6 years as a hospice nurse, and i recently had a new situation tha36-5t i was not sure how to handle symptom control. this patient was actively dying, peaceful,unresponsive,pain-free,afebrile...yet, so tachypneic! his respiratory rate, though non-labored , was 36-52 rr./min. regular for over 12 hours before he finally passed. there seemed to be no associated distress-and i felt that using roxanol to slow him down did not seem appropriate, somehow. it was like he was 'finishing a race'-which of course he was...and i let him do it. any comments? his underlying disease was motor neuron (als)and he was not congested.getting occas.dosing of roxanol to assure comfort only. any ideas on cause or treatment options, or your own experiences -let me know. thank you!
i am thinking the tachypnea was compensatory, and without it ,there would be no drive, and using roxanol to that point for that finish would take a heck of alot of roxanol to shut off the autopilot i do believe he was comfortable, and never doubted that, plus made sure there was enough ativan to assure that. i do understanding the principles behind double effect, etc., and have no problem with that. this was unusual, and i guess you would have had to be there. bty, there was another hospice rn present and she concurred. i just wondered if this was metabolic, brain stem...i have seen lots of respiratory failure in my 35 years experience, and this was different. (6 yrs. in hospice)
Sometimes during the dying process the breathing can become labored and "machine-like". As in Kussmauls respirations. I've experienced it myself with a few patients. Sometimes you are able to assist your patient in a "good death". Then, there are a few that no matter how much Roxanol and Ativan you administer....it just doesn't seen to ease the breathing. I understand how horrible it can make you feel when you are unable to ease and make your patient comfortable. I unfortunately experienced this when my dad passed away last May. My dad responded to absolutely no painful stimuli.....he just kept breathing 30-40 x/min. This went on for almost 24 hours.He was a labored breathing machine. Believe me...I tried all the Roxanol and Ativan possible. Nothing eased the respirations. It was very difficult to watch as a nurse but also as a daughter. There are just some...and very few patients, in my experience, that have went through this.
All that being said, even if the pt seems to be having kussmaul's resps, you still need to medicate aggressively ... can you imagine how much your intercostal muscles must hurt after only a short time breathing that hard?
I tend to max out on both opioid and benzos in this situation ... I just don't expect a dramatic response in terms of resp rate ... I figure I'm treating the pain of having such a fast rate in the first place.
We actually know very little about physiological processes involved in the ending of a life ... our patients deserve a rest from aggressive testing, so we're going on theories and empirical experience more often than not. We can only guess at what an "unresponsive" patient is actually feeling while going through it. I can only imagine what it would be like for me to go through it and do the best I can.
All that being said, even if the pt seems to be having kussmaul's resps, you still need to medicate aggressively ... can you imagine how much your intercostal muscles must hurt after only a short time breathing that hard?
I tend to max out on both opioid and benzos in this situation ... I just don't expect a dramatic response in terms of resp rate ... I figure I'm treating the pain of having such a fast rate in the first place.
We actually know very little about physiological processes involved in the ending of a life ... our patients deserve a rest from aggressive testing, so we're going on theories and empirical experience more often than not. We can only guess at what an "unresponsive" patient is actually feeling while going through it. I can only imagine what it would be like for me to go through it and do the best I can.
Just wanted to say thanks for this thread. I am new to hospice--and this information was so helpful this week when my patient died. She was unresponsive--with deep, rapid respirations. My instinct was to medicate aggressively and you have confirmed for me that this was the right thing to do.
oncalllorraine
21 Posts
i am thinking the tachypnea was compensatory, and without it ,there would be no drive, and using roxanol to that point for that finish would take a heck of alot of roxanol to shut off the autopilot i do believe he was comfortable, and never doubted that, plus made sure there was enough ativan to assure that. i do understanding the principles behind double effect, etc., and have no problem with that. this was unusual, and i guess you would have had to be there. bty, there was another hospice rn present and she concurred. i just wondered if this was metabolic, brain stem...i have seen lots of respiratory failure in my 35 years experience, and this was different. (6 yrs. in hospice)
thats all.
thank you!