Excerpt from Cheryl Ford, R.N., regarding Terri's Exit Protocols -- from the last episode: -- READ, CALL CONGRESS - DEMOCRAT SENATORS AND REPRESENTATIVES (www.house.gov; www.senate.gov)- cry, pray, pray, pray:
This is a very critical piece of information from a nurses point of view, Ford said. We have a patient with no apparent signs of distress, yet enteral tube feeding is going to be discontinued on 4/20/01. This is murder. And its premeditated murder, because look at the dates notes were prepared the day before the tube was supposed to be withdrawn.
What would make the death more difficult is that Terri is a healthy woman, weighing approximately 138.5 pounds, which means she will endure longer than other patients who are in the midst of a natural-death process.
I was an oncology (cancer) nurse, Ford said. These people are very weak and gaunt. Their bodies are already shutting down, and their tube feedings are withdrawn when their body systems can no longer handle it. But Terri is not a cancer patient thats what bothers me. Shes a healthy young woman.
Upon discontinuation of enteral feeding the following signs/symptoms may or may not occur. The following is a brief list of symptoms for which to monitor and recommended interventions.
Monitor symptoms of pain/discomfort. If noted, medicate with Naproxen rectal suppository 375 mg. Q8 prn [Q8 prn means eight times a day as needed].
If someone in a persistent vegetative state cannot feel pain, as Michael Schiavo and his attorney, George Felos, have consistently told the world, why do Terris charts tell nurses how to treat her for pain?
According to Ford, that is because Terri can and will feel pain during this process and a lot of it.
Think about what hunger pains are like if you havent eaten in a while, Ford said. You start to get that gnawing feeling, almost a burning in your stomach. Most people dont extend themselves into the depths of hunger. They grab a cracker or bread if theyre out shopping for a while just to make themselves feel better.
Terri would not have this option, however. Within several hours, shell start to feel this kind of hunger pain, Ford said.
Dehydration would only add to the discomfort: When she starts going into the dehydration stage, her metabolism will start to change. Her electrolytes will get imbalanced. Shes going to get uncomfortable and will start to writhe.
Advance a couple days without food or water. Now her mouth is parched, her lips, her gums, her tongue will start to crack and bleed. The nasal cavities will start to dry, crack and bleed. The stomach will get dry and shrink, causing vomiting and heaving, Ford said.
Pulmonary (a) Inability to clear secretions reposition and swab mouth, consider scopolamine patch behind ear every 3 days.
When you first go into dehydration, your body will automatically compensate by making saliva. But when she gets into the stage where the stomach shrinks and nausea begins, theyre going to stick a patch behind her ear for the nausea. What the patch also does is dehydrate you by taking away this fluid.
(b) Dyspnea nebulize low dose 2-5 mg. Morphine sulfate Q4 prn [four times a day as needed]. Dyspnea is when you have difficulty breathing. What theyre going to do is use a nebulizer the way you might use for asthmatics only instead of giving a histamine to help her breathe, theyre going to give Terri morphine sulfate, which only suppresses respiration more. In the later phases shell start gasping for air.
In seven to nine days, as most of her body fluids are lost, her blood pressure will go down and her heart rate will rise. The blood will be shunted to the central part of the body from the periphery of the body, so that usually two to three days prior to death, the hands and feet become extremely cold. They become mottled and have a bluish appearance. The eyes will become so dry the patient cant move them anymore because there will be fluid in them.
Multifocal myoclonus or terminal agitation [sometimes caused by electrolyte imbalance]. Consider diazepam rectal administration 5-10 mg. May repeat in 4 hours if not resolved then daily twice daily as needed. Multifocal myoclonus means seizures taking place in various parts of the body. Because of the electrolyte imbalance, Terri will begin to have seizures, Ford said. Shell start to twitch. You dont see this in an oncology patient because theyre already dehydrated. Even the elderly, who are going into the natural process of death, their bodies are doing what God created them to do slow down.
Our job as health-care professionals at this point is to understand the death process and to oblige the process God has given these people to help them in comfort measures palliative care not to enhance death. But Terris not terminal, Ford said. What theyre doing here is starving a healthy person to death. This is the only reason why shell go into multifocal myoclonus.
Grand Mal seizure, which is highly unlikely given current conditions and lack of contributing factors (meds) [medication]. Recommend diazepam 15 mg. rectally as indicated in seizure management orders.
If she happens to make it into a grand mal seizure, they will give her 15 mg. of valium.
The valium wont make this easier, it will just help to bring her to death faster, because she wont have the ability to fight her way out of it, Ford said. Her body will not be in good shape at this point. You wouldnt look at her and say she was comfortable. Shes been without food and water for a long time. Shes pretty much withered, her skin is broken down, her metabolism is broken down, her kidneys havent received anything. Her body is reacting to the lack of food.
At this point, death is imminent.
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