conscious pt terminal wean

meanmaryjean, DNP, RN · Dec 28, 2013

Just because the nurse seemed unfazed by it at the time--- does not tell the whole story. I have participated in terminally weaning peds ICU patients (brain dead, no drugs given) and I kept it together for the sake of the family. And then cried all the way home.

Nalon1 RN/EMT-P, BSN, RN · Dec 28, 2013

... I couldn't wrap my mind around the lady literally signing her life away...

Do you still feel that a person can't decide they don't want to suffer when their outcome is terminal no matter what?

...And the fact that the nurse seemed unphased by it I just wondered how other nurses dealt with things like that.

As others have said, what you saw then may not be how she dealt with it after her shift. Everyone deals with job stresses differently.

Always_Learning, BSN, RN · Dec 28, 2013

I wanted to add a few thoughts to the discussion...

First, "terminal weans" and/or hospice care are NOT euthanasia. The line is difficult for those outside the field to see, but for starters, you can research the "principle of double effect." We give medications that have the possibility to somewhat hasten death, but it is not our intent to do so. In this case, motive has a great deal to do with it. If a COPD hospice (DNR-CC) patient is short of breath and nearing death, I will give morphine (as ordered by the MD) without hesitation to relieve their suffering. Morphine is a narcotic, a vasodilator, and also acts on the sensory cortex to relieve the sensation of dyspnea (shortness of breath). As such, morphine helps with pain AND breathing.

For what it's worth, nurses who may seem "unfazed" to the casual observer are not necessarily heartless. Rather, nurses must "be" what the family and pt. need them to be. I am often moved by many of the situations and patients I encounter, but if I - the caregiver - am sobbing, how does that help the family? This is not to say that I have never shed a tear, but as a whole, I must be the emotional support for the family and patient.

Lastly, you commented that it was hard for you to understand how this lady could "sign her life away." However, you mentioned she was on a vent, on dialysis, and had a wound vac. The devil is in the details here. If you have witnessed the violent reaction of anyone who is endotracheally suctioned, you have an idea that this is very uncomfortable. Hemodialysis - likewise - is a horrendously uncomfortable, time-consuming, and restrictive process. Patients are poked - several times a week - with a large-bore needle to access their dialysis site. For hours (pretty much an entire day), they are connected to machinery. When their blood is cleaned of its toxins, they are helped temporarily, but the vast change in their system's equilibrium causes them to feel exhausted. So they bounce back and forth between feeling crummy because they need dialysis and feeling crummy because they got it. The wound vac is another discomfort. I don't know the nature of this lady's wound, but typically vacs are reserved for those long-standing wounds that just won't heal any other way. The wound might be infected, or chronic, or smelly...or all of the above. Each vac change - which is typically several times a week - involves peeling off an adhered dressing, applying and/or packing in a new one, and connecting it back to suction. All of this is frequently significantly uncomfortable. Not to mention the times when the wound vac starts beeping in the middle of the night because it is clogged, or loses suction, and requires an urgent dressing change. Put all of this together (and much more that we likely don't know), and I can absolutely see why the patient might decide to enjoy a short, blissful time of not being poked and prodded.

I hope that you will look into hospice/palliative care some more, as I am very passionate about the need for this field. But even if you never do, and even if you never work in this area, I hope that you can recognize that each patient has a right to determine what treatment they receive...even if that's no treatment at all. We must advocate for patients' decisions, even if we don't agree with them or understand them. I hope this information gives you a bit of an idea on why some patients and families choose hospice and palliative care.

BuckyBadgerRN, ASN, RN · Dec 28, 2013

I REALLY doubt that the nurse was excited about the patient dying. REALLY doubt it...

First this is the pov of a tech /nursing student..I thought this might be the place for this post. I have only had one terminal wean patient and the patient was concious and she made the decision to remove her vent.
This is my biggest issue w/becoming a nurse..the whole experience did not sit well with me at all and still doesn't 2yrs later. So here is the story from a techs pov:
I show up to work to find ive been pulled to the icu ..I get report from the tech and she tells me that one of my pts is about to be taken off the vent ...I say what!? (This lady has been in the icu for about 6weeks and I knew her..she was totally alert and would ask for things used the call light etc.) Im a float pool tech so I wasnt familiar w/ the process. This lady was on dialysis , masthenas gravitas , had a gaping abdominal wound with a wound vac that wasnt healing..she wasnt mobile and was incontinent, couldnt eat and had ards ...so after report I go to her room and the process was under way ..her husband ,two daughters, her nurse and the doc were in the room ..so I just kinda peeked in and saw the pt sign a paper the doc had....I never entered the room I just sat at her monitor to watch her vs as things "progressed" about 10mins later I see a respiratory therapist enter the room ..the RT leaves and gives the husband a long hug outside the room..then the doc comes out and sits near me to put in the patients "final med" orders....the nurse comes out of the room very chipper and Normal every 10 mins or so to check the pts vs ..she makes a comment to me "shes lookin real "smurfy" in there" as if shes excited the pt will be dead soon. ..Finally the pt passes ..her family leaves very shortly and the nurse comes to get me for the post mortem care I enter the room and see 15 or so little bottles of morphine on the counter ..i felt sick and really didnt want to be apart of it ..but of course i did my job and helped..I could see tons of sores in her mouth that I never noticed which aluded to the intense suffering she was going through....during the whole time the nurse just seemed to happy and not phased by any of it. Im not sure how I would feel after something like that as a nurse. It was the fact the patient was of sound mind that really disturbed me.

