Is anyone else ever guilty because they feel they should have done more?

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Specializes in District nursing - palliative care, LU management.

Hi all. I’m a District Nurse of 10 years experience and a recent situation has really hit me hard.

The gist is I became involved in the care of pt with a poor prognosis. Having never met this lady, I visited to find her in pain (she had ca pancreas with multiple mets). She had been started on a fentanyl patch (previous analgesia paracetamol and oramorph.) I knew from experience, by assessing this lady she had days to live. The patch along with oramorph for breakthrough pain was not sufficient. IMO a syringe driver was necessary to prevent these “peaks and troughs” in pain. I consulted the Macmillan “specialist” who suggested it was too early for a syringe driver and that we should commence additional oral meds. I knew this was inappropriate and the wrong choice but I let the Macmillan team over rule me. My pt had to suffer 48hrs of reactive pain relief, and I can’t help but feel if I’d of acted in a stronger manner this may have never happened. After two days a palliative consultant assessed my pt and started the driver. Which confirmed how inadequate my own actions were. Has anyone ever felt they didn’t do enough?

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Specializes in retired LTC.

Go easy on yourself!

I retired some time ago after many years. I believe all nurses question themselves at some time or other. There are times when you just have to defer to a 'higher upper' practitioner. You may not always agree; you did try.

Maybe you COULD have pushed harder, but the results may have still been the same regardless.

If you have an EAP counselor thru your employer, you could ask for some guidance to settle that NOT NICE feeling. I know that feeling myself.

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Specializes in Surgical, quality,management.

Hugs to you. District nursing is tough, you are out there on your own and the Macmillan specialist I'll bet was not seeing what you saw. There is something called graded assertiveness that you could use going forwards. It is a 4 step process.

CHECK - I am concerned that this pt pain management is not sufficient, her pain is peaking before next doses are due. Can you check what her her plan is?

OPTIONS - I think that a syringe driver might need to be added.

DEMANDS - I need you to re view this patients pain management. Her verbal reports / non verbal pain assessment is XX, my experience is telling me that her pain at EOL is not being managed

ELEVATES - I am going to talk with (insert person/ service) or refer her to A&E to be seen by a palliative care team in person.

Have a look for something similar in your organisation.

Also like the PP said please access EAP to help you process this situation and not let it fester with you or cloud your relationship with Macmillan as a service.

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Specializes in retired LTC.

to K+ - learned something new from you re 'graded assertiveness'. Never quite heard it called that.

Great thing about nsg - always an opp'ty to learn something new even when retired.

TY

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.
9 hours ago, K+MgSO4 said:

Hugs to you. District nursing is tough, you are out there on your own and the Macmillan specialist I'll bet was not seeing what you saw. There is something called graded assertiveness that you could use going forwards. It is a 4 step process.

CHECK - I am concerned that this pt pain management is not sufficient, her pain is peaking before next doses are due. Can you check what her her plan is?

OPTIONS - I think that a syringe driver might need to be added.

DEMANDS - I need you to re view this patients pain management. Her verbal reports / non verbal pain assessment is XX, my experience is telling me that her pain at EOL is not being managed

ELEVATES - I am going to talk with (insert person/ service) or refer her to A&E to be seen by a palliative care team in person.

Have a look for something similar in your organisation.

Also like the PP said please access EAP to help you process this situation and not let it fester with you or cloud your relationship with Macmillan as a service.

This is a great tool that could help guide so many nurses in different situations. I'm going to keep it in mind in my practice for sure, as recently I've also found myself in a few frustrating situations where I wasn't sure that the MDs were really aware of the discomfort the patient was experiencing based on the orders I received at the start of my shift. I think there's nothing more frustrating than watching a patient endure discomfort that you think could be alleviated, but your pathways seem to be blocked by the providers.

Cobby545, I'm sorry you had a disheartening experience. I think we can all identify with those situations and how you're feeling. I hope you can take solace in knowing that you had the best interests of the patient at heart and you did what you could at the time for that patient. Your efforts are appreciated, for sure.

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Specializes in Surgical, quality,management.

Check out the Cognitive Institute "always checking ".

Nurses tend to get stuck at the options or demand stage and rarely go to elevate even if their gut is saying so...

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Specializes in ICU/community health/school nursing.
On 10/19/2019 at 4:17 AM, K+MgSO4 said:

Hugs to you. District nursing is tough, you are out there on your own and the Macmillan specialist I'll bet was not seeing what you saw. There is something called graded assertiveness that you could use going forwards. It is a 4 step process.

CHECK - I am concerned that this pt pain management is not sufficient, her pain is peaking before next doses are due. Can you check what her her plan is?

OPTIONS - I think that a syringe driver might need to be added.

DEMANDS - I need you to re view this patients pain management. Her verbal reports / non verbal pain assessment is XX, my experience is telling me that her pain at EOL is not being managed

ELEVATES - I am going to talk with (insert person/ service) or refer her to A&E to be seen by a palliative care team in person.

Have a look for something similar in your organisation.

Also like the PP said please access EAP to help you process this situation and not let it fester with you or cloud your relationship with Macmillan as a service.

I love this so much!

OP - we've all been there and I think this is the thing that drives nurses away from the bedside and away from nursing in general. We are not so much nursing as managing expectations and frantically waving our arms...

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Specializes in District nursing - palliative care, LU management.

Thanks for the responses. Some really good techniques and I do need to process this situation. It’s great to have other nurses to listen, share experiences, and advise.

Many thanks all

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