Grow Brave Part III: A Case Study
Now that moral distress has been defined and the effects of continued exposure have been explored, let's look at a fictional case study. The goal is to identify the stressors of the situation and the emotions experienced by the nurse involved.The scene: a tertiary care combined adult/pediatric hospital in a large city on the first Sunday night of spring break. The PICU is full although there is one patient who could have gone to the ward but didn't due to staffing problems there. The staffing in PICU isn't any better, in fact, it's tight; the only unassigned nurse is the charge, who is covering breaks and keeping the unit afloat. The hospital is a referral center for a large geographical area and has patients from several smaller cities.
Around 1 am a call comes in from an outlying EMS dispatcher: a late-teenaged boy has suffered an accidental penetrating wound to the head following a 10 foot fall from a porch roof onto a wrought-iron fence and is enroute. "ETA 40 minutes. GCS is 3, patient had a pulse and agonal resps at the scene and has been intubated. HR 136, BP 74/40 on dopamine at 15 mcg/kg/min and 2 L Ringers given. Another fluid bolus is in progress. See you in a few."
The charge nurse calls the house supervisor to notify administration of this direct admission and to remind them that the unit is already tight. The supervisor calls back several minutes later to advise that the neuro ICU has agreed to accept the patient. But this solution does not meet with the attending's approval. In his view, PICU is the only suitable place for this patient to be, although it's improbable that the patient will survive. "If this patient dies, and I'm not saying that he will, he needs to be in PICU because we can provide much better support for the parents. He's coming here." Reluctantly the charge nurse moves a second patient into a single room and doubles up an assignment to comply.
Within minutes of this decision, the code pagers go off. The code RN has a patient and must leave the bedside to attend to the arresting patient. The charge nurse gets on the phone again with the supervisor and a bed is arranged for the one transferrable patient. The unit scrambles to accommodate the arresting patient. The resident attending the code calls the unit to make the charge nurse aware that the patient will need ECPR, please have the circuit at the bedside. The charge nurse is the only person available to run the equipment so now the unit is rudderless. As the surgeon is establishing ECLS, the teenager arrives.
Of course, all available hands are occupied with the ECPR effort, so the admitting nurse has no help. On arrival the boy is hypotensive and bradycardic. The dopamine is running at 20 mcgs now and there's minimal response to it. On examination the patient has a GCS of 3, pupils are 6 and fixed with no cough, gag or corneal reflexes, the wound to his head is bleeding profusely and there is gray matter on the sheet. The point of entry is just above the boy's right eyebrow and the exit is on the left, midocciput. Core temperature is 35.6 C. The admitting nurse has many years of PICU experience and knows that the attending would switch the dopamine for epinephrine, so she starts the infusion she had mixed and waiting. Briefly the patient's BP increases to 92 systolic but it doesn't last. She draws a venous blood gas from his antecubital vein and it reveals a significant acidosis. With her PALS algorithm in front of her, she gives the boy some sodium bicarbonate. She briefly leaves the room to touch base with the attending who tells her to continue until the parents arrive. "Do whatever you need to do. I'll sign off on whatever later." So she returns to her room, to her patient that she feels is probably already gone. For several minutes the boy seems to have leveled off. Just as his BP plummets, the code pagers go off again... and she's left completely alone with a dying boy. She titrates infusions, gives epinephrine boluses and fluid as needed to keep his heart beating while waiting for his parents to arrive.
She has no idea what is happening outside her own little world. She is unaware that the second patient who coded has died in the ER, where the resus had been moved due to the lack of space and personnel in PICU. She's unaware that the supervisor has come in from home and is now manning the phones and running for supplies. She's unaware that it's almost morning. All she knows - all she cares about- is that her patient still has a pulse. Finally the boy's parents arrive. They've driven through the night terrified of what they'd find, and their worst fears are realized. Dazed and bewildered, they stand at the bedside softly weeping. The nurse tries to explain what she's doing and why, what has already been done and what else there might be to do. The parents scarcely hear her. They hold his hand and whisper to each other. About 30 minutes after they arrive, the boy's heart stops. The nurse shouts for help and moves toward the bed, but his mother waves her off. "No, let him go. He's suffered enough." She leans over and rests her head against the boy's chest; her husband rubs her back and silently sobs. The nurse reaches over and turns off the alarming monitor and ventilator then offers her sympathy to the couple who gaze at her in stunned silence. They linger only a few minutes then leave. The nurse begins her charting...
