I witnessed the most horrible death last night at a LTC facility.

[stdntograd06]

As the title states, I had a death last night (the second night in a row to be exact) and I'll be at peace if I never have to watch someone die like that again.

This gentleman was approx. 85'ish, and in respiratory failure, and on Hospice. He had a foley catheter draining blood-tinged urine that just started going pink on the 3-11 shift, and a GT tube running at 65ml/hr. After I started the 11-7 shift, on initial assessment, he was quiet and his relatively stable self. He was given his 2400 ABHR gel and his tube flushed without difficulty. At 0145, on rounds, I was notified by the CNA to go to his room. Before I even got to his room, I heard the most horrible gurgling sounds. He was in definite respiratory distress and hyperventilating. I stopped the tube feeding, gave him Atropine gtts for the secretions at 0150 and told the CNA to stay with him and use the swabs to clear some of the secretions. Note: He had no order to suction (it is contraindicated with Hospice). I called my Supervisor and informed her of his status, that he was literally drowning in his secretions. She said she would be right there and call hospice, but that they wouldn't do anything. You could just hear tons of secretions sitting right in his throat and esophagus. He was unable to expectorate anything, and just choking on all of it.

He was due to recieve routine Roxanol 20mg (1 ml) at 0200, so I gave that to him. The supervisor came over, took a look at him and call Hospice immediately to discuss further treatment. She said that suctioning is contraindicated and that she was on her way (30 minutes away). At 0215, we gave him Ativan concentrate. His HR was 138-142 and Resp's TNC. His abdomen was severly distended and firm (he had 2 med. BM's the day prior). You could see the fear in his eyes and face, looking right at us as if begging for help. One of the CNA's stayed with him comforting him while my supervisor was on the phone. She told me to go ahead and give him more Atropine at 0230 even though it was ordered every hour. It had only been 40 minutes since I last gave it to him. The CNA put the call light on a few minutes later and when I entered the room his face and hands were blue, fingernails were blue. His eyes were half open and I watched as the color and life just drained out of his face. He took his last breath at 0235.

2400- ABHR gel

0150- Atropine gtts

0155- Roxanol 20mg

0215- Ativan Concentrate

0230 Atropine gtts

0235- Took his last breath

We all took this very hard, especially since he suffered immensely his last 45 minutes on this earth. I thought Hospice was all about dying with dignity and peacefully, with comfort?? Where was the comfort here? Any thoughts and advice are needed at this time. I am emotionally drained after last night.

Kelly

[miracleluke]

cxg174, I am sorry you did not have a good experience being a hospice nurse. It really is not an area for everyone. I believe Hospice in LTCF is a good thing. They are there to support the staff just like they are in the home situation supporting the family. I have seen more good come from having Hospice employed in a LTCF patient than when it wasn't. I too have worked in both areas and I believe that Hospice is a God-send for anyone regardless of where they are living! I am not lectureing you, I just want other nurses to know that it is a good thing and if you are in LTC then please utilize the services provided you by Hospice to ensure that the Resident gets all the benefits at the end of life! They really deserve that and Hospice is available to LTC staff for counseling just like they are available to family members up to a year after the death. So Kelly, look into this in your facility with the Hospice provider you had working with your resident! They can be very helpful to you too and maybe just talking with someone once can help you find some closure to the whole event! Gods Blessings to you all!

[Wishinonastar, BSN]

Are you kidding me? I LOVED being a hospice nurse. Your'e not reading my posting. In my experience hospice is not available to LTC staff or to the dying patient. They come once in a while and do nothing more than what the nurses who are there 24 hours a day do, only they don't know and love the patient the way the LTC nurses do. Of course I can only speak for the hospice that "marketed" the facility that I worked as a nurse PRN at. They were completely useless and I hope they do better in the homes because in LTC it was just a way to get cases.

