RRT on Patient for Hospice

beekee · Aug 29, 2019

Well, presumably since the patient was to be discharged to home with hospice, their code status was DNR/DNI. Therefore, RRT would be inappropriate. Everyone dies eventually.

SaltineQueen · Aug 29, 2019

Who initiated the consult? Nurse or was it family request?

If breathing is a struggle for the patient the I would imagine that might be pretty upsetting for the family to watch. Maybe it's just to ease their view of the patient's "suffering." It's not going to bring them back, it might not even actually help the patient much, but it might bring the family some comfort which I, personally, don't see as a problem.

If it wasn't anything the family mentioned/wanted and the nurse asked for it on their own, I wouldn't agree with that.

Crocsing · Aug 29, 2019

1 hour ago, beekee said:
Well, presumably since the patient was to be discharged to home with hospice, their code status was DNR/DNI. Therefore, RRT would be inappropriate. Everyone dies eventually.

20 minutes ago, SaltineQueen said:
Who initiated the consult? Nurse or was it family request?
If breathing is a struggle for the patient the I would imagine that might be pretty upsetting for the family to watch. Maybe it's just to ease their view of the patient's "suffering." It's not going to bring them back, it might not even actually help the patient much, but it might bring the family some comfort which I, personally, don't see as a problem.
If it wasn't anything the family mentioned/wanted and the nurse asked for it on their own, I wouldn't agree with that.

thank you guys. I posted this query just to know if you guys think that my co-worker did the right thing. This will definitely give me pointers if/whenever, God forbids, this type of situation happen to my assigned patients who are also confirmed hospice patients.

My co-worker was informed by the family that "she seemed not breathing right". She was definitely not gasping for air and she seemed like she was just sleeping. She definitely had too much secretions. The family didn't request for the RRT to be consulted. My co-worker did not end up calling for RRT as she is going to be discharge to hospice as per family's decision. The decision was made the morning before this happened according to my co-worker. What's keeping her in the hospital was that the hospice still needs to send a hospital bed to her house.

LovingLife123 · Aug 29, 2019

My question is, why would you think a rapid should be called? Let’s think about this. The patient is dying. Family has decided that no additional measures except comfort care in this situation. What would a rapid do for this patient? They will not be intubated, no volume expansion, no pressors........ There is literally nothing to do.

Some patients don’t make it to hospice. I hope this patient had comfort care meds on board, especially for secretions.

I would have explained to the family that we were in the dying process.

Crocsing · Aug 29, 2019

42 minutes ago, LovingLife123 said:
My question is, why would you think a rapid should be called? Let’s think about this. The patient is dying. Family has decided that no additional measures except comfort care in this situation. What would a rapid do for this patient? They will not be intubated, no volume expansion, no pressors........ There is literally nothing to do.
Some patients don’t make it to hospice. I hope this patient had comfort care meds on board, especially for secretions.
I would have explained to the family that we were in the dying process.

I appreciate your input. That's the main reason why I posted here to gain more insights ? from experienced nurses.

Jory, MSN, APRN, CNM · Aug 30, 2019

We don't call it a RRT consult, either you get a rapid response or you don't. Even a tech in the room can call for a rapid response. Hospice patients never get a rapid response called.

Does your hospital offer inpatient hospice? When I was still working the floor unless the family wanted to take the patient home, we didn't discharge patients home and transport them when death was expected within a few hours.

Once someone is in hospice, a DNR comes with it. When arranging the discharge the nurse needs to communicate to the transport team that the patient is a DNR and hand them a copy of the paperwork so they don't get resuscitated en route.

JKL33 · Aug 30, 2019

No nurse in a hospital should need to rely upon a patient's choice to pursue hospice to determine that patient's code status; the hospital should have a specific code status on record.

Yes, hospice has a palliative and non-curative focus, but being in receipt of hospice services is not in and of itself a DNR code status. And many hospices do not require the patient to declare a DNR code status.

This can be easily confirmed with a brief internet search, and everyone should be careful giving advice based upon what they know of the usual practices of specific hospices or the "usual" choices and understandings of patients.

I am not arguing than an RRT should be called in this situation or that any specific emergency interventions should be undertaken. I am only saying that it is not wise (and should not be necessary) to use someone's status as a hospice patient as a substitute indicator of their code status.

mi_dreamin, BSN · Aug 30, 2019

In this specific circumstance I would have educated the family regarding the dying process and asked the provider for comfort meds; roxanol, oxycodone SL, atropine SL, scopalamine patch, ativan, haldol, etc.

A rapid response is for patient's whose plan of care is not strictly comfort care. That is why communicating with the family first is so important. Maybe they feel something else should be done besides strictly comfort care, maybe they need the provider to come and educate them that the patient is imminent and nothing will change that.

We have called a rapid on a patient whose plan of care was hospice but that was only because when the patient was suddenly declining very rapidly (not unexpected) the family panicked and wanted everything done. That patient went to ICU only to come back to our floor and pass the next day. Communicating with and educating the family is one of the most important parts of hospice care.

amoLucia · Aug 31, 2019

Anybody else remember what we used to call a 'slow code'? First thing I thought of. Not really applicable here.

