Syringe driver terror

[milly]

Hello

I know that there will be allot of people disagree with me here

Am I only nurse that is quite simply terrified of syringe drivers?

I just feel like I'm helping someone die. I didn't want to be a nurse to help someone die.. I wanted to be able to provide comfort and health..

Are they really agents of death?

How can you make peace with it all ?

Please help me.. If got to get involved with it all tomorrow and I can't sleep..and I'm on the verge of a panic attack already..

Milly

[blondy2061h, MSN, RN]

When I first started working oncology I asked one of the experienced nurses how she got used to seeing all of the death. She said, "They will die whether I'm here or not. Because I'm here I get to ensure they're dying a comfortable and dignified death. That's an honor and a privilege."

It's really that simple.

[hppygr8ful, ASN, RN, EMT-I]

The problem comes when it is mixed up with palliative care. Thing being is the vast majority of people who end up with them for that purpose dies. I know there is a school of thought that stat doses and syringe drivers are so very close to euthanasia. That is something that totally adds up when I think about it logically."..

I question your logic and wonder where you got it? Please cite your source? The purpose of palliative nursing is to ease the pain and discomfort related to the disease (usually fatal) or dying process. As a Christian with very strong beliefs about preservation of life I to felt it was wrong to "speed" this person along to road to death. The facility where I worked accommodated my religious objection and I was given patients who had opted not to use such devices. Watching people die with out the availability of comfort meds was real eye opener for me. I came to understand that denying such care was really akin to torturing the patient in their final hours when they could be a peace visiting loved ones in comfort and dignity.

It's not about ego. Or a lack of empathy. I want to be able to sleep at night knowing if do the best for my patient's i can. And for the record I strongly believe that these patients are the people who we need to advocate for more so than any other. But I also want to be safe and protect both them and my own registration.

Hospice is all about maintaining a person's comfort and dignity. When I participated in the care of hospice patients I slept like a baby knowing that I had done every thing in my power to ease my patients mental, physical and spiritual distress. There will be no issue with regard to your license as long as you are following Physician's orders. One off the great theorists of nursing Virginia Henderson defines nursing as

" "The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible."

I don't understand how the rules change so much. For instance morphine in a surgical scenario, if respiration rate is below 12 it is contraindicated as it suppresses the breathing further and that is dangerous.. Yet in a palliative scenario it doesnt seem to matter because they are dying any way.....[/How do I know that these medications which are very potent and quite a cocktail doesn't play a part in the poor souls demise... I don't know how to wrestle with my conscience on this point. I do indeed plague myself torturing myself wondering if my so called caring act isn't some how killing someone under another guise. And that terrifies me ..I just want to have peace with it. There are hundreds who are incredibly blasea I want to be like that too..

It appears you do not have a good grasp on the concept of the purpose of palliative and end of life care. The rules are deferent because the goals are different. In the first scenario you are trying to help the patient recover and return to normal function. In the second scenario you are helping a person with no hope of recovery finish their journey in peace and dignity. I am trying to help you and this is said with every supportive aspect of my being. It might be wise to recuse yourself from palliative and hospice care for the time being and go talk to nurses in this area of practice. Also you could attend some CEU classes on death, dying and hospice care.

Hppy

[Cowboyardee]

For whatever it's worth, the evidence suggests that administering sedatives to patients during their end of life treatment probably actually prolongs their lives rather than shortening them.

Medscape: Medscape Access

Granted the research on the topic isn't exhaustive. But as far as I know the current theory is that pain and discomfort themselves actually increase fatigue and hasten death, while sedatives and analgesics both limit these factors and may also help by limiting the body's O2 demand, which is a factor in many or perhaps even most deaths.

On top of that, it's just more humane to allow dying patients to be comfortable.

Edit: edited to provide another link to an abstract in case medscape blocked the first one:

Sedative use in the last week of life and the implications for end-of-life decision making. - PubMed - NCBI

[hppygr8ful, ASN, RN, EMT-I]

How do you achieve that mindset? Without being terrified of killing someone?

There is a big difference between murder which is acting with intention of kill and assisting a person who is already dying in making the process comfortable and dignified.

A scenario I will give is a patient who had a very rare form of cancer and was essential being eaten from the inside out. Towards the end she had huge fistula's draining and she was in constant unbearable pain. She asked for a hospice consult and of her own will signed that she wanted to be at peace and without pain until she died She also understood such care might hasten her death. "You mean this misery might end?" as she came closer to death her family suddenly showed up and did not want her to receive any morphine. I walked in the room and found writhing and grimacing and said "Do you want your Medication?" she did not want her children to feel bad so she said no with her mouth but her eyes were pleading with me. I went and got supplies to clean her and came back with those items plus her sublingual morphine. I shooed the family out so " I can take care of her hygiene" once they were out of the room I asked her directly if she wanted her morphine and Ativan. She told me yes and thank you. I administered her meds and took them back to the locker. Family came back in and she was resting comfortably. She died four days later and as she was crossing she looked up at me and mouthed "Thank You"

Hppy

[Ddestiny, BSN, RN]

How do you achieve that mindset? Without being terrified of killing someone?