[miracleluke]

I dont know what part of the country you work in cxg174, but I work in the midwest and I have worked for 3 different Hospice organizations(for profit and not for profit) here and they all provide supportive care to the LTC Resident as well as support to the staff in those facilities. This is part of our model here and I can only speak for here. I am glad to see we are doing so well here at our jobs as our Social Workers and Chaplains are on top of this aspect of Hospice services and hold regular grief meetings around town here as well as in the LTC facilities themselves for LTC staff. We also provide this support to families at home and direct caregivers in the home whether related to or not to the Hospice Client. I know things are different in different parts of the country and I am sorry about this as Hospice is a wonderful service and I think everyone that needs it deserves the entire service, not just the nursing component. Our Hospice team is comprised of a Medical Director(MD),RN, LPN, CNA(HHA), Social Worker, and Chaplain as well as Volunteers. We all work together and communicate together regarding our Hospice patient and Caregivers(Family, LTC staff or just hired caregivers). My sisters MIL just passed away a few weeks ago on the West Coast and I was surprised how different their Hospice Services are compared to what we offer here. In a way, we are so much more ahead in the Midwest than what they offer on the West Coast which was so surprising to me! I am glad that you enjoy Hospice and I am sorry that, that LTC place you were in was missing the true benefits of what Hospice can offer them. You know, I have also worked in LTC with nurses that were too busy to call with questions or ask for Hospice to come in to help. There was a huge learning curve once Hospice went into the LTCF. They are now reaping the benefits now that they know we are not coming in to replace their care but to enhance what they can do to keep their Residents the most comfortable during their transition in end of life. Sorry, I really did not write what I did to offend you or anyone else for that matter. Take care.

[ayla2004, ASN, RN]

i'm curiuos.

for end of life care we use syringe driver running sub cut with an opiate anti emtic, a benzo and a anti secretions running slowly over 24hr with prn doses given sub cut given as required.

very effecticve in comfort care

[GrumpyRN63, ADN, RN]

I would be wondering why the pt ( presumably dying at this pt) would still be getting TF at such a high rate? TF's themselves are contraindicated in Hospice rather than the occas yankauer sxn. (Unless this was a longstanding TF that he had prior to being put on Hospice ?) His GI tract would be shutting down as well as his other vital organs and it sounds like he had an acute event, flash pulm edema or aspiration ( abd firmly distended) from not handling the TF/fluid. He probably would not have been helped by sxing. This is important to understand why IVF's and TF's are really frowned upon at EOLcare as they cause more suffering to the pt rather than (the misconception) that giving fluids is a part of comfort care, its the opposite, stop the fluids/ TF's, the death will be much more peaceful /comfortable and easier to manage the sx's. This is also why the pt is most always managed better and has a better death in the home, as these are not an issue. It amazes me all the time to keep fighting with the MD's in the hospital ( we see sign them on inpt as well ) to stop the fluids for the benefit of the pt, --even at KVO you just get another week of worsening sx's to manage and a slow drowning.

[CoachDiva23]

Wow I am so sorry. I am about to start clinicals and I must commend you for strength in witnessing such an event. Be strong and take care.

[Wishinonastar, BSN]

Unfortunately miracleluke what I hear from my home health patients who transfer to hospice is not very positive either. The hospice company that marketed their way into the LTC where I was PRN at has a rep for big promises and little follow through. They are for-profit which I suspect makes a difference, but part of the problem is the huge service area. Nurses are on call for multiple counties and they have a complex voice mail call system where you seem to wait forever for a call back, only to be told that she is 2 counties away and cannot help you. I think some of these companies try to expand too far and it is one reason why staff do not stay. The mark of a good company is one that can hold on to their nurses. I am in PA and we have quite a few hospice companies around here. Since the hospital agencies stopped offering hospice I have applied and interviewed at several of the private hospice companies, but only one seemed like a place that I really felt was right and I could not take the job because it involved spending a lot of time in the home office in the city. My son was pretty young then so I did not want to spend more time away from him.

I think anyone who works for a LTC facility who has the hospice reps come in and make big promises should know that they are not all alike. Ask questions, and remember there are many out there so you do not have to stick with one company. The patient has the right to choose! It is illegal to say "We only use ____ hospice here".

Back to the subject....

