CNA and death

[HurricaneCasRN]

This is what I shared tonight with a private group, nurses and non-nurses.

Background for you that don't know me, I'm a first year, grad in May working in a nursing home:

Intense night tonight. We were caring for a hospice patient who was also somehow a full code. Patient was new to us. Patient began to actively and imminently die on our shift. The full code thing sent things in to a real doozy. Patient's family member saw what was happening, saw the suffering and agreed to re-instate the DNR that patient had revoked two weeks ago. We don't have an MD in-house, so this took some rigmarole and got very hectic and stressful. We wanted to get this patient DNR before he DID code and we started pounding on his chest (which would have been unsuccessful) in front of his family member. Long story short, we were able to get this done and the patient died in relative peace. He actually died approximately 5 minutes after she signed the paperwork and we got permission from the doctor. It was the first time that I've had my hands on someone and felt them die. But, that is another story. I feel like my nursing BFF and I did a good job, did the right thing and really helped this family. Certainly it was sad and hard and will haunt me for a long time. But, I was prepared for that going in to this.

What REALLY infuriated me was one of the CNAs. I was speaking with the POA and making absolutely certain that this is what she wanted. With no MD in house to sign off, just telephone orders based on our assessments and relaying of information, I wanted it to be locked up tight. Otherwise, "Well hey you neglected this patient and let him die, why didn't you bag and start compressions? He was a full code." Get it? So, this CNA, IN FRONT OF THE FAMILY MEMBER kept questioning me about where the hospice nurse is (they manage the case, we deliver the care. They visit occasionally,...they do not come out to attend deaths. We do that.) In order to shut him the eff up, I excused myself and asked the CNA to come help me with something. When we left the room he started to BERATE ME that I was "cold and clinical." He would not accept my explanations that the hospice nurses don't come to attend deaths when there are three other licensed nurses in the building! "They need to be here! Do they know what's going on?" I finally left it with "Trust me, we've been in touch with hospice!" (I believe they were actually ON HOLD at that very moment. Maybe on the line next to the DON. @@)

The other aid in the room, who was waiting quietly behind the curtain in case her assistance was needed, grabbed me and said "You need to write him up! He shouldn't undermine you like that! He's clueless!" The other nurses agreed that I was fine. But, it stung. Yes, I was straightforward and somewhat clinical. But, I told her the truth. I HAD to tell her the truth or I KNEW that she was going to end up standing there watching us do CPR, cracking this poor, fragile patients ribs and he would die anyway! There would be overhead pages, an ambulance streaking in with sirens, the patient would be taken to ER and pronounced dead there. I did tell the patient when she said "I'm just concerned because he revoked the DNR a couple of weeks ago." "He has no quality of life left. He's not going to recover. Maybe he didn't understand that or maybe he was scared. I'm sorry. If you choose to sign the DNR, we will make sure that he is comfortable until he passes away." Then she asked me how we would do that, and I told her. Morphine, positioning, Tylenol for fever, something to help dry up his secretions, keeping him clean and dry, oral care, making sure he doesn't feel thirsty. Earlier when I was assessing him, she had said to me "It helps me if you tell me what you're doing, even if I don't understand." So, I did. "I'm doing this, this and this to see if the current problem is this or this."

This is not the first patient that I've had die. It is the first under the circumstances and the first that I've been there for the final breath. I know hospice measures and do them. I hug patients and their families. I've been thanked for my care at end of life. Unfortunately this was different and not easy. I had to be clinical in that moment, didn't I? I have a job to do as a nursing professional. But, bet your ass, everytime I left the room I asked that woman what I could do for her. What I could bring her, if I could call someone, etc... When he was in his final seconds, I made sure that there was room for her bedside and that she gently understood it was time to say goodbye and I made sure the patient had a hand free to hold. I stayed close to her and followed her cues for physical comfort. It was ME that she asked "What do I do now?" And it was ME that said "Say your goodbyes. We can handle everything else. You may stay with him until the funeral home comes or you can go home to your children. I'm sure you want to hold them close now and we will make sure that he is taken care of." She did. And we did.

And guess who didn't show up to clean the body, dress him and make sure his teeth and glasses went out with him? Yeah, the CNA that thinks I'm so uncompassionate. I had a talk with him. He still criticized me. He told me I came in to the room like a tornado, spieling off abbreviations to the other nurse. Well, perhaps. But, yes I had to let him know that we are allowed to take a "TO" (telephone order) from doc for "DNR." I had to let him know because we were seconds away from torturing a 3/4 dead man.

Mostly I'm just venting. My feeling are hurt and I feel like I've been undermined. There are some things that my CNAs know better than me like "Hey, lets use this cream, so and so had the same thing and it worked great!" and I listen. There are other things that the CNAs don't know about. And the law is often one of them. The process of death is another. And ALL that was going on in that hour is another. He did NOT know what we were up against. Plain and simple. And there was no time to kiss his ass and explain it all. But, I'm also seriously considering going in tomorrow and writing him up. He was out of line. And his demeanor the rest of the night expressed that he did know it. So, perhaps I won't.