On ‎8‎/‎29‎/‎2019 at 4:34 PM, LovingLife123 said:
My question is, why would you think a rapid should be called? Let’s think about this. The patient is dying. Family has decided that no additional measures except comfort care in this situation. What would a rapid do for this patient? They will not be intubated, no volume expansion, no pressors........ There is literally nothing to do.
Some patients don’t make it to hospice. I hope this patient had comfort care meds on board, especially for secretions.
I would have explained to the family that we were in the dying process.

To OP - only thing, while no FANCY resus efforts were to be made, I would make sure pt was well positioned, had O2 on, and maybe suctioning, if gurgling or in some distress. Turned, clean & dry, as comfortable as poss. Get a set of vs (not useful, I know). I check for mottling - that always seemed to be THE telltale sign of imminent expiration to me. And this may be over-the-top, but I would try to give a Tylenol dose - just for general comfort. And I let the family know that it was just for MAYBE (or possible?) discomfort.

It is a VERY difficult thing for family to watch a dying effort. So SOME staff effort, albeit even minimal and prob futile, helps the family to adjust & cope better.

This pt was prob Cheyne-Stoke-ing or Kuss-Maul (sp?). I've stood at the bedside of pts with agonal breathing and even agonal rhythm. Once I made those explanations to families, I just couldn't LEAVE the bedside without them thinking I was IGNORING the pt. I had difficult time explaining that their pt was technically still alive (I couldn't PRONOUNCE yet).

I was basically there for their sake. But they knew WE hadn't just left the pt alone to die. And I would be very, VERY careful how I explained my observations and the impending passing. These are the things that families fear most - that their pt will die. Alone and IN DISTRESS and nobody knew/cared.

One thing. This is the time families might really question decision re the DNR/DNI/DNH. Sometimes there is a real grey, nebulous cloud about the status with a change of heart. Esp when all the guilty feelings bubble up. Be prepared to gently guide them to understand THE PT'S WISHES.

This is the time families need the most gentle but REALISTIC support. Might they appreciate a visit from the facility chaplain? Or a designated staff 'grief 'counselor? Many facilities do have these positions.

A last thing - I always check about Last Rites for the Catholic pts. While this may not be very much to many younger pts and the families, it seemed to be very IMPORTANT to the older generation. I check & ask on the pts' behalf, but freq it is the families who are the most appreciative.

TY for your effort for providing sensitive care.

LovingLife123 · Aug 31, 2019

3 hours ago, amoLucia said:
Anybody else remember what we used to call a 'slow code'? First thing I thought of. Not really applicable here.
To OP - only thing, while no FANCY resus efforts were to be made, I would make sure pt was well positioned, had O2 on, and maybe suctioning, if gurgling or in some distress. Turned, clean & dry, as comfortable as poss. Get a set of vs (not useful, I know). I check for mottling - that always seemed to be THE telltale sign of imminent expiration to me. And this may be over-the-top, but I would try to give a Tylenol dose - just for general comfort. And I let the family know that it was just for MAYBE (or possible?) discomfort.
It is a VERY difficult thing for family to watch a dying effort. So SOME staff effort, albeit even minimal and prob futile, helps the family to adjust & cope better.
This pt was prob Cheyne-Stoke-ing or Kuss-Maul (sp?). I've stood at the bedside of pts with agonal breathing and even agonal rhythm. Once I made those explanations to families, I just couldn't LEAVE the bedside without them thinking I was IGNORING the pt. I had difficult time explaining that their pt was technically still alive (I couldn't PRONOUNCE yet).
I was basically there for their sake. But they knew WE hadn't just left the pt alone to die. And I would be very, VERY careful how I explained my observations and the impending passing. These are the things that families fear most - that their pt will die. Alone and IN DISTRESS and nobody knew/cared.
One thing. This is the time families might really question decision re the DNR/DNI/DNH. Sometimes there is a real grey, nebulous cloud about the status with a change of heart. Esp when all the guilty feelings bubble up. Be prepared to gently guide them to understand THE PT'S WISHES.
This is the time families need the most gentle but REALISTIC support. Might they appreciate a visit from the facility chaplain? Or a designated staff 'grief 'counselor? Many facilities do have these positions.
A last thing - I always check about Last Rites for the Catholic pts. While this may not be very much to many younger pts and the families, it seemed to be very IMPORTANT to the older generation. I check & ask on the pts' behalf, but freq it is the families who are the most appreciative.
TY for your effort for providing sensitive care.

We still sometimes do a “slow” code. Just had one a few months ago. We were waiting on family to get there and make the decision to terminally wean. We pushed lots of bicarb that day.

amoLucia · Sep 1, 2019

LL123 - TY for your comeback. This pt was hospice and a decision for homecare had been made; even a 'slow code' may have been too much. Just some intensive 'comfort measures' appear appropriate. Definitely not an RRT, IIMO.