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.
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.
Yes, I agree with you about making death as comfortable and as painful as possible. I said yesterday, I did not understand being hospice and full code, but after thinking about it I know why he didn't want to be DNR. He did not accept his cancer. He defied it and wanted to live for as long as possible. Even if it meant to undergo painful interventions.
I have a very dear friend who has ovarian cancer for 7 years now. It is an end stage. But drive to live in her is incredible, she is moving rivers and mountains to get herself newer, more experimental treatments and often has to overcome MDs attitude of just accept your cancer and make the most of what time you have left. And yes, she is suffering a great deal of pain and side effects of treatments, but she wants to be around long enough to see her grand kids graduate from college and see them married. She wants everything done to make it as long as possible.
Anyways, I want to thank you for your reply I learnt from it. A lot. I learnt that I need to change the way I am thinking. Especially in the environment I am working, where there are a lot of people who close to final stage of their life. My thinking was of saving the life, of not causing problems by overlooking something. Instead I should have may be concentrated more on comfort measures. And then also calling a code ....
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.
You did everything you possibly could....the patient was sent the out and the hospital sent them right back.... they seem to do that over and over with LTC patients. They obviously missed something at the hospital. I have experienced this over and over when I send LTC residents to the hospital! With you quotes saying "follow up with MD" heard this order from ER doctors/oncall physcians over and over! Do not blame yourself, you did everything you possibly could. I would have done the same thing in the situation and you followed all the orders you were suppose to with monitoring the wound. Hope this makes you feel better. :)
NN2BVE
31 Posts
Yes, I agree with you about making death as comfortable and as painful as possible. I said yesterday, I did not understand being hospice and full code, but after thinking about it I know why he didn't want to be DNR. He did not accept his cancer. He defied it and wanted to live for as long as possible. Even if it meant to undergo painful interventions.
I have a very dear friend who has ovarian cancer for 7 years now. It is an end stage. But drive to live in her is incredible, she is moving rivers and mountains to get herself newer, more experimental treatments and often has to overcome MDs attitude of just accept your cancer and make the most of what time you have left. And yes, she is suffering a great deal of pain and side effects of treatments, but she wants to be around long enough to see her grand kids graduate from college and see them married. She wants everything done to make it as long as possible.
Anyways, I want to thank you for your reply I learnt from it. A lot. I learnt that I need to change the way I am thinking. Especially in the environment I am working, where there are a lot of people who close to final stage of their life. My thinking was of saving the life, of not causing problems by overlooking something. Instead I should have may be concentrated more on comfort measures. And then also calling a code ....