The Dreaded Death Bath and a Moral/Ethical Dilemma?

Specialties MICU

Published

So my coworkers and I were discussing a patient who had died recently during bathing. Well, let me clarify..patient didn't actually die during bathing, but the stress of bathing caused a chain of decompensating events that we colloquially call the "Death Bath." This is a pretty common (and anecdotally well known) event in ICUs. With this specific patient another nurse (mind you jokingly) responded "WHY DID YOU BATHE HER??" to which the nurse taking care of said patient replied "She was dirty!"

This made me realize a very interesting moral/ethical dilemma within nursing. With insurance companies, medicare/medicaid cutting reimbursements for patients who recieve HAI's/pressure wounds, should you or should you not perform preventative wound care on patients who are terribly hemodynamically unstable?

One point you could bring up is that the patient who is so unstable that turning/bathing ultimately leads to their demise is statistically not likely to survive long anyway. But one case we have is a patient who went from horrid septic shock crashing to..."recovering" who is now still in our ICU on day 28, but hemodynamically stable. So, had we been doing q2 hour turns on him during his bad phase while he was on multiple pressors and CRRT, we could've possibly killed him (The Death Turn, the evil cousin of the Death Bath). On the other hand if we don't turn him and he gets a decubitus and survives, we don't get reimbursed.

Now, I hate to make you guys think that this is all about money...buutttt....I work in a Level I trauma center which also happens to be the safety net hospital. Money is a huge issue at our hospital and with the increasing costs and reimbursement cuts in healthcare...it's a semi-valid point argument. We're kind of backed into a corner on this one.

yeah thats bad a dead dad mavbe worse?

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Specializes in Case Mgmt, Anesthesia, ICU, ER, Dialysis.

We've had patients who roll into us on death's door...and have gotten VERY good at the art of the 20-second bed change. Make a bed roll, have it ready to rock, and get ALL the coworkers in there to help make it happen.

Even if I can't roll them, I can wipe their face, put a little cornstarch under their arms (condition permitting) and talk to them, so they know they're not alone.

You do what you can. Some days it's just not enough, and we come up short, but while they're my responsibility, they get the best care I can provide...even if that means NOT performing a measure CMS seems to feel we should.

This is why we are ICU nurses...to use our brain to make the decision as to how to best care for our patients. It's sure not the doctors in there with them 24-7, troubleshooting every physiologic crisis that arises.

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u know what's funny, why does it take 2 nicu nurses to turn a baby on a vent or HFOV when they weigh around a pound! This is so true about turning. Some do not tolerate it well and when they are doing good on the HFOV and I have to pop them off to put at the other end of the bed I don't always do it but pass in report that they need to be turned. And the desating with parent/family touching drives me nuts. Have your DH rub/stroke one spot on your body for a half an hour and see what it does to you. We have developmental touch that we can quote don't know what you guys in adults have to say to tell the people to back off with the handling/touching. (Smile)

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Specializes in CCRN, MICU, CCU.

I know exactly what you mean. A month or so ago, me and another nurse decided to turn a DNR, DNI pt of her's and we turned him to his side and BOOM: complete desat. He was dead in 5 min. Fortunately, the family was in the lounge and close enough to come see him. We dubbed it "The Turn of Death." I think that it takes individual discretion as whether to turn a patient or not. For instance, there was a pool nurse who had a patient whom was on our unit for 50+ days with ca mets in her lungs, brain, breast, bone, etc. Her tidal volumes were around 100 and her lungs sounded stiff as bricks. The nurse was hell bent on turning this woman every 2 hours. I told her I wouldn't help because it would kill her. She wound up getting one pillow under the pt's behind when her a-line pressures dropped and her tidal volumes and sats. It's really a tough call. What I ask myself is, "Is all this worth a pillow under their back?" Alot of times, it's the own nurse's ocd nature to want to turn that patient every 2 hours. Sometimes, it's not feasible.

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Specializes in Case Mgmt, Anesthesia, ICU, ER, Dialysis.

...and there comes a point when they're dying anyway, and in so much pain, that to do anything other than medicate them for the pain and leave them the heck alone is just cruel.

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Specializes in NICU, PICU, PCVICU and peds oncology.

We have an intensivist on our unit who does not allow bathing of a post-op patient in the first 24 hours on the unit, no matter how stable they may be. He's gone so far as to formally order it in some cases. He also does not permit us to put the child in the mom's arms in the first 24 hours post-extubation, unless it's as part of withdrawal of life-sustaining therapies. We all just accept this as a quirk of his, knowing that he has what he feels are good reasons for it. And he has. Death Bath... seen it. Death Turn... seen it. Death CXR... seen it too. And we've seen kids who looked perfectly fine one minute turn around and code in mom's arms. For all that, we have a low incidence of anything worse than a stage 1 PRI.

