Discharged at the point of death.

[DixieRedHead]

Are you getting lots of residents admitted from hospitals that are breathing their last breath or still sick as a dog. Hospital sent me a lady, that went back in 16 hours and died, one on 10 lts of 02 (hello, how high do your concentrators go?), he went back before getting off the stretcher, one who lasted like 5 hours before complaining of chest pain (she was in the hospital for an MI) who we sent back and she died.

I thought the new medicare stuff was supposed to stop some of this.

[nerdtonurse?, BSN, RN]

Actually 99% of the time it is a nurse who decides on the discharge, just not a floor nurse.

Not where I work! If I got to pick who was admitted or discharged, we'd have a lot of rich whinny behinds who are the CEO's best buddy or "politically connected" get kicked to the curb so I could try to help the truly sick person who needs the 1 on 1 care, instead of running blankets and water and sodas and snacks and magazines and oh, wait, maybe 1 actual nursing activity (that Zocor's really indicative that you need to be in ICU when it's the patient's only med all shift!) to people who aren't sick enough to be in ICU, but they've got the monetary resources to "buy" 1:2 care. I'm talking about the person where every nurse says, "And why are they still here...?"

Grrrrrrrrrrr...

[Asystole RN]

Not where I work! If I got to pick who was admitted or discharged, we'd have a lot of rich whinny behinds who are the CEO's best buddy or "politically connected" get kicked to the curb so I could try to help the truly sick person who needs the 1 on 1 care, instead of running blankets and water and sodas and snacks and magazines and oh, wait, maybe 1 actual nursing activity (that Zocor's really indicative that you need to be in ICU when it's the patient's only med all shift!) to people who aren't sick enough to be in ICU, but they've got the monetary resources to "buy" 1:2 care. I'm talking about the person where every nurse says, "And why are they still here...?"

Grrrrrrrrrrr...

You don't have RN Case Managers who coordinate the patient's care and plan the discharge? No RN CNO who sets the overall staffing budget? No RN Unit Manager who dictates patient ratios?

[lilredrn]

As a relatively new nurse to ICU, I wish more nurses on our unit would discuss issues like quality of life and futility of treatment. I've only been there for 5 months and have yet to see these subjects addressed by nurses. From what I have seen, it is discussed by the doctors in a very clinical, factual way and nurses step back and stay out of it. Nothing against doctors, but we are the ones who are with them 24/7 and they learn to trust us and talk to us. I just don't see the rationale for placing an ET tube in a patient with end stage lung disease that is an adamant DNI. We can't fix the irreversible structural damage that has taken place and the patient does not want to be vented. Does this make me ethnocentric?

I have held family members while they mourn the loss of their loved ones and can understand them wanting to do everything possible. But in my opinion, sedating and venting a patient takes away precious few last days that could be spent at home with family saying goodbye. These patients are mentally altered after we wean them off the benzos, even if they do fly after we extubate them. We add to this delirium with all of our noisy machinery, unfamiliar environment, and by going in and waking them up repeatedly, turning them, emptying their foley hourly all hours of the night, etc.

Don't get me wrong, if they are actively dying, I am not ever in a hurry to discharge my patients to die at home unless the patient or patient's family wants them home. It is an honor to be there and take care of them and their family during this milestone in life. And yes, I cry right along with them.

My previous job was working in an assisted living facility with 180 patients by myself on night shift as a new grad RN. I had 3 resident assistants that helped me care for this huge patient load. There just weren't enough of us to go around. Especially if I had a hospice patient. It broke my heart. There is no way I could give morphine q15 minutes and care for the other 179 patients. I really felt a sense of guilt when I got my dream job and left that facility. I worried about whether or not my patients would get the care they needed.

I guess this leaves me wondering, is there any one best place to die?

[DixieRedHead, ASN, RN]

I guess this leaves me wondering, is there any one best place to die?

At home in your bed, asleep.

[lilredrn]

At home in your bed, asleep.

I wish I could make this happen for my patients who have a poor prognosis, but this creates much anxiety for their loved ones. Often they ask for the patients to be transferred to a medical floor or to a SNF to die. I think they want to feel like they did everything they could.

You know, I wish our society didn't view hospice as the "grim reaper." They provide such compassionate care and really do an amazing job facilitating the most comfortable death possible, with as much dignity possible in the most comfortable surroundings.

[nerdtonurse?, BSN, RN]

You don't have RN Case Managers who coordinate the patient's care and plan the discharge? No RN CNO who sets the overall staffing budget? No RN Unit Manager who dictates patient ratios?

I'm in a small rural hospital. We have a set 2:1 or 3:1 ratio, but that would affect our admissions (like holding someone in the ER until another nurse gets in from home) -- and when we are full, it's the MD who decides who goes upstairs. I wish we did have unit case managers for our frequent flyers. We get to decide almost nothing about patient care, as we have a lot of paternalistic MDs -- they set things, not us.

Ah, the joys of rural nursing...

[txredheadnurse, BSN, RN]

At home in your bed, asleep.

Or at home, in the arms of your loved ones with your last words being I love you.