The Patient I Failed - page 24

She knew what she wanted. She'd watched her husband of 52 years die on a vent, and followed his wishes to remain a full code. But she knew that was not what she wanted for herself. So, she wrote a Living Will, had it... Read More

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    Our unit is going through something very similar with a patient right now and siblings that just can't seem to get it together. Meanwhile this poor woman is slowly melting into a hospital bed. The plus side is that the attendings have absolutely refused to withhold pain medication at the daughter's request because "she's getting better." But she's being transferred to another hospital like a car going to a new auto-shop because they're still holding out for something.

    Regardless, sometimes I just want to pull the family into the room and make them do nursing care so they realize what kind of life she's going to have until something finally takes her. If you're keeping someone alive for whatever reasons you might have then you don't get to leave when you're upset by a dressing change or procedure. You need to know everything about the life you're now responsible for and if we've explained that we've done everything we can you also need to realize everything is not always about you.

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    No, You did not fail her. The DR. could have written a DNR. The pt already had her wishes written out and the majority of the children agreed. The one child who refused to follow her mother's wishes obviously was guilt ridden about something. But why do we encourage living wills if they're not followed and honored? I've been in your position before and you provided her with compassion,love and dignity with the only means that you could. And I believe She knew. God Bless You!!
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    words cannot express how sad this makes me.....*tears fall*
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    I have been an RN since 1998 and have worked primarily in ICU for most of that time. I have seen this scenario played out more times than I can count and always with the same result. It makes me angry with the family, but also more than a little sad for them. I cant change family dynamics, but i work hard to explain to people the result of these actions and discuss their feelings. Often the family feels guilty, frightened, angry. All stages of grief. Helping them to talk about it often helps them to finally come to resolution and sometimes allows the dying family member to die with dignity.

    I found myself in the shoes of family member a year and a half ago when my mother died suddenly. I had spent the afternoon with her and my dad. They went home, had dinner and were watching TV. She was talking to and suddenly died. When I got the phone call, I thought it was her saying goodnight. It was my dad, hysterical, screaming. The EMS was there doing CPR. It had been 40 min or more. I had to tell them to stop what they were doing. It took all of my strength to make them stop and even more to calm my dad down and make him let them stop. I dont regret that decision.
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    Great read...yet so sad
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    It is so sad that the explanation for these events is probably that the children will be the ones around to sue the hospital, not the poor patient that had their most important wishes destroyed. Great article. Thank you for sharing
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    Quote from nerdtonurse?
    She knew what she wanted.

    She'd watched her husband of 52 years die on a vent, and followed his wishes to remain a full code. But she knew that was not what she wanted for herself.

    So, she wrote a Living Will, had it notarized, gave it to her personal physician, told all her friends and family what she did not want. She wasn't eligible for a DNR, as she was a healthy 89-year-old, but she knew what she wanted.

    "I do not wish my heart to be restarted through usage of any
    chemical, mechanical or physical intervention..."

    Of her 6 children, one fought against her mother's decision, and it was this child, this one desenting voice, who found her mother collapsed on the kitchen floor.

    "I do not want any external device to be used to maintain my
    respiration if my body is incapable of sustaining it on its

    The daughter told EMS her mother was a full code, and they intubated her on the floor of her kitchen. Once at the ER, her heart stopped, CPR was performed, and her heart was shocked back into a beat. Under the hands of those trying to follow the daughter's wishes, the woman's ribs cracked and broke.

    "I wish to die a peaceful, natural death."

    She was then sent to ICU, where her heart tried to stop 3 more times. Each time, the broken ribs jabbed and ripped into the fragile muscle and skin as CPR was performed. Electricity coursed across her body and her frail heart was restarted a 4th time. By this time, the other children were there, but the act had been done, over and over. No DNR was written, and the Living Will fluttered impotently at the front of the chart.

    "I do not wish artificial means of nutrition to be used, such as
    nasogastric tubes or a PEG tube."

