conscious pt terminal wean
1Dec 27, '13 by taylynnfreeFirst 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.
11Dec 27, '13 by umcRNPersonally if I were the patient in that situation I think I would make the same decision. I have had multiple major surgeries, each which included a (thankfully short) ICU stay. My biggest fear is being unable to make that decision and being kept alive against my will. Therefore I have made sure to create an advance directive each time I went in for surgery. If I was awake and conscious of my situation and was going through that much suffering I think I would rather not experience it anymore. If there's anything 4 years as an ICU nurse and 2 years as a patient have taught me, it's that there are things far worse than death in this world.
Also as a nurse you cannot judge someone for how they act in a situation. It's not your life. It's your job to support the patient and the family however they choose to make end of life decisions. End of life should be peaceful and pain free. If that requires multiple vials of morphine then so be it. Often at my facility when we are withdrawing on a patient we leave it up to the family (I work peds) to decide how much pain medication they get. If the nurse or family at any time feel like the patient is suffering (even if its something natural like agonal breathing, this to a family might make them feel like the patient is in pain) then the patient is medicated. Also the patient in your story, while she made the decision to end care, would not be acutely aware of the dying process or feel any pain if she was being properly medicated, as it should be.
17Dec 27, '13 by detroitdanoIf the patient is deemed competent and wants to give up the fight, they have the right to make that choice.
Terminal weans usually get enough Morphine to be out of it, but usually not enough to cause the death itself. I've seen orders written "titrate to effect" essentially meaning give enough until they aren't breathing anymore, but most nurses aren't that cruel and we usually just give enough to keep them comfortable, maybe a little under the weather, and time will take its toll.
Nurses doing terminal weans appear chipper because it's a sad situation. If you walk in to the patient's room looking all gloomy, the family sees that and they get even more down about things. Appearing happy and friendly, to a certain degree, actually makes the whole process easier for the family.
If you can't stand watching patient's die when they choose to, nursing might not be the career for you, or at least the hospital setting. It's even worse watching people die who did not choose to. Often you'll see patient's needlessly clinging to life because of some insane family member. They have 90 bed sores, no mental function, lungs/heart/kidneys/liver all completely shot, yet the family won't let go; that's tougher to watch than someone sound of mind choosing to go out with dignity.
21Dec 27, '13 by Esme12, BSN, RN Senior Moderator((HUGS))...it is never easy to see these things but as a nurse you will find that there are worse things than death.
There was a time that we were not allowed to removed "alert" patients from life support. We would torture these poor patients until they became so swollen that their skin oozed serosanguinous fluid continuously and their eyes would become so edematous that they would ooze from their sockets and the patients eyes would not close. They were trapped in a living hell. Torture for the family as well as the patients when there was no hope for recovery.
As a nurse when you care for these patients day in and day out it is sometimes a relief to allow nature to take it's course especially if it is the patients wish. It is a relief to finally know that their suffering will finally end and they will finally know peace. In the presence of terminal illness and medical intervention has reached and end point and there is not cure....the best thing to do is let go. To keep torturing these poor patients day in and day out when you KNOW your efforts are futile and will NOT change their outcome it draining.
The vials of morphine were not to end her life but to make her passing comfortable. In no way did the nurses give her morphine to hurt her...but they did make her comfortable and ease her suffering. Nurses will find relief that a patient's pain and suffering is ending especially when we care about them...they will use pet terms and phrases that ease their own discomfort and pain as they reach to their peers for affirmation that everything is ok.
The reality of nursing is that their are worse things than death. To allow a patient to reach their own decision and take control of their destiny is a beautiful thing. For many years we tortured patients and families..... knowing the end and charge the family thousands of dollars for what we all knew would be death.
While nurses seem chipper and normal...it is called professionalism. We still have a job to do and will cry later in our cars on the way home. You cannot fall apart and leave the family without support....it is your job to help the patient and family at this difficult time. YOU are the rock and support...it is your job.
Nursing is a tough job. You have to be strong enough...nursing isn't for the faint of heart.
It will all make sense someday.....((HUGS))
15Dec 27, '13 by Sun0408It was the fact the patient was of sound mind that really disturbed me
This should give you comfort, it was her decision and her family supported her. Her nurse and the MD supported her, there are worse things than death and death is not a scary or bad thing...Last edit by Esme12 on Dec 27, '13 : Reason: formatting
11Dec 27, '13 by MunoRNDeath is inevitable, and if a return to some reasonable quality of life is no longer possible, the only thing we can control the amount of misery involved. Nurses, rightfully so, take some pride in a terminal wean that goes reasonably well, because it can go very badly. And if you've spent 6 weeks subjecting a patient to care that is often anywhere from uncomfortable to torturous, the ability to provide a good outcome (and yes, a comfortable death can be a good outcome) is hardly a reason for remorse.
2Dec 27, '13 by taylynnfreeQuote from Sun0408I didnt add this to my story but the husband really didn't agree he felt like she was being killed.he didnt protest too much just made those few comments. but it was her decision and yes there are worse things than death ...it just shook me a little.
This should give you comfort, it was her decision and her family supported her. Her nurse and the MD supported her, there are worse things than death and death is not a scary or bad thing...
10Dec 27, '13 by MunoRNQuote from taylynnfreeThat's an important insight on the decision making process that usually occurs in the ICU in these situations; family makes decisions for the patients with the assumption that they are making the choice the patient would make, often that's not the case.I didnt add this to my story but the husband really didn't agree he felt like she was being killed.he didnt protest too much just made those few comments. but it was her decision and yes there are worse things than death ...it just shook me a little
12Dec 27, '13 by Esme12, BSN, RN Senior ModeratorQuote from taylynnfreeshe is alert and competent....it isn't his decision.I didnt add this to my story but the husband really didn't agree he felt like she was being killed.he didnt protest too much just made those few comments. but it was her decision and yes there are worse things than death ...it just shook me a little
It is never easy but it I was in her position I would do the same.
5Dec 27, '13 by Nalon1 RN/EMT-PQuote from taylynnfreeIt should shake you. You should never take it lightly, but it is the right thing to do sometimes.I didnt add this to my story but the husband really didn't agree he felt like she was being killed.he didnt protest too much just made those few comments. but it was her decision and yes there are worse things than death ...it just shook me a little
I am not sure if your issue is with the patients decision, the families reaction, the process of her death or the nurses attitude, but everyone reacts to death differently, you need to find your way. The fact that this happened 2 years ago and still sits on your mind like this is a bit concerning.
And I disagree with some of the comments about morphine. While technically it is not used to stop respirations, the end result of "stopping the pain" is respirations stopping.
Did the staff "kill" the patient, no.
Did they hasten the process, yes.
Did the patient die under her own terms and comfortable, yes.
As said, how many patients do we see that are obviously in distress and discomfort but family wants us to do everything to keep them alive. I have more issues with this than letting someone go.
If this episode bothered you, DO NOT even think about going into Hospice care.