Caring For A Loved One

Abrupt measures include removing the ventilator and removing any other support system, such as a temporary pacemaker. Pulling the plug is truly an awful phrase and does not describe what we do next. Withdrawal of care can also be done in increments. This allows events to take their course without counteractive intervention. Shortly after the respirator stops, the individual’s breathing may speed up before it slows and becomes shallow. Snoring and rattling breathing can be alleviated by certain devices and medication, or by repositioning the body. Changed breathing sounds or development of a rattle usually indicate that death will occur within 24 hours. The heart also soon stops beating, although it may take about five minutes to do so completely. The heart may even restart after a minute but with no measurable blood pressure. If death doesn’t occur relatively quickly and it appears the individual may hold on for days, he or she may be transferred to a hospice facility. Many people survive for several days, which can be very hard on their families. Some hospices are better than others.

Goodbye To Innocence

To my knowledge, good hospice experiences far outweigh negative ones. Hospice staff deserve the highest praise for providing care under often difficult circumstances. We have no good way to predict how long it may take a comatose individual to find eternal rest, but we don’t expect it to be more than 10 days. Although very little has been published about comatose patients dying at home, they require a certain level of nursing support to maintain hygiene and avoid overburdening family members with care that most family members aren’t equipped to provide. A patient’s physical, emotional, spiritual and psychological needs are often best met by a hospice team. While caring for a loved one at home with family at the bedside may seem ideal, there are many details involved, and getting them all right can prove difficult. This chart summarizes key parts of reviews done by palliative care providers when they’re called in to care for a patient. The chart is detailed and lengthy. Based on conversations with loved ones, the medical provider will make a judgment about who appears to be acting in a patient’s best interests and keeping with the patient’s known preferences. Eligibility generally is determined by a progressive decline in a patient in the context of overall health with a life expectancy of less than six months if the disease takes its natural course. Eligibility for general inpatient hospice is largely determined by the need for frequent medication adjustments, which may change if a patient’s symptoms become difficult to control after withdrawal of care. Provide education regarding artificial fluids at end of life.

Hang On To Yourself

Complications of too much fluid may include edema, abdominal swelling, nausea, increased secretions and prolonging the dying process. Initiate nonpharmacological treatments, including use of bedside fan. For dry mouth, use of lip balm, mouth swabs or sips of water as tolerated. If retention develops, recommend urinary catheter at the end of life. Cluster care to promote rest and sleep at night. Limit stimuli that may contribute to worsening symptoms, such as excess noise and conversation. Avoid physical tethers, such as any restraints, lines or monitors that aren’t medically necessary. If nonpharmacological interventions aren’t effective or if patient is harmful to self or others, recommend pharmacological treatment. Antipsychotic drugs such as haloperidol or risperidone. Recommend cooling measures, such as a fan, ice packs, cooling blanket or cool, wet washcloth over skin. No deep suctioning, given potential to promote gag reflex or vomiting. Atropine 1% ophthalmic solution.

One Way Or Another

I can’t overemphasize this. Any suggestion to the contrary is irrational. We don’t provide fluids or food because we know they don’t feel thirst or hunger. Family members often ask me about that, and I tell them that when a patient is deeply comatose or only minimally conscious, normal sensations simply disappear. Fluids may cause them discomfort due to increased body water and gastric and pulmonary secretions. Within days, urine production will slow or stop. This can cause increased acidity, which leads to increased breathing, the body’s natural way of compensating. Even if breathing sounds more labored, the individual isn’t actually in distress. Sometimes doctors may prescribe additional morphine if breathing becomes labored or there’s rattling with a lot of secretions. Generally, though, it’s not necessary. Withdrawal of care usually is sufficient in bringing about death. A dying person’s hands and feet will become cold to the touch due to poor circulation. The person’s pulse will become weaker and barely palpable. Drying of mucous membranes can be minimized with mouth swabs and eyedrops. Facial features may change due to fluid loss, and the person may become more unrecognizable, which can be distressing to family members. Over the years, I’ve heard and read concerns that individuals who are dying of dehydration have bleeding gums, parched lips, burning of the bladder from concentrated urine and difficulty breathing due to pooling mucus. I’ve never seen that in my patients, nor have the many other health care professionals with whom I’ve discussed it. I assure families that death is dignified and humane. Comatose patients aren’t wild or delirious after withdrawal of care. Many families remain at the bedside, and for most of them, having made the decision to withdraw care is a relief. In my experience, very few families have second thoughts about this step. Obviously, that outcome can only occur if they feel well informed and they trust the health care staff caring for their loved one. When caring for individuals in whom treatment is being withdrawn, experienced palliative care nurses should have wide latitude to give soothing medication as needed. The double effect of sedation is a major topic of discussion among bioethicists. Some speak of good and bad effects. Administration of a sedative drug must meet the challenge of having the good outweigh the bad. For example, the ease in discomfort that’s provided outweighs that fact that it may theoretically hasten death. A good effect, however, cannot come from a few bad action.