The Patient I Failed

[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.

Quote

"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.

Quote

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

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.

Quote

"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.

Quote

"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.

Quote

"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."

Quote

"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-existent, 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.

Quote

"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.

The-Patient-I-Failed.pdf

[Lizcollins68]

this is exactly why I quit the medical ICU after 6 months. I didn't feel that prolonging death and suffering was my calling.

[LUV ALZ]

It always make me so angry that one person would go against the final wishes of another because they are to weak to let go. How can they feel like they did everything possible when they have violated the person on every possible level? Thank you for putting into words what so many of us nurses have to deal with on a daily basis. There was no failure on your part only selfish cruelty on the other person part. I only hope her end of life experience goes against every thing she wants and that she is cognitively aware enough to know it, but physically and verbally incapable to do anything about it.

[CindyS1960LPN]

You didn't fail this patient, the daughter failed her Mom...You did your job...Huggggsss to you...

[gvernz]

Sometimes it is guilt and selfishness that motivates family members to act the way they do. Guilt, because they think that by trying to sustain a dying mother's life makes them feel better about themselves, absolves them from " not doing anything for their mother." I'd say we see it happen a lot. Selfishness because the intent is to show everybody that she is doing everything for her mother or in another tangent, it could be that the daughter is not willing to let go so she could still have her mother by her side. It is just sad, sad situation.

[gvernz]

There was a time when I was working in ICU way back when ...that we had family members who can't afford to pay for mechanical ventilators and they were willing to take turns ambubagging while the nurses are taking turns doing CPR until a loved one arrives or until patient's heart rate showed asystole and the doctor would pronounce the patient dead. I am not kidding!!!! That is probably why I had back issues now, 14-15 years later.

Cultural diversity also plays a significant part in these situations. In some cultures, DNR and ending life sustaining measures are frowned upon. Dying with dignity vs. dying a painful death. In some cultures, a family member who decides to end artificial life sustaining measures is considered disrespectful and will be judged by elders and other people.

[Kimmie Sue RN]

I am crying as I read this article. I see this day in and out on my unit. What a tradegy that a living will is useless if one child protests and does not agree. You did not fail this patient, the daughter and the Doctor failed this patient. The doctor should have took the bull by the horns and honored this patients wishes from the get go , this should have never happened. God Bless you for taking such good care of this patient. I hope that other Nurses reading your story will be a stronger advocate in the future when it comes to end of life issues. You did the best you could, you are an angel here on earth :)

[Lorrain]

This happens so often and not only are the children (relatives) but the facility and the doctors and some nurses to blame. 18ths ago I started my postgrad in an aged care facility and as we were taught about Advance Health Directives (living wills) I enquired how many of the residence know about these. I did a survey and 80% didn't know about these documents, when I wanted to pursue this subject by educating the residents I was immediately discouraged. This is a brillant message nerdtonurse? wrote and I have to agree you did all you could do. I think as nurses we have alot to do to educate the community and health professionals. We are the patients advocate especially when they can't talk for themselves. Lorraine

[byaya3]

I deal with this everyday working in an ICU, I think it is the hardest part about being a nurse in the ICU setting. You don't say whether ethics was called. People need education on what Health Care Proxy, Living Will and DNR really mean and it should start in High School. So sorry for this nurse, know what you went through and it is hard not to feel like we fail them.

[Lori Byrnes]

As a former ER/ICU nurse, I can't count the number of times that this very thing happened to me. It's horrible when you know the patient wants to go in peace, but the family wants everything done, even though the patient is in excrutiating pain from cancer, dying of Alzheimer's disease, or any other disease, including old age. In my opinion, keeping the one that they are supposed to "love" against their wishes is the most selfish thing any family member can do. While working as an ICU nurse one day, I had a patient who coded over the weekend. Her regular doctor wasn't on call, and the doctor on call refused to call the code, even after 45 minutes of non-stop CPR and so many shocks to the heart that we lost count. Finally, I took it upon myself to go to the waiting room and explain to the family that the only thing keeping their mother alive was the fact that we were manually pumping her chest and that it was the only thing keeping her "alive" (even though she wasn't). I gave them the option of coming into the ICU without even consulting the doctors, who were standing around refusing to make any kind of call. They all filed into the ICU, and after seeing what was going on, gave their permission for everything to be stopped. I thought that the doctors would be furious with me, but the cardiologist actually went to the nurse manager the next day and complimented me for taking it upon myself to get the family to stop what never should have been started. Although we know what is best for the patient, we are not allowed, as nurses, to refuse the families wishes, even if they are not the wishes of the unresponsive patient. I'm sure that a lot of you have seen "slow codes" in your careers, but the person who wrote this article didn't fail this patient; she only did what she took an oath to do. Until the rules are changed so that the families don't have the final say-so, this will probably always continue.

[nowwhat1]

As we as Nurses have seen many things it often changes our thoughts on Living and Dieing....Yes we know what we want for ourselves but put in the place of the deciding one is tough.We are Medical,caring and have families as well,I went against my sister as well to protect my father.All I got was years of not talking to my sister.There will never be an easy way to end the pain and suffering we see everyday,but if I give a patient/family five quality minutes a day I have done my job so to speak.Thanks for bringing us back to WHY WE BECAME NURSES.

[tinkerbellpn]

So sad :*(

[Tankweti]

I had a similar, although not so horrific, situation with a patient who had a living will while I was in clinicals. He also did not have a DNR and apparently thought the living will would be enough, which it was not. He had constant and severe UTI's which invariably lead to sepsis, inability to eat, altered mental status, just general suffering. He also did not want to be maintained with antibiotics, artificial fluids and feeds. But he was getting all of that against his wishes. I asked my clinical instructor why this was happening to him and she said the courts honor the family's wishes more than the Living Will and that judges do not consider the Living Will as strongly as they do the wishes of the family. Coincidentally, 2 weeks after he was my patient on a Med Surg floor, I was on a rotation to the E.R. and who should be brought in thru the door on a gurney via ambulance but my same friend. He was a nursing home resident as it turned out and his family came in with him, hard on the ambulance drivers heels, to make sure he got every single bit of care that was possible. Care that he did not want. But no nurse can consider themselves a failure in such a case. It is the court systems that are at failure for this, by not signalling that they will enforce the patient's wishes and the family who are to blame for wanting to cling to him when life wants to let him go.