The soul crushing part about nursing - page 3

by OnlybyHisgraceRN

6,971 Views | 35 Comments

There are many things I love about nursing, however there are some things that are really soul crushing. Like, having a 90 year old patient, who is a full code, trached, has a peg, multiple pressure sores, infections, renal... Read More


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    I am not at all familiar with the conscience law--

    *** Here is a general overview. http://en.wikipedia.org/wiki/Conscience_clause_(medical

    and I am not sure how it would be applicable if a patients POA/HCP who was chosen by the patient to make health care decisions decides to back out of a DNR--(and if we are not party to conversations and decisions that may or may not have been spoken about we can never know for sure what the thought process is)

    *** I am not sure either, never having been in that situation involving a POA/HCP myself. As I already stated previously in the situations I was in I had certain knowlage of the patient's wishes.

    I would think that pharmacists who don't fill BCP's need the backing of the pharmacy of which they are employed.

    *** No they do not need any backing from their employeer. It is illegal to disciminate aginst them in any way. Not saying it doesn't happen, just that doing so is illegal.

    So I would think nurses would also need that support from the hospital.

    *** Having admitted not being familiar with conscience laws I don't understand why you would think that.

    I do know that there are policies meant to protect nurses pertaining to if one chooses not to be part of certain procedures (ie: abortions, blood transfusions, etc) most hospitals will allow for those choices, but not sure why one would be the head of a code team and not participate in all codes.

    *** For the same reasons suregons don't choose to do surgery on every patient. Many patients are simply not surgical canidates. For the same reason physicians don't prescribe narcotics to every patient who asks for them. I am not head of the code team, but am a key member and the administrator. The head of the code team is a physican. Being on the code team does not authorize me to cause harm to my patients or go aginst their wishes. I am my patient's advocate.

    GrnTea and SHGR like this.
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    Quote from PMFB-RN
    I am not at all familiar with the conscience law--

    *** Here is a general overview. http://en.wikipedia.org/wiki/Conscience_clause_(medical

    and I am not sure how it would be applicable if a patients POA/HCP who was chosen by the patient to make health care decisions decides to back out of a DNR--(and if we are not party to conversations and decisions that may or may not have been spoken about we can never know for sure what the thought process is)

    *** I am not sure either, never having been in that situation involving a POA/HCP myself. As I already stated previously in the situations I was in I had certain knowlage of the patient's wishes.

    I would think that pharmacists who don't fill BCP's need the backing of the pharmacy of which they are employed.

    *** No they do not need any backing from their employeer. It is illegal to disciminate aginst them in any way. Not saying it doesn't happen, just that doing so is illegal.

    So I would think nurses would also need that support from the hospital.

    *** Having admitted not being familiar with conscience laws I don't understand why you would think that.

    I do know that there are policies meant to protect nurses pertaining to if one chooses not to be part of certain procedures (ie: abortions, blood transfusions, etc) most hospitals will allow for those choices, but not sure why one would be the head of a code team and not participate in all codes.

    *** For the same reasons suregons don't choose to do surgery on every patient. Many patients are simply not surgical canidates. For the same reason physicians don't prescribe narcotics to every patient who asks for them. I am not head of the code team, but am a key member and the administrator. The head of the code team is a physican. Being on the code team does not authorize me to cause harm to my patients or go aginst their wishes. I am my patient's advocate.

    Interesting concept, and I have learned something. Thank you for the responses. If I were to be in that situation, I would hope that I would be the first to excuse myself from the code team in the instances where I were morally objected. Especially if my team were floundering in what they believe to be a full code. My thought process in needing some sort of facility support was based on how one would explain why it is that they chose not to be a key person in a code when in fact patient is a full code. And should you use this law to protect you, it is based on hear-say? On the same token, if you know that the patient has said to you over and over again code me, do everything, I want to be coded and they are made a DNR when they are no longer capable of decision making, are you equally as diligent in coding them? Again, compelling, and thank you for sharing your knowledge.
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    Quote from OnlybyHisgraceRN



    I feel for the husband of my 90 year old patient. They had been married 60 plus years. Every time he comes to visit her, tears swell in my eyes. He is so affectionate and caring towards her and honestly believes she will return to baseline and come back home.

