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.
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.
This, right here, is why he died when he did. Ancedotal, but I completely believe in this: Before I was a nurse, this is how my mother died and my grandmother before her. They each weren't doing well, and it was going to be "any time now," except nothing was really changing...and then family left the room to go get a meal and when we returned they had died. I wasn't present for my grandmother's death (but my mother was) but I was present for this with my mom. We'd said our goodbyes before we left for food (we didn't know if she could hear us but you never know what might happen) and when we returned...maybe 90-120 minutes later, since we'd had to go outside of the hospital...she literally took her last couple of breaths. No matter how unresponsive they might seem, I fully believe that the dying can hear what's going around them. Your pt knew his friends had gone so he could slip away.
As a new grad with a comfort measures only patient, I had a patient who declined a little more before plateauing shortly after I'd medicated them. We didn't often have continuous drips, but we had order sets. Generally, the order sets included for IV ativan, IV morphine and IV robinul and the time frequency ranged from q5 minutes to q15 minutes. They often had some type of pain patch (fentanyl, etc). If the family (or patient) preferred we discontinue IV access we would medicate patients via alternate routes with orders that would provide similar effects. The indications were s/s anxiety or pain, excessive fluids, or patient/family complaint. I had one patient who had been anxious and in pain (very easy to see so), and over the space of 30 minutes I did medicate them, both for pain and anxiety. I documented why I gave what I gave and what I'd seen, what caused me to decide to medicate the patient. When the patient's respirations got even slower and more shallow, I asked a coworker to come in and see the patient with me. While we stood in the hall outside the door, we talked about the situation a great deal, the thing she pointed out to me was - what I had seen and described 30 minutes prior vs. the then-current situation. The patient was breathing less often and more shallowly, but they didn't appear anxious or in pain. She reminded me that this patient was going to die, and likely going to die soon, nothing I did was going to change that (without going against the patient/family's wishes). She also reminded me we become so cautious about medicating patients because of the potential for respiratory depression, rightly so when you have an otherwise (relatively/comparatively) healthy, not actively dying patient. She told me we'd never know whether it was medicating the patient that caused the change, or just where they were in the dying process. It stuck with me, she was right. It was uncomfortable for me, but I was doing what the patient needed for their "goals" (not so much that the goal was death, but that the patient be kept comfortable until they died). I think part of it is, outside of healthcare we don't really talk about death and dying, we are not comfortable with the concept, or process. We're also so worried about litigation of any kind, we're really trained to look at what is safest first. Most times that doesn't fail us (or our patients), but this is one where that approach and thought process can cloud our judgement of what is best for a patient.
A lot of patients do that, where they pass when no family or friends are present. I think they do know, and I think they probably know the people who visit them better than any of us would. We tried to have a staff member with patients so they didn't die completely alone, but sometimes that didn't work out.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
This, right here, is why he died when he did. Ancedotal, but I completely believe in this: Before I was a nurse, this is how my mother died and my grandmother before her. They each weren't doing well, and it was going to be "any time now," except nothing was really changing...and then family left the room to go get a meal and when we returned they had died. I wasn't present for my grandmother's death (but my mother was) but I was present for this with my mom. We'd said our goodbyes before we left for food (we didn't know if she could hear us but you never know what might happen) and when we returned...maybe 90-120 minutes later, since we'd had to go outside of the hospital...she literally took her last couple of breaths. No matter how unresponsive they might seem, I fully believe that the dying can hear what's going around them. Your pt knew his friends had gone so he could slip away.
I totally believe this. Have heard of it many times.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Okay....now, take a deep breath in.....now blow it out. Now relax.
((HUGS))
You are driving yourself crazy! It is not the TV "glamorous" kind of job. Nursing is hard. It's emotional. It's frustrating. It's over whelming! I do not know of your facilities policies. Some places do not allow nurses to mix up their own morphine drips....too much room for error (not in your case) and under.over dosing the patient. Be sure you check your calculations and follow your policy to the letter. This way you are less likely to make errors.
