Extubated my patient

hellonurse36 · Oct 23, 2006

It really didn't hit me until I got home because I was busy with my other patient. I had to kill someone. And it was hard because I don't know if it was what she wanted. She probably would have died during the night anyway because she was losing blood pressure and was maxed out on vasopressor drips so it really bothers me that she had to smother to death instead of slowly going.

Dear BlueEyedRN

First...I am sorry for your difficult night! Hopefully you are processing this. Do you have chaplains at your hospital? Our chaplains are available for staff too, what about employee counselling?

Next, you did NOT kill your pt!!! You allowed her to go quickly to a place of peace. While it was undoubtedly hard to watch her struggle...at least it was short. I admire pts/families who can make this difficult decision when presented with the situation. I work in a cardiac ICU and we code far too many people for far too long and keep them "alive" for even longer. I always figured if the family was in the room during a code most would beg us to stop long before we actually do. I guess you can take some comfort in knowing that your pt's last few minutes, while difficult, weren't chaotic resulting in broken ribs/sternum from CPR, burn marks from shocks, and massive drugs being given.

I think the fact that you are struggling with this is normal and shows that you are a caring person who will make a GREAT nurse! I hope today is a better day for you!!

Terri

rn/writer, RN · Oct 23, 2006

I'm so sorry you went through this difficult situation unprepared and unassisted. Someone should have walked you through it ahead of time, and, ideally, have been standing at your side to give your moral support. Maybe staffing didn't allow for that, but it would have softened the blow and given you a chance to lean on a peer.

You didn't kill your patient. You released her from the agonizing existence of being kept alive by meds and machines. You let nature take its course in the body of someone for whom there was no recovery. It's a pretty good bet that the fentanyl spared her any conscious pain. Respiratory struggle can occur on purely a mechanical level; it doesn't mean that she had any awareness or suffering.

I'm guessing that this is affecting you so strongly because you didn't see it coming. You had no chance to work through a nurse's natural resistance to halting the fight for life and taking the opposite direction entirely. This would be akin to going into labor without any childbirth education. Yeah, you do what it takes to endure it, but it leaves you traumatized and fearful of going through it again.

Here are some suggestions:

Do some journaling. Put into words the feelings that are swirling around inside you. The act of putting them on paper defuses some of the free-floating anxiety that can give you nightmares and jitters.

Talk to other nurses. Your colleagues in the ICU. NICU nurses. Hospice nurses. Ask them how they came to terms with dying and death, especially in cases similar to yours where they played a part.

Google for information and read the accounts of others who have struggled with these issues.

Give yourself grace. Killing is so very different from allowing someone whose body can no longer sustain life to pass.

If you are a spiritual person, give thanks for the peace your patient is now able to experience. Pray for peace in your own heart and trust that you will gain wisdom and strength from going through this episode.

Write a letter to your patient expressing your sorrow and your hope that she is alive in a much better way (if this is something you can believe).

Write out a scenario where you are the mentor to a new nurse experiencing this for the first time. Guide her and tell her what you wish someone would have told you. Imagine it the way you wish it could have been. I have heard many hospice nurses say that they see a similarity between helping someone die and helping someone be born. They are, in some respects, midwives, helping a soul to enter a new world. Viewed in this light, the actions taken can be liberating.

I hope some of these ideas are helpful. Allnurses.com is a wonderful forum in which to vent and seek support. I don't know that you'll ever take death lightly (or that you'd want to), but there will come a time when you will be able to be there for your patient without feeling torn apart. I wish you well.

MarySunshine · Oct 23, 2006

Do you think all patients should have to die on a ventilator and pressors? Should we eek out every uncomfortable minute that we can? I'm guessing you would say no to this question. If you would say yes, then maybe you should look into working on a different unit.

Otherwise, know that you did not kill her. Her disease processes and old age killed her. You simply respected her families wishes (which they made out of respect for her) about her dying moments. It's hard to see death and be so close to it. Someone absolutely should have walked you through it. Please relax and know you did nothing wrong.

JentheRN05, RN · Oct 23, 2006

When I had nights like this I would write in the journal on here. Write out everything I felt. I keep it as a reminder of things I have went through, which makes me stronger. I also have a patient actively dying at the moment. She refuses medical care, and probably could've been saved if she hadn't refused. But she's 95 years old. She chooses to not go to the doctor, and as much as I want to drag her there I can't. I can only make her comfortable. I had to call in the family tonight because she is making that sloooooowww pass. The kind you wanted that lady to have a chance to have. Let me tell you from my experience. No it's not better. It makes the pain take longer for the resident and the family. False hopes brought on by sudden upturns, only to be followed by refusals to eat and no output at all. Blue around the lips, heart rhythm all out of wack. But at least shes not in any pain. However she is drowning in her own fluids. And there's NOTHING I CAN DO ABOUT IT! That hurts too. But we will go on. We just need to do our best. Thats all we can do.