I don't really think that "repositioning" a patient has to mean turning them side-to-side. If I can turn their head even a smidgen and slip a folded receiving blanket under a shoulder or hip (or pull it out), they've been repositioned and the pressure points have changed. I always pay special attention to their ears, having seen many very red, folded pinnae, and I take great care to ensure there are no bed trinkets under or around the patient. I tidy up other nurses' beds while I'm talking to them, surreptitiously most of the time, but with some people I make it quite obvious that they've left a 3mL syringe under a baby's shoulder. Ouch!

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Great post. I am a new grad. I will be starting in the SICU on monday. I did my capstone in the MICU. My preceptor ALWAYS bathed and turned the patient....even when there were 9 drugs going in, vent, CRRT, multiple organ failure. Was she wrong?

She wasn't necessarily wrong, I hope she just used good judgement. I mean when an oscillator patient starts dropping sats simply when you're screwing with their ted hose to check pulses then she needs to have sense enough to say hey let me stop and no this patient isn't gonna be bathed or turned until they can tolerate some stimulation.

Just because someone is on every drip and has crappy lungs doesn't mean they can't be turned. You get a feel for what people can and what they can't tolerate. And honestly sometimes you turn them, they tank and you know not to do it again until they stabilize.

Interesting thing though, I was in a skin meeting a few months ago and the WOC nurse was leading it for a new skin initiative on our unit. She was admit that ALL patients can and WILL be turned. Right. I say come on up and you can join in on a round of compressions when we follow the initiative on that patient. We turn unless we have an order not too. Our physicians are more than willing to write an order and physicians note stating that the patient is currently too unstable to turn and to list the reasons why.

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Specializes in Critical Care.
She wasn't necessarily wrong, I hope she just used good judgement. I mean when an oscillator patient starts dropping sats simply when you're screwing with their ted hose to check pulses then she needs to have sense enough to say hey let me stop and no this patient isn't gonna be bathed or turned until they can tolerate some stimulation.

Just because someone is on every drip and has crappy lungs doesn't mean they can't be turned. You get a feel for what people can and what they can't tolerate. And honestly sometimes you turn them, they tank and you know not to do it again until they stabilize.

Interesting thing though, I was in a skin meeting a few months ago and the WOC nurse was leading it for a new skin initiative on our unit. She was admit that ALL patients can and WILL be turned. Right. I say come on up and you can join in on a round of compressions when we follow the initiative on that patient. We turn unless we have an order not too. Our physicians are more than willing to write an order and physicians note stating that the patient is currently too unstable to turn and to list the reasons why.

I do so love the non-bedside (or, to be more accurate, the "occasionally at the bedside to evaluate the totally avoidable [sigh] decubiti") nurses who evaluate and walk away. Nice to be in the position to evaluate and be judge and jury regarding nursing care or the lack thereof. I fume at the flack we've gotten from them at times.

As one who has had to choose lungs and heart over butt recently---we chose the first two. As expected, the butt suffered. But the butt's owner will live to fight another day, thanks to excellent nursing care and nursing judgement. Yes, we got the "Do Not Turn" orders that covered our nursey butts.

It's not all textbook crap here, gang. Instinct, experience, and gut...they all play a part in saving the lives of our often extremely unstable patients. If we're lucky our docs trust our judgement and write the CYA orders. If not...:::SHRUG:::we're just gonna go with our gut.

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Specializes in Critical Care.
Great post. I am a new grad. I will be starting in the SICU on monday. I did my capstone in the MICU. My preceptor ALWAYS bathed and turned the patient....even when there were 9 drugs going in, vent, CRRT, multiple organ failure. Was she wrong?

Did the patient crump when he was turned? If not, nope. She was fine.

No doubt your preceptor had instincts which she had developed over the years regarding patient stability and tolerance. Nine gtts and CRRT and MOF is often the norm in ICU. No biggie. You clean up these guys on a routine basis.

Might I add that these patients do not benefit by what I fondly refer to as the "bonding bath." Skip the soothing back rub, the comforting applications of lotions.

Jeez----scrub 'em down, dry them, have a bedroll ready for the very quick turn and linen change. Slap some heavy duty cream on their butts---QUICKLY--- and call it a day.

IME you draw the line when the patient has serious decompensation, in any area, when they're turned. This happens with patients who are at death's door and have absolutely no reserve. They crash quickly and take a long time to get back to their very tenuous baseline, often necessitating extreme vent changes and gtt adjustments. And yep---sometimes they go beyond that and code.

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Specializes in Trauma ICU, Surgical ICU, Medical ICU.

We also get the fancy mattress for any patient that is hemodynamically unstable. We still bathe em, its a PTA bath if they can't tolerate more, and realistically if you've got a patient that sick, you are too busy with other priorities than about getting them bathed. Luckily they usually either get better or worse pretty quickly and they can be bathed later, no reason not to keep heels up though.

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