Thank God for nurses!

spotangel, DNP, RN, NP

"It's everyone's responsibility. I don't want any explanation as to why you didn't know!"

Tom, the administrator's voice was clearly frustrated as he spoke to the outgoing Night Nursing Supervisors. He was talking about a patient that was admitted who was waiting for a bed for almost 40 hours in the ED. The patient was an elderly 87 year old that was vented.

"Imagine that poor patient on a hard stretcher for all those hours. You should have intervened!"

The supervisors were silent. The administrator was on the phone getting morning report about the hospital from the outgoing Supervisors. I always came at least 15 minutes before my shift as the morning Nursing supervisor and was listening in to the report.

Tom then asked, "Who is coming on this morning?"

One of them answered, "Annie and Gwen".

I piped up, "Good Morning Tom!"

"Good Morning Annie. Can you please follow up on this?"

"Will do, Tom", I quietly answered.

After he hung up, I asked the outgoing supervisor that covered the ED what kind of bed the patient was waiting for and was told that the patient was waiting for a critical care bed. After report, when they left, I checked my units on EMR, got the patient's name and checked the admission status for this patient who did not need a critical care bed as I was told in report but a regular medical floor vent room! I called admitting and asked them to prioritize her admission. I then went over staffing with Gwen, the other supervisor and the staffer. Now it was time for rounds.

I started off at the admitting office and reviewed with Chris the admitting clerk all the vent rooms in the hospital. This was a four day holiday weekend. All rooms were occupied. The chance of a discharge/ transfer from those rooms was very slim. This meant that the patient might end up waiting another day for a bed. I went to the ED and asked where that patient was located. I then went to the patient cubicle and saw 2 family members there. I introduced myself and was told that they were the grand daughter and great granddaughter of the patient. They were not happy.

The granddaughter was upset that the patient was vented even though there was a clear DNR/DNI in the chart.

"They waited till her son had left and then tubed her", she fumed.

"My grandmother never wanted a tube down her throat and they still put it. Once I get her in a room, I am taking this up!"

I did not comment as I wanted to check my facts.

"This must be really hard on all of you. Do you know what the plan is for her? ", I asked her.

"She is admitted and waiting for a room. When she goes up they are going to pull out the tube in the room".

She had been admitted under pulmonology and had got a palliative care consult in the ED after being vented.

I thanked the granddaughter for being patient and told her the bed situation. I asked her who the health care proxy was. She told me that it was the patient's daughter, her aunt Veronica.

I went and spoke to the attending physician and nurse of the patient both who concurred that the patient was vented before their shift and they were not sure why as the patient was a DNR/DNI.

I also heard about a panicky family member who had been at the bedside in the ED, and insisted that the patient be tubed after Bipap had failed, although that person was not the health care proxy and that the doctor "gave in". I checked the records and found a recent DNR/DNI in the EMR.

It made no sense to hold a vented patient for the next 15 hours waiting on a bed on a four day weekend, and extubate the patient once she reached her room upstairs. The family was very clear on the wishes of the patient. They were fighting for what she wanted.

"Can we do this extubation in the ED and honor the patient's wishes"? I asked the attending as the ED was slow and we did have a few empty private rooms. He was comfortable with extubating as long as we followed all protocols.

So, I initiated a call to palliative care who then walked us through what to do. I then sat down with the family and told them of this option. I requested them to discuss this as a family and asked them to also call the health care proxy. She called back and was in full agreement and said she would be there in the next hour or so. The patient was moved to a private room in the ED. The entire family arrived. Lot of tears and hugs and goodbyes were initiated. The patient was already on a fentanyl drip. The proxy confirmed the DNR/DNI with the attending. The tube was withdrawn and she kept breathing.

The family had been prepared by the staff for this scenario and used the time wisely by staying by her. An hour and half later, the patient's son walked through the door and the monitors went crazy! Ten minutes later, she was gone peacefully.

I walked right in as the son walked out crying and the granddaughter looked at me with tears in her eyes and I just knew. I introduced myself to the rest of the family and they told me, "She just passed after her son came. She was waiting for him."

They wanted to put her dentures and asked me for permission and I said" Absolutely!" and assisted them. One of them introduced herself as the patient's daughter's friend. She told me that the patient was mother to many of them who were not related by blood. They all called her "Ma"!

I told them that she sounded like an awesome Ma and she went in peace surrounded by those who loved her and those she loved. They thanked me for my help and one of them ferverently said as I walked out," This is why I like nurses! Thank God for nurses!" I informed the attending that the patient had died and he went in and pronounced her.

Later on at night, I gave Tom, my boss, a quick rundown of the facts and he was appreciative. I went home feeling that my shift was worth it. It felt good providing closure and advocacy for this patient and family.

I thanked the ED team before I left especially the new attending that had taken over the case and agreed to the extubation after initially having qualms that quietened when I told him, "Let us do right by this patient even though we did not create this mess or situation". He came back to me and told me that he had completed all the paperwork (death Certificate), calls (Medical Examiner) and notes. The nurse had called the organ donation network as per our protocol. We left the family to grieve and celebrate her life. Driving home, I thought of this patient that I never once spoke to and hoped that she would now advocate for us, in the nursing profession, from above and be our Ma!

Thank God for nurses!

About spotangel, DNP, RN, NP

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