Extubated my patient - page 2
Worst day of my life. My patient's family decided that they didn't want to leave her on life support so they decided to extubate her and let her pass. She has only been on the vent since the night... Read More
Oct 24, '06Did you turn the pressors off before extubation? When I've had to extubate, I've always turned off all the IV meds other than the pain/sedation drip before I extubated - I think that it is easier for the patient that way.
It is perfectly natural to feel conflicted. Personally, I felt far worse having to keep up heroic and painful measures to keep a patient "alive" (meaning, a pulse and a BP) because the family can't bear to let go.
I had a similar situation last week. I practically begged the family to put their father on comfort care. In my defense, they did ask what I would do. The patient had a GCS of 3 unsedated (no cough, blink or gag and had been down in the field for over 25 minutes) and was maxed on 3 pressors - I usually ask them what they think their loved one would want and leave it at that. I am also quite honest about how much our interventions hurt. Intubation, a-line, pressors, rectal temp probes - etc.
Helping your patient at the end of their life is doing plenty. I know that you feel that you didn't do enough - but you did and then some. You gave the family time to say goodbye when you were doing all you could to keep the drips titrated and her airway patent and when it was time to let go, you let go. Good job.
PS - if you are still feeling badly in a few days, please talk to someone - clergy or someone with employee health even. Also, if your hospital has an ethics committee, I encourage you to attend some meetings. They are very enlightening.
Oct 24, '06The fact that you are questioning speaks volumns about your empathy and compassion. You heart will catch up with your brain but it sometimes does take a while.
The truely sad part is that you came across a cowardly doc. Not all but many; especially older physcians; do not face or deal with death well. Sometimes I think that does a better job of dealing with death then medical school. Many older docs I have dealt with over the years seem to see death as a failure. Nursing school taught death as a natural part of the life cycle. Unfortunantly this is not the last time something of this nature will happen. Allow yourself time to grieve. You have lost some innocence. The event were traumatic. Allow your self to be angry at the doc but also recognize that you showed greater personal strength. You were able to do what was necessary. In a few weeks re-examine the events and decide if you would do them any differently or time the steps any differently. One last thing. Think about what your response would be, what support you would give to a friend or classmate going through the same situation. Grant yourself that same support you would have offered to others.
Oct 24, '06if your patient was alert enough to shake her head "yes/no" appropriatly to ques., then she probabaly would have died a very uncomfortable death if you had let her wait, and pass on the vent. She was already alert enough to know that she was dying, she could probably feel it, and sustaining that would be how much worse?. If she only took a few breaths after you detubed, then God already had his plan in motion. People that are ment to survive don't linger. Have faith that you gave her a death with dignity.
We forget sometimes that GOd created Death, just as he created life, and both should be dignified. We also forget that we can't fight God forever. All the tools that we have, all the knowledge, it is nothing if God has another plan for that person. You simply took away the hands of man, and put the patient in the hands of GOD.
Oct 24, '06i wish more doctors were experienced in sedating pts prior to extubation.
although fentanyl works well, its' absorption can be variable and is why mso4 is top choice amongst palliative care md's.
actually, mso4 w/diazepam is kinder to the pt, and ensures a peaceful death.
as for the gurgling, fentanyl can change one's perception and so, am thinking the pt wasn't even aware of her dyspnea.
i'm just partial to mso4 as i know that my pts aren't aware of the 'reality' of their situation, when it comes to extubation.
scopalamine is often used, to prevent the gurgling.
i just think it's paramount that icu docs take courses in end of life care.
so when it's indicated to stop life support, the pt is aware and death is immediate, it's crucial to allay pt's fears/anxieties and prescribe the proper combination, to ensure peace at the end.
with that said, your measures and reaction, speaks volumes about your compassionate care.
it's never easy, but there are definite interventions that can be applied, in ensuring that pain and anxiety are minimal for the pt being extubated.
God speed, and may peace be with you.
Oct 24, '06I started in ICU about 3 months ago (1st night off orientation is tomorrow night - scared to death!!). Shortly after I started, we had a code and my preceptor made me get up front and center (another RN had the pt that day). I pushed the atropine and epi that brought her back. She was the cutest little old lady in her late 60's - lots of medical issues including a rare genetic disorder and multi-system organ failure - don't want to give much detail due to HIPAA. She was a med code only. I was so excited to get to push the meds that I did not even pay attention to the pt's name or anything. I was even more excited when she went from asystole to sinus rhythm. A few days later (or maybe a week), my preceptor and I were assigned this same pt. After I got report, I realized that it was the same pt that I had "pulled back from the light" and I felt so GUILTY. There were lots of family issues....pt was going to die. It was just a matter of time. Family looking to the oldest daughter to make the decisions (make a DNR, turn off ventilator?). I was working 3 in a row and I knew it was going to be a very emotional 3 days. I just kept thinking I wish it hadn't been me that had kept her from dying the previous week. I had a really difficult time with that. I felt guilty for being so excited about that code (it was my first one in the ICU). Luckily, I had a wonderful preceptor who gave me a lot of support to get through those feelings. Suffice it to say that the family took baby steps from med code to DNR to stopping dialysis (after recommendation from nephrologist) and finally to pulling the ventilator over those 3 days. No one wanted to make the decision individually and they finally came to a decision together as a family on what to do. The pt remained intubated but placed on a t-piece my last day with her. I watched the MD turn off the ventilator (happened toward the end of my shift) and I cried with the family. I made sure all day that the pt had Morphine to keep her comfortable. I am one of those nurses that will keep pushing it (i.e., q hr, q 2 hrs, etc) in an end of life case as long as I have an order. At the end of my shift, I gave all the family members a hug, wished them all the inner peace and strength, and told them they would be in my prayers.
The pt died peacefully the next morning surrounded by her family. They came by the hospital on Monday, brought a beautiful cake for the staff, thank-you cards for me and my preceptor with gift certificates inside to a nearby restaurant. They looked so at peace. They were smiling and gave us all hugs. It was a proud moment for me to be a nurse! :spin: I stopped feeling guilty for "pulling her back" that previous week, and told myself that her family needed that extra time to process what was going on and be at peace with one another.
BlueEyed RN, I wish you all the inner strength and peace in your job. Someone else mentioned keeping a journal. I was doing that when I first started in ICU and it helped me A LOT! I also called other nursing friends when I'd had a bad day (believe me, there have been several along my 3 month orientation!) And, this web site is great to come to when you need to vent, need support, and just need to read that someone has "been there". Best wishes!!
Oct 24, '06Again, you didn't kill her! I work with a lot of hospice and palliative care patients (in fact, other units send dying pts to us becasue they are not used to it and dont know how to handle it), and the fact is, people die. Nobody is going to live forever. It's one of the hardest things in the world to deal with (or even to understand), especially when you're not used to it. I have given meds or turned a pt only to have them die a few minutes later. And nothing that I did killed them. They just died the way they wanted to - as comfortably and peacefully as possible, with no tubes sticking in them or monitors beeping, or Heaven forbid, chest compressions. It's harder for me to watch the pts with families who refuse to let go...they force tube feeds in them and keep them along for as long as they can, just because they (family) aren't ready to let go. Think of what that pt would have gone through if you had not extubated her. Now it's over, and she's at peace. Don't beat yourself up about it. You did what was right for the pt and the family.