question about a hospice patient

[heidi1221]

I was just looking for an opinion on something...
if there is a ESLD pt. on hospice, would you still use Lactulose?  This pt. has very high ammonia levels, causing him to be very confused and lethargic.  He wants to wake up, speak, but just can't.  Is it unethical to give the lactulose?  He is not having frequent bowel movements, maybe once every other day.  I just think that being able to speak to his family and friends is comforting him.  I would love some feed back.

[HectorSF]

Is it unethical to give the lactulose?

When a patient is in hospice no medical interventions are performed to prolong or save life but treatment to make a patient comfortable is given. Where the dividing line between the two would depend on the hospice service.

"He is not having frequent bowel movements, maybe once every other day."
Without frequent bowel movements HE will be triggered. For us with advanced cirrhosis we should have 2-3 bowel movements per day to prevent ammonia and other toxic buildup. Assuming he is still able to eat?

Lactulose for encephalopathy only manages symptoms and is not curative so I have heard of lactulose being given so the patient can be as responsive as possible near the end. Please be aware that as a patient get close to death they will also have similar symptoms. They will be out of it and not aware that they are dying. Dying from liver disease is not like the Hollywood myth of the heroic patient being brave at the end. Patients usually with liver disease die from complication before there liver shuts down. For those that die from HE the go into a coma and never come out of it. It is a sad and terrible way to die.

I would encourage the loved ones of the patient to make sure they get to spend time with a conscious patient so Lactulose is necessary for the patient to be aware of their surroundings and who people are as much as possible so people can say their good byes.

Unfortunately when I patient is End-Stage they will have many complications that will trigger HE episodes so HE is not entirely controllable. But I think worth a try.

"I just think that being able to speak to his family and friends is comforting him."
I agree 100%. Personally I would insist on management of HE by hospice.

Best
Hector

[rivll]

Hi,
I really do not see how it could be unethical to give him lactulose..maybe unethical *not* to give it to him.
Hospice is where you go to be cared for as you die, the key word here is "care". He needs to be comfortable and if possible coherent.