[Laurie52]

I think you did a great job in an impossible situation. You advocated for your patient and gave great care to the patient and family. I can't think of anything else you could have done.

On a systems level, I would speak to your manager so that you are not placed in a situation like this again. Not sure how someone could be hospice and a full code. This should have been addressed with the patient's physician before an imminent death.

As far as the CNA is concerned, I would write them up. He or she could question you but it should not be done in front of the family. It undermines your relationship with the family and, no doubt, made a difficult situation more difficult. I'm would be more than happy to explain my decision to CNA, but after that, wouldn't discuss it further. Decisions re nursing care are not made by committee. If that CNA wants to make these decisions, get a degree in nursing.

[kool-aide, RN]

I would definitely write the CNA up, but first, I would have a sit down chat with him. Nothing hostile(not that I think you would) but just a "come to Jesus" moment, if you will. Explain to him the situation in detail and why you were doing the things you were doing. Explain to him why you're writing him up, including him undermining your authority in front of a family member.

[RxOnly]

You seem like a wonderful nurse, and I could only hope that someone like you would be taking care of my family member if they were ever in such a situation. It sounds like you did everything you could have/should have- and did a wonderful job at it! There's always THAT person at work who has SOMETHING to say, no matter what you do. Go ahead and write him up if he made any violations. But most importantly, DON'T let him get to you (easier said than done, I know)!

Again, it sounds like you did everything right and I doubt that family will ever forget you :)

[Flare, ASN, BSN]

Wow - this guy sounds like he's really got his head in the clouds. In nursing you have to learn to accept that death is a part of life. He is so far from grasping this concept that he's not even on the same plane as it. Perhaps he's an adrenaline junkie that was hoping to be part of the megacode - since the wind was taken out of those sails, he was frustrated and challenged you inappropriately. Perhaps he just doesn't get it. I think the write up is in order - only because i don't think he gets it and i think he needs to hear it from the upper eschilon for it to have any hope of sinking in.

[Blackcat99]

I would write him up. Absolutely.

[JOVANI]

You should write him up.

[nyrn5125]

In the future the best thing to do is immediately nip it in the bud when an unlicensed person challenges you. You do not need to justify yourself to him. If he is doing it in front of family members then it is absolutely unacceptable and in front of them you should have said to him "what is your title, because you are overstepping a boundary and you are not a licensed professional"

There aren't honorary RN degrees no matter how long this person has been a "certified" not licensed nurse aide. It sounds like you did the best you could

[richardgleaton]

It is very nice post..The conclusion is that we were able to get this done and the patient died in relative peace.

[enchantmentdis, BSN, RN]

This is one CNA that should be seen and not heard. How dare he try to pull rank on you and add stress to an already stressful situation. Write the jerk up, remind him of his job description even if you have to get a copy of it from human resources, and in no uncertain terms, tell him that he is NEVER to challenge your authority in front of a patient and family member EVER again! Remind him that if he wants to be authoritative and tell you how to do your job that all he has to do is go back to nursing school, become a nurse, and then apply for a management position. I am so glad i work in hospice and never work with aides anymore. In acute care they constantly put their two cents in where it wasn't needed, weren't doing their jobs, and made me wish that primary nursing was the only nursing their ever was. I'd rather do all the work myself than have an aide get in my way.

[ktwlpn, LPN]

You did a good job .I think you need to write the cna up and speak with him about it . How dare he give the family even a glimmer that something else should be done at that time? Maybe they ignored him but maybe his comments are something that are sticking in the loved ones mind -is she wondering what more could have been done for her loved ones comfort? It seems that there is always a cna like that on every unit-you have your excellent ones then the one that thinks they know more then you.I am dealing with one now-we have two difficult family members on the unit and they seem to seek out info from the cna's instead of coming to the nurses and then they flip out because the nurses give them different info.The DON is now involved.I don't think they truly mean any harm-they don't realize the ramifications of their actions.It's up to you to teach ....

[Forever Sunshine, ASN, RN]

I think the CNAs in my facility are great and very good at what they do. Most are older than me(could be my mother/grandmother) and been there longer than me, so it puts me in a weird spot sometimes. I'll help them if they ask, I value their opinion, I am very approachable if something is wrong and will pass it on in report or let the doctor/RN supervisor know. I don't make a big deal of things and like to let them do their job.

However if any CNA did that to me.. I would write them up. For two things.. undermining his superior and neglecting to care for his patient.

You are the nurse. They are the nursing assistant. You are their superior. Bottom line. I would have given him one shot. Next time he did it, I would remove that patient from his assignment and assign a different CNA, and make the RN supervisor aware of whats going on with this CNA.