I lost my first Pt today!

[southjerseyRN]

Hey all,

Well, I new it was going to happen sooner or later. I made it through all of school and 4 months on the floor before I had to deal with it but it happened last night. My pt was terminal with mets to the brain and spine. I think i dealt with the event professionaly. I made sure she was as comfortable and as painfree as i could keep her. I was a bit uneasy when I had to call the family, but they were as nice as pie to me. Actualy after they came and said there goodbyes a couple of them made sure to thank me for helping there mother pass with comfort (2 actualy gave me phone numbers to call them if I needed anything... imagine that IF (I NEEDED ANYTHING!!!).

The problem that I need advice on happened like this.... after i listend to report and started to assess my pt's I was approached my a Hospice nurse who had been assigned to care for my dying pt. We spoke for a bit and she was upset about not being able to admit this pt to hospices care this night. She said that she had spoken to the family and the day nurse and all she needed was to get the attending to DC to hospices care. Well the day nurse put a call out to the attending and he was short with her. He told her that this matter didnt need to be addressed right now, and told her that he would be in in the morning. So it was left like that and then my shift started. The hospice nurse addressed her concerns to me about it, she stated that since the pt wasnt an actual hospice pt until the attending DC'd her, the pt and the family as well (because as we all know our PT's arent just the actual sick people; family, especialy in a hospice setting are our pt,s too) woul not be able to recieve there aid. The hospice nurse told me without being an actual pt hospice wouldnt be able to help (NO funeral help, and No help with counseling, No help with the yearly follow up either). This bothered me I just could not see how the attending just pushed this onder the carpet until tommorow. The hospice nurse expressed her anxiety about calling the attending she didnt want to get the flack i guess. So she said she would wait until the norning to admit the pt to hospice. I on the other hand didnt see how i couldnt call the attending in this situation. Well, i got the same earfull of garbage the day nurse got; (I''l take care of it in the morning, I dont want to hear about this again tonight!!) I documented my call in my notes but I just cant help feeling as if i let the family and pt down. I feel as if i failed to do my job. And then the family was so kind to me in the end offering me their phone number if i needed anything, heck its them that needed hospice and i just didnt get the job done.

So, if any of you can tell how to do it different so this does not happen to me again I would love some feedback from all of you....

PS I did call the nursing supervisor and bring the situation to he attention but she offered no souluions.

Mark RN:o

[Tweety, BSN, RN]

Sounds like you did all that you could do. Take comfort in the family wasn't upset with you and patient passed comfortably in your care. We can't always get 100% of what we know our patients need 100% of the time.

I hope the attending is feeling guilty this morning, probably not, but at least a bit of a tug on his conscious.

[Antikigirl, ASN, RN]

You did the right thing! Some physicians, well even nurses truely don't understand that hospice has so much to offer the patient and family! Financial help, programs/services that can help, individual care, and heck...mine even offered bathing services and harp players! They are wonderful!!!!!

The only other thing I may have done was to call her PCP and express that the nursing staff and family wished for the patient to be on hospice before they passed (really focusing on the family and patient's wishes!). That the family needed financial aide that the hospice program provided in order to assist with this entire fianancial process, and sadly the patient may not make it through the night...sometimes that helps.

The attending may have thought nurses were trying to 'pass' this patient on to hospice, or doesn't understand the scope of hospice. Hopefully someone can enlighten them in the future (if you call the hospice team, they usually can do a small inservice...we had some of our MD's in attendance...well, our faclity made it mandatory..LOL!).

You did well! And what counts is your attention, compassion and help for that patient when they needed it most! Good job nurse!!!!!!!!!

[mommy2boys]

I can't offer you any help on how to prevent this from happening in the future, but I can tell you that you did a great job and to keep up the good work. I know that the family will remember your compasion and help.

[CCGMatt]

Dealing with a dying patient can be both a trying and life-affirming situation. It sounds to me like you did all that you could - the fact that the family was appreciative of your care should tell you that.

I've found that a number of Attending physicians, especially intensivists, see D/C'ing pt's to a hospice program as a "failure" on their part to be able to save the patient's life, and will not ever discuss or deal with it. I and other nurses I work with have been yelled at for discussing it with families. But as long as you're an advocate for the patient, the family, and their wishes, you're doing your job.

[JentheRN05, RN]

I lost my first patient 2 months into my first RN job. I had taken care of her previously, and she was talkative and coherent just a few days earlier. When I came back on, she was actively dying. It was obvious to me, as I watched my grandfather and my mom-in-law pass away. The nurse that passed her off to me said, she expected her to be there in the morning at least. Upon first assessment, I was positive it wouldn't be morning, it would be lucky to be a couple of hours. This was simple pneumonia that took this ladies life. Her husband had just passed away 4 days before she did. I think she just gave up. The entire family (all 14 of them) hugged me and thanked me so much for my care. I can't say I handled it as professionally as I should've. I cried. Cried with the family, for the family. My charge nurse came down and walked me through all the paperwork. It wasn't easy, but I made the call to the doctor. Got the release.

Last week I had a patient who was actively dying from liver/lung/several mets cancer. He was in the hospital, actively dying for a week. I finally asked someone, and the family, WHY isn't he in Hospice? He should be in Hospice! Needless to say, I believe the next day he was sent home with hospice.

I think the only thing I would've done differently (although you handled it beautifully) is to be a little more demanding. I am actively involved in my patients care. If I see a patient is ACTIVELY dying I will most certainly call the doctor and tell him we need a hospice order now, the patient is ACTIVELY dying! He can still say no and we'll wait till morning, but I'll be darned if I don't push the envelope for my patients. I could care less what a doctor thinks of me for calling him at 3am for zofran. I do what I have to do to make my patients comfortable. PERIOD :)

You did everything you could've done. With a certain amount of dignity that I don't possess. I'm bossy when it comes to my patients needs lol. Sometime you have to be, just take care in how you word it and make it clear what is in the best interest of the patient is NOT to wait until morning.

[leslie :-D]

i would not have handled the attending's dismissive attitude well at all IF this patient's pain wasn't being managed.

it sounds like she did have adequate pain mgmt in place?

in very rare cases, i have been known to go to the chief of staff when md's blew me off, therefore denying proper treatment for my pt.

sigh......yes, i've been known to step on quite a few toes but very little they can do w/me since i'm fighting for a pt's well-being.

as long as you don't yell and can contain your composure, you can certainly assert yourself to any doctor.

i've even told docs that i plan to document pt's moaning/groaning in my nurse's notes, along with conversation w/md and how md refused to prescribe anything stronger for relief. it usually works.

leslie