[saintplatypus]

I too have been told suctioning is usually not done when patient is hospice, and i have read the rationals and I do understand why this is. However, there are other means to attempt clearing the airway, did you turn the pt to his side and use a swab to try and clear his throat? If the secretions were clearly draining down into his throat I would have repositioned him to his side to allow them to drain and perhaps pocket into a cheek where they may have been clear more easily. Attropine often dries up the secretions quickly after one dose. It almost sounds as if your pt was bringing up stomach contents into his throat rather than secreting fluid into his throat. Was the HOB up 30 degrees?? This is important with GT feedings to prevent aspiration, and equally important for at least an hour once the feeding is stopped. And many times pts do produce emesis prior to passing which again might have been cleared if pt turned to his side,

You did the best you could under the circumstances, don't underestimate your nursing skills because you could not provide the pallative care you wish you could have for this man. No death is the same, and some will cause more suffering while other seem to just easily pass on in peace. It's all a new learning experience each time. Take what you learned with you and apply it next time around.

As far as hospice goes, our facility provides hospice. It is run by a subsidiary of our company, basically company within a company. Nearest office over an hour away. And they do not come and help provide any care for the pt at time of death, they come and fill out forms and perhaps talk to families if the family so wishes, or they may call in the clergy if the family wish spiritual councelling. Other than that, they will give you med orders via phone for the Roxinol, Ativan, and atropine. They sometimes will increase dosages if you are persistant and insistant, but this particular hospice our company owns does not seem to be driven to provide good end of life comfort measures pallative care. And they get irritated if you call in the night, and in my facility most of them die during the night, so go figure.

Recently we had an elderly man whose family IMO had abruptly had their loved one taken off all meds, made NPO, DNR, then a hospice patient... all in a couple of days. This man had a will to live but family for whatever reason decided to allow him to die. The family was at bedside round the clock for the whole week it took him to pass on. During this time we dosed the man up with all the meds he could have, everytime he could have them... per families request. We took vitals q shift and occas in between, they didn't change much at all until last day. But family on last day wanted nursing to be at bedside constantly. We explained to them he would be passing soon, we could no longer obtain blood pressure and his resps where apneic freq, We checked his temp at one point and it was 105.7, It had been running rather high and we were giving tylenol supp for this. This particular time the family refused to allow him to be turned to insert the supp. They said we were prolonging his life and causing him distress by turning him. The nurse at that time left the room, thought about what the family said and marched back in there supp in hand. She told them that she was his advocate and by giving the supp she was not prolonging his life but helping him to be more comfortable. Then she proceded to turn him and give it. Family was very angry. Later they asked for the hospice nurse to come in they wanted her to be there. This was 10pm. Hospice nurse was called, came in over an hour later. The family complained that the facility was providing inadequate care, that they had to ask for us to medicate him when it was due, which was false, that we refused to bed check him every 2 hrs, false again, family had refused to allow CNAs to turn him. And they complained that vitals were not being done regularly, oral care hadn't been given, and that the nurse on duty was obviously too old to still be on active nursing duty as they claimed she was lax and incomepetant. Mind you the mans nurse was 70 yrs old but she rocks, and is very capable and competant. So anyway, the hospice nurse came and gave the nurse hell and told her shape up, left the facility within 45 min after arriving. 2 hours later the man was getting weaker with more freq periods of apnea, still the family refused to allow CNAs to turn res for hygiene care this time saying it made the apneic episodes last longer. Temp was still over 105 and the family continued to protest the supp which we gave anyway. Meds given each and everytime they could be given, at the exact time. The family came to us one time to see if he could have his meds yet, it was 20 min too soon. Other than that the family never once asked us to medicate him. By 4 am the family again asked for the hospice nurse to come. The hospice nurse came as requested, annoyed and bedraggled as well. All the family wanted was for her to attempt vitals again, and complain some more about the nurse on duty. While hospice nurse was there the gentleman passed on. The family meanwhile seemed completely unphased about their loved ones passing. all they wanted to do was create chaos and set themselves up to sue the facility is my opinion.

Yet I am sitting there wondering, why family were you in such a hurry to discontinue his meds and nutrition, why did you want to allow your family member to suffer rather than have his supp for comfort. Why did you refuse to allow us to care for him if indeed you wanted him to have care??? And why did you think the hospice nurse could or would fix your complaints when she didn't even seem sympathetic to his death at all????

