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

  1. 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
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  2. 38 Comments

  3. by   Medic/Nurse
    I am so sorry that you had to go through that - it is so difficult AND nothing any of us will say will ever truly make your experience less than what it was - you were neck deep in the tough stuff.

    Bless you.

    I think it would be so hard for anyone in your position - I have never worked hospice and my entire career has focused on resuscitation, so I'd be torn up having to "watch" as well. Suctioning as forbidden seems odd to me, I'd think of it as a comfort measure to some degree - except, I had a T & A last year and had some complications, was admitted for several problems and de-sat'ed and stuff and I want you to know that even as bad as I felt, struggling and hypoxic - suctioning was torture. I think the body is a magnificent machine and I will choose to believe that hypoxia alters the patients sensorium and makes death less painful.

    Playing the "what if" and "done wrong" will not make this any better - it sure sounds like you were present, advocated for your patient and did EVERYTHING that was "allowed" under the most heart-wrenching circumstances. You are the best of what nursing is - competent, compassionate and considerate.

    Hopefully, some of our amazing hospice nurses will have something.
  4. by   AtlantaRN
    God bless you dear one. Had the patient been tolerating the tube feeding at 65/h? It is always difficult when family insists on continuing tube feedings for a declining patient. In addition, families are concerned that a patient will "dehydrate," but when everything slows down, they get soooo wet. Hospice doesn't usually suction, but if its at the back of the throat, I would have yanker suctioned him just to clear the airway, just once would have opened the airway.

    ((hospice doesn't suction because they say it causes MORE secretions, but if it was just sitting in the back of his throat).

    hindsight is always twenty twenty, but roxanol 20mg hourly can help slow down respirations because it decreases the workload of the heart.

    God bless you dear one. You did right by the patient.

    linda
    Last edit by AtlantaRN on Aug 12, '09 : Reason: clarification
  5. by   flightnurse2b
    i'm sorry all that happened and i know it was a hard thing to watch. it really sounds like your hands were tied.

    my personal opinion is that i find it hard to believe that a hospice nurse would object to you suctioning this patient, regardless of policy. personally, i would have suctioned him immediately and had someone else call the supervisor. i don't understand the reasoning for the contraindication of it, because a few passes of 10 second deep suction has to be less traumatic than literally drowning in tube feeding.

    i have cared for multiple hospice patients on my unit (PCU/tele) and we perform interventions such as dialysis, thora/paracentesis, chest tube placement, etc.... it is not prolonging life per say, it is improving the quality of it while they are still here... so that they can have a peaceful death.

    i hope you can find some peace in this situation. take care of yourself.
  6. by   mom35
    I look to you in amazement, and wonder how I will handle situations as this as an RN. To watch life energy leave the body, I've never seen it, I can't imagine it. I like to think about bringing the babes into the world-brand new life. I have not thought much about how I will handle one leaving this life experience. You have taught me something, thank you and positive thoughts and love to you.
  7. by   Tessaprn
    I find it to be outrageous that Hospice has a policy not to suction a patient if needed. What happened to dying with dignity and peacefully.
  8. by   donnasRN
    I'm so sorry you had to go through this... I have no experience with this (yet), but I just wanted to say I commend you and I know it must have been so difficult to witness something like that. Maybe they'll decide to change their policy one day, I don't understand how that is allowed.
    Last edit by donnasRN on Aug 12, '09
  9. by   Ms.RN
    if patient didnt have order for suctioning i would've gotten a suctioning machine and suctioned this paptient. you said this patient was gurggling with secretion. you have to act based on nursing judgement, not based on following orders. if patient's pulse ox go down to 80's do you immediately put patient on oxygen or do you call doctor and get an order for oxygen? . its all about advocatijng your patient. you dont just watch your patient to suffer, but call the hospice and get an order for more pain medicine or suictioning or scopolamine patch behine ears to make sure your patient is comfortable and pain free before patient expires.
    Last edit by Ms.RN on Aug 12, '09
  10. by   PICNICRN
    My grandmother just passed away in a LTC earlier this month and it makes my blood boil thinking what if this was her. Simple yankaur suction to the mouth and back of throat is BASIC nursing care that is never contraindicated. Was there an actual order that stated "No oral suction"?? I really find that hard to believe. I can totally understand not wanting to deep oral or nasal suction them frequently but to not suction a "gurggling/choking" patient is unacceptable. IMO.
    I really do not mean to flame you on this... I can see that you are very upset about it and I am sorry you had to go through this experience. I just think that, as educated nurses, we need to advocate for our patients- after all it is US who are at their bedside assessing them.
  11. by   SlightlyMental_RN
    In the past, I've seen patients in oncology on Hospice, and we've suctioned them with the yankauer (not deep suctioning, just the back of throat)--it can help a bit, but sometimes it doesn't do very much (I've seen lungs basically completely infiltrated--not a good way to go).....I had a similar death that I witnessed. Hugs to you, OP. From personal experience, I know it is very hard to witness such a passing.
  12. by   southernbeegirl
    i agree with everyone else. sometimes suctioning is the best thing you can do for the patient to make them comfortable. to say it is contraindicated every time is not right, IMO. every person is different. if suctioning them will keep them from dying a horrible death of drowning in their own secretions then suction them and get the order later. no way would i want to die that way.

    bless your heart and his.
  13. by   leslie :-D
    Quote from stdntograd06

    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.

    Kelly
    i get so upset when i hear about actively dying pts, still receiving continuous tf.
    pt always suffers.
    always!

    hospice does not use suction on their pts.
    at the very 1st sign of congestion, or- in anticipation of congestion, we administer atropine/scopolamine/levsin gtts.
    they are all effective in drying secretions and keeping them dry.
    and so, there is never a need for suction.
    it really IS a very invasive procedure.
    a quick mouth sweep, at most.

    but kelly...hospice is not talking about emergent situations, when they say "no suctioning'.
    as someone else stated, you really need to listen to and trust your instincts.
    they were telling you something today, aeb your reaction to his suffering.
    your 'heart' felt it wrong, and if there is anything a nurse can (legally and ethically) do, then it is our duty to step up and intervene.

    i'm really sorry this happened to you.
    your pt?
    he's more than ok now.

    the learning curve is deep on this one.
    be well, honey.:icon_hug:

    leslie
  14. by   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.

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