When Med-Surg Nurses Care for Dying Patients


When Med-Surg Nurses Care for Dying Patients

Ten Guidelines From Hospice

By Sue Montgomery, RN, BSN
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My dad died in a med-surg unit at the end of his long battle with pulmonary fibrosis. I’d been a hospice nurse for many years and supported whatever decisions he made about his illness; at the time, hospice care wasn’t one of them. That’s the case with many of the chronically ill patients med-surg nurses see, patients for whom a “routine” hospitalization may end up being their last.

I know from my years in the ICU that suddenly shifting gears from acute care to palliative care thinking can make a nurse feel downright schizophrenic. When my dad was in the hospital, I offered a few suggestions to help the staff care for him. Those tips can also be applied to similar situations any of us may face at work.

Here are 10 guidelines for med-surg nurses caring for dying patients:

1. Resuscitation

Dad gradually let go of one thing at a time: First, there was no intubation, then no chest compressions and finally, no resuscitation meds. Make sure the orders are clear and that the patient and family understand advanced directives and what will and will not be done.

2. Pain
Pain management is critical throughout the dying process. As patients become less alert, they typically can’t verbalize pain, but that doesn’t mean it’s not there. Use nonverbal pain scales as needed and assume the issue remains. Make sure pain meds are scheduled ATC, with PRN dosing available for breakthrough pain.

3. Fluids
It’s easy to fluid-overload the dying. Since failing organs can’t process additional fluid, artificial hydration usually creates more problems than benefits. That’s often a difficult concept for families to grasp, so be educated and offer resources about nutrition and hydration.

4. Agitation
Agitation for dying patients is common, so be ready to sift through possible causes. It could be pain or another physical issue, like a full bladder. It could also be more complex, like unresolved psychosocial or spiritual issues. Whatever the source, patient comfort is paramount. Attend to the apparent issues, use anti-anxiety agents as appropriate and tap into multi-disciplinary resources as needed.

5. Swallowing
As patients weaken, swallowing becomes more difficult. Make sure everyone involved knows this so that well-meaning efforts don’t lead to aspiration. Discontinue nonessential oral meds and switch essential ones to IV.    

6. Spirituality
Patients aren’t always vocal about their spiritual needs. Be sure to explore and support spirituality for the dying. Resolving unresolved emotional issues may end up being the key to a peaceful death.

7. Room
Typically, patients and families want to be together during the dying process, although individual needs vary. Try to have a sense of what the patient wants and support that. Move everyone to a private room, honor the space and let it become the patient’s “home.”

8. Monitors
Letting go of technology can be painful for both staff and families, but the more they focus on machines, the more quality time they give up. Give everyone permission to ignore the numbers by turning the monitors off if you can.

9. Quiet
It’s true: A patient’s sense of hearing is often the last to go. Help everyone in the patient’s vicinity refrain from inappropriate chatter and encourage the family to gently interact with their loved one as a reminder that he or she is not alone.

10. A Good Death
A good death is about both the dying process and the time after. When Mom and I wanted bathe and dress Dad’s body after he died, the nurse looked at me like I had three heads, but that’s how we do things in hospice care. Make the time after death special instead of clearing out the room and prepping for your next admission. Your charge nurse might not like it, but it’ll make a big difference for the family.

My dad had a beautiful death and I’m forever grateful. It happened because he had so many people who loved him and a wonderful med-surg staff to care for him in his final days. If you apply these tips to your practice, the families of your dying patients will say the same about you.   

For more information about caring for the dying, check out the resources offered by the National Hospice and Palliative Care Organization (www.nhpco.org) and the Hospice and Palliative Nurses Association (www.hpna.org).



Methodist Hospital reaches out to Chinese-American community on end-of-life issues

by Aaron Severson

Death is one of the most universal of human experiences and among the most divisive. Every culture and philosophy has its own beliefs about death and dying and the range of customs and funerary rituals is endless. That can create serious conflicts for healthcare providers, patients and families in dealing with end-of-life issues. Some families opt to avoid palliative or hospice care entirely rather than risk clashing with providers who may not understand or respect the family’s traditions and priorities.

Ancient traditions, modern hospital

Such conflicts have long been a dilemma for Methodist Hospital in Arcadia, which has a large Chinese-American patient population, including immigrants from Hong Kong, Taiwan and the People’s Republic of China. “Less than 1 percent of Chinese-American patients use hospice care,” says Rosslyn White, MSN, NP-C, a palliative care nurse practitioner who manages Methodist’s palliative care program. “They are hesitant and uncomfortable talking about death.”

While Chinese-American families may follow various different faiths, including Catholicism, Buddhism and Taoism, those beliefs intersect with strong cultural traditions about death, dying and family responsibility. For example, a terminally ill patient may be reluctant to share her diagnosis for fear of burdening her family while her children may see discussing advance directives as a betrayal of filial obligation.

Other problems arise from language barriers or the difficulty of accommodating practices like the Buddhist custom of family members chanting over the body of the deceased for a full eight hours after death.

Methodist builds a cultural bridge

Methodist has made an ongoing effort to alleviate some of that friction. A number of years ago, Methodist established a comfortably furnished “chanting room” where family members of a deceased patient can conduct postmortem rites without interruption and without disrupting other patients or providers.

Recently, the hospital teamed with the San Francisco-based Chinese American Coalition for Compassionate Care (CACCC) to launch a one-year staff education and community outreach program. The goals are to improve the Methodist staff’s understanding of Chinese-American patients’ sensitivities regarding end-of-life issues and to better educate the local Chinese-American community about end-of-life care.

In January, more than 130 Methodist staff members attended two one-hour seminars organized by CACCC. Those will be followed in June by a 30-hour volunteer training program for Chinese-American residents. “Those volunteers will then be available to assist us with our palliative care efforts,” says White.

Later this year, CACCC will also conduct four community outreach workshops about end-of-life care, including the use of advance healthcare directives and physician orders for life-sustaining treatment.

Rosslyn White says it’s too early to judge whether the project will encourage more critically ill Chinese-American patients and families to take advantage of palliative and hospice care. However, Methodist hopes these efforts will help bridge the cultural gap as providers and patients confront one of life’s most eternal mysteries. 

This article is from workingnurse.com.

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