I witnessed the most horrible death last night at a LTC facility.

[stdntograd06]

As the title states, I had a death last night (the second night in a row to be exact) and I'll be at peace if I never have to watch someone die like that again.

This gentleman was approx. 85'ish, and in respiratory failure, and on Hospice. He had a foley catheter draining blood-tinged urine that just started going pink on the 3-11 shift, and a GT tube running at 65ml/hr. After I started the 11-7 shift, on initial assessment, he was quiet and his relatively stable self. He was given his 2400 ABHR gel and his tube flushed without difficulty. At 0145, on rounds, I was notified by the CNA to go to his room. Before I even got to his room, I heard the most horrible gurgling sounds. He was in definite respiratory distress and hyperventilating. I stopped the tube feeding, gave him Atropine gtts for the secretions at 0150 and told the CNA to stay with him and use the swabs to clear some of the secretions. Note: He had no order to suction (it is contraindicated with Hospice). I called my Supervisor and informed her of his status, that he was literally drowning in his secretions. She said she would be right there and call hospice, but that they wouldn't do anything. You could just hear tons of secretions sitting right in his throat and esophagus. He was unable to expectorate anything, and just choking on all of it.

He was due to recieve routine Roxanol 20mg (1 ml) at 0200, so I gave that to him. The supervisor came over, took a look at him and call Hospice immediately to discuss further treatment. She said that suctioning is contraindicated and that she was on her way (30 minutes away). At 0215, we gave him Ativan concentrate. His HR was 138-142 and Resp's TNC. His abdomen was severly distended and firm (he had 2 med. BM's the day prior). You could see the fear in his eyes and face, looking right at us as if begging for help. One of the CNA's stayed with him comforting him while my supervisor was on the phone. She told me to go ahead and give him more Atropine at 0230 even though it was ordered every hour. It had only been 40 minutes since I last gave it to him. The CNA put the call light on a few minutes later and when I entered the room his face and hands were blue, fingernails were blue. His eyes were half open and I watched as the color and life just drained out of his face. He took his last breath at 0235.

2400- ABHR gel

0150- Atropine gtts

0155- Roxanol 20mg

0215- Ativan Concentrate

0230 Atropine gtts

0235- Took his last breath

We all took this very hard, especially since he suffered immensely his last 45 minutes on this earth. I thought Hospice was all about dying with dignity and peacefully, with comfort?? Where was the comfort here? Any thoughts and advice are needed at this time. I am emotionally drained after last night.

Kelly

[donnasRN]

What happens if the patient is suctioned but still passes? Would/Do they hold the RN liable for that since it's not their policy and there wasn't an order? I haven't started school yet, I'm just curious how they would handle it b/c I too feel in a situation like this the patient should be suctioned.

[leslie :-D]

What happens if the patient is suctioned but still passes? Would/Do they hold the RN liable for that since it's not their policy and there wasn't an order? I haven't started school yet, I'm just curious how they would handle it b/c I too feel in a situation like this the patient should be suctioned.

no, the rn would not be held liable...

unless, the death was r/t suction, such as decompensation r/t removing too much o2 and not reoxygenating.

and also, if the rn suctioned excessively, s/he may get in trouble if bon finds out.

i am saying that an rn who uses suction in an emergent situation, s/he will not be penalized.

but if suction was used prn and 'casually', yes, i would think the nurse could be found culpable.

besides annod, you'll be getting nsg insurance when you become a nurse, yes? ($100 or )

enjoy nursing school.

it's a ride you won't forget.:balloons:

leslie

[donnasRN]

no, the rn would not be held liable...

unless, the death was r/t suction, such as decompensation r/t removing too much o2 and not reoxygenating.

and also, if the rn suctioned excessively, s/he may get in trouble if bon finds out.

i am saying that an rn who uses suction in an emergent situation, s/he will not be penalized.

but if suction was used prn and 'casually', yes, i would think the nurse could be found culpable.

besides annod, you'll be getting nsg insurance when you become a nurse, yes? ($100 or )

enjoy nursing school.

it's a ride you won't forget.:balloons:

leslie

Thank you so much for clarifying, leslie! It's disturbing that not even supervisor would do it.

