Staying comfortable vs. hastening death

MunoRN, RN · May 2, 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.

To give an example, I was orienting a nurse to ICU not long ago, we received a patient from the floor who had coded. The patient had end-stage COPD and had already been on a low-dose opiate to optimize their respiratory status, and then was hospitalized for different reason and was requiring an increase in their opiates for pain control. On the floor, the patient appeared to tolerate the additional opiates well as their respiratory rate effort remained within 'normal' range and with supplemental O2 their sats were fine. But of course with end-stage COPD, a respiratory rate and effort that is 'normal' is often not sufficient. The patient quickly developed a severe acidosis and coded.

In the ICU the patient stabilized with narcan and BiPAP, the opiate dose was reduced back down to their home dose, which still left them somewhat dyspneic so we tried bumping up the dose slightly, at which point their CO2 levels started shooting back up, so we had pretty clearly determined the maximum dose of opiates that wasn't going to put them on a fast track to death.

A day or two later the patient decided to become comfort care as their admitting condition was not improving, and of course their COPD wasn't going to go away either. The goals, process, etc of comfort care was discussed with the patient and family, which included the fact that to adequately treat the distressing symptoms the patient was currently experiencing was going to require an amount of opiates that the patient had recently clearly shown could lead to a quick death, and all were in agreement.

After leaving the room my orientee pulled me aside and was almost frantic, explaining that she had always been told treating symptoms at the end of life doesn't hasten death and yet in this situation she recognized there was really no avoiding that this is most likely what was going to happen. She hurriedly found some articles from various hospice and palliative groups that misleadingly gave the impression that this doesn't happen.

Her view was that since comfort care isn't supposed to hasten death we should not give any more opiates than the maximum that we had already established did not worsen their acidosis, even though it left their symptoms vastly under-treated. The idea that a potentially hastened death might be an acceptable tradeoff for a patient if it means adequate comfort was a foreign concept to this nurse, largely due to this myth.

calivianya, BSN, RN · May 2, 2015

It doesn't matter whether the medicine hastens their death or not. It's still okay even if it does. Think about it if it were you - say you are dying. You know you are dying, and you know it's inevitable. You have terrible bone pain from cancer mets to your bones, let's say. You have two hours left to live if you don't take pain medicine, and you have ten minutes to live if you do. Would you rather live the next two hours in excruciating pain with no relief, or would you rather die ten minutes from now in comfort?

I doubt many people would pick the excruciating pain option, given the absolute irrefutable fact they are going to die anyway.

wannabecnl · May 2, 2015

I agree with the posts saying to discuss the matter with the patient and family whenever possible. I lost a dear friend 2 years ago to breast cancer with spine and lung mets; she was able to spend her last days at home and was having trouble breathing. Her husband told me that she flatly refused morphine; it made her too loopy, and even when she couldn't speak anymore, she would grit her teeth to keep it out! But the hospice nurse stepped in with Ativan as an alternative, and it worked wonders for her. It let her rest comfortably while her family was there to say goodbye, and she was able to be calm but not too loopy to enjoy being with them.

Morphine has the reputation of being good for relieving air hunger, but if you can assess what the family and patient want, you might find better alternatives, including Ativan. And obviously you need to stay within the orders you have; if you think the patient needs something different, contact the ordering provider and have a discussion! They will often be able to come up with some good ideas when they know the whole picture, pt/fam prefs, etc.

toomuchbaloney · May 2, 2015

I get Muno's comments and in reality, every pharmaceutical that we administer to the actively dying patient is likely contributing to their ongoing organ failure.

Recently at least one state demonstrated that if you want to execute someone that you CAN use hydromorphone and midazolam. However, they also demonstrated that while it is likely a peaceful death it takes hours to accomplish.

When we apply that knowledge to administration of similar drugs to an already dying patient we might anticipate that such medications given to a person with poorly functioning organ systems might incrementally hasten their already inevitable death. We accept that and couple it with the knowledge that hastening the death to any appreciable amount is NOT THE INTENT of the medication. We don't titrate the doses according to how close to death they are but to how comfortable they are using our assessment skills.

It is an interesting intellectual exercise that helps us to review and reframe the goals and ethics of hospice philosophy of nursing care.