Put yourself in this nurse's shoes and think about the following:
- What aspect(s) of this scenario bother you most?
- What emotions are you experiencing?
- What will you do after you leave the bedside?
- How will you feel the next day? The next week? In six months?
- When will you feel that you're over it?
- What will you do in the future?
I'm interested in your feedback. Please share.
About NotReady4PrimeTime, RN Senior Moderator
Over the past 16 years I have witnessed both the best and the worst of life in the PICU. As the realm of what's possible continues to expand, the line between best and worst blurs. For now, I keep looking for only the best.
NotReady4PrimeTime has 'more than a few' year(s) of experience and specializes in 'NICU, PICU and peds oncology'. From 'waiting on the wonderful'; Joined Jun '01; Posts: 9,796; Likes: 7,998.Jun 22, '11Reading this post breaks my heart. Again, thank you for all you do. I see enough on the general PEDS floor (where I take my clinical students during the fall and spring semesters). I could not imagine dealing with what you describe in the PICU day in and day out. In answer to your question, I would never get over that hypothetical case.Jun 22, '11I've witnessed and also been in scenarios like this. But at the end of day, as a nurse, you will be guiltless because you never gave up on your patients. There are just some things not under our control especially to this kind of setting. Traumatic as it can be,but that's how we live our lives as nurses.Jun 26, '11This was very difficult to read, I can't imagine living it; yet many days are made up of moments like this in ICUs. I felt the aloneness of the nurse which made me sad and angry. But, I was proud because you could tell she cared. Sometimes our greatest role is being a source of support to the ones left behind.Jun 28, '11I am not a PICU nurse. I am familiar with a scenario such as the one you described. Not as a RN but as an aunt at the bedside of my nephew who just died from a massive intercranial hemorrhage. I watched as they put ice water in his ear with no response and held my breath when they shut off the vent for the apnea test, to which there was no response. I watched my brother a big strong "manly man" openly sob, and his wife, who at times I have had ill feelings toward and felt guilty for every stupid thing I was ever upset about. I listened to my devoutly religious mother who attends church 6 times a week and could recite the bible from front to back beg God to save my nephew's life. Of course he didn't.
1. What bothers me the most about this scenario? The fact that innocent children have to suffer through things like this. It also bothers me that this RN is left alone to deal with it all.
2. Emotions? Anger and grief and an extreme respect for the nurse in this scenario.
3. Were I that RN, I would probably lock myself in the bathroom and sob.
4. I would probably still feel angry, disillusioned, and saddened that things like this ever happen. I truly believe that bearing witness to things like this permanently changes a person.
5. Is it possible to ever get over something like that?
6. As the RN? I would probably keep showing up for more of the same. Sounds a little sick and masochistic but honestly as medical personnel I kind of liken us to that of fire fighters. You know when everyone else runs out we run in type of thing. Does anyone really want to be at the bedside of a dying child? He%% no. Does someone need to be there? Absolutely.
I can tell you that the nurses and doctors that attended my nephew did more than you could ever imagine to help my family cope with this. I work in trauma and I have seen some pretty crappy things but there is no way in this world I could ever be a PICU nurse. I am not strong enough. Thank you God there are those of you that can do it, you have no idea the comfort you provide. I have no doubt it comes at great cost to your own mental health.Jun 28, '11Sugar, I'm terribly sorry to hear about your nephew. It's hard enough to experience these kinds of things as the "detached" professional and quite another to be a family member. Cold calorics are brutal to observe and the apnea test always has me holding my own breath. I'm quite pleased though that you and your family received the support you all needed so desperately while events were unfolding. The staff did what they are there to do and that's take care of everyone.
