A patient made me cry today - page 9

my skin is really thick. i've seen alot of things between being a nurse and a paramedic. i've seen abuse, neglect and death before. today, i got a patient from the emergency room with a massive... Read More

  1. by   CanuckStudent
    Quote from cherrybreeze
    Canuck student:

    The fact that you say you will be pre-med explains your statement about "MD's order the meds that help patients die easier and nurses poke and prod until they do." (something like this). Please also understand the error in your statement and belief. You posted about it before, about ordering morphine to hasten death, and that is NOT TRUE. I hope you truly come to understand this before you become a physician, so that you don't find yourself sued for killing somebody. Also, you said it yourself.....MD's ORDER the meds...that's it...they write an order. The nurse is the person who administers that med, based on their judgement. The nurses are often the people that call the physician in the FIRST place, to GET the order for that med, or to increase a current dosage that is not adequate. Nurses are the ones who know the patient's condition and needs, the physician too often never even lays eyes on that patient during their last hours, and when they do see them, during the course of rounds, it's for a matter of minutes. Your view of physicians being the heroes in this scenario is skewed, so please, please think of the bigger picture, and give credit where credit is due.

    I think you misunderstood me or have made an assumption about my intent. I never meant to imply that MDs are the 'hereos', but rather that they typically do not provide bedside care for palliative patients. My interest lies in the best way to manage palliative patients, although not through providing direct hands on care. The nursing role in palliative care is not for me. But I would like to learn more about what works best for patients, and how to allow patients to die with dignity on their terms. I also would like to know how I can work with nurses to streamline care for patients who are dying and also make it easier on the nursing staff. Basically, I am asking how I can improve the 'team'. Because that in turn will help the patients.

    You are very correct, it is the nurses who are with the patient for the majority of the time. They are the MD's eyes and ears (and I'm sure some of you would say 'brains' as well). So I want to know the best way to provide streamlined care for these patients and work WITH the nursing team. MDs need that input. MDs focus on diagnosing and treating disease (my interest). Nurses have to focus on everything else, including response to illness and treatment. These other numerous factors impact the course of a patient and thus affect disease process and/or treatment as well.

    Each person deserves to have a dignified death on their own terms, if possible. I want to know how to make palliative care the most 'efficient' for patients (for lack of a better term). As an analytical person, I like to look at data and try to find solutions. Although I may come off as abrasive, please do not mistake me for someone who does not care. I care a lot, perhaps too much.

    I was simply stating my personal (limited) experiences with dying patients. As a student, I have been exposed to palliative patients in LTC and was agast at what I have witnessed. Washing up a dying client just so she can look 'nice' for her family is something just doesn't doesn't make sense to me. I did not feel 'right' disturbing this patient who was clearly near death. I have watched staff flip and turn dying clients, who are moaning in delirious discomfort at the motion. Is bedsore management really a concern for a client that may not live 5 more hours?

    Please understand that my comments come from my frustration with nursing theory and what I see in reality. I am supposed to be providing 'compassionate care' to these patients, but I feel that the nursing duties that I do are a 'sham' of simply protocol. Going through the motions, if you will. I just felt so empty after these shifts. From a detached standpoint, I did not want to be the person who 'pokes and prods' a dying patient. This was all that I meant by this statement.

    However, I am still interested in palliative care. I know that I will be looking to gain this experience by using my Practical Nursing diploma. Thus, I will have to provide nursing care for awhile, but I feel that it will be a worthwhile experience in the end. I am struggling how to balance my views on nursing duties in palliative care with my personal viewpoints. I'm smart enough to know that I know very little. But at least I recognize that, and that's a start. You have to recognize that this is an internal struggle, which I'm sure you can infer if you deconstruct my posts.

    How to I provide excellent care for patients as a student nurse who prefers the medical model of care while disillusioned by nursing theory vs nursing reality?

    As for the morphine question, it sounds like others have made the same mistake. I was under the impression that morphine/opiates can be a respiratory depressant or can place the patient at risk for respiratory arrest in certain situations. This data can easily be found on Pub Med.

    I have heard from more than one person that doctors will increase the dose 'off label'. I did not know if it was true or not, hence why I asked the question. I am not here to judge. In other countries, this is not illegal. If a terminal patient requests to die sooner, with dignity, and not prolong suffering (or have their family watch them struggle), is that not their right as well? Is the doctor doing more harm by denying their request and letting them struggle? These are not simple questions, and therefore it would not be in anyone's best interest to take a stand. There are similar issues in nursing, such as the nurse who will request a DNR for an elderly patient with multiple comorbidities. Is she doing the right thing by assuming the patient does NOT want to be resuscitated and/or making the choice for him?