    I can't imagine what he must be feeling. I empathize with him. When he asks me how she is doing? I lie and say she's comfortable. That comforts him. Even though I know she isn't comfortable. The 25mcg of fentanyl ordered doesn't even touch the surface of managing her pain and discomfort, and ofcourse the doc doesn't want to order anything else despite the plea of us nurses.
    I understand how you feel. In my entire life, I had never walked past somebody pleading for help untill I became a nurse. A similar case to what you describe is one of the reasons I left the ICU.

    Stop lying. It is unethical, and contributing to the harm of your patient.

    Use simpe, honest words when speaking to the husband. "Your wife appears to be in a lot of pain. When I move her, she grimaces, and her pulse goes up. The fentanyl that is ordered is a very small dose, and is not effectively reliving her pain." You are trained and qualified to make this assesment- whitholding this information from a loving husband is unfair to him, as well as the patient.

    Can you honestly say thay you are living up to your ethical responsibilities?

    Stop pleading. You are a professional. Advocate for your patient. And document.

    After giving pain medication, I assume you are documenting it's effect.
    "Provider informed of continued pain. No change in orders at this time."

    While this approach may or may not help your patient, it will help you. We work in a flawed system, but at least we can do our best within that system. And- it ruly might benefit your patient as well.

    Once, during ICU rounds, I was asked to sum up what we were "doing for Mrs. Smith" I answered: "I am not sure we are doing anything FOR Mrs. Smith. I can sum up what we are doing TO Mrs. smith."
    GrnTea, PMFB-RN, pomegranate, and 3 others like this.
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    I have faced the soul crushing part of nursing as well, but I had felt I was alone. I could not understand how it seemed not to bother the other nurses as much. (or maybe they did a better job of hiding their dislike). My rendition of experiencing this part of nursing led to assertive actions of speaking out on behalf of what seemed to me as ethically & morally justified on behalf of the patient. To this day, I still can't distinguish if I had acted as an appointed vessel of God or if it was a life lesson or if I was simply out of order for not being professional enough to separate my personal beliefs from the beliefs of others. Nowadays, I just go with the flow. Clock in and do what the doctor orders and respecting family wishes despite the fact the patient is suffering. I resent playing this role in nursing care. If its too bad for me to handle, I WILL NOT accept the patient assignment again and that usually ****** off the charge nurse as well as another nurse.
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    Not many (if any) nurses are comfortable with a patient suffering. As nurses, part of what one has to learn is to seperate one's own personal feelings from that of the patient's wishes--which includes that the person who they chose to be their voice when they are voice-less --and be assured that this person is speaking the same language as they would. Our own ethical and moral justifications are not that of everyones.
    In my many years I have seen patients who are suffering so much I can't hardly make it to my car without being in tears, and my heart hurts--but are in some form of denial (STILL!!) and with their level of conciousness still saying "I want you to code me". Unfortunetely, death is sometimes to some people not something that they even want to consider or accept. I feel for the proxies who then have to say "code them" when they perhaps would make them a DNR in a hot minute, however, it is not what the patient wants or has indicated.
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    I cannot get my head around a physician refusing to increase the Fentanyl. I have placed multiple patches on an 80 lb. woman. She did not start out with that much but as her tolerance for the narc. increased the doctor knew enough to increase the med.

    I do not underestand why you are not being a forceful advocate for this patient. Movement in bed is painful, suctioning is painful. If you are not properly medicating this woman you need to accept your part in this bizarre circus. If you cannot get the ethics committee to touch it, then direct the husband to a clergyperson that you have previously primed for the issues. Yes, you might even have to do this over your own time, but this woman is renting space in your head when you are not at work. Why not be honest and work towards solutions.

    Address the pain issue with each professional who comes in contact with the patient. Resp. lab, x-ray. Make sure each person documents her pain level. Make sure the husband knows she is not comfortable and there are meds that will help. If you are not being forceful bout the pain issue how can the physician know it is significant. You are at the bedside not the doctor. You see the pain. The doctor worries about the labs, the output, etc. The doctor relies on the nurse for appropriate assessments even when the doctor does not seem to address the issue.

