conscious pt terminal wean

[taylynnfree]

First this is the pov of a tech /nursing student..I thought this might be the place for this post. I have only had one terminal wean patient and the patient was concious and she made the decision to remove her vent.

This is my biggest issue w/becoming a nurse..the whole experience did not sit well with me at all and still doesn't 2yrs later. So here is the story from a techs pov:

I show up to work to find ive been pulled to the icu ..I get report from the tech and she tells me that one of my pts is about to be taken off the vent ...I say what!? (This lady has been in the icu for about 6weeks and I knew her..she was totally alert and would ask for things used the call light etc.) Im a float pool tech so I wasnt familiar w/ the process. This lady was on dialysis , masthenas gravitas , had a gaping abdominal wound with a wound vac that wasnt healing..she wasnt mobile and was incontinent, couldnt eat and had ards ...so after report I go to her room and the process was under way ..her husband ,two daughters, her nurse and the doc were in the room ..so I just kinda peeked in and saw the pt sign a paper the doc had....I never entered the room I just sat at her monitor to watch her vs as things "progressed" about 10mins later I see a respiratory therapist enter the room ..the RT leaves and gives the husband a long hug outside the room..then the doc comes out and sits near me to put in the patients "final med" orders....the nurse comes out of the room very chipper and Normal every 10 mins or so to check the pts vs ..she makes a comment to me "shes lookin real "smurfy" in there" as if shes excited the pt will be dead soon. ..Finally the pt passes ..her family leaves very shortly and the nurse comes to get me for the post mortem care I enter the room and see 15 or so little bottles of morphine on the counter ..i felt sick and really didnt want to be apart of it ..but of course i did my job and helped..I could see tons of sores in her mouth that I never noticed which aluded to the intense suffering she was going through....during the whole time the nurse just seemed to happy and not phased by any of it. Im not sure how I would feel after something like that as a nurse. It was the fact the patient was of sound mind that really disturbed me.

[peacelover]

I think the fact that it shook you only proves you are human. Don't be too hard on yourself or expect that you 'should' magically have had a different reaction to the situation.

I wouldn't say you get used to seeing death; especially when people are on comfort care or when they decide to stop treatment. I think you just get to a place where you accept it better. I have just come to really embrace the fact that every living thing has a life cycle and that includes us. I have watched many patients suffer so much trying to live and seen the peacefulness that occurs for the patient and the family as the choice is made to stop fighting and move into the next phase of things.

As for the nurse that you think was 'happy'..probably not..probalby just that persons way of coping with the situation.

I am glad you are exploring your feelings and letting them out and taking the time to figure it out for yourself. Lots of nurses don't do that..so pat yourself on the back for this please....

peace-

[wanderlust99]

Maybe that was the nurse's way of dealing with it. Sometimes you mask hurt feelings by making jokes or making light of a situation. Sounds bizarre when dealing with death, but seeing so much death and end of life stuff in the ICU you develop various way of coping with it.

The story doesn't bother me in the least but I've seen a lot of torture in the ICU over the years. It's a nice change that a patient was able to make her own decision.

Morphine is given so the patient is not in pain while dying. The patient was already dying but they were keeping her alive via machines. I hope you get that. Is that morally correct? Is it right to not give pain medication to a dying patient??? You know having a endotracheal tube down your throat is not comfortable, neither is dialysis and a wound vac in your stomach. The poor woman suffered long enough. Geez.

[Altra, BSN, RN]

No euthanasia in this story.

As an ICU nurse I consider it a good day any time that a patient/spouse/family are all on the same page regarding care. If an alert & oriented patient gets to make his/her own decisions ... I just might feel chipper. That's a win.

Regarding the many bottles of morphine ... pre-mixed morphine drips are not always immediately available/stocked. If you can imagine the enormity of making the decision to be taken off the vent ... you'd be emotionally ready for it to occur right now. That nurse & physician instead used IV push doses of morphine which were immediately available, rather than imposing another indignity on the patient by making her wait for the wheels of hospital processes (order entered, pharmacy filling order, meds brought to the unit, etc.) to play out, remain in pain longer, and prolong her possibly fearful anticipation.

