Dealing with Guilt

[JA89]

Just in need of feedback from other experienced RNs on this one. I've been a nurse for about 4 years, working mostly ER. I've seen some bad things, but one case still haunts me. It was roughly three years ago. Had a pt who was 50s-60s in age, obese, diabetic, high blood pressure, and if I recall correctly some coronary disease as well. He was admitted to the floor at my small rural hospital. I worked nights, and our only staff was me, one other nurse, and a cna. This pt was admitted with a diagnosis of acute renal failure. I mean absolutely zero output. The docs were pushing fluids on him at the time, which I found odd since he was unable to diurese whatsoever. Because of the renal failure he was unable to rid himself of the metformin buildup that had acquired. Due to this, his blood sugar would tank anywhere from 25-50 every couple hours or so, and a shot of d50 would be required to normalize him. He would present with the usual hypoglycemic symptoms; confusion, slurred speech, or just grunts and moans. Over the shift I gave him d50 about three times, notifying my doc each time. Well about midway through the night, me and the other nurse were working on an ER pt. Our cna had made rounds and came back saying, "'mr. So and so isn't responding to me". I naturally assumed she meant he was displaying hypoglycemic symptoms again. I walked back to the floor, and went to my med room to chart the dose I was about to give and prepare the d50. It was at this point I became distracted by something on my cell phone(I know, huge mistake). I read something on my phone for probably 4 or 5 minutes, then proceeded into the pts room. When I arrived I knew something was wrong. The pt was cold to touch and had no chest rise. No pulse detected. I called a code, but we were unable to save him. For three years I've wrestled with guilt over that situation. I just feel I didn't move fast enough. I know he had other comorbidities that could have caused his death, and for all I know he coded well before we ever found him. My biggest fear is that the man coded due to severe hypoglycemia while I was wasting time reading something on a cell phone for those few minutes. I can't help but feel responsible for his death. Can anyone give me some advice here? All my coworkers and old administrator tell me it wasn't my fault, it was just his time, let it go and move on. I just can't seem to do that. I'm to the point of guilt that I want to call my board of nursing and report myself. I'm just desperate for advice here. Can anyone help me?

[la_chica_suerte85, BSN, RN]

I can't help but wonder though, that had it not been the cell phone that distracted you, would you have rationalized your guilt with another reason? Like, maybe you would feel that you had a hunch that you ignored and that maybe you could have rounded on the patient one more time and caught a decline before it got to the point of unresponsiveness? That's a tricky situation and it's totally normal to feel this way. There are things that I have done in life in general that have haunted me, maybe left me with a feeling of guilt that can be fairly paralyzing when I happen upon that memory. In time, the feeling should fade. If it gets to the point of abject distraction, though, maybe some counseling outside of work might help.

[westieluv]

My first thought when I read your OP was why, if this man was severely fluid overloaded and dangerously hypoglycemic, was he not on telemetry? I assume he wasn't, or when he flat lined it would have alarmed and alerted the staff. Also, if he had zero urine output over the course of many hours and the doctors kept pumping fluids into him anyway, why was no effort made to insert a CVC and run a dialysis treatment to alleviate the fluid overload and get rid of the extra Metformin on board? Metformin is excreted by the kidneys and has a half life of six hours, so to continue to give him multiple doses of Dextrose was a silly way to treat the problem, the man needed dialysis STAT. His electrolytes must have been all over the place too, and it's just possible that something else, like hyperkalemia or pericardial effusion from an elevated BUN caused his death, in which case it was malpractice on the part of the physician(s), not you.

Just something to think over, because unless I'm missing something, this man was badly mismanaged by his physician(s), not you. If he had been stable, the few minutes you were on your phone would not have caused a problem, and if he was not stable, why was he not a.) on telemetry, b.) getting dialysis, or c.) in ICU?