SwansonRN · Dec 28, 2013

I think it's good to reflect on events you see that make you uncomfortable. If you were the nurse, how would you handle that situation differently?

From my perspective, I am very glad this patient was able to make her own decision. It seems as though she had many comorbities and a painful existence with little dignity. She probably could not expect a meaningful recovery and obtain the quality of life that she wanted. If she is alert and of sound mind she has the right to decide to let go.

Also, the morphine was not to euthanize her. When someone is terminally extubated, especially someone with ARDS, they're likely to struggle. Once the decision is made to extubate, your focus changes and your priority is to make she that she does not spend her final moments gasping for air. Morphine is an excellent drug to ease air hunger.

BuckyBadgerRN, ASN, RN · Dec 28, 2013

I can appreciate the fact that this experience is a soul-searching situation for you, but you really need to get some notions out of your head.

No nurse is excited about a patient dying. The morphine was to make her comfortable, it did not hasten her death. She was NOT being euthanized, pushing morphine as ordered is to make the inevitable as peaceful as possible.

It sounds as though this woman's passing has shaken you to the core, even two years later. I'd think long and hard about making a mental committment for end of life care if you feel like this instance was murder in essence...

SoldierNurse22, BSN, RN · Dec 28, 2013

On the contrary, I used to get excited at times when my patients neared death, but that happened under a certain set of circumstances.

I got excited for the ones who were ready to go, the ones whose pain had long outweighed their desire to live.

I rejoiced with those patients who had accepted that their death was a part of life, and they went, unafraid.

I held the hands of those who, days prior, had told me in whispers over a pained smile, "I get to meet Him soon, LT." And a few days later, I'd wait with them as they slipped out on their way and promise to be along in due time.

Death is, as many have said above, not the worst thing out there. Medically, it is a part of life. And regardless of one's religious beliefs, there comes a time when death is preferable to the suffering that is inherent in a failing, dying body.

Do-over, ASN, RN · Dec 28, 2013

On the contrary, I used to get excited at times when my patients neared death, but that happened under a certain set of circumstances.
I got excited for the ones who were ready to go, the ones whose pain had long outweighed their desire to live.
I rejoiced with those patients who had accepted that their death was a part of life, and they went, unafraid.
I held the hands of those who, days prior, had told me in whispers over a pained smile, "I get to meet Him soon, LT." And a few days later, I'd wait with them as they slipped out on their way and promise to be along in due time.
Death is, as many have said above, not the worst thing out there. Medically, it is a part of life. And regardless of one's religious beliefs, there comes a time when death is preferable to the suffering that is inherent in a failing, dying body.

Yes. I have seen, and felt joy at the end of a life. Of course it is bittersweet, but it can be a beautiful thing, especially when the patient is ready and is able to die on his or her own terms. I have cried and laughed at the bedside of a dying patient. I feel privileged to nurse someone at the end, and strongly suspect I will pursue hospice when I am done with critical care.

schnookimz · Dec 28, 2013

She left a legacy. You'll never forget her and what she taught you and made you think about. She's more comfortable and you learned something! I think that's a good way to leave this place :)

KelRN215, BSN, RN · Dec 28, 2013

I think all of it bothered me ..and the fact she was basically euthanized ..I never got the memo in school lol that that happened..and me being a float pool tech and not an icu tech it just took me off guard ..it was nothing new to the icu techs..and also how the nurse kept coming to check her vs every 10 min then go push more morphine ...and actually she told me the order for morphine was q5 or 3 mins (which made me feel she was basically killed) ..so just all of it was foreign and I couldn't wrap my mind around the lady literally signing her life away. This was just a post to just I guess tell my side of the story and some of the emotions I was feeling on the outside of nursing looking in. I do have an interest in end of life care and critical care nursing that doesnt mean my emotions turn off. And the fact that the nurse seemed unphased by it I just wondered how other nurses dealt with things like that.