Yes, I have purchased it already (mandatory by the school) so I guess I'm covered haha.

Thank you again, and I'm sure I'll be on here often for guidance lol.

[nkara, CNA]

That was a horrible thing to go through. I don't think I would have been able to just stand there. I work in a hospital and we put the patients on CMO (comfort measures only) The nurse will give the pain meds until the end.

[nerdtonurse?, BSN, RN]

:icon_hug:

It's never easy watching a person die, even when you know it's their time and it will be a blessing. I've had my share of hospice pts (ICU, get made a DNR, then out to the tele unit to die). The fact that this was your second in 2 nights makes it even worse.

I lost a pt one night to pulmonary "flash" edema, where they died drowning, and there was nothing I could do. Yes, I was suctioning and hyperoxygenating, but when your lung tissue is running down your chin, there's not much anybody can do. The RNs had just pronounced him when we lost the guy in the next room to lung ca. We had 2 deaths less than 30 minutes apart. That was over a year ago, and I still remember how helpless I felt, how defeated. Don't forget the first two rules of nursing: 1) Sooner or later, everyone dies, and 2) You don't get to change rule 1.

Your patient knew you were there. He wasn't alone, he knew you were trying to help him the best you could. He's at peace now, and he'd want you to be at peace. too.

[NRSKarenRN, BSN, RN]

thank you for caring and being there for the patient. sometimes death is disturbing no matter how much you prepare for it or years of experience. quite often these secretions are in the posterior pharynx and bronchiole tubes, beyond reach of a catheter. medicating with atropine/scopolamine upon discovery, morphine, ativan or antianxiety med, stoping tube feeding, positioning on side with elevated head of bed helps......sounds like you did the best you can in situation.

american academy of hospice and palliative medicine:

fast fact and concept #109: death rattle and oral secretions

midwife for the end-of-life: symptomatology of dying: death rattle

understanding and responding to the death rattle in dying patients

predicting active dying

death, dying, hospice - nursing assistant central

[PopeJane3rd]

He was old and already very sickly. This may explain why he died this way. Death is not always pleasant but it is inevitable.

[miracleluke]

Well, I guess I am the first Hospice Nurse to reply?! Kelly, it sounds like this man turned for the worse very quickly and as a hospice nurse you did everything right! You stopped the TF right away! You gave Roxanol, Atropine gtts, Ativan all as prescribed. All of these meds are indicated in helping open the airways and help the patient to breathe a little bit easier. But, Kelly the damage was done. His body obviously was shutting down and couldnt handle the fluid overload of the TF he was getting. This all can happen very quickly. Now as far as suctioning, at Hospice we will suction with a yankur(oral) suction when indicated but that is something we too have to have an order for. We will initiate if needed and then call and get the order if we have the equipment there and available. But in the meantime we have to employ what we have available. The Atropine gtts generally takes 3-4 doses before the gurgling is quieted. I agree that sound is very hard to listen to. The gurgling is usually deep and not in the back of the throat like it sounds and suctioning in that situation would be more uncomfortable to the patient. So in Hospice we evaluate what will make the patient the most comfortable the quickest and at that point it is the Morphine and Ativan. Both help each other and can potentiate the effects of the other in this situation. We would crank up the HOB and employ oxygen if it is not already being used. All of this is to make the patient more comfortable. In Hospice we treat the symptoms as they show themselves and we don't look at it in a curative sense because we know that this patient is terminal and all the efforts to get them well have already been tried. This sounds evil a bit, but I want you to know that TF are not indicated with Hospice and are usually done only because the family in not willing to stop them. This is when we as Hospice nurses need to step in and start doing some education on what is happening to their bodies. When a person is actively dying or in the dying process their need for nutrition or fluids is not in high demand. They actually are more comfortable with less on board than having the IV's for hydration and TF's for nourishment. I have seen patients go for days without food or fluids to drink. We aren't there to hasten their deaths we are there to offer them comfort and quality during what is going to be inevitable. We all will make this transition in our lives just like we were born and we all will face a certain amount of fear during this process because we don't know what is happening or where we are going. To be a good Hospice nurse one really needs to be in touch with their own mortality and spirituality. You don't need to be spiritual but it helps! I have seen so many positive beautiful deaths in my time as a Hospice nurse that outweigh the more tragic ones. Please remember you did all you could for this man and you did the best! He is in a better place now and is pain free! I too, take to heart my patients when they pass because they impacted my life in a way I will never forget them, but I learn from each one. Please trust in your local Hospice nurse and also trust in your own gut feelings like you did! Hospice did not tell you we don't suction, but that is probably what you heard because there is so much more we can do that is more comforting for that patient than sticking a tube down their throat at that time. Maybe that particular Hospice Nurse didnt say what she really meant to say so you could understand that. She sensed your angst on the phone and was trying to get there as soon as she could to help you. It is very hard to talk , drive and give instructions without sounding sometimes abrupt! I try to always put myself in the person I am talking to shoes and hear what she is hearing when I tell them what I am trying to explain. Some people don't do that, I know. Please, don't remember this situation as a nightmare you care not to repeat any time soon, but learn from this and next time you will know exactly what you need to do. Take care and all my best!:wink2:

