Dealing with Guilt

BeenThere2012, ASN, RN · Jul 11, 2016

@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

"Alarm Fatigue"! That's a biggy also. Please learn from that one too.

JA89 · Jul 11, 2016

I'd like to thank all of you for your supportive comments, they have helped quite a bit in the way I look back on this case. As to why the CNA did not recognize the emergency, that is a question I've asked myself countless times. She was very inexperienced. To be honest, she probably didn't even think to check for a pulse. Either that, or the patient was still alive when she left to notify me, and he coded in the 8 to 10 minutes between then and when I walked into the room. To be honest, that's been my biggest hang up. But thank all of you again

TriciaJ, RN · Jul 12, 2016

I'd like to thank all of you for your supportive comments, they have helped quite a bit in the way I look back on this case. As to why the CNA did not recognize the emergency, that is a question I've asked myself countless times. She was very inexperienced. To be honest, she probably didn't even think to check for a pulse. Either that, or the patient was still alive when she left to notify me, and he coded in the 8 to 10 minutes between then and when I walked into the room. To be honest, that's been my biggest hang up. But thank all of you again

I don't think it would have mattered by then if his arrest was witnessed and coded. Too many things going on that should have been addressed by his physician hours previously. Several previous posters have already enumerated the factors that could have killed him. At some point the cascade was well under way and not likely to be reversed. I do not believe CPR was likely to be successful in his case.

I know I'm second-guessing, but I do believe the situation became irreversible at some point long before the actual demise.

jadelpn, LPN, EMT-B · Jul 12, 2016

I'd like to thank all of you for your supportive comments, they have helped quite a bit in the way I look back on this case. As to why the CNA did not recognize the emergency, that is a question I've asked myself countless times. She was very inexperienced. To be honest, she probably didn't even think to check for a pulse. Either that, or the patient was still alive when she left to notify me, and he coded in the 8 to 10 minutes between then and when I walked into the room. To be honest, that's been my biggest hang up. But thank all of you again

But you don't know if the patient was alive when the CNA went in or not. Does take longer than 10 minutes for a body to get cold.

Takeaway from this is that your CNA's under your direction today should feel absolutely free to push that code button or immediately call for a rapid response without consequence. Today, you would advocate for an alternate level of care. You know what resources you could use.

There were little to no resources in a setting such as the one you describe. And the facility is now closed. Time to make peace with your demons. Even if you advocated your butt off, and questioned every order, the outcome could have been exactly the same. The MD makes the plan. And this was just not a good one. But at the end of the day, what exactly could you have done differently? Not much except decline to take the patient? Decline to give the fluids? Hold the meds? You were really stuck on this. The patient was highly unstable. Whose thought process was it to have him admitted to a floor when obviously requiring an ICU level care? Who made that decision? Perhaps it was for "comfort care"? I am not sure the MD is losing sleep over it. And ultimately, that is who should unless "arrangements" were made for not treating this patient in an aggressive manner. Which could be as "back in the day" at small community hospitals, sometimes things got a tad twisted....

Would've/Could've/Should've does nothing but make you relive something that you can not change now. Only that you are clear with yourself and those working under you direction to never hesitate to call a RR or advise you of changes, you can advocate for alternate levels of care, and that newer nurses know first hand what resources are available to them and steps in how to use them.

Pca_85revived, LPN · Jul 12, 2016

He was already dead long before whatever occupied you on your phone caught your eye. He was improperly managed from the medical side of things and should have been flown to a better equipped hospital long before you even came on shift. I'm an LPN now, but had a guilty incident when I was a CNA. We had three of us on a floor when we should have had seven. A patient of mine swallowed some food wrong at breakfast, during a two hour window that I didn't see her during. She was turning blue and gurgling the whole time. I was busy with a huge code brown, but the other two aides and even the RN saw and heard all this, doing nothing. They couldn't be bothered to do the Heimlich and even mentioned they were glad cuz they didn't like her. It was really disturbing that two sides twice my age and a nurse three times my age couldn't be bothered to perform a two minute procedure to save someone's life. I don't know what they thought was going to happen. Did I mention this was on my eighteenth birthday? I quit and reported this to the state the next day. I still struggle with this. You will get over this, you'll save many more lives than you'll lose over the years, and you owe it to your future patients to be there. No good would come from reporting yourself. This would be the equivalent of accidentally almost hitting someone with your car and demanding you be charged with attempted murder.

Libby1987 · Jul 12, 2016

I really disagree with the rationalization in this thread but I don't think reporting yourself to the board will repair anything.

JA89 · Jul 12, 2016

I really disagree with the rationalization in this thread but I don't think reporting yourself to the board will repair anything.

Just curious, what is your opinion? Just wondering how you disagreed with the rationalization as you said.

TriciaJ, RN · Jul 12, 2016

I really disagree with the rationalization in this thread but I don't think reporting yourself to the board will repair anything.

