Dealing with Guilt

Horseshoe, BSN, RN · Jul 12, 2016

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.

I'm sure you now realize that hypoglycemia can indeed be an emergent situation. Was the CNA as upset about this as you? I hope she learned a great deal that day also.

Been there,done that, ASN, RN · Jul 12, 2016

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.

Did you screw up? Yes. YOU were responsible to assess the CNA's "statement".. and get your patooty into the room.

You have learned from this situation, reporting yourself to the BON will not assuage your guilt.. it will open up the nastiest can of worms you could ever imagine.

Move ON.

JA89 · Jul 12, 2016

As far as I know, I'm the only one of the team that night that lost a moments sleep over it. Aside from the fact that the other RN on shift was convinced that we "drowned" him by pushing fluids while he had zero urine output and already on fluid overload

Libby1987 · Jul 13, 2016

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.

Here's the grace, you learned this very harsh lesson on someone who was going to die anyway. And you will never commit it or anything like it again. Acknowledge this grace, from wherever you believe such things come, and then forgive yourself and let go of the struggle. In fact, honor this grace by not making it futile, make it worth receiving by not sabotaging your future contributions.

You screwed up, welcome to the human race, and now you are a better stronger human and nurse who will use your skill and drive to help others moving forward. You will still make mistakes but it won't ever be something like this again, and you've probably prevented something similar by others by your sharing this very private episode in your life.

BeenThere2012, ASN, RN · Jul 13, 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

Hang in there. I believe you simply are not responsible for this patient's death. I know this was a huge experience for you and understand why you are haunted by it. The majority of the responses are all in your favor. I'm glad you are feeling better. Take everything you can from this as a leaning experience and keep going.

BeenThere2012, ASN, RN · Jul 13, 2016

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.

JA89....Listen to what is said here. Most of us agree and I have 30 plus years of experience and about 20 in Critical Care. This is not on you. Most f us feel you did about everything you could do under the circumstances.

BonnieSc · Jul 13, 2016

Regarding the CNA: I don't say any wrongdoing or naivete or anything here. CNAs and other ancillary staff are extremely reluctant to do anything as drastic as say that anyone is "dead" or to call a code. I work with some extremely experienced and smart CNAs and I can't think that I've even had one call a code, a rapid response, etc, even though they are welcome to do so. When resources are available, I would be very surprised if any CNA checked for a pulse rather than calling for help immediately (and actually they're supposed to check for breathing and then call for help before checking a pulse anyway). I've done a lot of CPR recertifications for experienced ancillary staff and they all know HOW to check for breathing and pulse and start CPR, and I think they would if alone... but not when nurses are right there. I once had a phlebotomist come across a dead patient who came to me and said "uh, the patient, he's not waking up... no, I mean, he's REALLY not waking up." The patient had died at least 30 minutes earlier by my wild estimate.

I have been thinking about this post over the last couple of days and how often I do hear someone tell a nurse (could be family, a CNA, another nurse, a housekeeper, anyone) something that sounds urgent to me and the nurse finishes charting or takes a minute more on her/his phone before getting up. Even as charge nurse I try to stay out of that because I don't know the patient as well (maybe the patient is ALWAYS claiming he can't breathe even though he's breathing just fine). If I'm really concerned, whether I'm in charge or just another nurse, I'll ask "are you busy? do you want me to go check on that guy for you?" Anyway, my point is: I think this kind of situation might happen more than it seems. And I may have my own blinders on. Because I had this post on my mind, last night when the unit secretary told me a patient was asking for pain medication, and then five or ten minutes later came back and told me she was asking again, I thought--in my mind what I was doing was reasonable and there was no need to jump up and run to this patient's bedside (I won't go into specifics on the situation), but do I really always attend to my patients as quickly as I think I do? How would it appear to others?

I think there's a lot we can all learn from this discussion.

TriciaJ, RN · Jul 13, 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.

Best response yet.

Hrdlvn · Sep 1, 2016

I also struggle with haunting experiences where I wonder if I did something, or not enough. I compare myself to others and think to myself, they would have been smarter on how to handle that situation, and I think I am a terrible nurse. You already talked to your supervisor about this, and with most deaths the circumstances surrounding it are reviewed by QM. It has been some time, so I am assuming that this pts passing is closed. The hard part is the lingering feeling of your part in this, which is the hardest. Like many difficult situations that happen in life, the guilt associated with this subsides a little each day. It can rear its head up every once in a while when you again are in a situation where you question your responsibility, but each time you will learn from it. Just know that you are not the only one who feels this way, I am grappling with my own guilt with a situation where it was relayed that myself and the primary RN did not do enough to notify an MD resulting in a pt injury. Undermines your self esteem as an RN. I may take the advice of the post where you write to the pt and open it in a month to see if you still feel the same way. Time has a way of healing. Be good to yourself and I will keep you in my thoughts, please keep me in yours.