We ALL will die. Just as we were all born...we must die. It is a natural part of life. I don't think we as nurses get "hard core". I think we develop a tolerance to pain and realize that there are worse things than death. Whether you are religious or not....we all know that we too must someday die. It is natural process like breathing. Patients will die in their own time and in their own way.
Find something to help you see that dying is ok. Whether it is religion, personal beliefs...find how to make you realize that making patients comfortable is not hastening their life.
We as nurses are privileged to be there when life begins and ends. Allow yourself to grieve for your patient but remember there is another patient that needs you. It does get "easier" if that means anything. You become accepting that you did your job. You care for the patient the best that you can and to feel good about that.
I'm not in palliative care/hospice but I think this is a cut and dry that it was his time-and nothing that you did hastened it.
I was there when my mom died and she received morphine that helped her not harmed her and when she died it was her time to die.
I'm still anxious about a patient's death I had in acute care several months ago. There were lots of moving parts to it as he was initially to go to an ICU after a second surgery in two weeks then it changed to my non-telemetry unit on a night shift with 1:6 ratio with no nursing assistant on that night. He had Stage IV cancer so he wasn't in good shape but I still question if I could've done something more.
Specializes in Mental Health, Gerontology, Palliative.
I once had a patient who passed after I gave them four drops of clonazepam and they passed 10 minutes later.
You mentioned they were on a pump? When you rehung the next bag, unless you actually fiddled with and changed the numbers and noticed that the entire bag had gone through, you didnt do anything wrong....
Sometimes it happens. I admit my experience made me a touch nervous the next time I had a patient in end of life, however when someones terminal and actively dying, its far nicer for them and their family if its not a long prolonged struggle.
You did all the right things from the sound of it.
Specializes in Home Health, Mental/Behavioral Health.
Excuse me for asking, but what in the world is PPS 10%?
It is a rating system used in hospice/palliative care. It stands for Palliative Performance Scale, 10% indicates the patient is near the end of their life, total care needed, no intake, little to no output, usually VERY drowsy or in a comatose type of state.
I absolutely believe that some people don't want their family to watch them die and will wait until they leave to let go. I tell family members this if they're holding 24/7 vigil at the bedside for days.
Specializes in psych, addictions, hospice, education.
On a related note...I worked in a hospice owned by the Catholic church. There's a Doctrine of Primary Intent that fits here. Sometimes we don't want to risk hastening death in an already dying patient. The doctrine says that our primary intent (providing comfort/relieving pain) is what matters most.
The morphine didn't speed up the death. He was going to die anyway and the morphine made it a comfortable process. He was sick. He wasn't healthy and you gave a deadly dose of morphine. Don't worry.
It is not your fault that the patient died and you did not "cause" it.
As you know, logically speaking, a PPS 10% indicates the patient was already doing poorly and in the active dying process from what you are describing. Irregular breathing is actually a sign of imminence and had nothing to do with the morphine.
Next time do not lower the morphine drip because the breathing is "low" - when we look at the morphine drip as a means to treat the symptoms related to end-of-life including pain and shortness of breath - we accept that this will also slow down respirations to a certain degree. It is not the morphine that "killed" the patient (or you by extention) - it was the illness that killed the patient - but he/she was lucky to be cared for by you as the morphine helped with symptoms that would have been very uncomfortable for the patient.
It sounds like your anxiety got the better of you and got you into overdrive - it sounds somewhat obsessive, which also means that most likely most re-assurance will not completely take away your "worries". I am sorry that you struggle because of your anxiety - I believe you did not do anything wrong.
marienm, RN, CCRN
313 Posts
This, right here, is why he died when he did. Ancedotal, but I completely believe in this: Before I was a nurse, this is how my mother died and my grandmother before her. They each weren't doing well, and it was going to be "any time now," except nothing was really changing...and then family left the room to go get a meal and when we returned they had died. I wasn't present for my grandmother's death (but my mother was) but I was present for this with my mom. We'd said our goodbyes before we left for food (we didn't know if she could hear us but you never know what might happen) and when we returned...maybe 90-120 minutes later, since we'd had to go outside of the hospital...she literally took her last couple of breaths. No matter how unresponsive they might seem, I fully believe that the dying can hear what's going around them. Your pt knew his friends had gone so he could slip away.