Your thoughts and responses to the questions I posed are quite typical. They reflect the attitudes of many PICU nurses. Even those who are well-beyond burnout and into self-destruct will keep showing up. And you're right, you really never do get over this kind of situation. What did surprise me about your response is that you made no comment about the staffing on the unit. This sort of problem not only contributes to the development of circumstances that create moral distress but often is the catalyst for them.
Again, my condolences on the death of your nephew. Thank you for your strength and willingness to share this with us and for your comments.Jun 28, '11Hi Jan,
You know you are abosultely right I glossed right over the staffing issue in this scenario. My first response was primarily to the circumstances of the patient and not really the staff. I have had some time to ponder this because while I know there is difference between the impact on a family member and staff I know staff is affected. I saw 2 of my nephews nurses and one of his doctors openly cry. I have given your scenario much thought today because I am about to move into critical care myself. Not with peds but adults and I know I will face more death than I do on the floor and I question if I will be strong enough for this type of work.
The fact that this nurse was basically left alone to deal with a catastrophic situation is immoral in my opinion. The attending who insisted the young man be admitted to the PICU should have been there at the bedside with that nurse. The Neuro ICU would have been appropriate for this young man in this situation. They also deal with death routinely and I am sure would have known how to offer comfort to grieving family. The charge nurse should have declined this patient. And lets not forget that second pt. who died in ER. While I know ER staff are jack of all trades and can deal with these situations is that really the best option when you have a unit of highly experienced and specialty trained staff who do this on a daily basis? Could that second child have been saved if he/she were in the picu? Probably not likely but who knows? And his family deserved just as much comfort as the other pt.s did. Grieving in a crowded chaotic ER would not be my first choice.
I know it is almost impossible to predict the needs of a unit because of the fluctuations but shouldn't they always be prepared for a full house with a RN or two on call? Could a nurse have been pulled from another ICU? What about agency staff? These are not perfect solutions obviously but it is better than throwing people to the wolves.
In a perfect world no unit should ever be short-staffed but especially not a PICU. Thank god this was an experienced PICU nurse. Imagine how bad it would have been had this been a new grad fresh off orientation? I can see directly how the staffing circumstances would contribute to the moral distress of the staff involved. Where is the time to destress? Where is the support personnel to run questions by? Where is the re-assuring presence of your team? What if the doctor who said he would sign off on anything suddenly decides the nurse did something he did not like and refuses? What if something had gone wrong? A med error? An allergic reaction etc? Hospital, physician, and RN would be in a postion of liability. If this had been me as this nurse I would have been very angry. For my patient, his family, and for myself.
I am currently on a unit with high acuity patients that is chronically short-staffed. I can tell you it has affected my mental health greatly. I have suffered depression as well as guilt. Guilt that my patients who really needed an experienced set of eyes got a baby nurse instead who by the grace of God did not miss something that killed them because there was no one else to ask. Just me, my equally inexperienced coworkers and first year residents who we had to tell what to do half the time. My days off were spent reading up on every condition and complication I could to try to quell my anxiety. While that guilt has eased now that I have experience I still feel like I was betrayed by my hospital and management. Now that I am out, barring some catastrophic circumstance...I will NEVER go back to the lateral violence and dog eat dog kind of atmosphere that these type of staffing circumstances cause. And the big difference between me and this nurse is that I am not dealing with peoples critically ill children!!!!! I think my job is tough but really it is cake compared to hers. It is bad enough that the people who do this work will be haunted forever by the things they see. To add staffing issues on top of that is just too much.Jun 28, '11This scenario is purely fictional, of course. I built it using little bits and pieces of situations that have been described to me and to some extent, elements of situations I've observed over 15 years of PICU practice. Chronic short-staffing afflicts units around the world; the lack of physical space and resources do as well. I wanted this scenario to reflect what could happen if all the possible adverse condtions coalesced into the perfect storm. I hoped it would stimulate thought and discussion, and it has. Insight is valuable and when we're examining something as subjective as moral distress and its affects on humans, the horrible seems all too real. Thank you for taking the time to dissect the issues underlying the situation and for commenting. As you make your move to critical care, I hope you take some of the suggestions I will make in the final part of this article with you. Best wishes.