Vaginal bleeding in terminal Ca pt? Hospice question.

[Cat_RN, ASN, BSN, RN]

I have never heard of this myself until now, but I'm assuming it is result of metastasis of lung cancer. Resident has been having increasing lady partsl 'bleeding' (large clots found in brief), for 2 days, intermittently. Dr is aware, states it is a result of lung cancer spreading and since resident is newly on hospice, is not going to treat this. I am off for next 3 days so I won't be there but, is resident at risk for complications from it or does this pretty much mean she is actively declining now and is only a matter of time, therefore it is just considered part of dying process. If so, how long do you think she has?? I ask this out of curiousity- I am brand new at nursing and know almost nothing about death from real life perspective. I never get to see hospice nurses since I work nights. I feel neglectful seeing such a large amount of blood in briefs and not really 'doing' anything about it, since the dr. said not to treat the condition.

Insight? Sorry if this seems like a silly question.. thanks!

[madwife2002, BSN, RN]

When a relative of mine had this kind of bleeding she had Uterine Cancer. In your patients case it will be due to mets. It is very difficult to predict how long your pt has to live it depends a lot on her will and the care she is getting. Sometimes it is hours, days and weeks. We really have no control over this

[mamamerlee, LPN]

This is not a silly question by any means. Of course you feel helpless, and maybe a bit overwhelmed. But don't feel neglectful - this is part of this patient's dying process.

I am sorry to say this, but prepare yourself for the pt to literally bleed out from her lady parts. It might not happen, but I have seen this, as well as bleeding out from the rectum, and from a colostomy. It is sad, and it is messy. There is nothing you can do but chart the pad changes.

You are probably a very caring individual; remember that. Best wishes.

[tencat]

There is nothing to be done about it. Just keep the patient clean and comfortable. How long does she have? That's the million dollar question. No one really knows the answer to that. After a while you might get a sense of a range of time, but even then it's never absolute. Give your patient her ordered pain meds and keep her comfy.

[leslie :-D]

in event that pt is on coumadin or any type of anticoag, make sure all these type of meds are dc'd now.

if she stays on them, there's a good chance you will see mass bleeding from sev'l orifices when she dies.

as to time left, it can be weeks, but it's more likely days.

leslie

[kathy313]

Far from a stupid question, people can exhibit lots of different things during their dying process. Make sure she's clean, comfortable and pain free.

It is hard to say when someone will pass, they can linger for days or weeks...she'll go when she's ready.

[AZTECA]

Cat...

I can tell you are a caring person and that's why you feel like you should be doing something about your patient's bleeding.

However, you also have to remember that when a patient elects to receive Hospice services they are choosing to allow themselves to follow a natural dying process. That means no heroic measures and usually no treatment that will result in "curing" or "fixing" a condition. This is where Palliative care comes in. The palliative care you provide is as the above posters have mentioned. Keep her clean, and comfortable. I have seen patients like yours choose to go home and pass there with their family and the RN's I've worked with will most often reccomend that the family purchase several sets of black linnens and black towels. The black minimizes the visual impact the blood has and is usually a palliative measure the family benefits from.

Remember that your patient and her family are mostly concerned with her comfort. Good luck in your hospice carreer. It is extremely rewarding once you realize that hospice care to the patient is about LIVING and not about dying.

p.

[heron, ASN, RN]

Agree with all of the above. And good for you for asking ... it can be a real shocker to take care of one's first hospice patient. The thing to remember is that the overriding priority is the comfort of the patient and support for the family.

Monitor for (and treat) shortness of breath, anxiety, possibly chest pain if crit gets too low to support the work of the heart muscle. Make sure that anyone caring for the pt slathers the peri area with barrier cream as blood can be very irritating. Smells can become a problem ... we use a coffee filter full of grounds under the bed to cut some of the odor. If you have colostomy bag deodorizer on hand, a drop on a 2x2 at the bedside can be helpful.

The sight of large amounts of blood in the briefs or bed can be highly distressing to pts and families. If we have a pt at high risk to bleed out, we will often use dark-colored sheets or even a dark bedspread on the bed to minimize the appearance. If visitors can't be shielded from the sight of lots of blood, be sure you're available to explain/support and reassure them that the pt is comfortable and that you're making every effort to keep her clean and decent.

And finally, be kind to yourself and all the other workers taking care of her. Helping people who are dying can be one of the most emotionally wrenching experiences we have, especially the first time. It's also one of the great privileges of being a nurse. Use us here at AN if you need to.

[Cat_RN, ASN, BSN, RN]

Wow, thanks everyone so much for their input! I need to stop thinking in the sense of wanting to 'stop' these types of things from happening rather than just treat the effects, because she is hospice.

[jnette, ASN, EMT-I]

Wow, thanks everyone so much for their input! I need to stop thinking in the sense of wanting to 'stop' these types of things from happening rather than just treat the effects, because she is hospice.

Exactly what you said is a very hard mental/emotional transition/adjustment to make.. to stop trying to "stop" things and instead to accept/treat what IS. Very challenging.

Kudos to you for asking.. for caring enough to ask.

[core34]

This lady partsl bleeding could as be a side effect of chemotherapy. Did she receive any palliative chemo recently (specifically Cytoxan and/or Ifex)? This lady partsl bleeding is called hemorrhagic cystitis, the drug Mesna is typically used for this side effect.

[heron, ASN, RN]

This lady partsl bleeding could as be a side effect of chemotherapy. Did she receive any palliative chemo recently (specifically Cytoxan and/or Ifex)? This lady partsl bleeding is called hemorrhagic cystitis, the drug Mesna is typically used for this side effect.

Thank you ... I didn't know this. Does that mean that the bleeding might be coming from the bladder rather than the reproductive system? If so, a foley might be a good way to minimize the disturbance caused by repeated cleaning ... although there will be some catheter irrigation to do, I suspect.

There may be cost constraints at work if this med is very expensive. Hospice is payed a flat fee out of which it must pay for all meds related to the hospice diagnosis. We also limit diagnostic investigation, so we may never know why the pt is bleeding. The goal is comfort, peace and dignity ... anything not contributing to this is eliminated