Poor fella, I felt his family was in some hurry for him to die and he didn't die fast enough for their liking, I felt there health decisions for him were made specifically so he would suffer, There was no reason to make all of it happen in a week, He wasn't on the threshold of death, in fact he may have been around for months had they not denied him his meds and nutrition. So I think they chose for him to suffer and then wanted to blame our facility in effort to ease their guilty conscience. My opinion again.

If nothing else let it be considered a blessing that the family was not present to witness your pts passing. Sure it is lying but you can tell the family he went in peace and ease their consciences and they will never know otherwise and they can go on peacefully. If they had been present during this event who know what they would have thought, and how the situation would wind up. I know its hard to watch people die, you feel helpless and worthless alot of times. Nurse help the sick heal, they don't sit back and watch as you die. But yes sometimes that is all you can do. And just your presence in the room can be the right intervention to do at that time. Even if they appear to have no brain activity going on they may know u are their and that may be the only comfort you can provide for them.

Bless you hon, Sorry I am so rambling.

[Wishinonastar, BSN]

Ah yes, reality. Very powerful. I am glad you rambled. Why didn't the family take him home to die if they wanted to do it their way???

[saintplatypus]

Well I have not the first clue. Attention maybe?? Um wanted to sue facility for fast money, I dunno. I maybe human, but for the life of me I sure don't understand other humans. People are greedy, selfish, mean, hateful, and yet others are compassionate, caring, selfless, and heroic. Go figure. Maybe I'll figure the human mind about the same time man learns to understand women. ya think?? LOL

I guess as nurses we will never understand why our pts and their families make the choices they do. Some folks are DNR, others avid CPR fans. Some people wanna live even if they are brain dead, while others who could live on for years with GT placement choose not to have it done and be allowed to die. I personally have changed my thoughts on these subjects over the years and I am determinded to see my wishes are carried out. I made sure I wrote an advance directive, I explained it to my hubby, told my kids, and now I am secure in knowing what I want will happen when the time comes. I am a DNR, GT nutrition only in event that my illness will not progress beyond a 20% loss of brain function, if more than 20% brain function is anticipated, no artificial hydration or nutrition.. enteral or parenteral. No ventilator. No defibrillator. No atb if disease process causes temp in excess of 105. And I want to be sent to the body farm at the university of tennessee to rot naturally as a science project.

Maybe weird, maybe not. You change when you become a nurse and witness death. I no longer fear death as I did growing up which is good, yet I am getting older and am more aware of just how short the whole life thing is and that I don't have that much left in the scheme of things. AT least my voice will be heard loud and clear when I need it to be heard most. I strongly advocate advanced directives if you have specific end of life do's and don'ts.

rambling again sorry. adhd

[miracleluke]

You are so right cxg174! And doesnt that make it that much harder for all of us who work for reputable companies to get in there and prove to them that not all are the same? I agree whole-heartedley! So back to Topic: Kelly, we are so sorry you had such a bad experience with this death, but please believe us that not all Hospices are alike! We did want to impart to you however that you did do the best you could under the circumstances. We believe as Hospice Nurses that having a TF going is only going to make the death more difficult on the patient. What we all as Hospice Nurses want you all to know is that having IV fluids for dehydration and TF for nourishment is highly discouraged in Hospice patients that are at the end of life because they would have a much more peaceful death having less fluids aboard without these. The body just does not require that much when the systems are shutting down. So please in the future we just want you to understand that is why we are telling you this, not to be mean or to try to starve someone to death it is just easier on them during this process. As I have read from other Hospice nurses in this thread all of what we are telling you is true. We have all seen it both ways and can stand by what we are saying! Take care and research the Hospice Companies you are letting into your LTCF's and know who are the best at providing you with the information and the care your Residents deserve! Now as cxg174 stated it is illegal for you to suggest a certain one Hospice program, but you can educate yourself to the ones that are more reputable. Take Care.

[miracleluke]

saintplatypus! Sometimes there is nothing you can do with families that are that way, Either they have other motives for a quick death or they are grieving in a way you cannot get through to them. I am sorry you had such a terrible experience in your facility. When something like this happens the only thing you can do as a professional is Document, Document, Document!!!!!!!! Make sure everything you do is in writing so if some family does decide to go to court the LTCF has a leg to stand on! Good Luck!