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?

[Been there,done that, ASN, RN]

I attended my best friend in her final hours. I performed gentle suctioning. Could not see her drown in her own secretions.

Was that selfish?

[MunoRN, RN]

The "death rattle" occurs because at even mildly decreased levels of consciousness that irritating tickle becomes unnoticeable to the patient, so they don't spontaneously clear those secretions. Even though persistent tracheal secretions might not bother the patient enough to get them to clear them, tracheal suctioning certainly might still be sufficiently noxious for the patient to be aware of it, and the sensation tracheal suctioning causes is essentially a choking sensation.

So suctioning the rattle isn't preventing the patient form experiencing a choking sensation, since that's why the rattle exists, but suctioning will. Beyond that, tracheal suctioning will stimulate sudden production of tracheal secretions, potentially hastening their death.

Causing the patient to feel like they're choking to alleviate a condition that only exists because the patient doesn't notice it seems extremely counterproductive if the goal is to alleviate suffering and to avoid causing it.

[NickICU-RN, ADN, BSN]

I agree, deep tracheal suction is contraindicated, but pharyngeal suctioning is not, especially if you can suction gently with a No-Bite Suction, just to clear out the back of the throat.

If you are telling nurses they should not gently suction a dying patient if it is needed.... It's a slippery slope.... Are nurses then supposed to let a patient lay in bodily waste because it is too much pain to turn them?

It does not make any sense!

[MunoRN, RN]

I agree, deep tracheal suction is contraindicated, but pharyngeal suctioning is not, especially if you can suction gently with a No-Bite Suction, just to clear out the back of the throat.

If you are telling nurses they should not gently suction a dying patient if it is needed.... It's a slippery slope.... Are nurses then supposed to let a patient lay in bodily waste because it is too much pain to turn them?

It does not make any sense!

In an actively dying comfort-measures-only patient, anything that brings more discomfort than comfort is contraindicated, which would include pharyngeal suctioning, a good rule of thumb is don't go past the uvula since noxious stimuli past that point is very uncomfortable.

There really isn't anything about the "no-bite" suction device that makes it more gentle. It just prevents the patient from preventing the discomfort you're about to cause by biting the tube. It's like if you tied someone's hands behind their back and then proceeded to punch them in face, then concluded they didn't mind being punched in the face because they didn't use their arms to stop you.

If you would cause an actively dying patient more pain and suffering by turning them to clean them, then no, you shouldn't do that. Do only what brings more comfort than pain and suffering. Trying to suction a death rattle does not bring more comfort than discomfort.