Anxiety following patient death

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Hi friends- I hope I can call you that:) some wonderful people on this forum have helped me through some hard nursing times.

My anxiety has been getting the best of me lately regarding a shift I finished.

i had a palliative patient (PPS 10 %) on a night shift who was declining quickly. He had been unresponsive since early in the morning. I came on at 7 pm and he had zero output since the morning. He had a morphine infusion subcutaneously at 6 mg/hour. His family left at 1230 and I hung a new bag at at 1250 (50 mg of morphine in a 50 ml bag).

Now, I went in at 0120, half an hour after hanging the new bag, and I am ashamed to admit this, but turned it down to 4 mg/ hour (4 mls/hour). He was only breathing at a rate of 5-6 an hour. It was almost like Cheyne- stoking but it was a 15 second gap, and then a big breath, and then another gap.

I pronounced him at 0140. 40 minutes after the new bag was hung. I can't help but think I did something wrong- I know I put the right medication in the bag, but what if I accidentally infused it at 50 mls (50 mg) per hour instead of 6 mls per hour. I mean 25-30 minutes after I hung new bag, he was struggling for air.

I know there is no way to know but my anxiety is eating me alive. The hard part is, I love palliative and hospice nursing. It is so rewarding. This death is just clinging with me for some reason. I'm hoping some nurses can provide me guidance. I have no reason to believe I messed up other than the fact he died quickly after changing the bag.

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Specializes in Critical Care.

I don't think there's any reason to assume it had something to do with hanging a new bag, the patient's death was expected and progressing normally from what you described. On any palliative patient on a continuous morphine gtt, they will pass within some timeframe of a new bag being hung, there's no reason to correlate the two without an actual reason to do so.

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Thank you, I appreciate this. I do suffer from anxiety and struggle in these situations. I wish I could go back on the pump and look at the history but unfortunately I can't.

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Specializes in psych, addictions, hospice, education.

I don't see that you hastened his death. Your wrote that he was declining quickly and had been unresponsive, had no urine output, and had a very low respiratory rate, along with gaps. Struggling for air is something dying patients do. He was actively dying when you first assessed him. Was the breathing pattern you described before or after you changed the morphine dosage?

How much was left in the bag? That's a big indication of whether you were giving a higher than prescribed dose.

One thing that bothers me, however, is that you decreased his dosage. Was this something the doc said you could do? I wonder if the decrease meant his pain wasn't controlled and the change in breathing was related to pain??

Again, I don't see that you hastened his death.

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His breathing significantly changed after I hung the new bag. It significantly decreased, although this was half an hour after changing it. He was breathing quite fast and then when I went to check on him , he seemed to be gasping.

I wish I could remember how much was left in the bag but I don't. I do not remember it being empty and have to believe that I would have noticed if it was.

i did go back on the pump after he died and checked how much was in bag so I could waste it with another RN. The pump say 46.0 mls- which of course should ease my anxiety but then I started thinking what if I put 100 mls on the pump and 54 went in. I'm just talking myself in circles at this point.

you bring up an interesting point- the order was for morphine 3-6 mg/ hour. I decreased it to four but honestly don't think I needed to because he was so close, I was just scared.

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Specializes in psych, addictions, hospice, education.

It was a 50 ml. bag, so 54 ml. couldn't have gone in. The pump said 46 ml. were left. That seems to be what it should be.

Was the bag empty awhile before you changed to the new one? That would account for the rapid breathing that slowed with the new bag.

I think you're overthinking this. Is this one of the first deaths you've experienced with your patients? It's difficult! It's difficult to not be able to help ease things, without feeling you hastened the ending. I still don't think you hastened things. Truly.

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Specializes in Med/Surge, Psych, LTC, Home Health.

((hockey))... You didn't do anything wrong. The patient was very actively dying. Once a patient is in the state that you have described, it is SO unpredictable as to how much longer it will be before they pass. Sometimes it is only minutes. Sometimes it is days. The only thing to do is keep the patient comfortable.

Some families want to decrease pain medication because their loved one is breathing very slowly, or they are "snowed" ie comatose. This is when you must come up with your own way to gently, lovingly educate the family that this is part of the dying process...

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Thank you so much for your kind words.

i really appreciate it. You will help me sleep tonight. No the bag was not empty a while, I was right on top of it. The only thing I can think of was that his friends were with him and almost immediately after they left his breathing slowed and he died.

And yes, you cought me! I have only had about four deaths now and this was my first continuous infusion. I have had several PCAs but not continual infusions. I made sure to clarify with another RN that 1 mg/ml dosage but just didn't get her to double check the pump, although I really don't thing I could have messed it up that bad. But here I am, second guessing myself.

I truly appreciate your kind words and hope I can find some peace knowing that I didn't make a mistake.

It was a 50 ml. bag, so 54 ml. couldn't have gone in. The pump said 46 ml. were left. That seems to be what it should be.

Was the bag empty awhile before you changed to the new one? That would account for the rapid breathing that slowed with the new bag.

I think you're overthinking this. Is this one of the first deaths you've experienced with your patients? It's difficult! It's difficult to not be able to help ease things, without feeling you hastened the ending. I still don't think you hastened things. Truly.

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Forgive me if I'm corny, it's been an emotional day. I feel so truly blessed to be among such wonderful nurses who not only nurse on their day jobs, but come home and nurse me back to sanity! Haha. This profession is HARD! And I will be the first to admit it. There are so many days I wish I had chosen an easier career path but I admire senior nurses and wish to one day be as strong, resilient, and bad-ass as they are í ½í¸œ.. And can't wait to get there one day!thank you so much.

((hockey))... You didn't do anything wrong. The patient was very actively dying. Once a patient is in the state that you have described, it is SO unpredictable as to how much longer it will be before they pass. Sometimes it is only minutes. Sometimes it is days. The only thing to do is keep the patient comfortable.

Some families want to decrease pain medication because their loved one is breathing very slowly, or they are "snowed" ie comatose. This is when you must come up with your own way to gently, lovingly educate the family that this is part of the dying process...

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Specializes in Acute Care, Rehab, Palliative.

Please don't feel that you did anything to hasten his passing. It sounds quite normal.

Where I work we are required to have a second nurse check and cosign any PCA programming including rate changes.

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Specializes in Hospice.

OP, what you perceived as gasping for breath were most likely agonal resirations, a very terminal phenomenon that often occurs just prior to the final shutdown that is death.

Don't make yourself crazy picking nits on this - you did fine.

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Specializes in ICU, trauma.

You did nothing wrong. They were pallative, unresponsive, and you kept them comfortable while they passed. Secondly, i hope that this experience doesn't veer you away from using morphine for end of life patients. Morphine in no way contributes to a pallative care patient's life and they truly need it to keep them comfortable

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