Staying comfortable vs. hastening death

MunoRN, RN · May 1, 2015

I think there's widespread misunderstanding of the research on end-of-life care and the potential for hastening death. There is absolutely nothing out there that says medications for symptom management at the end of life cannot hasten death, and actually the established pharmacology and pathophysiology involved suggests that they frequently do hasten death. What the research says is that if we administer these medications in the same way we would to patients who are not comfort care, then it's unlikely to hasten death, but of course we don't do that, that's the whole point of making a patient comfort care. To use the OP's example, in a patient dying of a hypovolemic process, anything that creates an additional relative hypovolemia will likely speed up the process, basic principles of pharmacology and pathophysiology don't magically disappear just because they are comfort care.

That being said, there is nothing wrong with prioritizing comfort over trying to prolong the dying process, that's the general purpose of palliative care.

Elvish, BSN, DNP, RN, NP · May 1, 2015

It's hard to wrap your head around at first, I get it. It was for me. So much of our education - and for many of us, our practice - is focused on helping the patient avoid dying. And sometimes that's appropriate. I'm a baby nurse at deliveries, so I can count on one hand the number of times I've been at a delivery where my goal wasn't to help the baby stay alive (diagnosis incompatible with life, short life expectancy). Before that I occasionally took care of babies born alive

It's a paradigm shift to be sure. But if the disease process were not already killing the patient, a dose of Ativan (or morphine or whatever) isn't going to. Ethics does consider intent when looking at situations like these. Your intent in giving the med is not to shorten life; your intent is to relieve suffering. If a medication relieves discomfort on a comfort-care patient, it is ethical to give.

When it's my time to go, I'll take all you have available, please.

Libby1987 · May 1, 2015

I guess I don't remember having this dilemma but somewhere it switched to managing pain and avoiding suffering being just as important as healing. I'm not comfortable with deaths, personally I struggle with mortality and have to watch that I don't over sympathize but I hate suffering more and my instinct to protect my patients from that is stronger than fear of not delaying death while actively dying.

megatronRN · May 1, 2015

I've never hesitated to use the ordered "comfort measure" drugs in a dying patient. If the patient is actively dying, it seems much more ethical to lessen their pain and make them comfortable through the experience. Most families agree with this practice. If death is imminent and the patient appears to be in distress, give the medications and allow them (and their family) a peaceful transition.

Jules A, MSN · May 1, 2015

That being said, there is nothing wrong with prioritizing comfort over trying to prolong the dying process, that's the general purpose of palliative care.

Amen and I can't imagine it could even be considered ethical to attempt to prolong the dying process! Even in rare cases such as family out of town please just pass along that I said "peace out" and give me my respiration depressing comfort meds.

Dranger · May 1, 2015

Trust me. Ativan, morphine or versed will not hasten their demise. Totally appropriate to give and give frequently.

DNR is a lot different than comfort measures though. DNR can be full treatment.

MunoRN, RN · May 1, 2015

Trust me. Ativan, morphine or versed will not hasten their demise. Totally appropriate to give and give frequently.
DNR is a lot different than comfort measures though. DNR can be full treatment.

I completely agree that the risk of hastening death never supersedes the treatment of discomfort or distress, but do you really believe that these medications "will not" hasten the process? What rationale are you basing that on?

BrandonLPN, LPN · May 1, 2015

You're not hastening death, you're treating a patient during the dying process.

Dranger · May 1, 2015

I completely agree that the risk of hastening death never supersedes the treatment of discomfort or distress, but do you really believe that these medications "will not" hasten the process? What rationale are you basing that on?

Whatever disease process at work is finishing the job. Drugs that we use for comfort care generously do not in my experience cause respiratory/hemodynamic depression as much as we think. The body is fighting to stay alive and the drugs help to alleviate that edge of desperation.

MunoRN, RN · May 1, 2015

Whatever disease process at work is finishing the job. Drugs that we use for comfort care generously do not in my experience cause respiratory/hemodynamic depression as much as we think. The body is fighting to stay alive and the drugs help to alleviate that edge of desperation.

The terminal condition will be the primary cause of death, but you'd have to ignore everything we know about these medications and how they affect patients to believe they can't and don't often alter the course that would have occurred without them, not that there is anything wrong with that. Perpetrating the myth that terminal patients are somehow immune from the well established effects that apply to all other patients only confuses the issue for many nurses and likely results in inadequate symptom treatment.

Often at the end of life, you are correct that the body is fighting to stay alive, which is often what is causing discomfort and distress. For instance, one of the main reasons why we give opiates for dyspnea at the end of life is to reduce or even knock out this compensatory effort to extend life; reducing or completely 'turning off' a process that extends life = likely shorter time to death.

The problem is that this leads to confusion for nurses who are able to understand what the purpose of the patient's severe respiratory effort is and that the goal of symptom management is often to reduce or stop that drive altogether. When put under the impression that palliative care isn't supposed to hasten death they hesitate, since they know full well that telling the patient's compensatory mechanisms to stop trying so hard to maintain life could hasten death. What we need to be honest about is that we accept the potential to hasten death if it's primary purpose is to provide comfort.

Home Health Columnist / Guide · May 1, 2015

Excellent resources:

The Double Effect: Terminal Sedation - PBS

Terminal Sedation, Euthanasia, and Causal Roles - Medscape Free registration required

[h=3]Palliative Sedation in End-of-Life Care: Nursing Positions[/h]

The American Nurses Association^[19] (ANA) position paper on pain management and control of distressing symptoms in dying patients provides that when restoration of health is no longer possible, the focus of nursing care is assuring a comfortable, dignified death and the highest possible quality of remaining life. One of the major fears of patients and their families as they approach death is intractable pain. The assessment and management of pain and other distressing symptoms must be based on an informed understanding of the individual patient's values and goals and his or her emotional, physical, and spiritual needs, and on an understanding of the pathophysiology of the disease state and evidence-based palliative care practice.^[20] When pain and other distressing symptoms are present, the patient should have appropriate and sufficient medication by appropriate routes to control symptoms in whatever dosage and by whatever route is needed to control symptoms as perceived by the patient.^[21] The ANA's Code of Ethics for Nurses^[22] also states that nurses may not act with the sole intent to end a patient's life even if motivated by compassion and concern for dignity and quality of life.

ANA: REGISTERED NURSES' ROLES AND RESPONSIBILITIES IN

PROVIDING EXPERT CARE AND COUNSELING AT THE END OF LIFE

_firefly, BSN, RN, EMT-B · May 1, 2015

Here is a quote from page 106 of the third edition of Core Curriculum for the Generalist Hospice and Palliative Nurse written by the HPNA:

"The fear of using opioids, due to the potential for respiratory depression, to ease terminal dyspnea often leads to inadequate symptom management. The use of these drugs to ease terminal dyspnea is often mistakenly equated with euthanasia or assisted suicide. Note: There is no justification for withholding symptomatic treatment to a dying patient out of fear of potential respiratory depression. Excellent communication with family and staff is required to avoid misunderstanding"

The same applies to Ativan. Our job is to give those that are dying a good death. Give them strength, support, and comfort. If that effort hastens their death, so be it. As my palliative nursing instructor wrote, it is all about intent.