Turning a hospice patient in severe pain?

[IheartICUnursing]

I am seeking the opinions and advice of some of you experienced hospice nurses :) I work nights in an ICU, and occasionally care for patients who, during their ICU stay, are changed to comfort care only and stay with us until we can place them in hospice. Sometimes I find it hard to get out of the ICU mindset and instead focus on comfort, and I feel like I usually do a fairly good job of that, at least the best I can.

So the situation.... elderly man with multiple comorbities admitted to our unit for altered mental status (on top of underlying dementia) & some really jacked up labs(missing dialysis) He had a recent AKA of one leg, and the other was completely cold and pulseless, and per the family, had been for about 2-3 weeks. The legs were causing him severe pain with even the slightest movement. He was to leave first thing in the morning to an inpatient hospice facility, and would probably pass away in a week or two.

During the day shift, he was very combative, vomited X2 so the nurse inserted an NG tube(?), and then had to be restrained. He was started on Morphine 4mg Q2hr prn and Ativan 2mg prn. Pt was given both shortly before I came in that night and was resting very comfortably, even snoring. He hadn't slept in a couple of days so we were all so happy to see him finally comfortable.

So, my goal for the evening was comfort. I kept the lights off in the room, curtain pulled as much as I could without blocking the monitor, and slid the glass door shut to keep it quiet. Honestly, though I checked on him frequently, I only repositioned him one time & cleaned up a bowel movement. Even with premedication before, it caused him a terrible amount of pain and he screamed so loud he woke up his family and you could hear him down the hall. I just couldn't bring myself to do it to him again.

Well, the charge nurse (who was the patients nurse during the day) came in that morning and basically accused me of neglecting him and being lazy because I told her that I let him rest and only repositioned once.

We are supposed to turn our ICU patients Q2hrs so she was livid about this. But I just don't think it was appropriate to wake the poor man up and cause him tremendous pain every other hour in the middle of the night!! The family told me they wanted him to rest, and I did everything I could to enable him to do so.

Did I do the right thing? What would you have done differently? Thanks for all you do!

[Punkrocksn]

I'm looking forward to reading an informed reply to your post. It looks like a huge conflict, hospice patients in ICU. Is it "safe" to change practice for a patient's comfort? I'm a student nurse, but having personal experience with hospice, I can't disagree with your decision.

[K+MgSO4, BSN]

Is this just me being in another country but why did he need to be on the monitor? you would not react if he brady'd down so why have the lines on him annoying him/

I am assuming that he was on an air mattress of some sort and was anuric or had an IDC. So he wasn't wet, was finally peaceful and sleeping. I would of left him as you did.

In fairness I have inserted NG tubes for vomiting on palliative pts. It is often less distressing than constantly vomiting.

Do you have a palliative care liaison nurse? Or a palliative unit? email their manager and ask for suggestions what should be done when pt become palliative on the ICU?

[BerryHappy]

I am a hospice nurse. Yes, you did the right thing. Sometimes, doing nothing is very difficult to do, but in hospice it is a necessity. For future reference when dealing with hospice patient's, sometimes reposition q2 just means gentle pillow tucks q2. Or even just repositioning the HOB or FOB. It does not have to be a full flip like what you are probably use to. Very often the ONLY relief we can provide our patient's is sweet sleep. It is very important because sometimes it is the ONLY way they are able to escape their pain and torment. Yes, I know that pain is often even felt during sleep, that is why we medicate when we notice increasing RR, or even facial grimicing while they are sleeping. You did just the right thing by pre-medicating before cleaning, and yes, that would be the only time would wake him. If possible, do not disturb, and medicate while they are fast asleep. Let them have at the very least, sweet dreams.

[loriangel14, RN]

I would have/have done the same thing you did.I have read and I believe that it takes at least an hour for a aptient in pain to get comfortable again after being turned.Where i work, if the goal is comfort then turning q2h is abandoned.4mg of morph q2h is a poor order for palliative measures. Our standard order for our palliative patients is 2-10mg q 15 minutes. Most of our patients end up on PCA pumps.Like the previous poster says, sometimes just a little pillow tuck is enough. Scopolamine patches are usually used as well.

[IheartICUnursing]

Thank you all so very much for your comments! I feel much better about the decisions I made now.

[tewdles, RN]

First...a hospice patient should not be in the ICU and should certainly not be monitored.

Second...N/V is NOT typically an indication for an NG tube in hospice, there are VERY effective meds to palliate those symptoms.

Third...his pain must be aggressively treated and is NOT adequately controlled based upon your description. He likely needs polypharmacy to tackle his "mixed" pain.

Rest is important.

I think you did okay in a difficult situation

[leslie :-D]

i'm with tewdles in that many icus/hospitals are ill-equipped in "comfort measures" and/or caring for a dying person.

as suggested, the med orders were grossly inadequate, and pt should not have needed ng tube.

that said (re ngt), if dropping tube is the only discomfort, then i can see where benefit would exceed invasiveness at that time.

IF pt had been more aggressively managed, then a weight shift is usually sufficient...esp at this point in the dying process.

repositioning is warranted when a bedbound pt has a ways to go before dying.

but again, this is usually w/o incident if pt properly medicated.

in your situation, you made a great call.

thank you.

leslie

[nurseprnRN, BSN, RN]

When I did in-house case mgmt we often called the hospice agency liaisons for pain consults, even if the patient wasn't on their service. They were unfailingly helpful in giving directions to the physicians for better pain mgmt orders, at no charge, bless them. Give your local hospice(s) a call and see if they would consult like this. They will come in to a staff meeting and give an inservice on pain mgmt that can help you and your fellow ICU staffers do a better job for this population, too.

[lykeen]

I completely agree with your interventions during your shift. In hospice care, patient comfort is of the utmost importance. It appears that your dayshift counterpart does not quite understand this concept, and I can understand that, since I came from a cardiac ICU background and went into hospice care. It can be difficult to move away from the routine nursing care that has been drilled into us since nursing school (i.e. turn q2h, etc). Unfortunately, it would have been much better for this patient if he could have been moved to a hospice/palliative care unit or facility earlier to prevent these problems. Many times when these patients remain in ICU, outcomes are not good when it comes to pain control and comfort.

[Do-over, ASN, RN]

Whenever we have a hospice patient on our unit, we tape the hospice nurse's phone number to the chart. I always call for change in condition, need for pain control, questions or concerns. Our hospice nurses are fantastic.

Generally, I look to the patient and family to help direct care. I think you did fine.

I agree with PP that all the monitoring is uncalled for with hospice/comfort measure only patients. I fear even the light/beeps could be distressing, let alone the patches and wires. Just because a patient is housed in ICU doesn't mean they are an ICU patient.

[JZ_RN]

He needs an air mattress, not turning. He needs strong antiemetic drugs, not an NG. He needs palliative and comfort care, not an ICU. He needs strong pain meds with an aggressive around the clock coverage schedule, not 4mg morphine q2 hours.