Some Things, You Never Get Used To

[VivaLasViejas, ASN, RN]

I just hate it when I get attached to patients sometimes.......

I admitted this 85 YO gentleman the other night, who had just left the hospital last Sunday following a hemicolectomy for colon CA and now was back with renal failure, and dehydration due to vomiting and diarrhea. I took care of him for two days, trying to get his doctor to actually DEAL with his problems (right-sided abdominal pain, constant nausea, absent bowel tones, and the presence of a bruit that I heard over the right side of his abdomen). MD ordered IV fluids to run at 150/hr., which sent him into fluid overload, and it took two shifts and going to the nursing supervisor to get the doctor to address the IV issue (Doc told the super, "I don't wanna talk to anybody about this patient anymore, I'm coming in to look at him and I'll just write orders"). Finally got the IV rate decreased to TKO, oxygen and breathing treatments were ordered, and a CT scan to find out what was going on in the pt's belly.

I was off for one day, then came back yesterday to find this patient in even worse shape than before. He had crackles everywhere, his urine (what there was of it) was tea-colored, and he still had the bruit and the nausea and the abdominal pain. Finally, the one doctor gave up and had Internal Med do a consult; no sooner had this MD been in to see him and new orders written for all kinds of new tests, than I walked in to see how he was doing with his dinner tray and found him dead!

It was obvious from the position I found him in that he never knew what hit him......he'd been sitting up in bed, nibbling at his soup, and now he was lying across the bed, legs hanging over the side, and he looked utterly peaceful. But it was SUCH a shock.........I'd just been talking to him after the doctor had been in, and he'd showed no indication that he had only minutes to live........I've seen a lot of people die, but I have to admit this one really shook me up. I'd taken a liking to this poor old fellow, who lived with his 60-something daughter and they were basically alone in the world; I knew he probably didn't have very long, since the cancer had been fairly advanced when they operated, but NOBODY was ready for this!

In a way, I'm happy for him because he was obviously NOT in pain when he passed on......yet I feel we all failed him somehow, because we kept having to fight with his doctor to get anything done for him, and some of what was being done was actually making things worse! One of the CNAs was very unhappy about the situation, she feels that this patient's life was basically thrown away for nothing, and a large part of me heartily concurs........when I found him, there was liquid stool literally coming from EVERYWHERE. Two other nurses and I had documented a lack of bowel tones, and it had basically been ignored. I'd reported the bruit, and the doc looked me straight in the eye and said "Don't worry about it". OK, so the patient was a DNR, does that mean we don't try very hard to get to the bottom of what's ailing him and just throw antibiotics at it? Does that mean we allow a patient with a history of AAA repair, a pulsatile mass in the abdomen, and pain in the same area to just blow?

Obviously, I'm still unsettled in my mind about this, and I'm not sure what I ought to do about it. On the one hand, I know the man was dying anyway; on the other, I don't feel his doctor took very good care of him (why did he just sit on this patient, not even calling for an internal med consult until three days after admission?), and I do believe that this patient should not have died like this.

Sometimes I wish I could view my patients clinically and objectively; I've never gotten used to the fact that some docs treat them like widgets on an assembly line. I've also never gotten used to walking into a room and finding them dead in bed! All I wanted to do yesterday was go find a quiet room and cry for fifteen minutes, but I never got a chance even to take a full dinner break so that was out of the question. Damn, I hate it when I get emotionally involved........this stuff just tears me up, and there isn't a thing I can do about it. The practical part of me says "Get a grip, girl", while the marshmallowy side knows that I never WILL get used to it, and that if I ever do I'd better get out of nursing, because I will have lost what makes me a good nurse.

Thanks for "listening" to my long-winded vent........unlike my family and friends outside of work, you all understand the kind of emotional crap I'm experiencing.

[jnette, ASN, EMT-I]

I just hate it when I get attached to patients sometimes.......

Sometimes I wish I could view my patients clinically and objectively; I've never gotten used to the fact that some docs treat them like widgets on an assembly line. I've also never gotten used to walking into a room and finding them dead in bed! All I wanted to do yesterday was go find a quiet room and cry for fifteen minutes, but I never got a chance even to take a full dinner break so that was out of the question. Damn, I hate it when I get emotionally involved........this stuff just tears me up, and there isn't a thing I can do about it. The practical part of me says "Get a grip, girl", while the marshmallowy side knows that I never WILL get used to it, and that if I ever do I'd better get out of nursing, because I will have lost what makes me a good nurse.

Thanks for "listening" to my long-winded vent........unlike my family and friends outside of work, you all understand the kind of emotional crap I'm experiencing.

((((((HUGS)))))) mj... really BIG hugs. I so DO understand your pain, sadness, and frustration. I feel very much the same as you.. and NO, don't ever get "used to it".

It is especially frustrating when the patient is treated ( or NOT treated) in the manner described above. The doc may have had vaild reasons, but I feel so "belittled" ?... "dumb little nursey wouldn't understand all the intellectually derived minute details of my allknowing plan of action and decisions"....

when the docs won't even attempt to share or care enough to explain.

How they forget that we actually CARE about and FOR these patients 24/7 as opposed to just popping in once a day to "clinically evaluate" ... that OUR hearts and emotions are involved here, too... it's just not right.

