Issues in acute care settings
Usually, the topic of end-of-life care brings to mind a patient dying relatively slowly, either in his home or in a hospital, residential facility, or hospice facility. The fact is, of course, that patients die in acute care settings, too, often with little time to plan what palliative workers call a good death. Even so, these patients and their families deserve and should receive palliative care and should be referred to palliative specialists even when there’s only a short time left to live.
This is the time when patients and families most need the services of nurses and other health care professionals who understand the principles of palliative and hospice care — not just the principles of patient care but also the emotional and spiritual assistance family members desperately need. This is the time that families most need information and teaching — and a time when they’re least able to listen, learn, and form realistic expectations.
When a patient is dying suddenly and unexpectedly, the family will always view the death as tragic, regardless of the patient’s chronological age. Years later, they may be able to reminisce that “grandma was healthy and driving right up to end,” but as their 90-year-old grandmother lies dying in an intensive care unit (ICU) after a head-on collision with a drunk driver, they’re going to be angry and feel that her life was taken too soon.
When a family must abruptly confront the unexpected death of a loved one, providing care and teaching becomes more difficult because the family is overwhelmed. Indeed, when a patient is dying unexpectedly, the family may be in denial and unwilling to even discuss end-of-life care. Especially in an acute care setting, they may have to make stressful, life-changing decisions when they don’t even understand the medical terminology or the stark reality they’re facing. (See One last shot, page 254.)
Expert InsightsOne last shot
On our oncology unit, many patients are admitted for end-of-life care. Our staff collaborates with staff from our excellent hospice program, which is affiliated with the visiting nurse association. The problem? One oncologist admits terminally ill patients who seem unaware that they’re dying. Instead, they think they’re in the hospital to “give it one more shot.” These patients are overloaded with I.V. fluids and even tube feedings and wind up suffering needlessly. How can we help them? — G.G., Okla.
I see nothing wrong with admitting patients to the hospital for pain and symptom management. The problem here is that this oncologist sees death as a failure rather than as a natural part of life. Conse-quently, he and the patient never have the important conversation about alternative plans to consider “in case this cancer gets ahead of us.” The patient and his family are swept along in this physician’s denial and unreasonable expectations.
Palliative care specialists understand that overloading failing systems with I.V. fluids and tube feedings causes third-spacing and edema. By impairing breathing, pulmonary edema only adds to the patient’s suffering.
Just as you have policies and procedures for administering chemotherapy, so too should you have guidelines regarding admission and care of terminally ill patients. If the oncologist isn’t following your facility’s policy, you and your nurse-manager should inform the chief of medicine and ask him to step in. If your facility doesn’t have a policy for terminally ill patients, or if the policy is outdated, work through channels to develop one. Encourage participation from everyone involved in the care of these patients, including social workers and members of the ethics committee. But be especially attentive to the advice of those who “do it right” — hospice and visiting nurses and physicians who specialize in palliative care.
— JOY UFEMA, RN, MS
Day-to-day living, and the patient’s dying, won’t suddenly stop just because the family is overwhelmed and needs more time to emotionally prepare themselves. Their loved one will die regardless of the family’s state of emotional preparedness. Emotions will run high, particularly when the family has little time to prepare or say goodbye. To make matters worse, in these situations, problems within the family dynamic become accentuated.
They may create an emotional minefield if the family is dysfunctional and has secrets or unresolved issues. It’s the job of health care providers to make sure the patient can die peacefully and comfortably and to provide emotional support to the family during the process.
They may create an emotional minefield if the family is dysfunctional and has secrets or unresolved issues. It’s the job of health care providers to make sure the patient can die peacefully and comfortably and to provide emotional support to the family during the process.
Two of the most difficult, and most important, aspects of providing care for a dying patient in an acute care setting are explaining the dying process to the patient’s family and helping them through the process of weaning from a ventilator.
Explaining the dying process
Up to the point of actively dying, the patient may still be receiving aggressive treatment. Ideally, regardless of the setting, aggressive measures should be stopped when a patient is actively dying. In active dying, the patient’s body is undergoing a natural shutting-down process designed to minimize pain and suffering. Continuing aggressive treatment that would help an ordinary patient recover will likely only increase the suffering of a dying patient.
The active dying phase is a protective mechanism. When you describe it to the patient’s family, use terminology that will reinforce dying as a natural process that protects their loved one from pain and suffering. (See Deciding for Nadine, page 256.) The process entails a combination of changes in vital signs and lowered consciousness. For example, the heart rate is usually increased, often to tachycardia. Blood pressure is usually decreased, often to hypotension. Respiratory rate may be increased, decreased, or unusual, as in Cheyne-Stokes or Kussmaul’s respirations. Normally, as the patient approaches death, periods of apnea will become longer and more frequent. Explain to family members that these changes are all a helpful part of the normal dying process.
Often, the patient’s temperature will be elevated, especially if the patient is in fluid overload. Try to avoid the temptation to “treat” a terminal fever, either with drugs such as acetaminophen or with cold compresses or ice packs. Usually, terminal fever causes the patient no discomfort while providing a means of reducing fluid and terminal congestion, particularly as urine output decreases or stops. Explain that, unless the patient is uncomfortable, it’s in the patient’s best interest not to treat terminal fever.
Caring for an actively dying patient requires keeping him pain-free and comfortable. Consider pain the “fifth vital sign” and assess it at least as often as the other vital signs, more often if a patient has severe pain. In that case, check the patient’s pain level every 15 minutes or less, if needed.
Other comfort steps include keeping the patient clean at all times and providing frequent mouth care. Dying patients typically breathe through their mouths, and the membranes can dry out quickly. Plain water on a
mouth sponge is usually the best option. If the patient’s mouth is particularly encrusted, you might try alcohol-free mouth rinse. Avoid glycerin swabs because glycerin further dries the membranes. A small amount of petroleum jelly can be used to keep lips moist, but avoid excessive coating. As appropriate, teach family members to provide mouth care as a way to help their dying loved one.
mouth sponge is usually the best option. If the patient’s mouth is particularly encrusted, you might try alcohol-free mouth rinse. Avoid glycerin swabs because glycerin further dries the membranes. A small amount of petroleum jelly can be used to keep lips moist, but avoid excessive coating. As appropriate, teach family members to provide mouth care as a way to help their dying loved one.
Deciding for Nadine
Our hospice service received a request to consult about a terminal patient who needed to be weaned from the ventilator. The patient was in a vegetative state after having a stroke. While the social worker spoke with the family, the hospice nurse examined the patient and reviewed the chart.
Active dying
Nadine was actively dying. Her heart rate and temperature were skyrocketing. Her blood pressure, urine output, and oxygen saturation were plummeting. Nadine was edematous and so bloated she must have been almost unrecognizable to her own family.
Trying to burn off the excess fluid, Nadine’s body temperature had climbed to 104° F. Her urine output was scant, and the tubing from her Foley catheter was dotted with the rust-colored casts put out by kidneys that are shutting down. Nadine’s urine was dark and thick, and a layer of the same rusty sediment rested in the bottom of the urine collection bag.
Family discussion
After her assessment, the hospice nurse joined the social worker in the family lounge to speak with the family. They were distraught. They didn’t want to prematurely stop efforts to save Nadine, even though they said they understood that she was vegetative and couldn’t make a meaningful recovery.
The nurse discussed the process of actively dying and explained how this related to their mother’s vital signs. She reassured the family that Nadine was already dying and that, regardless of whether life support was continued or not, their mother’s body was preparing itself to die. The ventilator wasn’t maintaining Nadine’s oxygenation, and removing it would allow the natural protective processes to occur and not cause Nadine to suffer.
Knowing that they weren’t “pulling the plug too soon” relieved the family of the emotional burden they had been carrying, and they agreed to remove the ventilator. Because the patient was in fluid overload, she was given an anticholinergic drug to reduce secretions, and she was placed in an almost upright position to lessen her pulmonary congestion and risk of oropharyngeal secretions. The patient was carefully and thoroughly suctioned before extubation. The ventilator was then discontinued, and Nadine died naturally and painlessly about 36 hours later.
Never remove an actively dying patient from his bed without a good reason. If you’re practicing in an extended care facility that requires all patients not on strict bed rest to be up, dressed, and in a cardiac chair, contact hospice immediately if your patient’s condition changes to active dying. The hospice physician will write appropriate orders to make sure the patient can die peacefully in bed.
Weaning from the ventilator
Often, when a patient is dying in an acute care setting, the family is emotionally overwhelmed and may be angry, guilt-wracked, or terrified. (See Never again, page 258.) Making the decision to remove life support may feel like more than they can bear.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
