A few minutes meant difference between life-or-death...or something

  1. Well... i dont usually share patient stories but...you guys can relate...

    Anyway, took care of a patient who had CABG about 3 weeks ago, did well, went to step-down for a few days...then came back to the unit for respiratory failure. The respiratory failure was mostly due to his copious secretions and inability to clear them/ resultant pneumonia. Was tubed, vented for a few days, then extubated about a week ago. However, same story...couldnt clear his (copious) secretions, aspirating, etc. Had adamantly expressed his desire to his family that he didnt want 'tubes and life-support' to continue living.

    So...i get the patient on a non-rebreather, saturation 89%, breathing 40 times a minute...barely arousable. This was all due to his respiratory status...and potentially 'fixable' if the patient had agreed to trach for secretion management, suction, etc.
    He was made a DNR the day before, family wanted him kept 'comfortable'.
    Pulmonologist comes through in the AM and we discuss this 'sad' case...and i ask if i can give morphine for 'comfort'. 10 minutes later, i'm walking into the patients room with a syringe full of sympathy...ready to ease his struggling. cardiologist was at the bedside trying to hold a conversation with the patient and get him to agree to trach. Pt is barely arousable, doctor is a foreigner with a BAD accent. Patient nods his head yes to the doc (probably didnt realize he was doing it)...and we get the ball rolling, he's trached 6 hrs later.

    Patient did well. Up in chair and interacting with family. Left yesterday for LTAC/rehab/eventual removal of trach.

    Had i walked into that room a few minutes earlier on that particular day...
    Or had the cardiologist come a few minutes later on that particular day...
    He'd have gotten morphine, undoubtedly gone to sleep and been unable to nod his head for the cardiologist...

    Sometimes it's strange how the universe unfolds...
  2. Visit Dinith88 profile page

    About Dinith88

    Joined: Jul '03; Posts: 748; Likes: 307
    Specialty: 15 year(s) of experience in CCU/CVU/ICU


  3. by   one2one
    Wow what a powerful message.
  4. by   vamedic4
    Wow...now that's one of the best posts I've read to date.
  5. by   christymwinn
    Scary, but at least a wonderful outcome!!
  6. by   Surgical Hrt RN
    god was working overtime that day! you know it is funny how things unfold during a shift......and, how personally involved we can become. it is extremely difficult in situations such as these to leave your personal feelings aside.

    while this man at one point did not want a trach, and family wanted him to be kept comfortable, a misunderstood shake of the head made all the difference for this man.

    so many times i have seen things like this happen. how many times have you heard nurses or other doctors utter in amazement "i can't believe dr. so and so is traching this patient." "i can't believe that they are taking him to surgery, this is clearly not what he wanted. "

    cases like this remind us all that god is in control......we are just pawns in the game of life.
  7. by   TennRN2004
    I gotta say dinith, I'm glad this situation turned out well for the patient. I would have been of the same mind as you to give him morphine and let him go peacefully. Unfortunately though, we often see the opposite happen. The patient is suffering, the family won't agree when enough is enough, what we do to some of these poor patients is just terrible. I'm all for doing everything possible if there is any hope of a reasonable recovery/quality of life. But, for so many of these pts I feel we are just prolonging the inevitable, we keep them hanging on, and for what reason?

    It does make you feel good though when you have a good outcome like this, for the patient and his family. I do also agree that a lot of it is out of our control. For whatever reason, it sounds like it just wasn't his time to go.
    These type of pts are what I like about critical care that you go from seeing them so sick and working hard to get them better, then few days later he's up in the chair talking with the family. You just never know, but I know the family feels blessed that he is doing better now.
  8. by   gonzo1
    Thank you for sharing this story. God certainly works in mysterious ways and we must always be open to what we can learn from each instance.
  9. by   steelydanfan
    So, the pt. nods, and you agree that he probably did not know why he was nodding, but gets a consent for a trach ANYWAY.
    Isn't this fraudentlent consent?
    No matter the outcome (He could have died), the consent was not legal.
  10. by   Dinith88
    Quote from cateccrn
    So, the pt. nods, and you agree that he probably did not know why he was nodding, but gets a consent for a trach ANYWAY.
    Isn't this fraudentlent consent?
    No matter the outcome (He could have died), the consent was not legal.
    No...maybe you misunderstand. Cardiologist was holding conversation with the guy, not me. Dr was certain he had agreed. Family (obviously) was involved...and spoke w/dr and patient together shortly thereafter (they were skeptical and confused initially)...final decision to go ahead with trach was made by family an hour or so later. The 'nod' was merely what got the process started.

    I hope you can settle down now.

    So...before you accuse me of being a criminal who gets illegal consents from people against their will, you should get all your stuff straight. And you sound a little hostile on your soap-box. Hold your horses and please dont call the cops (nurse police?) on me.

    Shheeesh. So much for sharing a moment...
  11. by   vamedic4
    Not to worry Dinith, I'm sure she misinterpreted your post. If not, then she's got issues of her own. Your story is uplifting and makes what we do that much more important and worthwhile.

    Have a good day.
    Still watchin Lilo and Stitch with Austin
  12. by   steelydanfan
    Sorry if I misinterpreted your post. I went by your statement that "the pt. barely nodded his head (probably didn't realize he was doing it)." This to a Dr.... "with a BAD accent".
    I interpreted your information as a case where a pt. firmly expressed his wish for no life support measures to be done; then a doctor comes in and gets what can only be termed "shaky" consent, from a barely arousable man with a sat of 89%. The family had been prepared for comfort measures,willing to to abide by his wishes, and then are confronted with a whole new set of expectations and decisions.
    You never mentioned that the doctor was "certain that he agreed".
    My reply was not about your actions, but the actions of the doctor.
    Nothing in my post inferred that you were negligent in any way, since you apparently did not witness the event. I was responding to the seeming thwarting of a pt.s expressed wishes by a doctor who got "consent" when the pt. was less than sentient.
    I'm glad this scenario had a happy ending.
    My apologies.
  13. by   Mymimi
    Great story!! A reminder of WHO is REALLY in control. Things happen for a reason, and there were many guardian angels on duty! Thanks for sharing, I will be able to use this example with my students, I also teach undergrads as well as work CCU.
  14. by   cathlab1
    Everyone should settle down. While clearly a profound moment, and clearly a profound result. Everyone did respect the patient's wishes, but... I am only playing devil's advocate here, but... I am wondering how much the patient and his family really understood about being a DNR. While he was obviously very ill, sometimes the patient and family really do not understand all the options. ... Thank God for that cardiologist, he had the guts to offer another treatment modality for the patient and saved his life(with the nurse of course)