Brief scenario: 75 yo, admitted for ulcerative colitis about 3 weeks ago, colon resection with colostomy about 1-1/2 weeks ago, admitted to our ICU, day later necrotic stoma, next day subtotal colectomy with ileostomy, now with comsumptive coagulopathy. Today this pt had a declining respiratory status. He has been lethargic, but very oriented. For the past couple of weeks he has been telling the nurses how tired he is and he doesn't want to fight anymore. His sats dropped in the low 80's and got them back up to about 95 with a 50% ventimask. Asked the patient if he got worse later on, would he want to be intubated, resounding NO! Spoke with the family who said he was not capable to make his own decisions and said they wanted everything done. Called the doc who first, promptly reprimanded me for not calling to increase his O2, then said give him narcan and 20 mg lasix (he had been given some MS about 6 hours before this happened. Gave both, no changes, pt still says he doesn't want intubation. Called doc back who said don't call unless there are respiratory changes, and I said if there are he doesn't want intubation and he is already feeling like he's smothering and can't breathe. Then said it doesn't matter, if he needs to be intubated we'll intubate him. Against the pts wishes? Yes. At this point I broke down crying and he asked how he was doing right now. So I told him, not well, he wants someone to tell him it's OK to die, he's tired, he doesn't want to fight, and he wants peace. He said he was on his way. Gets there, talks with the family, and still nobody asks this man what he wants. He then asks if we can go "have a talk". We go into a private area and he wants to know how long I've been in the unit and then proceeds to say that this man is not capable of making his own healthcare decisions and that if I want to call my lawyer and do something about it go ahead, but he will be intubated if that's necessary. So I tell this isn't about lawyers, this about trying to be an advocate for my pt. I've been his nurse for 3 days now and I don't see that he is getting any better, in fact he's getting worse. He said he had a great level of functioning prior, and he is "salvageable". I asked what he thought his level of functioning would be if he made it through and did he really think this man would survive being put on the vent, he already has no will to get better. He told me he didn't have a crystal ball so he didn't have any idea. If it came to the point where he's on the vent and things are looking like they won't improve, then he'll discuss a DNR status with the family, but until then the man will be intubated if it's necessary.
Then he calls back about 15 min after he left and told the night nurse to not give the family any information about the patients care. If they have questions, he will be by in the morning and they can talk to him because he's tired of having to correct all the wrong information given by the nurses.
So here I am, feeling like I failed my patient. I'm supposed to be the voice for my patient and the eyes and ears for his doctors and nobody's listening, and that is making me hurt and very angry.
I can't sleep, this all just happened this evening (at shift change of course) and I really just needed to get this out.
The nursing supervisor is aware of all this as well as my charge nurse and another nurse who witnessed my patient saying what he did and didn't want.
Oh, and BTW, for whatever it's worth, he has an advanced directive.