    Her swallowing ability was lost in the storm in her brain that had left her with no voice, no sight, no movement. A scan showed she still had brain activity; she was aware of what was being done to her. Including the PEG tube sank down into her stomach, and the trach in her throat.

    "I wish nature to take its course, with only medication to prevent
    pain and suffering."

    The daughter who wanted the mother to remain a full code also refused to allow narcotics to be given, stating she did not want her mother sedated, since she would "wake up" when the correct medical procedures were performed. Her nurses begged the doctor to write a DNR, and he said, "the family can't get it together, and I'm not getting into the middle of it."

    "Allow me the dignity we give to beloved pets. Let me die in peace."

    I met her one Tuesday night, and spent that night pouring Jevity into her tube, only to suction it back out. Her legs were cool and mottled, her bowel sounds were non-existant, and her blue eyes stared blindly at a ceiling she could no longer see. The MD refused to terminate feedings, but I held them since there was no digestion taking place. The woman was turned and repositioned every 2 hours, and each time, she moaned and gurgled as her lungs slowly filled with fluid. I whispered my apologies as I did the very things to her she tried so hard to prevent.

    Suctioning improved her lung function, but would make her body tremble. Over the next 2 nights, she slowly died, all while the daughter demanded more interventions, and maintained that her mother wanted to be a full code. We had read the Living Will. We knew better.

    "Thank you in advance for helping me in the last moments of my life
    to have a gentle, peaceful passing."

    She had another stroke, and went back to the ICU, where she was coded until there was not enough surviving heart tissue to maintain a beat. Finally her heart was broken.

    And so was mine.
    As sad as this is, the reality is it happens all to often.
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    Quote from kbucksn
    Now please excuse my ignorance as I am a pre nursing student, but what I don't understand, which Im hoping you can help me to, is having a Living Will in the chart, why were these interventions continued by the doc? I understand when EMS arrived and the daughter lied, but when they reached the hospital as well as the codes that occured after that time, why were heroic measures performed and the Living Will ignored? Working in hospital envirnoment in the past I have seen occasions where the doc has had to basically apologetically inform a family memeber that they are following the Pt's wishes. Is it because heroic measures had been taken from the beginning so they must continue? i don't quite understand the protocol or legalities behind that. I would have thought that once the Living Will was discovered they would have to follow it regardless of the wishes of the daughter. Did they bring in a social worker or anything to discuss the ramifications, etc with the daughter? How does that all work? Its awful that docs should have to take a "I dont want to get in the middle" stance on such things, when they know full well the Pts wishes are not being respected. But I can understand out of fear of the every looming possibility of a medical malpractice suit, they really have no other choice.

    Living Wills vary by state so the following relates to Alabama - here the living will can be over-ridden by family. Whether there is 1 or 100 family members it only take one to undo a living will. Most people believe that the living will is a solid binding legal document but here it is not. If a person wants to make sure that their wishes are followed they appoint a "health-care proxy". A proxy speaks for the patient and overrides any family members attempt to ignore the living will.

    Now, as to the social worker to talk to the offending family member, by the time this can be arraigned the damage is done. Working in the ER I saw many living wills ignored and several fights breakout between family members that disagreed about whether to follow the will or not. My oldest son holds my proxy because I know that 4 children cannot agree on anything.

    I have seen physicians continue coding patients on arrival despite having the will on the chart just because "it was started in the field" or because they did not have time to review the document. Patients have very little control of themselves while under medical care, physicians sometimes forget that just because you can does not mean that you should. I think that medical school needs to add a new required course - Respecting the Living Will or Stop playing God and follow the patients end-of-life requests.
    Last edit by Dragonnurse1 on Jun 12, '11 : Reason: spelling
    nerdtonurse? likes this.
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    No, you didn't fail her, you cared for her and she knows that. Any of us who work in critical care can definitely understand what you went through and felt. My prayers go out to you and please know you were a blessing to her during her last days.

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