[warrior woman]

So sorry Marla. The day we stop letting it get to us is the day we should hang up our stethescope.

[RN-PA, RN]

I hear you and feel for you since I've also experienced similar situations with patients and frustrations with doctors. I WISH the docs would search us out and TALK to us now and then. I often miss getting the chance to grab them and discuss a patient's status with them because I'm so busy and miss when they're making rounds.

I worked 3-11 last night and after a long, overwhelming report from the 7-3 nurse, I was hit with having to initiate continuous epidural fentanyl on a patient (who'd asked for it to be d/c'd the previous night and now had PCA MSO4 ordered-- Long story; don't ask....). But the worst part of the report was a patient in his early 60's with cancer who I'd enjoyed and become attached to over the past few weeks, who got the news that he has weeks to 6 months-- tops-- to live. I also just wanted to go somewhere and bawl my eyes out for 15 minutes, but there's never any time. He didn't want to talk about it, and I just held his hand and squeezed it different times throughout my shift, and tried to give him the best care I could, but it was difficult with 6 patients.

I also had a patient last night I'd cared for in the past who has metastatic breast cancer. She'd been my patient a few years ago and I couldn't believe how much she'd deteriorated...

And, a patient who had been on our unit for more than a month died yesterday at noon. Very sick lady, very attentive family, and we'd all cared for her at one time or another during her stay.

This job is just so damn sad sometimes.

[LadyBugLass]

poor fellow...did he ever get anything for pain and nausea?? if he was a dnr, then i assume he was told that he had a terminal illness. hospice care and support for both him and his daughter would have been helpful, at least.

doctors are strange creatures sometimes, reared in medical school at a young age with some very strong opinions on death and dying. death is not seen as an inevitable outcome, but as an enemy, and a failure on the part of the physician. they really do not know how to handle a patient that they have "given up on." so, it is all or nothing, and in this patients case, the primary doc did nothing. an oncologist might have dealt with this a little better.

even when i was a nurses aide when i was like 19, it always shocked the hell out of me when i of all people, would explain to family members that a dnr order does not mean "do not respond", that we would still be providing care and meds and fluids! you could literally see the relief in their faces. i always wondered why on earth the doctor did not explain this better.

please do remember that 85 is a long time to be alive, and that death is an end to physical pain.

[jemb]

(((((Hugs)))))))

Been there. It really sux big time!

I'm sure the man knew that you, at least, cared and tried to do something for him. Sometimes that is the best that we can do when so many obstacles are in the path.

[nurturing_angel]

It is with many years of being a nurse but only a short time of being a med surg nurse to my credit, I still have difficulty dealing with terminal pts. What do you say? How to you respond when they say they are dying? I have worked a long time in Maternity and yes, I dealt with dying newborns and stillborns...that was hard but I learned to deal with it with compassion and caring.

Earlier this week I walked into the room of a 61 year old woman..I had cared for her the night before but was totally unprepared by what she said...I said good evening Betty. How are you? She looked at me with the saddest eyes and said...."They told me today that I am dying. How do you expect me to be?" No, I had not cared for her long enough to be "emotionally attached" but it felt like the wind had been knocked out of me. I just said "I'm sorry" and left the room. I felt like such a failure as a nurse. And I was angry that the nurse before me had not reported that little gem of information to me....I knew her diagnosis did not look promising but I had not been made aware that they told her she was dying. I wish I had been more prepared to go into that room.

Eventually we did talk about her diagnosis and things got a bit easier but she remained sad and withdrawn and slept poorly all night.

[Tweety, BSN, RN]

So sorry Marla. The day we stop letting it get to us is the day we should hang up our stethescope.

ditto. Hugs Marla. You're awesome! :)

[leslie :-D]

you know marla, i think it would have been more bearable if you had felt that this gentleman received some interventions without being terribly invasive. it's a slap in the face when your assessments are held with such little regard. and it's not only your clinical assessment but you can actually feel your pt's discomfort. sometimes you just want to wring doctor's necks despairingly pleading "why don't you care, why don't you do anything?" those are overwhelmingly difficult for me to handle. i'm glad your patient didn't see it coming. i'm not glad that he didn't get the attention he should have. this totally sucks and i'm glad he had you.

leslie

[NursesRmofun, ASN, RN]

I know what you mean. If we see someone has potential to get better, we want them to get better and do well. We feel for them. I have heard it said many, many times...when we stop feeling, that is when we shouldn't be in nursing anymore...That's what they say.

[nurseygrrl, LPN]

(((((mjlrn97)))))

That's a terrible story. Sometimes docs can be so unfeeling. How would they like to be lying there for 3 days like that? You can rest assured that you did all that you could possibly do for this man and you made his last few days a little brighter just by caring.

[VivaLasViejas, ASN, RN]

I thank you all so much for your wise words of comfort.........it does help! :kiss

Tonight I had a different dying-patient situation: a gentleman whose wife had been told by the MD today that his long-term prognosis was not good, which she took to mean "he's not expected to live through the night" and called all the family members and friends, plus their minister.........ALL of whom have called tonight to ask me how many hours I think he's got:rolleyes: Mind you, this is a man who is still alert, though somewhat confused, and he could go on like this for another 6 months or so.........but then, I've been wrong before. :uhoh21: