death rattle" and it was very uncomfortable for US, the family to watch. But then again, he seemed to struggle

less to breath. Maybe that was

our perception and not the reality for him.

[KMRN81]

I think clarification is needed on the type of suctioning you are talking about in order to gauge a more accurate response to your survey. For example, deep suctioning = mostly a no-no due to increased production of mucus from agitating the mucosa. Oral suctioning is much better tolerated.

[nursecolley, ASN, BSN, MSN, RN, EMT-P]

I can only speak for myself as a hospice nurse many moons ago. I recall that we had suction machines brought into homes for several patients, but not all. One case in particular was one in which fluids were gushing from the patient's mouth faster than could be caught by a suction machine, although she was not vomiting, per se. It was so bad that I couldn't allow her daughter to come into the room, and the patient died within ten minutes. I am sorry that the daughter could not be in the room with her mother in her last moments, but my nursing judgement at the time for that family leaned toward the daughter not being able to emotionally handle the way her mother left this earth.

I can see when it would be best to not suction, but that should not be an end-all decision. Sometimes, it's necessary, and sometimes, it's not.

My mother recently passed, and while she did have a death rattle, it was semi-controlled with atropine, and she was able to die peacefully. Not every patient will be this 'lucky'.

[simmy247]

As a homecare infusion nurse I see hospice patients quite frequently. Based on my experiences, it is incredibly difficult for family members to accept and face the reality of death, no matter how prepared they are. I see them mostly for hydration and sometimes antibiotics. The goal is to keep the patient and families as comfortable as possible. And just as hydration has its place in hospice, suctioning should not be overlooked, especially when there is a way to suction in a more comfortable manner via the No-bite. There is innovation taking place in all fields of nursing, hospice and home care cannot be left out.

[Tenebrae, BSN, RN]

Honestly I'd rather resort to postural drainage, eg turn someone over on their side with their head down and get the secretions out that way. It also involves a role for family to assist with if they wish to.

I am anti suctioning in people who are end of life.

To me it goes against the idea of 'comfort care" and to stick a rigid plastic tube into someones mouth and to the back of their throat is not promoting comfort. There are other things that can be done to reassure the family that the nursing staff havent given up on their family member, eg buscopan for secretions, passive postural drainage, mouth cares, also important to educate the family that while secretions and the death rattle appear very distressing for us to observe, usually the patient is less distressed by it

[Tenebrae, BSN, RN]

If the patient is medicated adequately then there is no need for suctioning. Subjecting the patient to the torture suctioning involves to "relieve the family" is inappropriate, and fails the patient who is your first priority.

Ding, ding, ding, give this poster a medal

Cant suction for air hunger

[/username, BSN, RN]

If you were dying, would you rather choke on your own secretions, or have a yankauer shoved down your throat.

[retirednotdead]

No one should have to listen to their family member/friend gurgling to death. There was little choice historically, but we have tools to promote comfort for all concerned. Why should we give care that was substandard in the early 1900s?

[maybug, ADN, BSN, RN]

I worked in an IP hospice unit and we do not suction. I have been taught that suctioning at the end of life makes secretions worse. If anyone has any evidence based practice proving that wrong I would love to read it. Of course I think suctioning of a trach continues to be necessary and is performed as needed. But for "death rattle" secretions we educate that this is a common symptom at the end of life and causes no distress to the patient. We given Levsin, scop patches, etc.

[Smilingnurse1011]

We have hospice beds on our 27 bed unit.

I have hospice patients awaken during the "death rattle," and have asked them if it is hurting or if is bothering them and I have only heard them tell me, or shake their heads to communicate "no,"

I think that if the "death rattle" is truly rattling the patient enough to where the family in the room is concerned, it is audible enough to want to deep suction then I don't think the patient is comfortable enough with less aggressive measures such as positioning and medications. Maybe the respiratory rate is 28-34 and the sounds are loud because of that? If so more medication is needed because that is a clinical sign the patient is not comfortable. Give atropine, morphine for air hunger. The last thing I want to do is go down into their lungs and start suctioning away. Not to mention start soft tissue bleeding and in the hospice patient depending on their morbid factors they could even bleed to death. Wouldn't want that on my hands.

I think you have to look at other factors such as facial grimacing, muscle tension, respiratory rate etc to see if they are uncomfortable and use other less invasive measures first.

If there are visible secretions that are easily accessible, then of course a gentle suction can be used.

[cardiacfreak, ADN]

If you were dying, would you rather choke on your own secretions, or have a yankauer shoved down your throat.

The"death rattle" is NOT the same as choking. But to answer your question if I have excessive secretions at the end of my life, please use atropine and do not suction me.