She wasn't "basically euthanized". That's not an accurate description of what happened... at all. At the end of life, we give high doses of pain medications to keep the patient comfortable. I once had an 8 yr old (who weighed something like 24 kg) who was getting 100 mg of morphine AN HOUR plus 10 mg bolus doses q 10 min. This, in addition to high doses of ativan and continuous ketamine. The normal dose of morphine for a child is 0.05-0.1 mg/kg q 2-4 hrs. In an hour, this kid was getting the amount of morphine a child his size would receive in a week were it for post-operative pain control. Morphine is titrated to effect. This child lived for DAYS on this dose and when he finally let go, it wasn't the morphine that did him in, it was brainstem herniation from a rapidly progressing tumor.

I would find the fact that this patient was cognizant and made this decision of her own volition comforting. She was suffering and she had decided she'd had enough. I would do the same thing in that situation.

That her husband didn't necessarily agree doesn't matter. Of course he didn't want to lose his wife but he loved her enough to stand by her and let her go.

I agree with SoldierNurse22... I am happy for my patients when they are free of their earthly bodies. I haven't cried about a patient's death in years- even when my favorite patients have gone. These kids had cancer and their deaths were not unexpected. The ones who survive but with little to no quality of life hurt my heart so much more than the ones whose families can say "enough is enough" and let them go peacefully.

Esme12, ASN, BSN, RN · Dec 28, 2013

I think all of it bothered me ..and the fact she was basically euthanized ..I never got the memo in school lol that that happened..and me being a float pool tech and not an icu tech it just took me off guard ..it was nothing new to the icu techs..and also how the nurse kept coming to check her vs every 10 min then go push more morphine ...and actually she told me the order for morphine was q5 or 3 mins (which made me feel she was basically killed) ..so just all of it was foreign and I couldn't wrap my mind around the lady literally signing her life away. This was just a post to just I guess tell my side of the story and some of the emotions I was feeling on the outside of nursing looking in. I do have an interest in end of life care and critical care nursing that doesnt mean my emotions turn off. And the fact that the nurse seemed unphased by it I just wondered how other nurses dealt with things like that.

No one said you turn your emotions off. You maintain a professional demeanor at all times. Could you imagine the burden to the family if every time you walked into or out of a room sobbing uncontrollably? Do you think perhaps this nurse found it unbearable to continue to torture this poor patient day in and day out in horrible pain from an open wound in her abdomen and watched her suffer every day...day in and day out, day after day, after day? It is unthinkable sometimes what we put patients through.

She was NOT basically euthanized...she was medicated for her comfort to give her as much dignity and lack of discomfort as possible in her last moments. There are no memos in school, although there should be, to deal with the real life and death issues. They are teaching you the basics to be a safe nurse...the rest is on the job. Of course it is natural for you to have conflicted feelings....even in nursing. I have always said we are kinder to our pets...we don't let them suffer but we are perfectly comfortable doing this to a loved one.

We are faced with ethical dilemmas all the time......especially in critical care. This is a subject that is debated amongst the academics...here is a great resource from the AHRQ...(Agency for Healthcare and Quality) .National Guideline Clearinghouse | Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American Academy of Critical Care Medicine.

If you are truly interested in end of life care and an ICU setting....http://www.aacn.org/wd/Cetests/media/C1232.pdf and http://icu.gr/guidelines/963.pdf. A simple Google search will give you plenty of resources.

KelRN215, BSN, RN · Dec 28, 2013

This thread reminds me of an experience I had in college. My clinical instructor sent me to the MICU for the day. The nurse I was assigned to was caring for a man- relatively young, 40s or 50s, with end stage multiple myeloma. He was a full code, intubated, NG tube, foley, rectal tube, cental line, tube in basically every orifice of the human body. On the front of his chart was a document labeled "living will."

1. I do not wish for CPR to be performed

2. I do not wish to remain on a ventilator for a prolonged period of time

3. I do not wish for artificial nutrition via a feeding tube

His siblings were his next of kin as he was a life-long bachelor. Despite these written wishes, they insisted that he would "want everything done." He didn't want everything done. He had end stage cancer and he knew it. He wanted to be allowed to go peacefully.

This happened 8 years ago and it bothers me when I think of it to this day. If my family ever did that to me, I'd haunt the hell out of them once I finally broke free of my body (and I've told them as much).

Here's a great article about what happens in the situation where the patient's wishes are not followed:

https://allnurses.com/nurse-colleague-patient/patient-i-failed-329686.html

The patient described in the OP had a good outcome. We are all going to die. She decided she was ready. Given all that was going on with her, she was going to die either way. She decided she wanted no more suffering before the inevitable.