conscious pt terminal wean

Specialties MICU

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First this is the pov of a tech /nursing student..I thought this might be the place for this post. I have only had one terminal wean patient and the patient was concious and she made the decision to remove her vent.

This is my biggest issue w/becoming a nurse..the whole experience did not sit well with me at all and still doesn't 2yrs later. So here is the story from a techs pov:

I show up to work to find ive been pulled to the icu ..I get report from the tech and she tells me that one of my pts is about to be taken off the vent ...I say what!? (This lady has been in the icu for about 6weeks and I knew her..she was totally alert and would ask for things used the call light etc.) Im a float pool tech so I wasnt familiar w/ the process. This lady was on dialysis , masthenas gravitas , had a gaping abdominal wound with a wound vac that wasnt healing..she wasnt mobile and was incontinent, couldnt eat and had ards ...so after report I go to her room and the process was under way ..her husband ,two daughters, her nurse and the doc were in the room ..so I just kinda peeked in and saw the pt sign a paper the doc had....I never entered the room I just sat at her monitor to watch her vs as things "progressed" about 10mins later I see a respiratory therapist enter the room ..the RT leaves and gives the husband a long hug outside the room..then the doc comes out and sits near me to put in the patients "final med" orders....the nurse comes out of the room very chipper and Normal every 10 mins or so to check the pts vs ..she makes a comment to me "shes lookin real "smurfy" in there" as if shes excited the pt will be dead soon. ..Finally the pt passes ..her family leaves very shortly and the nurse comes to get me for the post mortem care I enter the room and see 15 or so little bottles of morphine on the counter ..i felt sick and really didnt want to be apart of it ..but of course i did my job and helped..I could see tons of sores in her mouth that I never noticed which aluded to the intense suffering she was going through....during the whole time the nurse just seemed to happy and not phased by any of it. Im not sure how I would feel after something like that as a nurse. It was the fact the patient was of sound mind that really disturbed me.

Specializes in private duty/home health, med/surg.

Many nurses have already made beautiful comments about end-of-life care.

I'd like to address the OP's perception of how the nurse handled this situation. I can't imagine the emotions this poor nurse was dealing with -- it sounds like this woman had been a patient on the floor for some time. However, I'm going to assume that this nurse had at least one other patient to care for, OR would likely have another patient in the bed once the deceased patient left the room.

I've been in the position of stepping out of the room of a newly deceased patient as a new admit rolls up. It isn't an easy thing to do.

A nurse needs to do what a nurse needs to do to keep it together to finish her shift for the other patients.

Specializes in Acute Care - Adult, Med Surg, Neuro.

I always think about myself. I would not want to die gasping for air (my biggest fear) or in horrible pain. The morphine is a mercy and I am not afraid of giving it to my comfort cares patients. I have also titrated fentanyl drips per MD's orders for respiratory distress. I am honored to care for a person in their last days and find it to be the most humbling and fulfilling part of this career.

Specializes in SICU, trauma, neuro.

I haven't yet read the other replies so forgive me if I'm repeating something. BG: I work in a SICU which includes trauma and neuro in a level 1. We withdraw ventilation quite a lot, such as when after moving heaven and earth to save someone not knowing what the outcome will be...but they were just too gravely injured. Catastrophic strokes. I also happen to be pro-life.

The fact that she is of sound mind and can make decisions is assuring, because it was likely her decision made with her family. It sounds like she had some devastating health issues and had decided she'd had enough. ARDS, big open non-healing wound, MG... a really raw deal. The decision to remove a vent is not the same as actively euthanizing someone ("assisted suicide"). They made the decision to stop utilizing a machine. A situation that I think is comparable is when a cancer pt decides to stop chemo if it creates more suffering than it alleviates. The staff and family didn't kill her; her disease killed her.

Withdrawing mechanical ventilation is not withdrawing care. We want to alleviate suffering, right? We give drugs as the pt is dying to make them comfortable. Morphine relieves pain, and it also relieves the feeling of air hunger. Physiologically, her body was starving for oxygen; morphine helps take away that feeling of needing to breathe. Our palliative care MD's usually prescribe morphine, ativan for anxiety, atropine eyedrops under the tongue to and a scopalomine patch behind the ear dry up the secretions that a dying person can't clear. When a pt is actively dying, we give them the meds prn as often as they have symptoms of respiratory distress, pain, anxiety, "death rattle." All that morphine you saw was not given to speed up her dying, but to help her be comfortable in her last moments. Can those drugs result in a faster death? Of course. But the alternative is a somewhat slower but agonizing death. Either way, death is imminent.

Was that "smurfy" comment flip? Yes. You can have a "positive" attitude during difficult times without being unprofessional. When my patient is actively dying, I give the family lots of smiles. Not cheesy, forced grins, but the soft genuine ones that reach the eyes. If the family initiates interaction with me, I ask about their loved one. What and who were important to them, what special memories are part of their story? Maybe Mr. Johnson stormed the beaches of Normandy. Maybe Sally was the first in her family to go to college. Maybe Esther did an amazing job raising six children alone after her husband passed away. Get some of these memories going, and before you know it you've got an impromptu memorial service that the pt is there to enjoy! If they're focusing in on each other, I keep my presence less obtrusive. Quietly asking them if they need anything for comfort, asking if they have questions about what to expect. You can absolutely be a bright presence without being inappropriate.

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So there's some perspective; I hope it helps. That said, if you've thought from every angle and can't in good conscience be a part of this, you should consider what setting you should be practicing in. ICU, hospice, oncology could be challenging for you.

I don't think some of the previous comments about if you can't handle this, maybe you're in the wrong profession, were necessary. The OP obviously has a big heart and is passionate about helping her pt's to get well. Hugs, ((((Taylynnfree))))

In contrast to your story, one patient whose memory still haunts me ten years later is an alert gentleman with end stage COPD. He was DNR/dni and I was told in shift report that he wasn't expected to last the night. His doctor had left orders for IV morphine that could be given every three hours as needed or something like that. There was no in-house doctor covering this pt and this attending was notoriously difficult to reach. My patient woke up from his respiratory-depressed-morphine-induced sleep before his next dose of morphine was 'due.' He was short of breath and scared, saying 'I didn't think it would be like this.' After receiving his next morphine dose, he didn't wake again and passed a few hours later.

I was a poor advocate for this patients comfort at the end of his life. I was also poorly educated in end of life care and had been given a woefully inadequate order set. Now with more education and experience under my belt I know how to be more proactive in anticipating the needs of my patients at the end of life. I have taken classes in palliative care which explain common symptoms at the end of life as well as the medications used and the theories behind their use. Being more aware of the dying process has allowed me to provide information to pts families and even other staff members which can help with their coping during this time by letting them know in advance some of the things they can expect and what we can do to keep the person comfortable.

I know this topic has already been extensively discussed but someone posted an article recently written by an ICU nurse and I thought it gave a great POV from the nurse in these situations daily.

A Letter to the Family of My ICU Patient | Savor the Essence of Life

Specializes in lots of different areas.

Great post, soldiernurse!

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