Trauma Columnist · Oct 23, 2006

I want to just echo the previous posters. Please know that you did not kill this patient. Their disease process did. They were alert enough to give you nonverbal cues that they didn't want to live on life support.

Please do confide in someone that you trust. Take care.

Long Term Care Columnist / Guide · Oct 23, 2006

What rn/writer said.

There is an enormous difference between actively taking a life and simply allowing Nature to take its course. A very wise nurse I used to work with back when I was a CNA once took me into a patient's room to watch her give some IV morphine; only minutes later, he'd stopped gasping for breath and lay still, his face relaxed and utterly at peace. What she told me then has stuck with me all through the years: "Now you see, the medication didn't cause him to die.......all it did was help him relax enough to just let it happen."

Giving your patient the fentanyl and extubating her didn't kill her, either; what you did was to allow a natural process to continue and finally put a merciful end to suffering. You have done NOTHING wrong. Be gentle with yourself. :icon_hug:

kellerpatty · Oct 23, 2006

Dear Miranda (RN/writer):

Thanks for the great information on processing feelings. The original poster's situation has not happened to me (yet), but having these tools will definitely help before that time comes (I work in an BICU where people do die). These suggestions will help me not only with death issues, but with the pain and suffering issues that I sometimes must cause in my care of burn patients who actually will survive. It is nice to have a place where I can read really good advice and ideas from people who have been there. Thanks again for taking the time to let us all know your thoughts...I am sure they will help tremendously when the time comes. Also, to the original poster, my best wishes go out to you. Just reading and thinking of your situation and how you had to go it alone, breaks my heart. You sound like a great nurse and have pretty much been thrown into a situation that you will probably look back on as a huge growth experience. Take care of yourself and if you feel like it, let us know how you're doing.

cardiacRN2006, ADN, RN · Oct 24, 2006

This EXACT situtation happened to me within the past two weeks. I felt the opposite, I felt like the family did the most kind, humane thing that they could have done. My pt was only on the vent for less than 12 hours, but they knew that he would never had wanted to live like this. He stopped breathing very quickly, but took a while for his heart to totally stop.

When he died, I, of course, wondered if I did the right thing. I wondered if I might have allowed too much morphine to go into him through his drip. I wondered if there was the slightest chance that he could have survived. But, like your pt, mine was maxed out on pressors. He was also getting over 1 liter an hour in IVF, in trendellenberg and barely maintaining a pressure.

How great for the family and pt to know that your cared so much for him that you still feel this way. I believe that a dying pt knows that we care. I believe that the family sensed your struggle to terminate care, but sensed it in a good way. You can go back to work and give really kind care to your pts-because we never really know when they are going to go.

And remember, it's not up to us when a pt is going to go. It was his time, or the events wouldn't have played out the way they did.

lovingtheunloved, ASN, RN · Oct 24, 2006

Let me amen the previous posters: You did NOT kill your patient. She died of whatever disease/disorder that caused her to need the vent in the first place. I've never had to do that, and I can't imagine how difficult it would be, and I know you have to reconcile that within yourself no matter what anyone says, but you are not a murderer. You are a compassionate caregiver.

gonzo1, ASN, RN · Oct 24, 2006

When I was a very new nurse I extubated a pt that everyone thought would pass, but they didn't. They lived for almost 3 more months. So you see, you did not kill the pt, it was merely their time. For my patient it wasn't. I don't know your patient or their family but I and my family believe very strongly in not being kept alive by machines. If I were that patient I would be greatful to you for helping me to pass on the the next and better life. And greatful to my family for allowing this. There are many great books on this subject. Try to pick up a couple and read to become more comfortable with what is probably the hardest aspect of our job.

BlueEyedRN · Oct 24, 2006

Logically, I know that I didn't really kill her. But it just feels like I did. I mean, it would have been the same if we had just stopped the drips and let her blood pressure go, but that wouldn't have had such an immediate response. And I know that she is in a better place and didn't want to be kept alive on machines for an extended time. She had suffered enough and was probably ready to go. And it wasn't my decision at all. I guess I just feel that I didn't do enough for her. I had expected it to be peaceful and it wasn't for the first couple of minutes. It was after that. It was very sweet and her whole family was there and they were playing her favorite song to her and then the chaplain said prayers. But I just can't get her struggles out of my mind. I mean, never in a million years did I ever think I would take someone's life, and I know, I know that all I did was remove the machine, but it really really feels like I killed her. It's just an emotional crisis and I know that I will get over it, but it's hard. But thank you so much for writing me back. The first couple of posts really did help me to make more sense of it and I appreciate your concern. I'll be okay. And I'm trying really hard to think of it as being a privelege to have been there for her in her last few moments and being the one to help her return to God and peace. I don't think she's mad at me now. I am grateful for this experience because it opened my eyes and helped me to understand better life and death and suffering. And I know now how I can do things differently so that it feels more peaceful. We were pulling things off her frantically because we extubated her first and then had to pull all of the other things so that her family could come in and we could see that she was going fast and needed to get her family back with her. I am so grateful for her loving family. She was never alone and you could feel the love in the room.