To Suction or Not To Suction, End of Life & Hospice Patients

I recently was at a nursing conference where some nurses stated they do advocate suctioning on their dying patients. This article examines both schools of thought and finds a middle ground of common sense suctioning. Nurses General Nursing Article

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  1. In End-of-Life Care, which side of argument you are on "To Suction" or "Not To Suctio

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      To Suction
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      Not To Suction
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To Suction or Not To Suction, End of Life & Hospice Patients

I've been an ICU RN for 15yrs, so I have dealt with End of Life Care plenty. I was always taught to either oral suction or deep suction with a suction catheter if your patient sounds like he or she needs suctioning. But of recent, I have run into some nurses with a different school of thought, in which they do not believe in suctioning of the dying patient.

"NOT to Suction"

Some nurses believe suctioning of the dying patient is actually more harm than good. They believe it is uncomfortable and goes against the comfort care principles. They feel suctioning is unnecessary because it is not a curative treatment of the dying patient, but only symptom mangement. Some think it makes the family feel better but does nothing for the patient.

  • Nasal suctioning can cause Pain, Trauma, and Bleeding in your fragile End-of-Life Patients.
  • Many patients in the active phase of dying are not aware of their surroundings and therefore bite down on or "tongue-out" suctioning equipment.

"To Suction"

Some nurses believe they are not only dealing with the patient but also the whole entire family, therefore treating both is of most importance. They think it only seems reasonable to suction a person who is in need, even if it is only considered symptom mangement. They want to give patients a dignified death, not one where they sounded like they were drowning in secretions as the family looks on.

  • The Death Rattle is common and can be a very unnerving experience for families as well as caregivers.
  • Medications and patches used to dry up secretions causing the Death Rattle do not always work... Some patients still require pharyngeal or subglottic suctioning, for example: pneumonia patients.

My Conclusion "Suction with Dignity"

Although I can understand not wanting to do excessive suctioning to a dying patient, some suctioning may be necessary. I would not consider any suctioning comfortable, but there are techniques and methods of suctioning that make it much more comfortable such as No-Bite V suctioning with the use of a red rubber catheter. Red rubber suction catheters are much softer and minimize any insertion trauma. And the No-Bite V allows you to introduce a catheter orally and avoid the nose altogether. I think everybody basically considers nasal suctioning an act of torture at this point, especially repetitive nasal suctioning. But if suctioning can be done in a minimally invasive manner, it increases the patient's comfort level once suctioned properly. And I definitely think suctioning a dying patient brings a calmness to the room, as well as the family. I would never want a family to take away that their loved one suffered or went through some difficulty breathing, in that they actually heard the patient's breathing difficulties in the form of the death rattle. This is something a family would never forget. A nurse's goal is to minimize any degree of suffering, physically and mentally, to both the patient and the families.

PLEASE COMMENT and share which side of argument you are on "To Suction" or "Not To Suction" your End-of-Life Care / Hospice Patients

Hospice and Palliative Care provides humane and compassionate care for people in the last phases of an incurable disease. The focus is on patient comfort and symptom management. One symptom, the death rattle, which refers to the gurgling noise of excessive secretions, can be misinterpreted as the sound of gagging or choking to death. The death rattle occurs in up to 92 percent of people actively dying and can be an unnerving experience for the patient's family as well as the caregivers.

One way to treat the death rattle is to dry up the secretions with medication. But that does not always work and some patients still require pharyngeal suctioning.

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NickICU-RN

About NickICU-RN, ADN, BSN

ICU RN with 15yrs exp in all areas of ICU: MICU, SICU, CV-ICU, Neuro-Surg ICU, CCU, & Burn ICU

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Specializes in CVICU, MICU, Burn ICU.

Hi Nick, Great article!

I fall right about where you do on this. There are times when some strategic suctioning can be very therapeutic... not only for family, but presumably for the patient as well. I think this should not be happening via NT suctioning (as you stated).... which I have seen done and do not advocate and will not perform on a dying patient.

This is a very valid topic for investigation and discussion.

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Specializes in Critical Care.

This is certainly one of those tricky dilemmas with no definitively correct answer, but in general I don't believe it's appropriate to suction patients who are truly at the end of life, and is bad practice. An increase in oral and upper airway secretions and a decreased ability to manage them is a normal part of the dying process, and in most situations I've seen where suctioning is performed, the secretions are causing no obvious distress and the suctioning itself imparts far more discomfort and distress. Obviously this is different if the patient is not actually in the actively-dying process.

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I think selective therapeutic suctioning can be done and beneficial to family and patient alike. One can use a trach suction kit which is much less invasive then the yankaur.

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I think selective therapeutic suctioning can be done and beneficial to family and patient alike. One can use a trach suction kit which is much less invasive then the yankaur.

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Specializes in Pedi.

In general, I'm on the no suctioning side of the debate unless the purpose of the suctioning is really to promote comfort. There are medications that can be given to dry out secretions. We frequently used robinul at end of life when I worked in the hospital and whether or not to deep suction was typically spelled out in our DNR orders.

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I fall more onto the side of no suction. I am okay with gentle oral suction with drying medications - but not deep suction or NT suction - that has always seemed to cause discomfort in my experience. A lot of the time the secretions just come back quickly anyway. Turning the patient can help loosen up the secretions sometimes. If you explain your rationale to the family they will understand the reasoning behind not suctioning for comfort.

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Specializes in SICU, trauma, neuro.

If the pt looks like they are struggling with their secretions, I might. If they are at that unconscious with the death rattle stage, I give meds. Our hospice team (consulted for the ICU care to comfort care transition) sometimes recommends Robinul, and usually a scopalamine patch, and atropine eyedrops given sublingually -- those for me mostly eliminate the death rattle sound... which I totally get is distressing for families.

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Specializes in Family Nurse Practitioner.

In Palliative Care at the facility I am employed we do not deep suction comfort patients. All are given Robinul, scopolamine patches, & sometimes Atropine. We consider deep suctioning to be against comfort. We may suction the mouth but that is it. We do provide family with education on end of life changes as well.

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I think any intervention at the time of death takes away from the spirituality and emotion of the moment for the patient who is definitely going to die. I refused CPR for mom when she was passing. It was a difficult decision, but non-interference allowed her to pray, ask for forgiveness, and for us to communicate our love and forgiveness. It still traumatizes me to remember her gasping for air (with 100% O2 via NRB), but I understand that was part of the life-death spectrum. So, the death rattle is just one way the body functions at the time of death and though, it naturally bothers families to witness them breath like that, it may add to the sprituality of the moment and allow families to contemplate on life. It would be surely a better experience than seeing strangers poke a tube down mom's nose. Which is horrendous. I think oral suctioning is appropriate but should be kept to the minimum. Families should be educated in advance for impending death.

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Specializes in Critical Care.

For those that believe suctioning a death rattle is appropriate, maybe you could share your rationale.

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Specializes in LTC, assisted living, med-surg, psych.

I am not in favor of suctioning. I think it's cruel in most cases. In working with the families of dying patients, I gently educated them on what to expect during the active dying process and they were almost always understanding. I did use hospice-provided meds to help dry up the secretions and oxygen as necessary to promote comfort.

I suppose there are times when suctioning is needed, but I personally have never done it (except, of course, on patients who are NOT actively dying). And nasal suctioning is just awful, and I can't even imagine torturing a dying patient that way.

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