When a patient is being weaned I am there to do all I can to make them comfortable, to monitor progress, and to provide emotional support as needed. But when a wean has been chosen, by the patient or family, it is unlikely that they require my constant presence. I would not impose myself and invade their privacy during their limited time together. And regardless of how I personally judge their decisions, I will present a confident, under control demeanor. To do otherwise would be to unfairly add *my* feelings to what is THEIR situation. So I will "pop in and out" quietly, monitoring, saying a few words or providing a touch or hug as needed, but otherwise go about my business.

[umcRN, BSN, RN]

It was the fact the patient was of sound mind that really disturbed me.

There is another way we can look at this too. Say there is a patient who has just been diagnosed with end stage cancer. No amount of surgery, radiation or chemo will cure her, but it will cause her pain and suffering for a few extra months. Instead of living out her last few months in pain and discomfort she decides she would rather spend as much time with her family and loved ones as possible so she makes a conscious, of sound mind, decision to not get treatment and to go on hospice. When the time comes and the end is getting near the hospice nurses and doctors ease her suffering with pain medications until she peacefully passes away.

We have all heard this story, how is it any different than the one you described? Death is a very scary and taboo subject in our world and people fear what they don't understand and can't control. Any time a person who knows they are going to die can take control of the situation then they should be allowed to do so.

[Emergent, RN]

Using morphine to ease pain of dying is NOT Euthanasia, even if it hastens death. And, giving pain relief to the dying can actually prolong life.

Killing the Pain Not the Patient: Palliative Care vs Assisted Suicide

In competent medical hands, sedation for imminently dying patients is a humane, appropriate and medically established approach to what is often called "intractable suffering." It does not kill the patient, but it can make his or her suffering bearable. It may also allow a physician the time to re-assess a patient's pain needs: The terminally ill sedated patient may later be withdrawn from the sedatives and brought back to consciousness, with his or her pain under control.

The factual evidence supports these claims. In 1992 the Journal of the American Medical Association (JAMA) reported on 97 terminally ill patients who died after life support was withheld or withdrawn. Sixty-eight of the patients received painkilling drugs or sedatives to relieve pain and other distress while dying--and they lived longer than the patients who did not receive drugs. The study found that the dosages of these drugs were chosen to ensure relief of suffering, not to hasten death.

Only recently has the medical profession begun to appreciate that unrelieved pain can itself hasten death. It can weaken the patient, suppress his or her immune system, and induce depression and suicidal feelings. It can keep patients from living out their lives with a modicum of dignity, in the fellowship of their families and friends. So adequate pain relief can actually lengthen life. According to a JAMA news item of March 25, 1992, part of modern medicine's task may be that of "killing pain before it kills the patient." Or as the Catholic Health Association says in its 1993 guide Care of the Dying: A Catholic Perspective: "Unrelieved agony will shorten a life more surely than adequate doses of morphine."

[Emergent, RN]

And from the same article:

http://www.usccb.org/issues-and-action/human-life-and-dignity/assisted-suicide/killing-the-pain.cfm

The Principle of Double Effect

What of the rare case when providing pain relief or sedation does risk hastening death? Is this really the same thing as deliberately killing a patient?

Centuries of Catholic moral tradition say it is not. Sometimes it is impossible to achieve some good effect without causing a bad effect as well. When an act has both a good and a bad effect, we should ask ourselves whether it meets four criteria.

First, the act itself must be good or at least morally indifferent; giving medication to relieve pain certainly meets this test. Second, the good effect must not be attained by means of the bad effect--we cannot claim, like Jack Kevorkian, that we may deliberately kill suffering people because once they are dead they can't suffer. Third, the bad effect must not be intended; we cannot give pain medication in order to end pain and cause death. Fourth, there must be a serious reason for pursuing the good effect; it would be irresponsible to risk hastening death to relieve an ordinary headache.

