What happened to make him die?

Nurses General Nursing

Published

Had a patient a couple of days last week and this week. HX: Pulm.HTN, Afib, CAD, mitral valve prolapse. Came in with change in mental status and hypercapnia. The only way to get his CO2 down was with bipap. Gases yesterday not good: 7.26-95-73.

I took him over at 7am, he fed himself breakfast. Son concerned he was not eating much. Patient coughed with fluids, not felt he was aspirating. I was feeding him lunch, he coughed here and there but able to clear his airway, he also had a cough at baseline. I gave him a bite of pudding. At that time he wanted a blanket I had around his shoulders off, said he was hot. I noticed his color was getting dusky, HR going from 70's to 50's with pvc's, switching bundles, nodal rhythm then t-wave inversions, pupils dilating and he stated "I can't breath" I attempted to orally suction, called for help and we ambued, he was a DNR. I left feeling like I contributed to his demise by feeding him, but then if he was choking how could he say " I can't breath." Any thoughts? Just prior to eating and during the morning he was restless, tired. Was not on any DVT prophyaxis by the way. I would like to think he threw a clot or had some other catastrophic event, would his ability to speak rule out choking on pudding?

TopazLover, BSN, RN

1 Article; 728 Posts

I think you probably would have recognized him choking on pudding. As a thickened liquid it usually goes down easier than many other fluids. I doubt if you contributed to his demise.

He could have had an MI, stroke, etc... Sounds like everybody was doing all they could. My guess is that it was his time to go. If there is concern about COD then an autopsy is in order. It does not sound as if he had much chance to make it. You did not mention age but with his hx I am guessing he had a few of these medical conditions for awhile. Time does take its toll.

tiddles

68 Posts

As Aknottedyarn said, it was just his time to go. Try not to stress about it. I'm pretty sure he ain't stressing right now.

husker_rn, RN

417 Posts

Specializes in med-surg 5 years geriatrics 12 years.

Silent aspiration ?? Happens sometimes; a patient may aspirate but have no cough afterwords, body doesn't realize he/she has aspirated. Don't beat yourself up, you did your best and as others pointed out, it was his time.

Specializes in LTC.

Maybe he had a PE ?

Kymmi

340 Posts

Specializes in CVICU-ICU.

Are you saying his PCO2 was 93 and his PO2 was 72? Doesnt really matter actually even if I have the numbers reversed with a PCO2 that high patient was bound to not last long. He might have been aspirating the pudding into his lungs which would have made the PO2 level drop but even if he had been NPO with blood gases like that esp after wearing Bipap there really isnt much hope to help other than intubation but he was a DNR. Sounds to me like his heart was not getting enough O2 and therefore he went brady and passed so in conclusion of my long explanation.....NO you did not cause his demise it was nature and time for him to move onto a peaceful place.

The fact that this is on your mind and you are concerned tells me one thing though.....you are a very caring and compassionate nurse and he was lucky to have you to care for him in his final time on this earth so when the thoughts you are currently having start kicking in please remember this instead.

Emergency RN

544 Posts

Specializes in ED, CTSurg, IVTeam, Oncology.

I mean the OP no offense, as you're probably not going to want to hear this, but sometimes, a cold analysis is the best teacher.

Frankly (and respondent Kymmi hinted at this), IMHO, too much time off from the BiPAP to eat was probably what put him over the edge. Here is a man with a horrible blood gas to begin with. He likely needed to have every ounce of O2 that the Positive Airway Pressure was forcing into him. Without the needed oxygen, he went into a brady arrhythmia, declined into a junctional rhythm and became ischemic (as evidenced by the onset of cyanosis, PVC's and flipped T's). He desperately needed O2, but instead, he was suctioned, depriving him even more of what he needed most. :uhoh3:

I would have immediately manually ventilated with 100% O2, put him into a high fowlers, and then returned him to the BiPAP.

To the OP. Don't feel bad. Years ago, I learned a very similar lesson in almost exactly the same way, with exactly the same results. I beat myself up over it for a very long time, too, until a colleague woke me up by saying that nobody's perfect. :crying2:

Like Kymmi just said, the fact that you're chewing this over in your head, means that your heart is certainly in the right place, and you're most certainly in the right profession. No patient can ask for anything more out of their nurse. In essence, we all learn from our previous patient contacts, good or bad, and in the final analysis, they ultimately make us better caregivers. :up:

oramar

5,758 Posts

Oh heavens, the guy was on the edge, it was time. If you kept him on bipap forever and never fed him he would die of starvation.

ktwlpn, LPN

3,844 Posts

Specializes in LTC,Hospice/palliative care,acute care.

"Son concerned he was not eating much...." "he was a DNR"

I agree with oramar . It's a shame he didn't get a hospice consult on admission.His son certainly could have used their support and the patient may have been a bit more comfortable at the end.

leslie :-D

11,191 Posts

Oh heavens, the guy was on the edge, it was time. If you kept him on bipap forever and never fed him he would die of starvation.

thank you for that visual, and laugh.:lol2:

op, everyone is right.

it was simply his time.

leslie

Batman25

686 Posts

You did nothing wrong. It was simply his time. You sound like a wonderful and caring nurse.

massrn116

117 Posts

[quote name=

I would have immediately manually ventilated with 100% O2, put him into a high fowlers, and then returned him to the BiPAP.

Thanks for your input, this particular patient had initially been refusing bipap for 2 days. With his hx of afib he was not on coumadin (86 yrs and frequent faller at home). The day I took him over he had come off bipap at 5am, O2 sat on 1.5-2 liters was 87-96%. I got him OOB at 11:30am to have him in an upright position to eat. In retrospect and reviewing things in my mind, he looked to me like he threw a clot. It took about 2 minutes for him to essentially "go out" initially he complained of being hot, before I knew it his color was becoming that pasty blue, pupils were dilating, he said "I can't breath." The rhythm was changing, I called out for help and within seconds I had an intensivist and RNs at my side and we were ambuing. We got nothing back. I fully understand that by suctioning I was pulling what air he needed but my hope was that I would get back what he might have aspirated(?)But thanks again all for the support.

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