Did I make a judgement error in caring for terminal neonate??

[neonurse28]

I have 10 years of NICU experience. I recently moved to the midwest and took a job at a large NICU. A couple of months ago I was orienting with a preceptor, but largely on my own due to my experience, and taking care of a micropremie. This infant was maxed out on ventilatory support and oxygen and still having persistant desaturations. The infant was also on iNO but we were attempting to wean because it was not helping. The infant had experienced days of low sats despite max settings and 100% oxygen administration. The infant had multiple other issues as well. An order had been written for no inotropes, no chest compressions, and no epi. The only reason the infant had not been removed from the ventilator was that the parents were not quite ready to take this step yet. I was told in report that alarm limits for sats had been lowered to 60% from our usual 80%. All during my shift the infant was on between 80% and 100% fi02. Sats were sometimes in the 70s on 90% fi02, yet turning the infant up would only temporarily increase sats and then we would be back down to the 60s on 100% fi02. Toward the end of my shift, the infant was lingering in the low 70s on 80% oxygen. I was observing this, but had not turned the infant up yet. This had been fairly "normal" for this baby all day, no matter what the fi02 was set at. I made an out loud comment that my baby was 70% on 80% fi02, and how he was just chronically not doing well. Another nurse in the unit who had taken care of the infant the day before said that the alarm limit had just been lowered because it was constantly alarming with a lower limit of 80, and that she had turned the baby up everytime he dipped down below 80. I turned the infant back up, and he did go up to the 80% range for a while, yet it was not sustained for long. A few days later the parents decided to withdraw support and the infant passed away. I have been beating myself up for letting her linger at 70%. I just thought with the lower alarm limit orders, the fact that we were desating while on 100% earlier throughout the day, and the poor prognosis and partial DNR order already in place, we were not "rushing" to turn up the fi02 on this infant. In fact, the administration of 100% fi02 can be detrimental also due to the production of free oxygen radicals. Should I forgive myself and move on?? I love my job and have never before questioned my judgement or abilities until this experience!! I am considering a move to adult ICU because the thought that I did not do what was best for an infant devastates me!

[SuesquatchRN, BSN, RN]

The baby was, sadly, terminal. A day later or a day sooner, the baby was not going to live. I don't know enough about titrating O2 on a neonate to comment on your nursing judgment but I can comment on your care. You do not hold the power of life and death. You are a nurse, not a higher power, and the book of life is not in your hands.

{{{{neonurse28}}}}

[linRdsNay]

AlmostABubbieRN is right. If they changed the lower limit to 60% there must have been a reason for it. Like you said, the nurse caring for the infant in the days prior stated that the infant was desating regularly. You cared for the infant as best as you should given the circumstances. Don't beat yourself up because over thinking this will eat you alive.

[babyNP., APRN]

With the micropreemies, there are so many issues with them that there's no one factor that gets them. Certainly lowering your alarms didn't do this. *hugs*

[dawnebeth]

You did absolutely no wrong that I can see. Taking care of terminal babies is really, really hard. Especially a baby that is not viable by the point you come onto the case (as with that preemie) and I doubt any action on your part could have given the baby a little longer or hastened his demise. Most times, in my experience, the baby chooses the time to die.

We recently had a baby who was about five months old but had not been viable for some time at that point. It had just taken the parents that long to accept the fact. The baby was switched from high frequency vent to a conventional vent (which many thought would cause him to go faster--it did not). Finally, on a Sunday, all the family and friends were allowed in at one time. (we usually limit 2 at a bedside) There were 25 people crowded in, plus the six other babies in that room, four other nurses, two RTs and 2 doctors. I assumed that they would remove support right then, but no, the mom asked for one more dose of lasix--a vain hope, imo. That was given and the baby was put in Mom's arms intubated. A cry of anguish went up from the crowd of relatives and much crying so I assumed the baby had died. Not so--and not at all that night, because Mom couldn't make the call. She was waiting for that lasix to take effect. Time passed--the relatives stopped sobbing. Morphine was given to the baby. The relatives started chatting amongst themselves, obviously starting to get bored. At the two hour mark, relatives started to leave. At the three hour mark, mom was still holding the baby intubated. At 11:30, the baby was still alive. My student nurse was heartsick and we all were very sad.

I found out later that the baby lived until Tuesday morning and then 'declared' himself, as we say in out unit and died on his own without being extubated.

I really do think sometimes we help these babies too much, sad to say, but in the end, they have the last word.

[littleneoRN]

Don't stress! In our unit, a micro-preemie's lower alarm limit is usually 80, and I have always been taught not to jump on the oxygen dial. Oxygenate gnetly. Our docs always remind us that cardiac kids sat in the 70s often for months prior to being repaired and are not neurologically affected (at least by that..) The effects of frequent/drastric changes to the FiO2 and the resultant effects on PaO2 can have significant negative effects. In general, I would not increase oxygen right away for any preemie who dips below 80. How long I'll watch a desat, I guess that depends on the kid, how well I know them, the heart rate, how low the sat is, etc. So, without knowing all the circumstances, it doesn't seem like you a did wrong thing, or at the most, there could be more than one approach or way to think about it. I certainly don't think you caused any harm to this child! You need to stop beating yourself up right now and move on. This is most certainly not a reason to change jobs. What actually shocks me is that in 10 years you have never felt called to question your abilities or done something that you later felt was not in the best interests of an infant. We all make mistakes or make a quick judgment call that hindsight proves otherwise. Although we strive to do the best by our patients, we also need to recognize that we are human!

[psychonaut]

I am SO over dying babies, I cannot even tell you.

My hat off to all the awesome nurses that can continue to do this for years, but 2 years of super critical neonates and I'm at my limit.

Oh, and to the OP...you already know this, but I'll say it any way: you letting this particular kid sat in the 70s in no way, shape, or form contributed to, caused, or hastened it's demise. Your care plus a metric ton of technology kept the baby alive.

[neonurse28]

Thanks for the support. I really love the babies and want to always do what is best for them, otherwise I would not be in this profession. And to littleneoRN, I have of course made mistakes before, thankfully nothing detrimental, such as forgetting a med, etc...but those were largely attributable to forgetfullness, busy work load, etc. This actually made me question my judgement, and to me a judgment error seems much scarier and makes me question my abilities more than forgetting to give a med on a busy day.

[littleneoRN]

You sound like a wonderful nurse! I don't think the NICU can afford to lose you. :)

[Penelope_Pitstop, BSN, RN]

Should I forgive myself and move on?? I love my job and have never before questioned my judgement or abilities until this experience!! I am considering a move to adult ICU because the thought that I did not do what was best for an infant devastates me!

Yes. Please forgive yourself.

Is it possible that you still are uncomfortable in this new NICU and that's why you're judging yourself so harshly? I know when I came to my current floor, I had a lot more experience than many of the nurses here. Therefore, I held myself to a much higher standard because I figured my coworkers expected an "experienced nurse" to not make mistakes.

Also, what was best for this baby is really a matter of perspective.

Let me put it this way, if I ever do have children and any of them end up a NICU patient, I would hope that you or someone like you would be the nurse in charge!