What does everyone think about this situation?

PMHNP10 · Nov 20, 2003

I am going to assume first, that your patient is no longer verbalizing her needs. Correct me if I'm wrong, please. The second thing is: if interventions were to be implemented to extend this woman's life (if you believe this is a possibility), would her quality of life be improved? Also, how mentally with it is your patient?

If the daughter is trying to extend her mom's number of days on this earth, then she needs to buck up and do everything she can. Look into the options of peg tube placement, for example. She needs to understand everything that is going to be involved in keeping her mom breathing. If the daughter wants to consider quality of life, don't make the last days of this woman's life be a struggle. When a patient starts spitting out meds and food, IMHO she is telling you in every way possible that she is ready to meet her maker.

You write:

That really upsets her. She thinks that as long as her mom is eating she should let her eat, make her take her pills because she needs them, and just let her die when it's naturally her time.

My beliefs tell me that my Lord and Savior is going to bring me home when he is ready. Eating and taking pills isn't going to do a thing but add/subtract from quality of life, not quantity. I hope I'm not coming off insensitive because I do understand not wanting to lose a loved one. But oh what a relief when that loved one is gone and you know they are in a better place. There's my opinion for what it's worth.

sjoe · Nov 20, 2003

these would be good things to know:

1) are we to assume that this patient has made no advance directives? no living will? no durable power of attorney for health care? if she has done this paperwork, what does it say? (another good example why we ALL need to do this for ourselves)

2) everyone who has not been legallly judged incompetent and who can communicate in some reasonably clear and reliable manner has a legal right to refuse any and all medical interventions. is this daughter the DPOAHC? is she a legal guardian? is this patient able to communicate, or has she communicated, the wish to not be fed or have medications forced upon her? if what you (and/or the daughter) are doing is against her wishes, you are guilty of assault and battery, no matter what the daughter has to say (unless she has legal control of the situation, that is)

Agnus · Nov 20, 2003

Hospice is not a death sentence. People live and go off of hospice all the time. Hospice does not mean giving up. Hospice goals is for patinets to live the rest of their life to the fullest.

Hospice is as much for the family as for the patient. They would provide support to this daughter. They would provide a way for her to cope and understand what is happening.

Her mom is dying natrually. Prior to dying they themselves stop taking nurishment and pills, and cut back of fluids. Forcing this does not good. This is a natural death.

Adding IVs and pegs as suggested do nothing positive and only create discomfort by creating fluid retention as the body no longer can process this.

The fact she is spitting out this says volumes. She knows what her own body and what she is experiencing better than anyone. She intuitively knows that her body cannot process the pills and the food.

In answer to the above question "has she communicated her wish?" Yes, that is exactly what she is doing is communicating her which when she refuses and spits.

Assault and battery are not really issues here as she would have to take it to court to be valid and she is in no position to do that. Obviously the daughter who is the one who could bring litigation is not going to do this.

However, on an ethical level the patient's rights of self deterimination are being violated in favor of the daughters.

PMHNP10 · Nov 20, 2003

Originally posted by Agnus
Adding IVs and pegs as suggested do nothing positive and only create discomfort by creating fluid retention as the body no longer can process this.

Agnus

I apologize if I was not clear, but in no way was I suggesting this should be done. I was saying that if the daughter is not interested in maintaining a quality of life (which is how it sounds), there are the things she is going to need to do. I totally disagree with such actions (eg. peg tube, IV, etc).

The fact she is spitting out this says volumes...In answer to the above question "has she communicated her wish?" Yes, that is exactly what she is doing is communicating her which when she refuses and spits.

Exactly what I posted, so it's safe to say I agree.

Assault and battery are not really issues here as she would have to take it to court to be valid and she is in no position to do that. Obviously the daughter who is the one who could bring litigation is not going to do this.

To some extent I agree, mom can't sue, but the daughter is alive, so she can. I don't know the laws in the original poster's hometown, but when it comes to family members and their terminal loved ones, often times, unfortunately, being civil is out the window, and the love is an afterthought.