[fulzgold]

Sorry you went through that without preparation, death is not pretty. You did all the right things. I used to work hospice. I have had patients pass this way. They seem fine right up until the last minute then boom, everything starts to slide and there is nothing you can do. When the body systems and organs are shutting down, the body doesn't respond to treatment. No amount of suctioning will stop the lungs from filling up. By the time you hear that death rattle, the lungs are already full. Suctioning often causes more distress at that point than helping. Immagine suctioning your own throat while healthy and then imagine how much worse it would feel if you were dying. It sounds like he went pretty quick. I had a hospice patient with Lung ca. At the end, he layed unconcious for 2 days with a rattle and looked like a bubble machine. Tiny bubbles literally flew up out of his mouth. At first, his wife wanted him suctioned. It did'nt take her long to figure out why we tried to talk her out of it, but she had to see for herself. Not all deaths are like this. Some die gracefully and some will suffer in spite of your best efforts. I can tell you that without hospice in the picture, there "will" be much suffering for the patient and the family.

[military spouse]

I worked for Hospice and I would usually get an order for suctioning well in advance, primarily to give the family something they could do if they felt it was needed. I can't remember a situation where I've seen a death and light suctioning would truly have been helpful, but it seemed to make the family feel better. We used Scopolomine patches and they worked fairly well, but many people seemed to experience "death rattles".

[Wishinonastar, BSN]

I have also worked in hospice and I agree for the most part suctioning is ineffective. The stuff is down too deep, but it does make people feel better to be able to try it sometimes. Death is never pretty, even when they are in a coma. It is not like in the movies where you slip away looking perfect until the end. Morphine and other drugs help the patient not to feel it so much but the people witnessing it still see it all. That is one reason why I do not ever encourage people to ask for IVs for dehydration, the less liquid you have at the end the better. The body can't handle all of the fluid when it is shutting down. Raising the head, atropine, cleaning out collections in the mouth and giving meds to relieve pain and anxiety is about as good as it gets. A little O2 for comfort doesn't hurt. At least he was not alone. You did what you could. Remember birth is pretty ugly too.

Incidentally, I also worked PRN at a nursing home and hospice was sometimes ordered for our patients. This was the biggest governement insurance ripoff ever. The hospice nurse did nothing, was never available and the patient already had 24 hour skilled nursing care. What was hospice even there for? Home health can't go into nursing homes, so why can hospice? Being there for respite is one thing but these were nursing home residents. Just my opinion, and yes I know about hospice and how it is supposed to work becuase I worked as a hospice nurse for 3 years so no lectures please.

[tencat]

If it had been my patient, I would have gotten an order for hourly morphine and perhaps ativan every two hours. It sounds like he didn't get enough medications. Also, those ***** tube feeds for hospice patients is pure insanity and always ends badly, as leslie pointed out. As to suctioning, I try to discourage it as it does cause more distress most times. Atropine helps if administered early on. Scopalamine is also great, in fact I like it better, but you have to get the patch on well before symptoms get bad.