    I have seen a palliative patient die rather quickly after morphine, so I simply assumed that it couldn't be ruled out that it played a role. This did reinforce my ideation of 'off label' dosing. Of course, the RN had been worrying about her math skills all night so it's entirely possible that she didn't give the actual dose that the doctor had actually prescribed...

    Anyway, I don't mean to offend anyone. I'm seeking answers, of some sort, in some form. Like many of us here. Don't worry, I do NOT plan on 'killing anyone'. Well, maybe my spouse if he forgets to take out the garbage yet again...

    But I digress...

    I was simply seeking an answer to a question. However, medical ethics is something that cannot be resolved by many practicing healthcare workers with PhDs. I won't even attempt to solve the topics I have brought up here. I just wanted to know what others thought. And now I do.
  2. by   LEN-RN
    Quote from CanuckStudent
    Truly horrible. I am so glad this poor man got some comfort and dignity in his last hours. But I have to ask myself, do nurses really make a difference, or do we just prolong suffering? MDs can prescribe meds to help the patient pass quicker or 'easier', but nurses just poke and prod until they do. Sometimes I wonder if a dying person even WANTS a stranger holding their hand in their last moments. I would feel violated and awkward as that patient. We are brainwashed with so called 'nursing theory' into thinking that we help, but do we really in such cases? Or is this what we tell ourselves to cope at the end of the day after unspeakable horrors such as this? Is this a nursing success story, or the horror of reality? Some food for thought...
    Have you ever looked into the eyes of a frightened dying patient? Have you ever taken care of a dying patient? You would be amazed at the firm grip of someone in their last moments too weak to speak or breathe but will not let go of a hand. Even a stranger's hand.

    Its not called nursing theory, its called COMPASSION.
  3. by   cherrybreeze
    Canuck, I won't quote the reply, as it is long, but I will respond to just a couple of points you raised:

    As far as streamlining care for dying patients, I think that's exactly what we DON'T want to do...I think individualized care is most important at that stage, and there isn't going to be a "set" or "standard" that will be appropriate for all.

    For the repositioning, it's not about bedsore management, it's about comfort. Lying in one position without being able to move at all gets extremely painful. We don't know what they can or cannot feel. If they are on their back, their coccyx is going to ache after a relatively short time, since they can't even make slight adjustments in their position. On their sides, their hips, shoulders, whatever pressure points there are are going to hurt. I know how much certain areas will hurt if I sit or lie in one position for a half hour without moving, or shifting my weight. The patient may be unresponsive, but we do not know how much they can feel, so we can't assume that they don't. That's more the issue. No, chances are they aren't going to get a bedsore in those last few to several hours, but the same mechanism that is going to cause what would eventually be a bedsore is going to cause pain.

    I also disagree with that extent of bathing before the family's arrival. Mouth care, etc, yes, but not a full bath. Also, if the patient is moaning in that much discomfort when being repositioned, they are not being medicated enough, plain and simple.

    There is no doubt that the morphine doses can and do hasten death, but that's the potential effect of easing their discomfort. I personally do not think it's wrong for a patient to want things moved along more quickly, so to speak, but that's from an ethical standpoint and not a legal one. It doesn't matter if I think a terminal patient should have that choice, by law they do not. If it were something they could do completely on their own, that would be their choice and a whole other story. By the time they are unresponsive and near death, it's not like they can tell anyone to give them some medication and let them go, so that would negate it also, they would no longer be capable of making that decision, which would mean it would be the doctor ordering (or more so, the nurse administering) that would be deciding it was time for them to die (which would be considered murder). I have certainly given patients a dose of morphine and had them pass away very shortly thereafter. Whether it was due to the meds or the dying process I'll never know for sure, but the intent was to ease their pain and not to cause their death.

    I am not sure if what you mean by making the process more "efficient" for patients means that they pass away sooner, well....I'd stop hunting down that avenue (unless you live in a country where euthanasia is legal). Whatever words you choose to use, you are talking about killing them, or assisting them to kill themselves, and as much as you think we or they should have that option, we don't (unless, as I said, they choose to do it totally on their own, with no involvement or assistance from another person).

