Lost my first ICU patient today

[TigerGalLE, BSN, RN]

So I recently transferred to ICU from a med surg floor. I absolutely love ICU. I have learned so much and I really love being able to focus on my 1-2 patients. I feel I really know my patient from head to toe.

So today was my first death. I know you can't save them all but something about her death really disturbed me. She came in with a mesenteric arterial bleed that was emergently repaired in the OR on Tuesday. Against everyone's expectations she was still alive today. The surgeon did not think she would make it through the night Tuesday let alone until today. So she returned to OR for a wash out/ debridement this morning. They found that her entire bowel was dead. The surgeon told the family there was nothing more we could do and end of life care was initiated. The patient had been on a fentanyl drip and was resting calmly before and after surgery. She was on high dose pressors and intubated. We asked the family to step out to pull the ET tube and we also turned her pressors off at that time. As soon as we pulled the ET tube the patient began to moan and stated "it hurts so bad, it hurts, it hurts." I medicated her with prn morphine and ativan and called the family back in to say their goodbyes. She died about 15 minutes later.

I can't get over what her last words were. My heart breaks for her. I hate to think she was in this much pain the whole time she was intubated. She always seemed to be comfortable. It seems obvious to me now that this wasn't the case. I hate that she suffered so much. I just hope she didn't die in pain.

Tiger

[leslie :-D]

i'm sorry, tiger.

whether it is expected or not, death is never easy.

it's a good sign she only lasted 15 minutes, as i have seen many pts linger and linger, r/t unrelenting pain.

(((gentle hugs))), sweetie.

leslie

[PostOpPrincess, BSN, RN]

Please clarify for me: Why turn off the Fentanyl drip immediately? Why not let the morphine get on board first and then turn it off? Patient was not very sedated and to hear her say that in her last moments must've been miserable for the family.

I'm interested in hearing the rationale.

[Forever Sunshine, ASN, RN]

Thats really sad

I haven't had a patient die on me yet. There is one who is close to dying and I make sure I keep her really comfortable. Nobody should have to die that way.

[traumalover, RN]

I'm sorry your pt died. It will happen the longer you are in ICU and take sicker and sicker patients. Please take comfort in the fact palliative care was initiated and she did not suffer a prolonged code, or being trached and pegged and live in an LTAC for years. These things happen. If you had given her more medication and she had died immediately you may have been questioning if you gave her too much and put in resp arrest. Any death makes me question myself. Just knowing that you were there and your empathy probably helped the pt and family a great deal.

[emnicams]

Please clarify for me: Why turn off the Fentanyl drip immediately? Why not let the morphine get on board first and then turn it off? Patient was not very sedated and to hear her say that in her last moments must've been miserable for the family.

I'm interested in hearing the rationale.

Where does it say they turned off the Fentanyl drip? I've reread the post 5 times and can't find it... maybe it's too early in the morning for me.

[netglow, ASN, RN]

I wonder if the surgeon considered use of Propofol for DNRCC? IMHO!!!

I know, a lot of consideration. But, gosh. If she had an entire dead bowel, and massive surgical manipulation... there probably is no pain control and death is imminent. Do any of you ICU seasoned nurses feel the need to advocate? OP, I hope this something the surgeon considered.

[aubreysmommy]

I do not see where she turned of the drip either and I reread the post many times, and she did say that the family was NOT in the room when that happened. I've lost a patient in the ICU as well but it was very peaceful and she did not wake up at all. I've been told that it gets easier each time it happens, but I think it depends on the patient and the nurse.

[netglow, ASN, RN]

...Do not extubate, Morphine 4 mg IV every 15 minutes, Propofol drip titrated to total sedation/unconsciousness, turn down sound on all monitors?

[TigerGalLE, BSN, RN]

We didn't turn the fentanyl drip off. And it was going at quite a high rate.

Also, we do not use propofol at my hospital anymore.

We usually do extubate our Cat 5 patients so their family can see them without the tube in their mouth and the patient can die without that horrible ET down their throat.

She did not have any respiratory distress. She complained of pain, I medicated her with 5mg Morphine, she then closed her eyes and died 15 minutes later with her family at her bedside.

I think she died comfortably. I'm just disturbed because I'm afraid she was in pain all day and the fentanyl drip wasn't enough. Esp since the first words she said on extubation were "It hurts." Hre abdomen was completely open with only a sterile towel and large tegaderm type dressing covering the wound. The surgeon wasn't able to close her. So that had to be excruciating.

[XingtheBBB, BSN, RN]

Sounds like you did everything you knew you needed to. It can be hard to assess pain. Especially when someone can't move or make sound (FLACC becomes useless) when they are so septic/shocky that they need multi pressors (can't follow VS trends to look for pain) You didn't see signs of pain and you were aware that there was a possibility but you were treating her with Fentanyl so to the best of your knowledge you were addressing that concern. You just didn't know. Sadly, it can happen. It sounds like everyone was using their best educated judgment so there's nothing to beat yourself up about. Sorry it had to happen.

We always extubate. It's nicer for the family to see that whole face they love.

Propofol is not a pain med, has no effect on nociceptors or opiate receptors so I'm not sure what that point would be? Just because a patient is too sedated (asleep? no.) to complain of pain or react to it doesn't mean it's not there. Treating pain with Propo is like treating pain with Vec?

[XingtheBBB, BSN, RN]

Perhaps part of the problem is the gag and increase in abd pressure, even in an open abd, that increased pain as you were extubating. Just a thought. It might have been worse at that moment that prior that day.