    Of course the easiest answer is to allow natural death. Who presented all these options: PEGs, tubes, etc? Why did they ever even suggest them? Doctors are fully aware of the cost and futility of these measures. Is there more to this story? Are they trying to keep her alive until a relative can get there?
    jadelpn and not.done.yet like this.
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    Codes were started many years ago for SUDDEN UNEXPECTED DEATH and in my opinion should remain so. We have gone from one extreme to another-- not all for the good of our patients/ residents.
    PMFB-RN likes this.
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    These are indeed difficult patients to handle. I understand the desire to tell the family that the pt appears comfortable, but agree with others: I would be honest and tell them that the pts pain is in not in good control, and I would continue to discuss with the powers that be (in my nursing home, that is the palliative care nurse, even if the pt is not on palliative care). The problem here is if all of the nurses are not on the same page with the message given to the family: if one nurse is saying that the pt is fine, but another is saying that the pt is not, who is going to be believed? And I find far too many nurses are willing to just give the meds and call it a day; this may be a self-preserving attitude; they keep telling me that I'll get past my willingness to do battle, but I hope not.
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    Quote from OnlybyHisgraceRN
    The even confusing part is that the husband wanted the drugs but no compressions.
    Did she have a prosthetic heart valve?
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    Quote from OnlybyHisgraceRN
    There are many things I love about nursing, however there are some things that are really soul crushing. Like, having a 90 year old patient, who is a full code, trached, has a peg, multiple pressure sores, infections, renal failure, heart failure, S/P CVA , GCS of 8 or less and the family wants EVERYTHING done. Maybe it is just me but if it were my loved one I would not want them to suffer. I've been on the other side. I know what it is like to have someone you love become sick and be at deaths door. I know what it is like to hang on to a that little bit of hope that makes you believe that their prognosis will change; and sometimes it does. However, it pains me to see a 90 year old, who is frail and clearly is miserable to be made a full code to appease the family. I know it is hard to let go of loved ones, at the same time it should be just as hard to see them suffer. I feel for the husband of my 90 year old patient. They had been married 60 plus years. Every time he comes to visit her, tears swell in my eyes. He is so affectionate and caring towards her and honestly believes she will return to baseline and come back home. I can't imagine what he must be feeling. I empathize with him. When he asks me how she is doing? I lie and say she's comfortable. That comforts him. Even though I know she isn't comfortable. The 25mcg of fentanyl ordered doesn't even touch the surface of managing her pain and discomfort, and ofcourse the doc doesn't want to order anything else despite the plea of us nurses. We offered hospice, we offered counseling, we offered support but to no avail. The husband still refuses and wants us to do everything we can for his wife. Every time I touch his wife she grimaces and gives me a look of agony. All I can do is say "I'm sorry" every time I have to assess, suction, or change a dressing. I hate seeing my patient suffer, especially those who are in their 80's to 90's. They lived a long life, why can't the family understand this and let them die with dignity, instead of tubes inside every orifice of their body? Once again, this is soul crushing. I feel guilty for feeling like this, but I see this so often and sometime wonder how much more I can take.
    Suggestion; Next time her husband asks you how she is, touch her gently eliciting that grimace and ask him (nicely, compassionately) how she looks to him..... let him know that you see her in pain without relief. If time and his state of mind permit, and his clergyperson is available, tell him that (especially) women's bones are very fragile and CPR will cause multiple rib fractures, which would add to her pain and misery. Unfortunately these days, personal physicians absent themselves from the bedside leaving doctors called "hospitalists" there, who know nothing about the patients and patients usually have no idea who they are, in charge of the orders for them. Ask her usual doctor to have a word with whoever the hospitalist is, who was assigned to her and have him/her advise the husband of her survival chances. That IS empathetic and should elicit permission for No CPR. If it doesn't, you've got to involve administration to pursue legal award of custody to an official of the court. Obviously no other member of their family is willing to cross that husband, who may be out of touch with reality or abjectly hostile. There is always something a Registered Nurse can do to alter a destructive path. This is just another challenge for you. Stop wringing your hands and "crushing" yourself! We've all been there, and we need support from co-workers to form a nursing plan in which there is agreement and the desire to properly get the job done.
    SHGR likes this.


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