[Kati114]

I'm so sorry you had to encounter this situation. That said, I wonder if the counselor meant more than you heard by asking if the guild would go away if you quit nursing? There is usually a lot said in counseling sessions and, if you went in saying "should I report myself to the BON", the likely response is well, would that take away your guilt? As in, is that very drastic step going to make you feel less guilty and instead of quitting or reporting yourself for something you did not cause, maybe it would be better to work through your feelings of guilt and put a timeline of events (realistically) together to show you that he was likely gone long before you were notified? On one hand - this can be used to "teach" priority nursing but on the other, forgive yourself and if that needs counseling to get there...it's helpful. Being as honest as you seem, you will likely not make that decision again...learn from that. In the meantime...maybe consider EAP again and listen to the counselor and ask what they mean when they ask you those questions. I'm tcertain they were inviting you to explore your feelings more. Be well, nurse well....forgive yourself. Many blessings.

[JA89]

@westieluv, you make several excellent points, many of which I have considered in the past. He was on telemetry, but in our small town rural hospital the equipment was extremely old and unreliable. Many RNs there paid no attention to its read outs anyway. Half the time the telemetry would lose connection without warning. With what I know now, that man needed immediate dialysis and a bed in an ICU. Not a med surg floor at a small country hospital that was understaffed and underresourced. One of many reasons I'm thankful to no longer work there

[TriciaJ, RN]

My first thought when I read your OP was why, if this man was severely fluid overloaded and dangerously hypoglycemic, was he not on telemetry? I assume he wasn't, or when he flat lined it would have alarmed and alerted the staff. Also, if he had zero urine output over the course of many hours and the doctors kept pumping fluids into him anyway, why was no effort made to insert a CVC and run a dialysis treatment to alleviate the fluid overload and get rid of the extra Metformin on board? Metformin is excreted by the kidneys and has a half life of six hours, so to continue to give him multiple doses of Dextrose was a silly way to treat the problem, the man needed dialysis STAT. His electrolytes must have been all over the place too, and it's just possible that something else, like hyperkalemia or pericardial effusion from an elevated BUN caused his death, in which case it was malpractice on the part of the physician(s), not you.

Just something to think over, because unless I'm missing something, this man was badly mismanaged by his physician(s), not you. If he had been stable, the few minutes you were on your phone would not have caused a problem, and if he was not stable, why was he not a.) on telemetry, b.) getting dialysis, or c.) in ICU?

Can't "like" this one enough. Exactly my thought. Not to blame the victim, but if the guy was in his 50s and morbidly obese, his health problems started many years ago. From what you described, he needed a whole different level of care from what you were in a position to provide.

Your 5 minutes on a cellphone was the least of this guy's problems. I can't see how it would have made a bit of difference at that point. What if you'd spent that same 5 minutes doing something legitimately nursing-related? Same outcome.

So keep your resolution about cellphone use for the purpose of best practice. But quit beating yourself up over this unfortunate patient. You were NOT the one who failed him.

[westieluv]

@westieluv, you make several excellent points, many of which I have considered in the past. He was on telemetry, but in our small town rural hospital the equipment was extremely old and unreliable. Many RNs there paid no attention to its read outs anyway. Half the time the telemetry would lose connection without warning. With what I know now, that man needed immediate dialysis and a bed in an ICU. Not a med surg floor at a small country hospital that was understaffed and underresourced. One of many reasons I'm thankful to no longer work there

OP, read what you wrote here. The telemetry would lose connection without warning and the RNs ignored it even when it was working? No patient is going to be safe under those circumstances, why even order telemetry if that's the way it's monitored? Most hospitals have a dedicated monitor tech whose job is to make sure that all telemetry units are in working order and leads are in place at all times. Had he flat lined under normal circumstances, a code would have been called and he might have had a chance.

This man was morbidly ill. He was a complicated ICU case and should have been transported to that unit, if not a larger and better equipped hospital. He was going to die under this inadequate medical care no matter who his nurse was.

[RNperdiem, RN]

OP, it sounds like you have been haunted long enough by the dead. You did nothing to intentionally cause harm, you did not smother this man with a pillow.

I hope you will find some peace.

[BeenThere2012, ASN, RN]

Yes, it took you a few "extra" minutes to respond by looking at your cell phone. Also, you thought what any reasonable nurse would have thought in that he was likely experiencing another hypoglycemia episode. We make assumptions which we kick ourselves for on a lot of occasions. These are learning experiences. Never assume. On the other hand why didn't the CNA recognize death??? Why didn't she call a code? No matter how inexperienced, she could have started CPR. Why didn't she communicate the urgency? And you blame yourself?

