The soul crushing part about nursing

jadelpn, LPN, EMT-B · Sep 24, 2012

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.

TopazLover, BSN, RN · Sep 24, 2012

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?

sherdk · Sep 24, 2012

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.

catlvr · Sep 24, 2012

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.

Anna Flaxis, BSN, RN · Sep 24, 2012

The even confusing part is that the husband wanted the drugs but no compressions.

Did she have a prosthetic heart valve?

lamazeteacher · Sep 24, 2012

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.

PMFB-RN, RN · Sep 24, 2012

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.

*** I do not excuse myself. I remain present to advocate for my patient and provide whatever appropiate care I can. I realize in reading over my messages on this topic I may have given the impression that this is a daily or weekly occurance. In realiety I have been in this situation 3 or 4 times in the years I have had this job and in my previous job as an ICU/ER nurse.

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?

*** I will do what I believe to be in the best interest of my patient and their expressed wishes reguardless of the concequences to my job or lisence. I hope that neither are at risk. In realiety nothing has ever been said to me. In each case it was recognized that coding those particular patients wasn't the right thing to do and the code team seemed relieved that somebody said something. I have also been told (by our hospital's risk manager) that, in therory, the code team could be charged with battery for coding a patient aginst their wishes.

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?

*** That issue doesn't come up since a code would not be called on them and I would not be present. Hypotheticaly I may or may not code them. Let's say your patient is asking you for narcotic pain meds. Your assessment, and the patients comments lead you to belive your patient has unrelived pain. In such a case I assume you, and any RN, would do what they could to get pain control for your patient. Either providing ordered PRNs, or if nothing is ordered calling the provider and obtaining an order, maybe even going over the providers head if they choose not to address your patient's pain. You would advocate for your patient in that situation. Any of us would. Now lets say the exact situation except your assessment makes you question if the patient is really in pain and on the way out of the room you clearly hear the neurologicaly intact patient tell his visitors that he isn't in pain but just wants some narcs. Would you still be a strong advocate for obtaining pain meds for that patient? Probaly not. At the very least I assume it would cause you to re-assess his pain with his comments in mind.

We (health care providers) do not provide whatever care a patient asks for just cause they ask for it. Nobody would amputate a perfectly health limb just cause a patient requests it. On the other hand it isn't unusual to have a patient refuse the amputation of a diseased limb, even if it means they will die. Their wishes to refuse care are respected. I don't see how a code is different. In the case where I knew nothing about the patient and just arrived on the scene I would fo course code them if they were a full code.

JMBnurse · Sep 24, 2012

I worked in Oncology, so I have seen the scenario described by the OP played out many times, sadly. On our Oncology floor, it was often up to us nurses to talk to the family. We would have our "You have to love them enough to let them go" talk, sometimes. There are worse things than death. But, you have to be very honest with the family. Often, they are waiting for a cue from the doctors and nurses to make those painful decisions. In a sense, we can help relieve that guilt and uncertainty they feel. We want so badly for them to make the decision on their own, but they look to us for guidance.

Been there,done that, ASN, RN · Sep 25, 2012

It's not our call.The family makes the decision.

Our job is to offer education and support to make their choice. If the choice remains denial...so be it.

Beating yourself up..when you don't agree with their decision is USELESS.

Comfort the patient and the family.. to the best of your ability .. nurses cannot and should not judge the family wishes.

Anna Flaxis, BSN, RN · Sep 25, 2012

I agree with JMBnurse. I think sometimes family members need "permission" to let go. I think that for some, there is a tremendous amount of guilt that comes with thinking you didn't do everything possible for your loved one, and they just need to know that they have, and that it's okay to let go.

whd13b · Sep 25, 2012

This is why it's SO important to convey to everyone you know, friends, family, and YOURSELF, to have a health care proxy, living revocable trust, just something legally in writing letting healthcare facilities know your wishes regarding your healthcare in the event you cannot express them yourself at the time. If more people took care of this on their own, we wouldn't have to worry or see it on the scale that we do.

anangelsmommy, ADN, BSN, RN · Jun 4, 2013

good for you! we have home nursing laws for pediatrics where the nurses have to call ems and do everything regardless of a dnr. however if the parents or guardians are there and in charge they can take over and change the situation. This doesn't always happen though.