[That Guy, BSN, RN, EMT-B]

This lady was on dialysis , masthenas gravitas , had a gaping abdominal wound with a wound vac that wasnt healing..she wasnt mobile and was incontinent, couldnt eat and had ards ....

Why are we so afraid of death as a whole? This sounds like a very hard way to go on with life. I dont think I could do it either and given the option, would pull the plug too. I would hope that my wife doesnt like the idea, I want her to show she loves me and wants me around, I would want the nurse to give me morphine to ease my suffering. I would want my nurse to be happy knowing that my wishes are being honored and that my so called "life" is going to the world of quality and not quantity.

Keep your own opinions in check. It is great to have them, but some education behind the matter is necessary before the anger you present with.

[rdsxfnrn]

When my dad wad terminally ill with lung CA, he was home. His bed was in the living room, and all family members took turns caring for him. When it was "that time", as told to us by his hospice nurse, all immediate family stayed at his house. We had plenty of oral morphine, as well as several other meds TO KEEP HIM COMFORTABLE. We medicated prn per doctors orders to keep him comfortable. His death was peaceful and PAIN FREE. He went from alert and responsive to the end rather quickly. He died surrounded by the sounds of his wife, kids and grandkids in his own home.

Now, my mom on the other hand, died at a LTC facilty. (this is not a bash on LTC so please don't make it so) She did not die a peaceful death. For whatever reason, she was NOT MEDICATED PROPERLY. The staff there would only give her the scheduled meds, (q4hr) we had to beg for prns. She lingered on and on and on. Yes, hospice was involved but they were only making visits, and their hands were tied.

I hope you can see the difference in what the PROPER medications can do to ease a dying person's last journey. This is our very last chance to do right by this person, let's hope we get it right.

[taylynnfree]

Keep your own opinions in check. It is great to have them, but some education behind the matter is necessary before the anger you present with.

Absolutely not how you address me or anyone on the web or face to face . So check your comments when you address me. Thx

To all the other constructive posts thanx for your input and motivation. I dont have any anger..if I did I wouldnt want to be a nurse. I dont argue so im not going to respond to any assumptions about my feelings or ignorance...Everyone is entitled to their opinion.

Im looking forward to reading more post about how they(emotionally) handled situations like this when it was still new to them.

[kungpoopanda]

Why are we so afraid of death as a whole? This sounds like a very hard way to go on with life. I dont think I could do it either and given the option, would pull the plug too. I would hope that my wife doesnt like the idea, I want her to show she loves me and wants me around, I would want the nurse to give me morphine to ease my suffering. I would want my nurse to be happy knowing that my wishes are being honored and that my so called "life" is going to the world of quality and not quantity.

Keep your own opinions in check. It is great to have them, but some education behind the matter is necessary before the anger you present with.

I think a large part of the OP's difficulty dealing with this event is that she was thrown into a new situation without adequate preparation, explanation or education. It is unfair to slam her simply for trying to understand the process and make sense of her own reactions to it.

OP, I'm sorry you have had to deal with this experience without education and support.

[Emergent, RN]

People are afraid of death because it's scary, that's why. Death scares people.

[Twinmom06, ASN, APN]

we lost my grandmother in October - fortunately she made her own end of life decisions 20 years ago long before she was ever in a position for us having to make those decisions for her. She had a massive L Ventricle infarct and wound up in CHF and was struggling to breathe - when her O2 got to 50% and her neck was swollen from JVD the doc looked at my mother and told her it was only a matter of time and why let her struggle. She got a big fat shot of morphine, relaxed and slipped away peacefully. She was coherent and responsive to our voices to the very end - there was no struggle to breathe, no more crying in pain and no more vomiting.

In 2012 my cousin summed it up very well having both my aunt and uncle in hospice at the same time and they died 90 days apart - no one comes out of this alive.