conscious pt terminal wean

Specialties MICU

Published

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.

To be honest, I think that it would be a difficult situation to understand to a person who does not have experience in the area. I mean, opiates simply by themselves are very misunderstood by a lot of people. This is a great educational opportunity for the OP (kudos for initiating discussion about something you were unsure about/something that stuck with you), and probably should have been for the patient's husband (as the patient was making her choice, or before - not during the death process or afterward). I can honestly understand how the OP could make the judgment she did without understanding the whole picture (medication patho, rationales, etc).

I have LTC experience and like many, many, others have personally been the nurse who has given the patient's "last doses" of PRN morphine/roxanol. The very first time, as a brand-new LPN, it was difficult to work through in my head. Morphine sulfate is a double-effect med, as others have said, so while I understood that what I was doing was best for the patient (increasing her comfort/reducing pain/reducing the struggle for air), it was still unsettling to know that I was giving her a medication that reduced her hunger for air and affected her respiratory drive. The cessation of respirations is associated with death, so I guess in a round about way, it could be seen as a medication that could hasten death. It certainly felt that way to my shell-shocked newbie-LPN brain as I tried to fall asleep that night, even though I knew I did the right thing for my patient (and still do). In my attempt to deal, I educated myself over and over about the dying process, the pharmacology behind roxanol, and everything else I could think of that pertained to the situation, which helped me reinforce my understanding of everything and sort of cope with all of it. I also talked to veteran nurses who also helped me understand things from other perspectives.

The one other thing that helped me to take it all into perspective was witnessing what could have been a "bad death" and seeing what comfort and positive effect the administration of the medication truly did achieve for the patient. Another nurse, with a different patient (also a newbie at the time of her first) was reluctant to administer the PRNs. We heard the death rattle/cheyne stokes halfway across the building. That is something I will never forget. We entered the room and the patient was displaying s/s of pain and air hunger (restless, anxious, VS all indicated such), the family was distraught, the nurse was a wreck herself.... it was just awful. Thankfully, a more experienced nurse was able to step in and educate the newer nurse regarding the administration of these PRNs and the patient was able to achieve comfort before he passed.

Coping with patient deaths is something that is very individual. Personally - I'm not a crier. I don't get emotional. That said - Every patient death that I have witnessed has affected me. It is one of the most tender, delicate moments of the human existence, and I feel like if one has a respect for the fragility of life, then they are most definitely affected by it's cessation. Its a nurse's job to support the family and take care of the patient during the transition. This is my own opinion, of course, but we have absolutely no business being emotional, though we MUST empathize in order to be effective support for the family and therapeutic caregivers. Sometimes that is tough!

Specializes in Emergency/Cath Lab.
Absolutely not how you address me or anyone on the web or face to face . So check your comments when you address me. Thx

Im sorry if I offended you but I dont take kindly to people saying nurses are happy they are killing their pts and that we give meds to kill them. I would address anyone in that matter face to face as well.

Im sorry if I offended you but I dont take kindly to people saying nurses are happy they are killing their pts and that we give meds to kill them. I would address anyone in that matter face to face as well.

You cherry picked my post and added your own context . Good Job.

To be honest, I think that it would be a difficult situation to understand to a person who does not have experience in the area. I mean, opiates simply by themselves are very misunderstood by a lot of people. This is a great educational opportunity for the OP (kudos for initiating discussion about something you were unsure about/something that stuck with you), and probably should have been for the patient's husband (as the patient was making her choice, or before - not during the death process or afterward). I can honestly understand how the OP could make the judgment she did without understanding the whole picture (medication patho, rationales, etc).

I have LTC experience and like many, many, others have personally been the nurse who has given the patient's "last doses" of PRN morphine/roxanol. The very first time, as a brand-new LPN, it was difficult to work through in my head. Morphine sulfate is a double-effect med, as others have said, so while I understood that what I was doing was best for the patient (increasing her comfort/reducing pain/reducing the struggle for air), it was still unsettling to know that I was giving her a medication that reduced her hunger for air and affected her respiratory drive. The cessation of respirations is associated with death, so I guess in a round about way, it could be seen as a medication that could hasten death. It certainly felt that way to my shell-shocked newbie-LPN brain as I tried to fall asleep that night, even though I knew I did the right thing for my patient (and still do). In my attempt to deal, I educated myself over and over about the dying process, the pharmacology behind roxanol, and everything else I could think of that pertained to the situation, which helped me reinforce my understanding of everything and sort of cope with all of it. I also talked to veteran nurses who also helped me understand things from other perspectives.

The one other thing that helped me to take it all into perspective was witnessing what could have been a "bad death" and seeing what comfort and positive effect the administration of the medication truly did achieve for the patient. Another nurse, with a different patient (also a newbie at the time of her first) was reluctant to administer the PRNs. We heard the death rattle/cheyne stokes halfway across the building. That is something I will never forget. We entered the room and the patient was displaying s/s of pain and air hunger (restless, anxious, VS all indicated such), the family was distraught, the nurse was a wreck herself.... it was just awful. Thankfully, a more experienced nurse was able to step in and educate the newer nurse regarding the administration of these PRNs and the patient was able to achieve comfort before he passed.