Other thoughts about what may have contributed to this situation. You are NOT solely responsible.

1) Should have been monitored more closely in an ICU, perhaps. In the very least, should have been on a monitor.

2) It seems the physician mis-managed by not directly addressing his renal failure more acutely as well as the persistent Hypoglycemia.

3) When you are 1 of only 2 RN's in such a small hospital and covering an ER patient at the same time, it appears to me that your hospital was not equipped to deal with such a risky case and he should have been transported to a facility with better coverage.

If your nurse managers etc., have all tried to reassure you that they do not believe you caused his death, then you need to listen to those words. Let them sink in and think about the logic here. And by all means, please get some supportive counseling. This sort of thing can eat you alive and anyone would need some amount of help emotionally to process this in a positive way. It is possible for you to come out of this terrible feeling of guilt. Some of the best nurses and doctors I have ever known have made some really bad mistakes. They become a cut above because of their ability to learn hard lessons and hold themselves to higher standards as a result of learning through mistakes.

You care. That is most important. You want to make amends somehow. Don't give up.

[BeenThere2012, ASN, RN]

This is awesome advice and perspective. I hope OP can let your words sink in.

[BeenThere2012, ASN, RN]

Thanks for the feedback. Every one of you have made valid points, and some encouragement. I feel sure I am not the only RN who has ever made a mistake, or felt guilt over a patient outcome. And I must admit the fact that the pt was cool to touch led me to believe some time had passed since his coding. It's simply a guilt issue. I am a Christian man, and integrity is important to me. I never reported my concerns to my administrator then(although I have now) and it seems clear she would not have even considered reporting my actions to the board. So I am not sure why I'm tempted to do so myself. Perhaps a way of soothing my conscience. But at the risk of sounding arrogant, I would say I am a much better RN now than 4 years ago. I think my best solution is to continue counseling, and continue my career. However, this is one mistake I will never forget. I hope possibly some younger new nurses read this, and learn from my mistake

Reporting yourself to the BRN would not help anything here. As another said, it is up to the manager over you at that time to report you if some wrong-doing had occurred. So, you are not obligated to report yourself for a mistake. If you purposely went around making this same sort of mistake...it stops being a mistake and becomes more of a malpractice, unprofessional conduct, or neglect type of thing for which one should be reported. Please don't confuse the 2. A mistake does not constitute malpractice.

[Been there,done that, ASN, RN]

Sounds like a general cluster you know what. Wondering why he was not on a cardiac monitor.

It's all hindsight now. If this 3 year old episode is still haunting you to the point of reporting yourself, find yourself a good therapist. No use having 2 lives lost.

[BeenThere2012, ASN, RN]

My first thought when I read your OP was why, if this man was severely fluid overloaded and dangerously hypoglycemic, was he not on telemetry? I assume he wasn't, or when he flat lined it would have alarmed and alerted the staff. Also, if he had zero urine output over the course of many hours and the doctors kept pumping fluids into him anyway, why was no effort made to insert a CVC and run a dialysis treatment to alleviate the fluid overload and get rid of the extra Metformin on board? Metformin is excreted by the kidneys and has a half life of six hours, so to continue to give him multiple doses of Dextrose was a silly way to treat the problem, the man needed dialysis STAT. His electrolytes must have been all over the place too, and it's just possible that something else, like hyperkalemia or pericardial effusion from an elevated BUN caused his death, in which case it was malpractice on the part of the physician(s), not you.

Just something to think over, because unless I'm missing something, this man was badly mismanaged by his physician(s), not you. If he had been stable, the few minutes you were on your phone would not have caused a problem, and if he was not stable, why was he not a.) on telemetry, b.) getting dialysis, or c.) in ICU?

Thank you! You sited several things I thought of also. And so I have to add this...Why didn't the CNA call a code, start CPR, or communicated the urgency? I'm sure OP wouldn't have stopped to look at his phone if the CNA had been more descriptive.