    I am curious who you've heard it from about doctors increasing the dose "off label." I also do not know what countries euthanasia is legal in. As far as not letting them struggle, they should be prescribed enough medication to make them comfortable. The end result CAN be that it depresses their respirations enough, but again it is in the intent. They are related, but it's not why it's prescribed. I do have to disagree that you shouldn't take a stand because it's such a sensitive issue. That's why we SHOULD take a stand. The most important thing is for a patient to be comfortable throughout the process. Anything else is irrelevant due to the legality.

    I'm a little confused on your last statement, after all of that, you say that medical ethics cannot be resolved by healthcare professionals with PhDs. I'm not sure what you mean by that. In the case of the specific questions you've asked, it's less about ethics and more about the law. What you feel the patient SHOULD have a right to (deciding how and when to die, and having their doctor and nurse help them do it) honestly doesn't really matter. Maybe someone with a PhD can't figure it out, but perhaps someone without a PhD can. Ethics isn't about level of education, and at least here in the US, euthanasia isn't about ethics (it IS an ethical issue, but what I mean is that, deciding whether or not to do it isn't an ethical question, since it is not an option).

    Somewhere in all that rambling, I'm quite sure I had a point.....
  4. by   cherrybreeze
    flightnurse2b, didn't mean to hijack your thread, I'm sorry.

    I have read your story several times now, and it's still just as touching every time. What a wonderful nurse you are. :heartbeat
  5. by   LEN-RN
    [quote=CanuckStudent;3713823]). So I want to know the best way to provide streamlined care for these patients and work WITH the nursing team. MDs need that input. MDs focus on diagnosing and treating disease (my interest). Nurses have to focus on everything else, including response to illness and treatment. These other numerous factors impact the course of a patient and thus affect disease process and/or treatment as well.

    Each person deserves to have a dignified death on their own terms, if possible. I want to know how to make palliative care the most 'efficient' for patients (for lack of a better term). As an analytical person, I like to look at data and try to find solutions. Although I may come off as abrasive, please do not mistake me for someone who does not care. I care a lot, perhaps too much.

    I was simply stating my personal (limited) experiences with dying patients. As a student, I have been exposed to palliative patients in LTC and was agast at what I have witnessed. Washing up a dying client just so she can look 'nice' for her family is something just doesn't doesn't make sense to me. I did not feel 'right' disturbing this patient who was clearly near death. I have watched staff flip and turn dying clients, who are moaning in delirious discomfort at the motion. Is bedsore management really a concern for a client that may not live 5 more hours?

    Please understand that my comments come from my frustration with nursing theory and what I see in reality. I am supposed to be providing 'compassionate care' to these patients, but I feel that the nursing duties that I do are a 'sham' of simply protocol. Going through the motions, if you will. I just felt so empty after these shifts. From a detached standpoint, I did not want to be the person who 'pokes and prods' a dying patient. This was all that I meant by this statement.


    I have seen a palliative patient die rather quickly after morphine, so I simply assumed that it couldn't be ruled out that it played a role. This did reinforce my ideation of 'off label' dosing. Of course, the RN had been worrying about her math skills all night so it's entirely possible that she didn't give the actual dose that the doctor had actually prescribed...[quote=CanuckStudent;3713823]).


    Nursing is not exact, it cant be streamlined. Human beings come in many shapes and forms, and with different needs. Your nursing skills should be exact, but how you treat and nurse can vary from patient to patient. You learn to improvise and be creative at times. Most days NOTHING goes as planned but you roll with the punches. You say that you want it to be streamlined, but go on to say that some nursing duties are a "sham" of simply protocol something of which you dont want to do. Those two sound the same. I dont understand what you are trying to say.

    A dying patient still has dignity and deserves respect. Cleaning them up is basic care. Cleaning them up to look "nice" is for their dignity. Perhaps you would prefer to let them lay in their waste or matted hair. Turning a patient is for COMFORT. Would YOU like to lay in the same position for 5 hours?? 2 Hours?? Have you learned about "neglect" in nursing school? Thats a quick way to lose a job and a nursing license. Believe me - it happens. Family members report nurses every day. And believe me, after just a couple complaints, management does some rearranging. Rearranging the nurse right out the door. At times it gets reported to the state board of nursing.

    Pallative patients often live long past their initial doses of morphine. I have seen many live on scheduled doses for months. One single dose will not send someone to an early death.

