The soul crushing part about nursing - page 2

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... Read More

  1. Visit  not.done.yet profile page
    12
    I am a really new nurse, but am beginning to learn that this kind of knowledge comes slowly to most families. It has to be gently broached over and over, starting with the honest assessments when they ask how their loved ones are doing. Please start telling the truth to this man when he asks about his wife's condition. It will definitely start the ball rolling - it requires an understanding of the patient's agony to begin thinking maybe it is time to let go.

    In all cases I have had, it has taken some time of seeing their loved one not doing well (and recognizing that) before they are even willing to consider it. Lying to him isn't kind, though I know you intend to be. If you can't say how she is honestly doing, how he, who is so emotionally attached, supposed to face how she is honestly doing?

    The husband's questions are his first tentative reaches into the question of "Is she going to die? Is it time to start preparing myself?" In telling him the truth you will be answering "yes" to those questions without having to force him to face it directly. Managing her pain is complicated and you can tell him that. Her liver and kidneys are, no doubt, not doing well. Those drugs can be hard on those systems. Explain she is ventilated but the drugs may cause her ability to oxygenate to decrease even further, requiring higher vent settings, which then increase the potential for lung damage, pneumonia, etc. Explain the tough balancing act that it is - that if you treat one thing, something else is going to suffer.

    I have been blunt with families, stating openly things like "And she is 90 years old - even when perfectly healthy the body struggles at this age -it just can't adjust to all this like it might have at a younger age. It doesn't look good right now. We are going to do all we can and are trying to keep her comfortable while we do that. I am here to answer honestly any questions you have and to honor your wishes, whatever they may be." It assures them you are going to do everything (because that is what they want) but also gently implies they can change that decision and that is okay too.
    Last edit by not.done.yet on Sep 23, '12
    JRP1120, RN, catlvr, IowaKaren, and 9 others like this.
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  3. Visit  SHGR profile page
    2
    Do you have an ethics committee in your organization? Find out and utilize their services. That is their purpose- to examine cases like this and support the staff. Yes, it is soul crushing- if you aren't supported.
    NutmeggeRN and VICEDRN like this.
  4. Visit  GrnTea profile page
    4
    Conscious claus? Oh, do you mean "conscience clause"? That makes some sense.

    In a situation like the OP's, I would run, not walk, to the ethics committee at my hospital. I would involve the patient/family's spiritual advisor-- pastor, priest, rabbi, imam, reader, whatever-- to help them understand that this is not God's will (there's no religion that requires "everything" when a patient is otherwise actively dying). Sometimes that's all they need to hear. Sometimes it's all the attending physician needs to hear, too.

    Great summary paper on the major religions: http://repository.upenn.edu/cgi/view...od_theses_msod

    http://ethnomed.org/cross-cultural-health/religion/health-care-in-islamic-history-and-experience Islam: The definition of death in Islam is the departure of the soul from the body in order to enter the afterlife. The Qur'an does not provide any specific explanation of the signs of this departure. The common belief is that death is the termination of all organ functions. In 1986, at the third International Conference of Islamic Jurists in Amman, Jordan, a fatwa was issued that "equated brain death to cardiac and respiratory death." This ruling accelerates and facilitates the process for organ transplantation.
    The Fatwa no. V: of this conference reads: "A person is considered legally dead and all the Shari'ah's principles can be applied when one of the following signs is established:
    (i) Complete stoppage of the heart and breathing which are decided to be irreversible by doctors.
    (ii) Complete stoppage of all vital functions of the brain which are decided to be irreversible by doctors and the brain has started to degenerate. Under these circumstances it is justified to disconnect life supporting systems even though some organs continue to function automatically (e.g. the heart) under the effect of the supporting devices" (Hassaballah,1996).
    Since death is viewed as a process that bridges the soul's existence from one life to the next, it is acceptable to discontinue the use of life support equipment that prolongs the life of a patient. In medically-futile situations, in which life support equipment is used to prolong organ functions, the condition needs to be carefully explained to the family so they do not mistake DNR orders with euthanasia.

    Jewish Values Online - A 60-year-old Orthodox Jewish male became ill with pneumonia, requiring mechanical ventilation and cardiopulmonary resuscitation. As a result, he became severely brain damaged and remains in a vegetative state months later. The
    (conservative) As Kant pointed out, when one cannot do something, one does not need to ask if one should; once one can do something, though, one does need to ask whether one should, for there are all kinds of things that people can do that they should not do (e.g., smoke, eat a half-gallon of ice cream every day, etc.). The machines and tubes that keep a vegetative patient alive were not invented for that purpose; they were invented to keep a person alive for a few hours or possibly a day or two so that the person could successfully undergo surgery. These interventions were not intended for long-term support, but now that we have them, we must ask when we should use them -- and when not.