Coping with patient deaths is something that is very individual. Personally - I'm not a crier. I don't get emotional. That said - Every patient death that I have witnessed has affected me. It is one of the most tender, delicate moments of the human existence, and I feel like if one has a respect for the fragility of life, then they are most definitely affected by it's cessation. Its a nurse's job to support the family and take care of the patient during the transition. This is my own opinion, of course, but we have absolutely no business being emotional, though we MUST empathize in order to be effective support for the family and therapeutic caregivers. Sometimes that is tough!

Thx for sharing your experience :)

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.

Thx for understanding :) . Im looking forward to learning more about end of life care ....

Specializes in Vents, Telemetry, Home Care, Home infusion.

Excellent resources:

The Double Effect: Terminal Sedation - PBS

Terminal Sedation, Euthanasia, and Causal Roles - Medscape Free registration required

Specializes in Hospice.

I've been a nurse for a long time, and I think sometimes people think of nursing as trying to save someone. I can remember all the times we successfully coded somebody and there were high 5's all around, it is a good feeling. BUT, the most memorable experience for me was the night I sat with a little old lady that was dying. I quickly made my rounds on my other patients, passed their medications and then asked a couple of co-workers to please keep an eye on them for me.

I sat by this little old lady stroking her hand, smoothing down her hair, and whispering to her that I was there with her and it was okay to go, I would be beside her in her journey. She was all alone in the world, she didn't have any children and her husband and sisters had already passed away, but she was not alone in the end. I was there with her.

There is something great about saving a life, but there is something more special about the end of life that words can not express.

Specializes in Pediatrics, Emergency, Trauma.

There is something great about saving a life, but there is something more special about the end of life that words can not express.

^This.

The times where I've made pts comfortable during the end of life, to me is very fulfilling of the cycle of life; for the ones that code and can walk out of it with full mentation and mobility intact is wonderful as well, however, to see a conclusion to life peacefully is much better that tubes coming out of their body, writhing and moaning in pain...that is FAR more scary.

One of the things I've learned about this business is nursing doesn't "heal"; we are "healing managers"; almost like life coaching in some parts: and that is empowering; if one wants do die, I will manage their decision; I will support their decision.

Specializes in Critical Care & Acute Care.

Hey just wanted to add my input. I've had a few patients I have placed on comfort care, and it is difficult for me. However, I cannot imagine going through all some patients endure through and often times they are in pain and even if the acute illness is reversed they still have a chronic disease that will progress. As far as the nurse making "different" remarks and always seeming happy- it may be how he or she deals with death. I have a close friend who has a nervous laugh. She is an amazing nurse but laughs when something makes her nervous. The point I'm trying to make is that suffering is horrible and some want to go with dignity and that's ok because they made a choice or have wishes that must be honored. As a nurse I'm confident that doing my part means ensuring them pain control and educating family and being there for them. I hope you can find a silver lining in your experience.

Specializes in LTC.

After going to a hospice seminar something that was said has stayed with me a long time.

"Pain meds(morphine, dilaudid, fentanyl, ect) are given to make the body comfortable so the soul can leave"

When faced with comfort care or end of life care the dynamics of care change . The nurse is still caring for the physical needs of the patient but also caring for the emotions of the family. End of life care is a challenge~it takes a special nurse to allow that patient to die with dignity and comfortable.

As nurses we have to separate our emotions.....if I involve myself with their emotions I would be a wreck! There will be time for me to grieve the loss of this person, but it gets set aside until I can do so privately. That way I am 100% available to the needs of this patient and family.

Specializes in Pediatrics, Emergency, Trauma.
After going to a hospice seminar something that was said has stayed with me a long time. "Pain meds(morphine, dilaudid, fentanyl, ect) are given to make the body comfortable so the soul can leave" When faced with comfort care or end of life care the dynamics of care change . The nurse is still caring for the physical needs of the patient but also caring for the emotions of the family.

***End of life care is a challenge~it takes a special nurse to allow that patient to die with dignity and comfortable. As nurses we have to separate our emotions.....if I involve myself with their emotions I would be a wreck!**** There will be time for me to grieve the loss of this person, but it gets set aside until I can do so privately.**** That way I am 100% available to the needs of this patient and family.

Your points need to be emphasized. :yes:

When putting your emotions HEAVILY during the most stressful aspects of nursing, it only leads to disillusion and burnout...being objective while caring for people during their most vulnerable times FOR the patient makes the situation be patient-centered, not nurse-centered.

Specializes in critical care.

You mentioned you are a student... End-of-life care should be covered in your nursing program. Hopefully it is done well. You have gotten a lot of good information and resources in this post, too. This is allnurses at its best!

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