Why IVF for stomach cancer patient on 2 diuretics

[AtlantaRN, RN]

I am frustrated. Does the patient condition warrant directing the plan of care or does the family. It is a sad, sad situation, a fairly young woman only diagnosed last month with stomach cancer, only had 1 chemo treatment, had multi organ problems couldn't tolerate any further chemo. Family said on admission they wanted IV fluids, I educated that no, we don't do iv fluids. Well, now family insists (even though patient is on two different diuretics, one of them lasix at 80mg bid), she has terrible ascites with her abdomen measuring 60" (and she is a small lady), also 2+ edema to lower extremities. she has dispepsia controlled with compazine, phenergan, and zofran. I just hate filling this little lady with fluids, I fear it will do her more harm than good. doc said "NS 100/h one 24 hour trail" is appropriate, for now, I suppose. I just fear it will cause her more harm than do her any good. My only other experience of any fluids in the field was a lung cancer patient whose wife insisted he continue TPN at home, he lasted 12 hours before he sounded like he was drowning. Thank you for your input, anyone have any experience with stomach cancer and IV fluids. Thanks

[leslie :-D]

i've seen ascites in different types of cancer.

diuretics do very little for it.

however, adding ivf only serves to distress the pt.

why the heck wouldn't the med'l dir speak up, and outright refuse?

unless your pt gets tapped or gets an implantable shunt, then the ascites will remain and eventually infiltrate the lungs, as well as putting more pressure on the diaphragm.

crank up the morphine.

leslie

[BandEmom]

I agree. It sounds like the decision maker in this family is aggressively pushing what they believe to be right. It's hard for us to argue with that, and convince someone that doing something they believe to be helpful can do harm. In this patient's case, there is no tangible benefit from IVF, yet obvious harm to be done. Perhaps the doctor who ordered it is not experienced with end-of-life care? It's an age-old issue to hospice care that always feel different with every patient because the families are so insistent.

[AtlantaRN, RN]

med director has his own internal med practice, and has been our med director for a couple of years. Goes back to the customer is "always" right....but it isn't the customer at all driving this, it's her husband. He even talked her out of being a DNR. It is just so sad. She has had paracentesis x3 since being diagnosed, the last time they could only get off 300ml before she became short of breath, so they stopped...fluids are not the answer. family wants her to stop being dispepsic...

[BandEmom]

I think it's sad that our ability of practicing sound judgement in the name of caring is stifled by "customer service" in healthcare. It makes it feel no different than selling cars or any other commodity. I think that we are depended on in the long run to help people understand when something harmful could take place. I'm sorry you've been put in such an uncomfortable position

[AtlantaRN, RN]

we have had patients in the past where their primary care physician would "schedule" palliative paracentesis once a week.... I wouldn't even begin to know how to set this up over the weekend. I hate feeling like I am the one to decide a patients treatment. I didnt' go to medical school. Thank you all for your input. I'm gonna make this my first stop in the am and speak to the husband. I stated on admission that we don't do iv fluids and why--because they do more harm than good, then my supervisor says we can--catch 22. Thank you all again for your input.

[tewdles, RN]

The agency I work for recently refused to care for a patient similar to this. We transferred them to one of our competitors who was willing to provide that care. We provided, in writing, explanation of the medical and ethical issues which were in conflict with our hospice mission. I wish them well...I certainly would not have wanted to be their hospice nurse.

[leslie :-D]

I wish them well...I certainly would not have wanted to be their hospice nurse.

same here.

i've had a few pts that i refused to continue caring for.

one was a legal concern, the rest were ethical concerns.

as a hospice nurse, i absolutely REFUSE to care for a pt when there is extraordinary suffering, inflicted by the treaters.

one time it almost cost me my job until they thought about perceived repercussions.

another time i walked off the job (had gotten another nurse to care for pt)...

i just couldn't be a part of the suffering.

atlanta, paracentesis can be done at bedside, w/proper equip present.

if the pt can survive the sob during procedure, it does resolve.

sometimes working (inpatient) hospice, is too much...

too, too much.

leslie

[Ginapixi, BSN, RN]

Why IVF for hospice patients?

because families and some times the patients are hoping for a miracle. all the education, all the cons we can list are not deterring them from hoping against all odds!

been there, seen it - on patients with TPN, gurgling, Atropine drops started and yet the TPN continued...

it bothers me to no end, though I do not loose sleep over it any more; I have come to the conclusion that we are products of our environment and upbringing; at times I feel really really bad for the patient, but it is the patient's family who decides - and a poor medical decision on the MD end; we can educate 'til we are blue in the face;

it takes time to face the fact that this is the end, some people need more time than others, unfortunately

I feel with you!

[LMTRN]

If the spouse has talked her out of a DNR, she probably doesn't have an Advanced Directives either.

Does he spend time in the room with her? Let him listen to her lungs!

I'm sorry for her and you.

[HospiceRN08]

Sounds like the poor husband is in denial which we all understand, but that doesn't mean he should be allowed to make decisions to the detriment of the patient. Some people just need to be hit over the head with a brick. It's the only way to get your point across. Explaining it nicely just doesn't work for some people. So you've pointed out the ascites and edema to the husband, explained the pathophysiology, and he still doesn't get it. Ask him how he feels about watching his wife drown to death in her own secretions. And yes I've actually used the phrase "drowning to death" for a family who just didn't seem to get it. It finally clicked for them and after the patient passed (peacefully) they were so appreciative.

I won't even say what I think of this medical director, but I will say that this makes me :redbeathe the docs I work with even more.

[AtlantaRN, RN]

The GOOD thing through this, she tolerated 1500ml fluids. I almost rolled my eyes when I got out there and found she hadn't vomited one time since I took her out a 2 week supply of phenergan. I told the husband she didn't need the fluids, she consumes 3/800 ml containers of water/gatoraid/juices daily so that is 2400ml/day. I hung them because they were ordered, but I reiterated to hubby that in the last 2 years, this was the first time I had heard of a patient being on IVF out in the field....... BTW: I don't know how this happened, but her abdominal girth declined by 3" over last weekend....don't get it-i measured at umbilicus each time....

thanks again for all the input

linda