I need help processing my first hospice patient experience.

[pkateRN]

Hi Guys,

I'm a new grad RN who was hired into a palliative care/hospice unit at a VA hospital. I have no prior experience with hospice (or nursing in general) and was given very limited training in this area- only 4 days before I was on my own. Today I received a new admit who was given days to weeks. His sister was supposed to visit him on Sunday. The resident ordered morphine 2-4mg q2H PRN, and haldol 1-2mg PRN. I also called her to get ativan on board in case he needed it. At the beginning of shift, he was out of it but still able to answer yes or no questions. This gentleman was the yellowest man I've ever seen (think curry powder yellow). He had a hx of alcohol abuse and his liver and kidneys were completely shut down. I decided to give him the max dose of morphine and haldol every 2 hours on the dot because I didn't want him to experience any discomfort. He wasn't very responsive so it was hard for me to tell whether he needed more. After the first couple doses, he went from minimally responsive and very restless/moaning to almost totally non-responsive and fell into a deep sleep. I asked for advice from the other nurse, who thought it was better to err on the side of caution and keep giving him the morphine every 2 hours because he was still occasionally moaning. He received a total of 16mg of morphine, 6mg haldol and 0.5mg ativan from me during my 8 hour shift. By the time I gave report at midnight, he was apneic and only breathing once every 30 seconds or so. I can't help but think I sped up the process too fast since his body can't metabolize the morphine or haldol. What would you have done in this situation? Did I give him too much too fast, in essence shutting his respiratory system down within 8 hours? I know it was inevitable, but I am feeling intense guilt that his sister won't see him because she lives far away and thought he had at least the weekend. Should I have spaced out the doses/given him less when I saw he went into a deep sleep? He is my first dying patient and I'm still not sure how all of this is supposed to work.

[pkateRN]

tewdles, I wanted to say thank you for giving the advice of "it is your loss professionally, not personally." that mantra is one i repeat over and over and as a result, the deaths have become easier to deal with. thank you for the perspective!

[tewdles, RN]

I, simply too much as there is a personal component to it, but the primary loss is certainly professional.

My weakness is reviewing the case repeatedly in my head, as the difficult cases are the ones we mourn most...many hours have typically been spent with those patients and families. I have to be diligent in giving myself permission to move on, let go...give it to God...

Funny, how we often have to give patients permission to let go of this world...and then, as nurses, we have to give ourselves permission to let go of them.

[pkateRN]

last night a patient died right in my arms as I was holding him. that is one I need to give myself permission to move on from.