    It appears that showing compassion is hard for you. There are many occupations that are streamlined and have very little contact with the public. I am sure there are advisors at your school who would assist you in finding the perfect fit.
  6. by   CanuckStudent
    Thanks for the reply. By 'efficient' all I meant was how to best care for such patients. I did not mean to imply any other implication. I simply want to learn more. To get some experience in the field. That's all. I wanted to work with palliative patients (via a hospital volunteer program) prior to beginning my nursing program. I am trying to sort all of my conflicts out, as you can see. Just a personal conflict right now. Thanks for trying to help.

    I think we are actually more on the same page than it appears. All I meant was that I am not nearly informed enough to take a firm side on any of the issues raised. I simply meant that people debate such issues as a career, and I have minimal to non-existent knowledge in this area. I think we'd need another thread to debate this, was all that I meant.

    As for the 'off label' dosing, that may be a black side of medicine that is known about but rarely expressed. I mean, we sometimes have no way to measure a dying patient's pain, right, as you stated yourself? So it's hard to justify giving a dying patient more morphine for pain if you cannot in fact measure how much pain they are in. Are we *really* giving it for 'pain'? And even if so, if (more rapid) death is a known 'side effect', does the fact that it was given 'for pain' somehow negate that?

    Note that these are simply my 2 am ramblings also, not a personal attack on anyone. Just some questions.

    I guess it's similar to Catholics who can use the BCP for 'acne' treatment with full acceptance of the Priest, who is fully aware that the 'side effect' of contraception is taking place. It's technically "illegal" but a blind eye is turned or it is justified.

    All I can say is that I have heard of 'off label' use from more than one source. I'm seeking more answers just as you are.

    Thank you for your response.
  7. by   CanuckStudent
    [quote=LEN-RN;3713884][quote=CanuckStudent;3713823]). So I want to know the best way to provide streamlined care for these patients and work WITH the nursing team. MDs need that input. MDs focus on diagnosing and treating disease (my interest). Nurses have to focus on everything else, including response to illness and treatment. These other numerous factors impact the course of a patient and thus affect disease process and/or treatment as well.

    Each person deserves to have a dignified death on their own terms, if possible. I want to know how to make palliative care the most 'efficient' for patients (for lack of a better term). As an analytical person, I like to look at data and try to find solutions. Although I may come off as abrasive, please do not mistake me for someone who does not care. I care a lot, perhaps too much.

    I was simply stating my personal (limited) experiences with dying patients. As a student, I have been exposed to palliative patients in LTC and was agast at what I have witnessed. Washing up a dying client just so she can look 'nice' for her family is something just doesn't doesn't make sense to me. I did not feel 'right' disturbing this patient who was clearly near death. I have watched staff flip and turn dying clients, who are moaning in delirious discomfort at the motion. Is bedsore management really a concern for a client that may not live 5 more hours?

    Please understand that my comments come from my frustration with nursing theory and what I see in reality. I am supposed to be providing 'compassionate care' to these patients, but I feel that the nursing duties that I do are a 'sham' of simply protocol. Going through the motions, if you will. I just felt so empty after these shifts. From a detached standpoint, I did not want to be the person who 'pokes and prods' a dying patient. This was all that I meant by this statement.


    I have seen a palliative patient die rather quickly after morphine, so I simply assumed that it couldn't be ruled out that it played a role. This did reinforce my ideation of 'off label' dosing. Of course, the RN had been worrying about her math skills all night so it's entirely possible that she didn't give the actual dose that the doctor had actually prescribed...
    Quote from CanuckStudent
    ).


    Nursing is not exact, it cant be streamlined. Human beings come in many shapes and forms, and with different needs. Your nursing skills should be exact, but how you treat and nurse can vary from patient to patient. You learn to improvise and be creative at times. Most days NOTHING goes as planned but you roll with the punches. You say that you want it to be streamlined, but go on to say that some nursing duties are a "sham" of simply protocol something of which you dont want to do. Those two sound the same. I dont understand what you are trying to say.

    A dying patient still has dignity and deserves respect. Cleaning them up is basic care. Cleaning them up to look "nice" is for their dignity. Perhaps you would prefer to let them lay in their waste or matted hair. Turning a patient is for COMFORT. Would YOU like to lay in the same position for 5 hours?? 2 Hours?? Have you learned about "neglect" in nursing school? Thats a quick way to lose a job and a nursing license. Believe me - it happens. Family members report nurses every day. And believe me, after just a couple complaints, management does some rearranging. Rearranging the nurse right out the door. At times it gets reported to the state board of nursing.

    Pallative patients often live long past their initial doses of morphine. I have seen many live on scheduled doses for months. One single dose will not send someone to an early death.

