Written up and confused.

[pageturnstyle]

I have been a nurse for 2 years now and have been fortunate enough to avoid any deaths on my shift until recently. Last week I had a hospice patient with a DNR who was exhibiting Cheyne-Stokes breathing, fixed pupils, and a thick green secretion in her mouth. She also was known to pocket food- I found bits of banana pocketed in both cheeks at the time. Without a second thought, I retrieved the suction machine from the crash cart and used a Yankauer to suction the pocketed food from her cheeks and some of the green secretion around her teeth. The family was present and was very grateful and surprised by the things coming out of her mouth. The patient hung in there until the next shift at which time she expired. The next morning my new unit manager wrote me up for suctioning without a physicians order. Her MD had a standing order to suction PRN and the only Hospice orders I could locate in the chart said to D/C all previous meds, not all previous orders. Her hospice has no standing order to suction, however. This supervisor threatened my license and basically called me a lousy nurse for my actions. Am I completely wrong here?

[nursything]

I mean, you could have just as soon reached in and scooped it out with a swab or toothbrush. You don't need a doctor's order to perform oral care do you? But how gross and undignified is that? And what if something had droped back into her throat as you did that? THAT would've killed her. So, I'm sure the suction was quick, clean, and safer. The removal of the pocketed food was appropriate, regardless of what tool you used. I think you demonstrated a decent amount of critical thinking and problem-solving. Especially since it would have just rotted in her mouth (also undignified) and the family would have to be in there sitting with the stench (also undignified and obstructive to their grieving process). Don't let her do this to you.

[jadelpn, LPN, EMT-B]

You know you did the right thing. Comfort care and DNR's don't equal no treatment. You did not un-necessarily prolong the patient's suffering, nor did you do anything that would be out of the norm of comfort care. A yankaur suction to the mouth is definetely not something that needs an order in most facilities. You were not deep suctioning the patient--and even then, sometimes that is needed to alleviate the patient's distress that no amount of morphine could help. I wonder what the family would have said if said patient choked on the pocketed food, started flailing and gagging.....that would have been a heartbreaking scene and completely uncalled for.

Apparently your NM needs the education on how to conduct herself appropriately. Hopefully, she will take it to heart.

[artsmom, BSN, LPN]

I have had to suction w/o an order before in emergency situations. If there was no order, I called after to update the doc and get the order. What did she want? Let the pt cont regurgitating/choking on food while you called the doc?

[tewdles, RN]

I agree that you acted with the intent of providing comfort for the patient who was in the process of actively dying.

There was no way this poor individual was going to swallow the food pocketed in her mouth. At best it was going to sit there, rot, and smell bad. At worst it was going to actively choke her and cause an uncomfortable death.

If you had an active medical order on the chart, which had not been discontinued by hospice, to suction as needed I believe you are covered.

It sounds as if, perhaps, hospice had a conversation with your manager about how much the family appreciated your efforts. You acted like a nurse who could provide good compassionate care for a dying patient again.

[amygarside]

I think you should consult a lawyer and if you are a member of a nurse's union consult with them also. I think that you are just doing your duty and what you believe is best for the patient.

[applewhitern, BSN, RN]

Wow. In my 23 years of experience, I've never heard of having to have an order to orally suction a patient in this manner. We suction our hospice patients, and hospice actually set up a portable suction machine at my house when my son was dying. To not do so is simply inhumane. Your manager needs to educate herself.

[martymoose, BSN, RN]

Your manager needs to go jump off a bridge. Maybe you should reconsider, and get a job in hospice, and run away fast from where you are. I would never be able to trust that manager ever again.

[Pheebz777, BSN, RN]

Ask your NM if you need an order to change diapers, bath a patient, apply skin lotion, brush their teeth and provide perineal care. Just to be on the safe side. And while you're at it, ask the DON to look into her profile.

[rn/writer, RN]

This is why I encourage people to get professional Liability Insurance. For less than one day's pay you get a year of coverage. In a situation like this, you can call and receive legal advice about how best to protect yourself.

If you don't already have a policy, starting one now wouldn't cover you for this incident. But it might be a good investment for the future. Things happen. Patients and family members can be looking for a windfall. Management could be clueless or corrupt. The sad reality is that no one is entirely safe.

I'm glad the DON is supporting you on this. That's the most encouraging sign in your posts. Make sure you write that rebuttal and have it reviewed by real life people you trust. Keep details to a minimum on this board.

I hope this passes quickly and the outcome is good for you. Thank you for giving your patient capable and compassionate care.

[Esme12, ASN, BSN, RN]

I spoke to my DON and she advised me to attach my own written statement to the write up. She said signing the write up only indicates that it was read to me, not that it was an admission of guilt. She agreed that I was providing comfort care and said she would look into the matter. She also said she would do an inservice for the unit managers to help prevent intimidation and other inappropriate behavior in the future.

Oh, Honey.......you did good. Threatened your license.......what an idiot. When is the last time this poor patient had oral care. If I was the manager I would have the floor on the carpet at the next meeting informing them that oral care is rendered on the dying.

I agree with rnwriter.....get malpractice insurance. It is cheap and will help your when some idiot does something crazy. It will provide you with legal advice to protect your license as a part of your policy. It's worth the approxamate 0.5 cent a a day. (about $200.00/yr)

The manager was also inappropriate in her attitude and in dealing with the issue...you don't use intimidation tactics and threaten the staff. Watch out for this one for they are insecure and in charge and a power hungry control freak....the worst combination in a Supervisor.

Signing or not signing a write up is not an admission of guilt......it is just acknowledging your met with the manger regarding the matter ask the DON to remove this from your file for it is utter nonsense and at the very least write your response.

You did good....((HUGS))

[Whts_Ur_Emergency?]

I dont see how that was a heroic measure but maybe your facility has a policy in place that states what a heroic measure is or that you need a doctors order to suction. I would demand to see the policy that backs up her claim. Policy can work to your advantage. If she can not produce it then take it to the DON and if not resolved there say you will contact the board of nursing.

[rn/writer, RN]

I agree with rnwriter.....get malpractice insurance. It is cheap and will help your when some idiot does something crazy. It will provide you with legal advice to protect your license as a part of your policy. It's worth the approxamate 0.5 cent a a day. (about $200.00/yr)

My last renewal in September was just over $100. It's inexpensive peace of mind and covers me if I volunteer or if I'm called to testify against someone else. Facility policies only take care of you if you did everything perfectly and there is no conflict of interest. That's a rare occurrence. If your employer can cut a deal by tossing you to the wolves (as evidence of their "corrective" action), you'd better believe that will happen in a heartbeat.

Some specialty areas are more vulnerable than others--OB, peds, surgery. But even an area like hospice is open to misunderstanding and confusion. Besides that, every area has people in it and when there are folks like the one who threatened the OP, it's good to have someone in your corner.