With most patients and on most units -- labor and delivery, most med/surg, etc -- death is the enemy. New nurses are taught this and it's pounded into your head; don't let the patient die, you'll lose your license, you're doing something wrong, etc.

But people do die, because everyone dies.

Sometimes it comes suddenly, like from an accident where a patient is DOA, and other times it is drawn out because of an end-stage diagnosis. In the latter example, these people still need care, but it is a DIFFERENT kind of care.

With hospice (which I differentiate from palliative care because they are often, but not ALWAYS the same thing. People that are not dying and/or experiencing a terminal diagnosis can still benefit from palliative care), death is not an enemy, it is an inevitability. Some people in hospice view death as a colleague. If you are working with someone with end stage organ dysfunction, cancer, etc and you are more concerned about their QUANTITY of life over their QUALITY of life, then you really need to consider your priorities.

Death is painful. Gasping and fighting for every breath is painful. Cancer is painful.

Is it more important that these people live out their lives conscious but screaming? Or is it better that they are at peace, as their bodies are shutting down?

I once spoke with a hospice nurse who had a 20-something female patient come into the hospice house unconscious due to medication. Her diagnosis was something neurological -- unfortunately I don't remember the details. The family was very concerned about her not being awake as they expected to be able to say goodbye, have meaningful conversations, etc. The nurse said she'd decrease the dosing but warned them that they were not sure exactly how her neurogical status would present upon awaking. The family wanted to persist anyway, so she did....and the patient, once awake, could do nothing but scream. She was in such agonizing pain and fear. The family still couldn't understand, until the nurse finally told them "This is all that she has left". That was her natural state, without pain medication, and without the care she was receiving from hospice.

Sometimes in hospice a patient can be relatively stable (in so far as being unchanging/non-volatile) but then they're turned to be cleaned up or to avoid skin issues, and then they pass.

Does it mean that turning them "killed" them? Should the person interacting with the patient in that way really feel bad about it?

Hopefully your answer is "no". And hopefully it helps to put some of these things into perspective. When a dying patient's nurse is fighting against death, the patient loses. When death is accepted and expected then it allows for the correct focus, of comfort. In hospice the enemy isn't death, it is unnecessary suffering.

[Agatha12]

OP,

But you dont kill anyone with syringe driver but relieve the symptoms and make patients more comfortable. Do you think all medications are the killers because they might have side effects some potentially fatal like chemotherapy?

[Julius Seizure]

When I first started working oncology I asked one of the experienced nurses how she got used to seeing all of the death. She said, "They will die whether I'm here or not. Because I'm here I get to ensure they're dying a comfortable and dignified death. That's an honor and a privilege."

It's really that simple.

This is the best answer that I have ever seen to that question. Beautiful. I wish I could "love" this instead of just "liking" it.

[KatieMI, BSN, MSN, RN]

How do you achieve that mindset? Without being terrified of killing someone?

By understanding that the poor human being is now dying, regardless of my actions. Everything I can do as a nurse is to help him or her to depart this world with as much comfort and dignity as possible. Nothing less, nothing more. If I just stand there and do nothing, the patient will die anyway - and possibly sooner than it would be with palliative care because extreme suffering doesn't help anyone to stay here any longer.

It is like working in Ob, to certain extent. Babies will be born, with assistance or without it - but you can make it less risky and, to some degree, less painful, and that makes all the difference.

[milly]

Thank you for your understanding.. Your first paragraph summed it all up.. Patients dying has always been viewed negatively..and if it happened on my watch I did something wrong .. And I let them down.. Both of which I don't want.

I have very rarely come across death.. Iv never seen a loved one die.. It's always been out of the blue when someone I cared about died.. I went through all my training seeing very few extremely poorly people.. On more than one placement i was referred to as the Angel of calm...

Even when I worked for a palliative care service I still managed to avoid being involved in symptom management side of things mostly.. I did care for people in terms of basic cares and always took great pride in knowing is done a good job and they were clean and comfortable when I left them..

I'm in a new role now which does involve palliative care, but it's only a small percentage of my work. I will be having some training and mentoring throughout this. I know that I am being thought of as cruel that is not my intention. I'm just scared and I want to understand and develop.

Thank you

[djh123]

I've never heard of a syringe driver ...

[meanmaryjean, DNP, RN]

I've never heard of a syringe driver ...

A syringe pump. Like would be commonly used in NICU or to deliver TINY continuous volumes.

[Susie2310]

My experience of the use of syringe drivers/pumps from the point of view of a family member at the end of a person's life is that much depends on the quality of the care and co-ordination of care provided by the hospice team, including family member education.

In the case of a family member who died in their home, the medications infused undeniably hastened their death; however, their pain and suffering were relieved. We did unfortunately experience a lack of co-ordination of care, with assurances being given by the physician about care that would be received which were not met by the hospice nurses, which made things much more difficult and prolonged my family member's suffering. Also, family member education of what to expect was sorely lacking, and family members who were present who had no nursing/medical training were left to process the situation for themselves.

Lack of co-ordination of care/quality care can definitely have a big impact on how the use of a syringe driver/pump to deliver medications at end of life is perceived by the family, even when the patient's pain and suffering are relieved.