"Rationalization" refers to wrong-doing that's made to sound right. In other words, the OP did an egregious thing by looking at his/her cellphone and the patient stood a good chance of surviving if this hadn't happened so the OP should feel bad.

I stand by my opinion: There is no way the OP could have saved this situation. It was a train wreck and if you'd 1:1'd this patient your whole shift he still would have demised.

JA89 · Jul 12, 2016

I have to admit, part of the reason this bothers me so much is spiritual. As I mentioned in an earlier post, I am a committed Christian man. And my fear is that if my hesitation, or distraction with a cell phone, In some way contributed to that mans death...I just simply feel responsible. It seems to me that other nurses have lost licenses for mistakes like that, and for me to continue practice and get off Scot free would somehow be dishonest. It's just something I'm slowly working through. But again thanks for all the encouraging comments.

Libby1987 · Jul 12, 2016

Just curious, what is your opinion? Just wondering how you disagreed with the rationalization as you said.

I'm disagreeing with the "he would have died anyway.." so forgive yourself and move on. The part I'm disagreeing with is that the patient dying anyway s relevant to ignoring the urgency of a patient not responding to be on a personal cell phone for 5 minutes. His predictible death anyway in no way minimizes the decision to delay checking on him. On the flip side, had the delay been the cause of his death, the decision wouldn't increase in degree of wrong doing. The reason it isn't relevant is that the patient's prognosis wasn't considered in the decision to stop and spend 5 min on the cell phone.

So where do I think you go from here? Pretty much what everyone else has suggested in terms of counseling and self forgiveness of your lapse in judgement. I'd think that whether the patient died or not, if he had a poor or outstanding prognosis, if he was a chronically ill poor lifestyle middle aged man or someone's otherwise healthy kid. You didn't less blow it or commit a greater sin because of the patient's prognosis and potentially already dead, because neither of those were considered at the time.

Personally I would need to attone my actions by staying committed to provide my best care every patient every time, which it sounds like you already are. AND I think OP that you have owned this, it's *part* of some of the posts that I don't agree with.

I don't know if that makes sense or if anyone would agree but that's how I look at it.

JA89 · Jul 12, 2016

I'm disagreeing with the "he would have died anyway.." so forgive yourself and move on. The part I'm disagreeing with is that the patient dying anyway s relevant to ignoring the urgency of a patient not responding to be on a personal cell phone for 5 minutes. His predictible death anyway in no way minimizes the decision to delay checking on him. On the flip side, had the delay been the cause of his death, the decision wouldn't increase in degree of wrong doing. The reason it isn't relevant is that the patient's prognosis wasn't considered in the decision to stop and spend 5 min on the cell phone.
So where do I think you go from here? Pretty much what everyone else has suggested in terms of counseling and self forgiveness of your lapse in judgement. I'd think that whether the patient died or not, if he had a poor or outstanding prognosis, if he was a chronically ill poor lifestyle middle aged man or someone's otherwise healthy kid. You didn't less blow it or commit a greater sin because of the patient's prognosis and potentially already dead, because neither of those were considered at the time.
Personally I would need to attone my actions by staying committed to provide my best care every patient every time, which it sounds like you already are. AND I think OP that you have owned this, it's *part* of some of the posts that I don't agree with.
I don't know if that makes sense or if anyone would agree but that's how I look at it.

I totally understand what you're saying. I've not denied for one minute my lack of judgement in not going straight to that room. Yes, there were many comorbidities and other factors that contributed to his death. And chances are that a shot of d50 five minutes faster wouldn't have saved his life at all. No doubt he was circling the drain and deteriorating fast. What I'm having trouble forgiving myself for is the fact that I did not take the cna seriously when she told me the pt was not responding. She was very inexperienced (although so was I at the time) and I assumed she didn't recognize the symptoms of hypoglycemia, and it was not an immediate emergent situation that required me to run full speed to the pts room. That taught me a very hard lesson about assuming anything in the medical field. I'm not so much questioning whether I was right or wrong in my actions that night; I know I made a mistake. I suppose the main thing I'm struggling with is whether I am obligated to report myself to the state board for negligence on my part, whether it caused the pts death or not.

Horseshoe, BSN, RN · Jul 12, 2016

I don't think for a minute that the time lost while "checking" something on your phone cost this patient his life.

I will say, it was a pretty crappy thing to phone surf or whatever after you had been told your patient was "not responding." I cannot imagine doing that. But the good thing is that you recognize your error, you have beaten yourself up over it a million times already, and I'm pretty sure you would probably never do anything similar again. I really hate the power our "devices" have taken in our lives, and in general (not at work), I'm as guilty as the next person-maybe even more.

And NO, there is no good to come from reporting yourself. You did NOT cause this patient's death.

Seeing a counselor might help you work through this, but reporting yourself to the BON serves no one.