How could you give up and do NOTHING?

[clemsongal68]

One of my most memorable patients was Pete*. 85 year old Pete had come from a nursing home with significant abdominal pain and vomiting. After a quick trip through the ED, he got himself a CT of the belly, a NG tube, some IV fluids and some pain and nausea meds. Admitted to the 4^th floor, he quickly started going downhill. The ICU nurses at the hospital where I worked served as resources for floor nurses if they thought a patient looked like they were declining...a measure put in place in hopes to avoid a code. His floor nurse had called ICU asking for help, so I headed on up to see Pete. Running into his surgeon in the hallway, we spoke briefly before going in to see Pete. It wasn't good...at all.

Now Pete was a tiny thing, probably 90 pounds soaking wet. It was obvious his appetite had waned significantly the last few months as he literally was skin and bones...except for the biggest brown eyes you could imagine. Eyes that mirrored his fatigue, anxiety and pain. So much was out of his control and he appeared a helpless victim in the war of disease. He was on a 100% nonrebreather mask when I first met him. His respirations were labored as he struggled to catch his breath. Yet, he clung to every word the surgeon told him...words such as small bowel obstruction, sepsis, cancer everywhere, poor surgical candidate, probably won't make it off the table. Powerful words. His sister beside him openly wept while receiving the news. Afterwards, the surgeon headed out and told the patient and his sister to let me know what they decided, for they needed to decide soon before it was decided for Pete (via a code).

I sat next to Pete and held his hand. I told him that I would support him in whatever he chose. If he wanted to fight, we would take him to surgery and afterwards to ICU if he made it. That we would do everything we could to save him and would try to minimize his distress. Yet, I made sure I explained to him and his sister what "do everything" entails. It's not pretty...and it's not easy. It's certainly not like on TV! He needed to know that it would be an uphill battle, probably for weeks. I covered being on the vent and having multiple lines and tubes. He most likely would have to be restrained at times. The "do everything" was option #1. I also told him about option #2: comfort care.

His doctor and I were recommending comfort care because we felt that Pete's body was dying. With the poor odds of him surviving surgery and recovery, we felt like it was more humane to just make him comfortable. Yes, the doctor and I knew it would result in his death, but we also felt that aggressive measures would still result in his death, yet with the addition of much suffering. But, ultimately the choice was up to him and his sister. You see Pete had never married...nor his sister...they had been best friends their whole lives. Pete didn't take long to decide...he revealed that he was so tired of hurting and struggling to live. He said, "I just don't have any more fight in me. I know I'm dying. I'm fine with it. " I updated the surgeon and called his hospitalist.

A DNR (do not resuscitate) was signed and hospice consulted. A morphine drip was started with prn Ativan orders for any restlessness. The morphine did wonders. It truly is the drug of choice for air hunger. We were able to change his oxygen mask to nasal cannula for comfort. His respirations settled down, he was able to relax and go to sleep. As the evening passed, Pete's coloring changed: his hands and feet became mottled, reflecting his lowered blood pressure as the sepsis progressed. He started having periods of apnea...5 seconds...then 10 second stretches...yet he slept peacefully on. His sister sat beside him, having said her goodbyes as the morphine was started. By midnight, Pete slipped away, peacefully and in the presence of the one who loved him the most: his sister.

Many folks would ask, "How could you give up and do NOTHING?" Yet, there was much we did do: we gave a kind and gentle man rest, a peaceful passing in the presence of someone who loved him dearly. We gave his sister support during his transition and the chance for hospice to follow HER for 14 months after his death. Hospice is not only for the patient, but very importantly for the family, especially that first year after their death. Believe me, it IS something!

*Name changed to protect patient

[moldyoldyrn]

Saw this scenario too much, I am so thankful they leveled with the guy and let him make the decision. Give that surgeon a hug. I do think that they were on target by telling him all of his options though. I do not think it ever appropriate to not give people the information they need for the informed consent, that is a given. I worked a lot of palliative care and hospice off and on over 43 years. I never had any difficulty accepting what a patient and/or their family wanted as long as they were told the truth and given all options. I also got my backup when some aggressive surgeons wanted to to do radical neck surgery on a patient (85 years old)with lung CA with diffuse mets. He would have never made it through any surgery. All of us RNs got our backs up and threatened an ethics referral and suddenly the surgeons backed off and said they could not do it. We all thought that the surgeon had never done that particular surgery and needed to "get his ticket punched". I think we showed them the strength and compassion of the nursing staff. The man died about a week later. I think this case was handled to the very best it could be. Sometimes the best treatment is to back off and support. My children know that is what I want.

[WoundcarePhilRN]

After over 26 years of seeing patients die long drawn out deaths, I'm all for Hospice. Just because we can keep people alive longer does mean we should. It's inhumane to do this to elderly people. Many times it's done to simply bill Medicare. I think code status should be strenuously addressed on admission.

[VivaLasViejas, ASN, RN]

I'm strongly in favor of hospice in these situations. They are not only great during the patient's dying process, but they're there for the family both during it and afterwards. I have a wonderful hospice grief counselor who calls and visits often; I can't imagine how much money I'm saving on therapy right now! What a wonderful gift to have someone follow me for 13 months after my husband's death and be there whenever I need her. :)

[catsmeow1972, BSN, RN]

A couple of years ago, my grandmother passed away at the age of 99. She was quite healthy up until the last maybe 6 years or so. Around then she started complaining about "feeling weak" but could not be more specific than that. She reluctantly started using a walker, but you could tell that just picking up her feet was an effort. Some degree of dementia also started in. After 2 falls (that we knew about and God knows how many we didn't) we moved her into an assisted living place that also had a pretty high level of nursing care. After about 6 months of gradual decline, she had an MI that was the cause of death. Up until the last day or so of her life, the cardiologist (the new one near where she was now living) was pushing for a TAVR procedure to fix the aortic stenosis that was finally determined to be the cause of both the vascular dementia and the "weakness" (with lousy blood flow to the legs and the head, that makes sense.) The guy had to be smoking something. A highly technical procedure on a demented, weak 99 year old woman for what end? Geez. She was 99 and had a wonderful long life. Worked until 82 and drove until almost 90. She'd outlived all her friends and with the dementia, she was more afraid than anything else. What kind of a lousy physician even thinks that such a procedure would be ethical, not to mention even useful, on such a patient. Needless to say, we declined and she passed away peacefully.

[moldyoldyrn]

What kind of MD? One who thinks they can cure anything and has a god complex they are working out. Agreed he was probably smoking something. So many practitioners look past the patient only to the disease that they feel they have to eradicate. Trouble is they wind up eradicating the patient in the process. If you gave your loved one the care she needed and kept her comfortable and happy then you did your due diligence and loved her the best you could. I applaud you.

[Dgrant580]

I worked as a hospice nurse for 2 years. It was some of most rewarding times that Ive had a nurse. I am amazed a the compassion and caring that hospice nurses give to their patients.

[Verygreennurse]

Made me cry. But good tears. Thanks for sharing.