    Given that our ancestors could never have even contemplated a situation like this, let alone deal with it, any rabbi trying to apply the tradition will not find a case or precedent directly on point. He must rather apply some of the principles of the tradition to this new case. Yes, the tradition asks us to preserve life whenever we can, but it did not even imagine that we could do so for patients in a vegetative state, and one passage in the Talmud asserts that "we do not worry about the life of an hour" (l'hayyei sha'ah lo hashinan) -- that is, we do not seek to preserve life when it is clearly and irreversably ending. Furthermore, Tosafot on Avodah Zarah 27b states that the underlying principle that we should use in judging these cases is the welfare of the patient. Tosafot assumed, of course, that the patient's welfare was always in sustaining life as much as possible, but even if that was true in the 12th century, it probably is not true in ours. So based on the principles that the Talmud and Tosafot announce, I have ruled that we may remove life support from a patient in a vegetative state after due examination to make sure that he or she is actually in such a state. See Elliot N. Dorff, Matters of Life and Death: A Jewish Approach to Modern Medical Ethics (Philadelphia: Jewish Publication Society, 1998), pp. 213-217.
    (Orthodox) We are not required to call people back from heaven (as it were) particularly when they are this compromised

    however if someone (and hopefully the family is reflecting this person's expressed desire) wants to continue to live even a very compromised life
    no one has the right to take that life from them and no DNR order is appropriate
    (reform) "Just as a man has a right to live, so there comes a time when he has a right to die."

    This is how Rabbi Solomon B. Freehof, then chairman of the Responsa Committee of the Central Conference of American Rabbis, interpreted the words of Sefer Chasidim, reflecting on the words of Kohelet, "there is a time to live and a time to die": "If a man is dying, we do not pray too hard that his soul return and that he revive from the coma; he can at best live only a few days and in those days will endure great suffering; so 'there is a time to die.'" Rabbi Freehof goes on to show that the Talmudic and post-Talmudic record permits us to remove that which hinders death, providing that in doing so we do not disturb the patient in a manner that may hasten death (e.g., B. Ketubot 104a, where the servant-woman of Rabbi Judah the Prince smashes a earthen jar as he lay dying in order to disturb the incessant prayers of his students, that his soul might peacefully depart; Shulchan Aruch, Yoreh De-a 339, which states that one may not remove a pillow from beneath the head of the dying patient but may stop someone from chopping wood outside when the rhythmic sound of wood-chopping "focuses the mind of the dying patient and prevents his soul from departing").[1]

    In other words, "preventing that which delays the death" of one whose death is imminent is permitted. Jewish law does not require us to preserve life regardless of outcome.[2

    What is the Catholic position on do not resuscitateCatholic: The Catholic position is that if there is reasonable hope that resuscitation would preserve the patient's life, and that to do so would not represent an undue burden to the patient, then resuscitation would be part of the minimum standard of care.

    If the patient is not expected to recover from a fatal illness or injury, and has begun to enter the dying process, then to continue to administer resuscitation would most likely be truly burdensome to the patient and not good care for them. In such cases, a do not resuscitate order would be appropriate.
    simonemesina, catlvr, KelRN215, and 1 other like this.
  5. Visit  VICEDRN profile page
    1
    I wouldn't lie to the husband about his wife's comfort level and I agree that you need to consult with ethics if you haven't done so already.So sorry that your heart is heavy.
    Aongroup1990 likes this.
  6. Visit  jadelpn profile page
    2
    This reminds us all to be VERY sure who we make our Health Care proxies, our POA, that we are on the same page as them, and have the conversation NOW to decide how and what we would want to happen or not happen. There are people in this world who really, really will do anything to live. Even if living is a fate much worse than death. And we are not the judge and jury to decide this. Have this conversation with your parents. Have this conversation with your adult kids. Make sure whomever you choose, that they are going to stick by your beliefs and wants and not wig out at the last minute.

    I am not at all familiar with the conscience law--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 would think that pharmacists who don't fill BCP's need the backing of the pharmacy of which they are employed. So I would think nurses would also need that support from the hospital. 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. I would perhaps excuse myself from that role in circumstances where I would think it morally unjust. I just find that a bit odd, and just my opinion. And I absolutely support anyone's moral belief in the procedures they are not willing to participate in. However there needs to be a plan B, because believe in it or not, it is still legally the choice of whomever patients decide can make those decisions for them whether we would like it to be different or not.
    Last edit by jadelpn on Sep 23, '12
    Hoozdo and SHGR like this.
  7. Visit  CapeCodMermaid profile page
    0
    Yikes. You'd lose your license in Massachusetts. It's only been 3 years since we were told officially we didn't have to do CPR on someone who had been beheaded.It is, indeed, heartbreaking when the family can't let go, but it's their choice to make.
  8. Visit  taramb7263 profile page
    0
    I have recently read an article about this and the issue regarding a "slow code" it was quite interesting. I guess it is considered unethical by some but I guess it is a case by case decision.
  9. Visit  PMFB-RN profile page
    2
    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.
  10. Visit  jadelpn profile page
    0
    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.
  11. Visit  hherrn profile page
    6
    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.
  12. Visit  gcupid profile page
    0
    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.
  13. Visit  jadelpn profile page
    0
    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.
  14. Visit  aknottedyarn profile page
    2
    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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