On the other hand, if the other children (who don't want these life prolonging measures to be taken) do have DPOAHC, they can press charges for assault and battery.

robynrn2b · Nov 20, 2003

i truly believe that there are too many occasions where the patient is trying to tell you she is ready to go--i.e. not taking pills, not drinking, etc. There is a REASON why people refuse their pills, food, fluids, etc. Their bodies are ready to go!!! It never fails to amaze me how many try to stop this natural process! I am not saying that every person 65+ who is refusing food/fluids, etc. is ready to die, but too often, I see family trying to hold on to them.

TonyafutureRN · Nov 20, 2003

Hi guys. Thanks for your responses. As far as her verbal abilities, they have deteriorated along with the rest of her abilities. She went from being able to move and talk, to not moving and not talking. She occasionally says something very softly. Yesterday she said "you're sweet" to me after I smiled at her when she woke up. But this is few and far between. Sometimes I will ask her if she's trying to give us a hard time and she will say "yeah". Other than that she rarely talks except occasionally saying something incoherent. As far as an advance directive, I don't think she has one because the daughter talked about having to make the decisions if something happened to her, and she said if her mom stopped breathing, she would not put breathing tubes in her or have anyone do CPR, which I totally agree with. I don't know about power of attorney but I'm SURE if anyone has it it's this daughter who's taking care of. She's been taking care of her for a long time with no help from the other siblings and from what I understand she was always the "favorite". As far as the assault thing goes, could I be charged with that if someone complained, even though it says in the care plan I'm supposed to do these things??? Thanks. Tonya

BBFRN, BSN, PhD · Nov 20, 2003

Originally posted by TonyafutureRN
As far as the assault thing goes, could I be charged with that if someone complained, even though it says in the care plan I'm supposed to do these things??? Thanks. Tonya

Firstly, you may want to convey this info to your HH agency, so the Case Manager can come out and evaluate the situation. Secondly, you are an aide, so you are not responsible for making sure the patient is getting her pills, are you? I would be more concerned with that, as you are not licensed to even try to administer meds, so stay away from that altogether. The administering nurse will be responsible for documenting the fact that she is refusing her meds, and you should report this to the nurse. I would not force-feed the patient, either. The care plan should say something along the lines of, "Encourage fluids/food." This does not mean force-feeding. All you can do is to encourage. I really think the Case Manager needs to be notified to document, and to make any care plan changes needed. The only things you are responsible for is to make sure her ADL's are being met, and to report any changes or hinderances to those activities to the appropriate people. I hope this helps.

sjoe · Nov 20, 2003

"Assault and battery are not really issues here as she would have to take it to court to be valid and she is in no position to do that. Obviously the daughter who is the one who could bring litigation is not going to do this."

At any point, the state could appoint a guardian, another relative could appear out of the woodwork, advance directives that the daughter had "conveniently" forgotten about could surface, etc. After any of these things would happen, ANY further medical intervention in contradiction to limitations legally imposed in these, or in any other ways, certainly would constitute assault and battery. Since it was not clear from the original post whether or not such advance directives were already being ignored, nor is it presently clear, the same thing holds.

At the very least, any paid caregiver needs to chart that she/he has examined the chart, spoken with the primary MD, and has been unable to find any such documents or directions to restrict the current treatment plan. In other words, that "due diligence" has been exercised to prevent any non-compliance with the patient's wishes.

maelstrom143 · Nov 20, 2003

i think the others have given valuable data. what concerns me is the issue of hospice care and the daughter's perception of what it is and entails. :idea: it sounds as if both your patient (if she is capable of understanding) and her family need teaching as to what hospice is and what it does for the individual and his/her family. right now, both your patient and her daughter are suffering. the daughter because she is having difficulty letting go; the mother because she can no longer verbalize and make her wishes respected. maybe having more information as to resources and options available will make it easier for this family to come to terms with the issues they are facing. good luck with everything.