Wouldn't the key phrase "Actively dying" be a clue ... That's what jumped off the page for me. If she is receiving IV pain meds and is in danger of falling, wouldn't restraint be a wise choice?
If you are adding to the pain meds, with sedation meds, could you possibly be helping the dying process by sedating the patient further? I would be unsure as to how the sedaiton meds interact with the pain meds. Too much of a good thing is problematic.
Yes, they have choices, sedation or restraint. but to use sedation must carry with it more pros than cons. shouldn't it?
Safety is not the same as sedation in my head. It is a state of "being" sedated can create further complications - wouldn't it? If she is actively dying does sedation only further the process if not managed correctly??
Beyond the two choices, would be a minder in the room overnight to make sure she does not get out of bed. A family member to be there all night. what else is there beyond these three choices? Send her home to die and have a full time nurse? I take it this patient is in palliative care ward?
If she is actively dying - If I were actively dying, Do It Quick. End it now, after seeing sister georgette die a long morphine drip death over 15 hours that last night, Kill Me, do it, get it over with. There would be no actively dying crap for me.
But the family needs the choice and to be informed. I am not one for drugs - although when sister G was taken off oxygen and iv support the trade off was a morphine drip that took 15 hours to help her die which she eventually did, there was no escape for her, she was prtetty sick.
It was painful for me to watch and accept. But I stayed and was there till the end, almost...
If one is actively dying, wouldnt you want to make the transition easier for everyone? but euthanasia is illegal in most countries, I know that.
Sedation meds on top of pain meds is a nasty mix, which I would not want to have done to me, in any case or scenario.
thnx
jeremy
I feel that this patient needs to be reviewed by a palliative care physician. The use of IV pain killers is inappropriate for this sort of patient, as she will be receiving peaks and troughs of analgesia instead of a steady therapeutic level which she would get with a syringe driver. Appropriatre dosage of analgesia AND sedation, such as 10-20mg of Midazolam OVER 24 HOURS via a syringe driver, and if necessary adding in haloperidol 3mg will greatly reduce her agitation, and will not kill her. The use of analgesia and sedation prescribed by a palliative care physician is common practice and highly effective. To imagine that a combination of, say morphine and midazolam in appropriate doses is harmful/lethal is one of the misconceptions that we in palliative care are constantly trying to put right, in order to prevent patients from suffering unnecessarily in their last days of life. Have a look at the work of John Ellershaw from Liverpool University Hospital who has developed an intergrated care pathway for the dying, and be guided by that.
Hope I haven't come on to strong, but as you can see I have an interest in caring for dying patients.
I would go with the sedating drugs. The wrist restraints sound cruel to me.
This is from the point of a family member, not a nurse: I hated to see my g-mum in restraints when I went and saw her, and had to deal with her pleading for me to remove them. At least I knew that when she was sedated that she might not know who I was when I walked into the room but she knew I was supposed to be there and that I was family. I don't think it is fair for nurses to have to use restraints for long periods, families need to do what is best for their loved one, even if it means that they become less responsive because of it.
my personal preference- chemical at night, because sleep is good. Physiscal during the day, if needed. Little old people can sometimes be little enought to use the pediatric restraints called "No-no!s". They are a velcro splint that imobilizes the elbow, so that they cant reach their own face or arm, and it covers a lot of piv sites. All caveats apply- remove and ROM, etc. The best thing, of course is for a sitter or family members. My hospital uses sitters more that physical restraint, except in the ICU, where restraints are issued with your ET tube.
I had to make this decision this weekend for my Father. I'm really glad to see the comments here....it helps. We opted for pain and sedation but both are administered by syringe, not IV. I don't know that my Father is actively dying or what's going on yet but he needs both these meds just now. They did want to apply a waist restraint but after discussing the situation in some detail with several medical staff, we realized he needed more pain meds and sedation. He's doing much better now and not upset as he was when he was suffering.
Carrie, glad your father is doing better. Jennynyc
Situations like this, I think the family is right, their wishes should be carried out.
Jeremy made some very good points, that I feel ought to be checked out.
May God Bless,
Jerry
"Let not your heart be troubled:
John 14:1
well, i think the qustion is "what is the effect"
i mean, if physical restraints make them feel bad then go chem, but if chem will make their state worse go physical
yeah, i like to ride that fence
I would go for chemical restraints because that way nobody can be accused of anything
?
I found your blog are very informative. I hope you don't mind I've bookmarked your blog for my future reference.
Cancer Type
Very good article...infomational for sure...looking forward to reading some more posts placed on this topic...will be checking this page again..have saved in favorites and bookmarked...thanks
Seo Directory Web Directory
enjoy your blog!
here's a link to my weekly newsletter for nurses:
http://www.nursingcareertransfor...sformation.com/
simplenewslettersignup.html
enjoy and happy thanksgiving!!
kate loving shenk
I can't believe I haven't been to your blog before. I really like it. I think you'd have to take a scenario like this on a case by case basis, but given the fact that she's dying, I think more sedation would be appropriate to help potentiate the pain meds and also because, I imagine, even demented persons must have increased anxiety with dying, d/t decreased oxygenation and perfusion to the brain.
I just realized that I never responded to this post myself. For starters, I would educate the family that studies have not demonstrated a decreased risk of falls with the use of restraints. In addition, restraints are also associated with injury, depression, and discomfort. Like others who have posted, I would argue in favor of having a sitter at the bedside when family was not available. Although less cost-effective, a sitter is the safest and least invasive option. As for the deliurium, please see my post on terminal restlessness by clicking on the symptomatology link in my sidebar.
My Dad passed on Wednesday the 14th of November, and his was the case of heavy sedation to calm his agitation and shifting in bed. It became impossible to get any sleep for those of us who took the night shift.
At least we knew the side panels would prevent him from getting up because he didn't have the strength to hoist himself or pull them up, but his moaning was loud and incoherent.
It was decided that he receive enough med to basically make him sleep as much as possible.
When I saw him the day after this was begun, the sight of him shocked me horribly: he looked dead and his breath sounded like marbles in a deep tube. His left eye was half-open in a fixed, glassy stare. It took only two days for him to leave us.
I'm so glad my sister and I were there for his final moment, when he seemed to 'wake up' and very strongly be present with us just as he went away. The inert lid of that left staring eye was 'alive' for a second, and he looked at us. It was so swift that a blink would miss it.
If we'd had him remain fully conscious, but restrained to prevent his thrashing, Dad would never have been able to relax enough to give us that unforgettable, precious gift.
NO RESTRAINTS. I agree, it's just cruel.
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