Hospice Case Study

Mr. Hamilton called to request a visit by the hospice supervisor to hear what type of hospice services were available. When the supervisor met with Mr. Hamilton, he was introduced to Mr. Hamilton’s two sons and a daughter and their spouses. Mr. Hamilton’s wife had died 10 years previously.

Mr. Hamilton had end stage renal disease and was receiving hemodialysis treatment three days a week. He was told by the doctor if he stopped the hemodialysis that would lead to his death within approximately a week. Mr. Hamilton decided that was what he wanted to do. His life on hemodialysis was not worth living, he said. He was constantly tired and becoming confused before each treatment. He wanted hospice care during the final week following discontinuation of hemodialysis.

The supervisor explained the hospice program to Mr. Hamilton and answered questions he and his family had.

When back in the hospice office, the supervisor talked with the medical director, Dr. Milton. The supervisor wanted to have a team conference with Dr. Milton, the nursing staff and the nurse manager of the hospital hospice unit to clarify any legal and/ or ethical issues with Mr. Hamilton’s case such as:

• Could this case be considered an assisted suicide?
• Would all the hospice staff, inpatient and homecare, be comfortable taking care of a patient who had chosen to give up living?
• Were all affected parties aware of the signs and symptoms associated with the discontinuation of hemodialysis for end-stage renal disease?

During the conference the team discussed the distinction between assisted suicide and the right of a patient to refuse treatment when discontinuation of treatment may lead to death. The hospice team agreed that the law supports the decision of a competent adult to refuse life-sustaining treatment, indeed it was Mr. Hamilton’s legal right to stop hemodialysis treatment. The staff were in agreement; they would support Mr. Hamilton’s decision.

There was concern about the signs and symptoms Mr. Hamilton would experience, that the family would be prepared and that the hospice staff would be prepared to effectively manage or suppress them.

Dr. Milton described the typical stages of dying from kidney failure. She cautioned that all patients are unique in how they proceed. The team should not expect a textbook process to occur. She outlined the following anticipated signs and symptoms.

• There will be a loss of energy with an increase in sleep times leading ultimately to unconsciousness.
• Mild confusion may occur leading to disorientation. The family needs to be alert to this and provide adequate supervision and protection.
• Muscle changes can occur with twitching or even seizures. Medication can be given to prevent the seizures.
• Urea may build up in the blood causing skin itching. Topical creams or antihistamines may help
• Loss of appetite and weight loss is common. Mr. Hamilton should not be forced to eat. Excess fluid from lack of urine production may cause swelling in the feet, legs and abdomen or other parts of the body. Limiting the amount of fluid may be helpful.
• Breathing may become more shallow and faster. If there is severe shortness of breath, raising the head of bed may ease breathing.
• Medications would be ordered and available to manage pain and anxiety, although pain is not common.

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