I recently had a pt admitted with an large fungating SCC of the face. When he was handed over to us via the community pall care CNC we were told that the pt would die within two days. This would be either to his palate collapsing and occluding his airway, or to drowning in his own blood. She handed us a med chart with an order for a huge dose of parenteral morphine and gave us the instruction to administer that and the dose of midazolam immediately that happened to him. The dose of morphine was greater than 50mg. The pt had never taken narcotics, hadn't even had acetaminophen. We were uncomfortable with this Stat order. As she made it clear the intent of giving the dose was to immediately end the patient's life it made us even more uncomfortable.
We are used to caring for terminal patients. We average two deaths a week. We have no problem administering meds when required to alleviate suffering, when the orders are legal. All the research we did indicated this was an illegal order. We asked the physician if he could change the order to smaller doses, administered at frequent intervals for the alleviation of suffering. Even an order for sedation. He refused.
Our NUM said she'd have no trouble giving the dose and would do it herself. The juniors on our staff, aware of legal and ethical obligations, were fearful about losing their registration if they were coerced into being a witness to the administration of the dose.
I asked our pharmacist for help and he consulted many specialists who all said it was an illegal order and amounted to euthanasia. He discussed it with the physician and the response was for the order to be rewritten and underlined.
I believed I had an ethical and legal obligation to act so documented all of this in the patient's notes.
I was called to see the DON. She said she had no problem with the orders and if she lost her registration for administering the dose, so be it. She told me she was giving me the first warning for documenting inappropriately in the patient's notes about 'political issues.' If I do it again I will be terminated. She said the concerns about the dose had nothing to do with the patient's care.
Please...........can I have some feedback about this?
Thanks everyone, for all your comments and support. Unfortunately my being one of only a couple seniors means I lack the opportunity to obtain feedback from more experienced nurses.
It is Xmas morning here. I wish you all a wonderful Xmas with loved ones and all the best for the new years.
I think any nurse who keeps turning up to work, to do the best they can with what they have, is special.
I feel privileged to receive your comments and am grateful you took the time to write them.
I later walked past his room and heard gurgling. I realised what it was and ran in. Unfortunately the doctors saw me dash in and followed. A yellow creamy coloured fluid was pouring out of his nose and mouth and he was aspirating. I still don't know what it was or where it was from. Doctors and nurses filled the room while I held his head to one side so the fluid could pour out. They were trying to get cannulas into him and trying to get a set of obs. I ended up loudly saying 'will you all just stop and actually look at your patient. He is about to die. You won't get a set of obs because he has almost shut down. Now can you please just leave him alone and let him die.'
They all left. I spent the next ten minutes with him, until he died, so he wouldn't be alone. At the end he went for four minutes between breaths, but there was a region above his right breast that was obviously his pulse and I watched it. At the end there was rapid quivering of that area, then he died.
That was a bad death. He'd been moaning for three days. We did everything we could and still failed to get him the help he needed. It has us wonder whether 'real' nurses in the cities would do better. Those with more education and more experience.
Dark, what you described is exactly how my Mom died. It does NOT matter how good of a nurse you are...when the time comes for a patient to die, there is nothing you can do but comfort. There was nothing you could have done differently for this man. Death is just very simply...ugly. From this experience, you will no doubt understand how important it is to let someone die in peace, and just be there with them. You are an angel my friend. Never doubt that.
Specializes in Trauma Surgery, Nursing Management.
I agree with you Leslie, that death is not the enemy. The MANNER of death however, can be very ugly.
Personally, I am not afraid of death. I see it as the natural progression of our existence. I accept this and am at peace with my mindset.
Having had the awful experience of Mom's death, I salute all hospice nurses. I don't know how you guys do it daily. You are all heroes to me. A hospice nurse changed the course of my life. I will never ever forget Emily. She was such a brilliant light in such a dark time in my life...I wanted to do the same for others. That's why I became a nurse.
Thank you, Leslie for offering another side to the heartbreak of death. You are ever the wise one, my friend!
Sometimes a patient dies and it is a natural progression, from life to death, with little or no need for intervention from us. These deaths have enabled me to see that a natural death can indeed be something not to be afraid of. Nature can provide dyings that make our 'managed' deaths seem so far from perfect, more like the fumbling interventions of amateurs.
Death can indeed be beautiful. An elderly person who is at the end of their fight often willingly embrace death as a friend. You watch as their body slowly shuts down, the patient sleeps for a little longer each day, until the time arrives when they won't reawaken.
I wish we could provide such a death for all our patients.
The order was changed today. 5mg morphine at very frequent intervals with doses of midazolam also at very frequent intervals.
I noted someone said that the patient can still feel pain, even when unconscious. That is true. A palliative care doctor told me a story about a patient who had very difficult to manage severe pain so the decision was made to sedate her. The patient was unconscious. The doctor went in and spoke to her every day for about ten days. On the eleventh day she went in and the patient had regained consciousness. She yelled at the doctor because of what she'd been through. Her sedation was enough to stop her being able to move and respond, but not enough to block awareness. The pt said she had been in severe pain the whole time but totally unable to do anything about it. She had been living a nightmare all that time.
And another thing, even if a patient is unconscious they can still get terminal agitation because they have a full bladder or are constipated. Those are things we can fix.
I was given demerol once too soon postop and you all know what that did... I was aware, still paralyzed somewhat, and then quickly became paralyzed once again losing my ability to breathe, which is nice .
I once had an endoscopy. I was given midazolam first. I choked right through the procedure and wondered if it would ever end. Tears were streaming down my cheeks and I heard the nurse say it was just as well I wouldn't remember. I remembered every bit of it.
Thanks OCRN63. My mom was a cancer researcher, which makes her death all the more Twilight Zone-ish. But my experience with caring for her and handling the fallout of her death is what made me go into nursing. I am MUCH more compassionate for those who are terminally ill, and will go to the ends of the earth to make sure that my patients are comfortable BECAUSE of Mom.
I agree that hospice nurses have a very heavy responsibility to care for those in end-stage illnesses. I am not a hospice nurse, and do not claim to know what y'all go through regarding the care of your patients. I can only raise my glass to you in a toast...YOU ARE MY HEROES!
So sorry for you, hope ur coping better these days :)
I once had an endoscopy. I was given midazolam first. I choked right through the procedure and wondered if it would ever end. Tears were streaming down my cheeks and I heard the nurse say it was just as well I wouldn't remember. I remembered every bit of it.
Did u tell them that afterwards? Maybe they didn't give u enough midaz?
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Darknights
75 Posts
Thanks everyone, for all your comments and support. Unfortunately my being one of only a couple seniors means I lack the opportunity to obtain feedback from more experienced nurses.
It is Xmas morning here. I wish you all a wonderful Xmas with loved ones and all the best for the new years.
I think any nurse who keeps turning up to work, to do the best they can with what they have, is special.
I feel privileged to receive your comments and am grateful you took the time to write them.
Thank you.
Merry Xmas