Abstract

Bio Ethical Issues in Hospice Home Palliative Care of an EOL Medical Drowning Crisis
by Donna A. Walsh Morgan, LPN CHPLN

Bio Ethical issues occur during an end-of-life drowning crisis. These issues are not primarily medical but rather experiential and keeping with the hospice mission to provide improved palliative care and offer a peaceful death. Heuristic research gathered from palliative nurses and directors outline the issues surrounding a drowning crisis. The following bioethical issues will be discussed: (1) Is it ethical to allow an EOL drowning crisis to occur? (2) What can be done to eliminate/alleviate the drowning crisis? (3) What is known about the impact on the family during the drowning crisis, and when death occurs because of a drowning crisis? (4) Who should be making these decisions?

The sensation of drowning is one of the most harrowing experiences an individual can have. At end-of-life, secretions in the lungs can build causing a drowning crisis. Our most vulnerable ESHF (End Stage Heart Failure) and lung disease patients, in the final trajectory of their disease and dying process, sometimes alert, are subject to suffering a flash pulmonary edema or unrelieved excessive secretions drowning crisis. Panic, discomfort, and the struggle ensue for the patient and those watching stand by feeling helpless and horrified. When all nursing measures are exhausted, proven ineffective, i.e.; drying agents, oral swabs and positioning; the family then turns to the nurse to do “something”. The nurse is powerless, until the suction machine arrives, if it has been ordered, and if it has been approved. There is an intervention that is not a standard of care that can alleviate the suffering of the patient, assure the family that all resources have been exhausted and is easy and cost effective to implement.

Interventions exist to alleviate the drowning crisis: positioning, drying agents, electronic suction machines and manual suction pumps (MSP). Drying agents are often ineffective for ESHF and lung disease patients, as they have a unique disease and dying process that often results from an internal buildup or release of excessive fluids unrelieved with drying agents. The electronic suction machine is a costly DME Priority “1” delivery, $200-$600 service, and must be approved through a time-consuming process of hospice protocol, and involves travel time and installation which can upset the family at the bedside during their very intimate time of grieving. The RespRelief Pump can eliminate these secretions without causing pain to the patient and be part of the kit the hospice field nurse carries in his/her car stock. Removing these secretions neither hastens nor prolongs death and provides the patient a level of comfort. It is cost effective, ready at hand and training to use the device is minimal. Advocacy for utilization of an RespRelief Pump as a best practice and standard of care is an ethical and cost-effective decision and keeps within the mission of hospice to provide continuity in improved home palliative care and offer a peaceful death.

When death of a loved one is not peaceful the family is often left with guilt, doubt, and blame. These psychological burdens are unnecessary when a remedy exists. The panic, discomfort and the struggle of the drowning crisis can be alleviated by utilizing the RespRelief Pump. It provides a measure of relief and comfort. An informal survey among hospice professionals revealed that 98% surveyed during all end-of-life events, agreed and recognized the need and benefits of the RespRelief Pump as an innovative solution that provided continuity in improved hospice home palliative care while offering cost savings to hospice, Medicare/Medicaid, and insurances. It is further postulated that by providing continuity in hospice home palliative care, hospice will see an increase in referrals, reduce On-Call time, ER and hospital readmissions when the families panic at EOL processes during a drowning crisis. Most importantly, the family will not be hindered by a lifetime of guilt, blame or doubt that they failed to do all they could for their loved one’s comfort.

The most ethical choice for end-of-life decisions is the patient themselves but often time, due to circumstance, other surrogates can be making end-of-life decisions. These surrogates can include family, guardians, social workers, nurses and/or doctors. While ultimately it is best to follow the patient’s intentions, not all situations can be prepared for. Utilization of the RespRelief Pump neither prolongs nor hastens death. It is more economical than the electronic suction device and it can be asserted that making the RespRelief Pump part of a hospice field nurse’s basic car supply would be in alignment with hospices mission to provide improved palliative care and a peaceful passing. The ethical decision is to advocate for the RespRelief Pump to be adopted as a standard of care and best practice. Ethics is doing the right thing because it is the right thing to do and by providing the RespRelief Pump, all efforts have been exhausted in creating optimum conditions for a peaceful passing of the patient and the family at the bedside.