My resident died yesterday. What should I have done differently?

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I am a new grad (4 month) working at a very busy long term nursing sub acute center. Yesterday morning I lost one of my residents. It is not the first time I lost someone, but this one got to me a lot more then others. This person who has end stage of cancer in pelvic cavity was found in the previous evening with a profuse bleeding from wound at the groin area (old deep wound). Nurses gave accounts of big clots passing through the wound. My colleges called 911 and resident was transferred to the hospital. Only came back a couple of hours later. No blood transfusion, No IV fluids were given. Only orders were to monitor the wound and to follow up with PCP.

When I assumed my shift, the resident was stable, no bleeding, vitals stable, no pain. I checked on him thought the night, checked vitals and a wound site for bleeding. All was good. Around 6 a'clock in the morning the resident started to complain of pain in a lower abdomen area. He often did in the last months. He had narc's to cover for pain and they were helpful. I checked wound dressing = dry and intact, no signs of bleeding. Checked vitals = WNL, BP on the lower side (92/50), but I expected that from the recent bleed. Yet something was different, I had this knot gut feeling. I was hesitating to give usual pain relief. I was concerned that there might be bleeding inside ( abd was on the hard side, but not rigid board like as I learned from textbooks in case of internal bleed ) and that pain relief would mask more serious problem. In addition BP was on a lower side and there is this side effect of lowering it even more. I wanted to call MD, only I didn't. I talked myself out of it. I said to myself there is no signs of bleeding, his dressing is dry and intact, vitals are as expected given recent bleed that day and no remediation for it in the hospital. The pain is expected for someone with the cancer in the pelvic cavity. I told to myself he's been on that med for long enough and will not be affected and he is in pain and needs pain relief. I gave him pain med and went to tend to the rest of my 47 residents who needed their morning meds too, 14 BS checks, 3 GTs and 4 IVPBs.

About an hour later I went to check on him again, found him screaming in pain and bleeding profusely from his wound. I yelled for help, we grabbed gauze still left by his bedside from previous evening, applied pressure to the wound , put him in the trendelenburg and initiated all the steps of the code. There was so much blood gashing from the wound, it would not stop. The BP at this point gone down to 50/20. As we were applying pressure on the wound, we saw the color disappear from his face , he was no longer responsive to us. 911 crew arrived and we worked more on him together. When they were taking him to the hospital he came back to us and was responding. I taught we got him back

When I came back to work, I learned that he didn't make it and died in the hospital an hour later.

Since then I have been replaying what happened in my head and feel responsible for his death. I should have listened to my gut feeling and sent him back to hospital. All my coworkers ( who are absolutely wonderful, ) kept saying they would do the same thing I did. What do you think? I want to learn from this experience so I can be better nurse and so at least I cna attempt to make sense of my resident's death.

Thank you and sorry it is so long

PS. Please be gentle to my English . It is not my native language and I haven't slept yet. Just been replaying what happened in my head.

Specializes in Acute Care, Rehab, Palliative.

If he was end stage cancer then why would he be a full code? He obviously had great pain and it wasn't being controlled at all. Why were they not treating him palliatively so he could be comfortable and die in peace instead of distress?

Specializes in CMSRN.

I am sorry this has been upsetting you.

From what I read, it was his time.

Unfortunate that it was painful for him.

1. Your English is perfect.

2. You are a good nurse who cares about all of your patients.

3. You had appropriate physician orders to address his pain and you carried them out appropriately after assessing.

4. I doubt very much that you would have recieved orders to do any thing differently if you had called the physician.

5. A person who had end-stage cancer, in a long term setting--why wasn't this person on palliative care with generous pain control orders? Palliative or hospice care accepts that death is inevitable to all, and comes sooner than planned to some, and allows that death to happen with minimum of pain and fuss. Maybe your facility needs to advocate for better palliative orders for these types of patients.

6. We hurt because we care.

Don't be too hard on yourself. It sounds like you thought of all the right things. Remember he had just been in the hospital and they obviously missed something since he only came back with orders to monitor the wound. I do like the reminder to listen to your gut and follow those instincts. If you feel uneasy about something at least a call to the on call MD can help reassure you. But do not beat yourself up. I think you sound very conscientious.

Specializes in Medical Surgical Orthopedic.

I am also puzzled that he was a full code. It doesn't sound like you did anything wrong, but it sounds like the patient could have been better managed by his provider. Maybe the family was a barrier? Poor guy...I'm glad he's not suffering anymore.

Specializes in Home Care.

I would have done the same as you.

He's no longer in pain.

Specializes in Plastics. General Surgery. ITU. Oncology.

I would never have called 911 but upped morphine, midazolam, diazepam. Those drugs that ease gently into the long sleep.

What was your facility THINKING of to call a code on what was clearly a terminal patient? Do you think the futile attempts at resuscitation improved his last hours? What would a blood transfusion have achieved? A few more hours in pain and distress.

There are times you have to let the patient go in as much peace and dignity as you can make possible.

Specializes in Hospice, LTC, Rehab, Home Health.

The tumor had probably eroded into major blood vessels and he bled out. This is not unusual in certain cancers. Outside of the family and MD agreeing on hospice or palliative care, there is nothing else that would have made a difference for him. You did everything right and made him as comfortable as you could. The failing here was not yours only that this poor man and his family were not able to benefit from hospice or palliative care. Be kind to yourself and if there is any lesson to be had from this, maybe just to advocate for your terminal patients to get hospice or palliative care referrals. :hug:

Thank you for your kind words of encouragement and wisdom. I am taking it all in and learning from it.

Let me clarify. This was a hospice resident who is a FULL CODE. I don't understand it and don't agree with it, but those are wishes of the resident and the family.

He did have pain control ATC and prn. He received scheduled morphine on time earlier that night. I was monitoring him thought night. Until 6 o'clock he was comfortable. AT 6, when he started to c/o pain, I was uncomfortable because of my gut feeling that something is going on, but I did give him his morphine, because wanted him as comfortable as possible. Until yesterday, when he started to bleed excessively, the pain was fairly controlled.

Thank you again for reaching out to me. I am still pretty shaken up from yesterdays events. I guess I learned a lesson that I did not get in nursing school. I learned my role as a nurse is not only to save lives, but also to help let go of live pain free as possible and in dignity. I think I get it now

Specializes in Gerontology, Med surg, Home Health.
I would never have called 911 but upped morphine, midazolam, diazepam. Those drugs that ease gently into the long sleep.

What was your facility THINKING of to call a code on what was clearly a terminal patient? Do you think the futile attempts at resuscitation improved his last hours? What would a blood transfusion have achieved? A few more hours in pain and distress.

There are times you have to let the patient go in as much peace and dignity as you can make possible.

If the patient didn't have a DNR order, this nurse HAD to call the code. It isn't up to you or me to decide who to code and who not to. If you don't attempt every measure you can be sued for negligence.

I have many many people in my building who are full codes. The doctors and nurses can only explain what the expected outcome is. It it the patient's choice (or family member if the Health Care Proxy is invoked) if they want to be coded. And in this country, staff nurses do NOT up the dose of anything without an MD order.

I agree with the previous poster. It was not her call to not code him?? You did fine OP, sometimes there is just nothing we can do.

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