    It appears that showing compassion is hard for you. There are many occupations that are streamlined and have very little contact with the public. I am sure there are advisors at your school who would assist you in finding the perfect fit.

    You obviously misunderstand my posts. I am sorry that I am not clear. I actually am stating the *opposite* of what you are thinking. I felt that by assuming the 'stereotypical' nursing role I am actually doing more *harm* to the patient. I am as disgusted by neglect as you are, so please don't put me in that category.

    I understand what you are trying to say, but you can't judge me on one (OK, a couple) 'confused student' post. If I were to judge you so rapidly, I would ironically assume that you are as compassionate as you assume me to be, judging by your last comments.

    I understand that I may have differing views than some of you, but since we are not all robots, that should be expected on a public forum. Please, can we let this go? If you are trying to help, thank you for your advice.

    To the OP, I'd like to get back to your original post, and I'm sorry for all of this.

    P.S. For anyone who actually cares about nursing retention (you do want to retire one day, right? ), I think it's important to let students ask questions and address REAL issues in nursing. If you can't ask questions here, where else would be best? If every nurse says that they have never felt conflicted, frustrated, or confused with their job, I'm willing to bet that at least some are lying.
    Last edit by CanuckStudent on Jun 29, '09
  8. by   LEN-RN
    Canuckstudent wrote:
    You obviously misunderstand my posts. I am sorry that I am not clear. I actually am stating the *opposite* of what you are thinking. I felt that by assuming the 'stereotypical' nursing role I am actually doing more *harm* to the patient. I am as disgusted by neglect as you are, so please don't put me in that category.

    Canuck,
    I am sorry. Please accept my apology. I came in on a conversation and missed your first posts.

    You will be a fine nurse. Dont worry.
    Last edit by LEN-RN on Jun 29, '09 : Reason: add
  9. by   gabby0226
    Canuck Student
    Understood. Your first response explained. I know you are giving exceptional bedside care. I understand not "having nursing in your blood". Understand 2 am ramblings also. I appreciate the route you are taking to get to your goal, your hard work is commendable. Again Best Wishes to you.
    Last edit by gabby0226 on Jun 29, '09 : Reason: missed puncuation
  10. by   cherrybreeze
    Canuck, I keep coming back to this, only because you insist on continuing to insinuate that morphine is given to dying patients to hasten their death. It just is not, I'm sorry. You keep phrasing it slightly different, and saying that if we don't know if we're giving it for pain, etc........pain and comfort is the reason it is ordered and administered and that is IT. Period.
  11. by   FranEMTnurse
    Quote from CanuckStudent
    My interest lies in the best way to manage palliative patients, although not through providing direct hands on care. The nursing role in palliative care is not for me. But I would like to learn more about what works best for patients, and how to allow patients to die with dignity on their terms. I also would like to know how I can work with nurses to streamline care for patients who are dying and also make it easier on the nursing staff. Basically, I am asking how I can improve the 'team'. Because that in turn will help the patients.

    You are very correct, it is the nurses who are with the patient for the majority of the time. They are the MD's eyes and ears (and I'm sure some of you would say 'brains' as well). So I want to know the best way to provide streamlined care for these patients and work WITH the nursing team. MDs need that input. MDs focus on diagnosing and treating disease (my interest). Nurses have to focus on everything else, including response to illness and treatment. These other numerous factors impact the course of a patient and thus affect disease process and/or treatment as well.

    Each person deserves to have a dignified death on their own terms, if possible. I want to know how to make palliative care the most 'efficient' for patients (for lack of a better term). As an analytical person, I like to look at data and try to find solutions. Although I may come off as abrasive, please do not mistake me for someone who does not care. I care a lot, perhaps too much.
    Canuck student, I like your intent, and I admire it. I believe I understand what your are saying. I wish you success in your endeavor. Your are a very ambitious person, who only wants to improve palative care for the dying patient. I am currently in palative care, and have been in hospice care. I would much rather die at home in my own surroundings than in a hospital or a nursing home where I would be shoved on a shelf in the morgue like a piece of meat.
    Flightnurse did give TLC care to that poor old man. I know she didn't want to make him hollar or cry out. Remember, his condition made her cry, and she is a well seasoned nurse who has seen a lot of trauma cases. What was done by her and investigators was what was needed to investigate further into his case. I know that former caregiver who abused him so much will get her/his reward for hurting him that way one day too.

    Respectfully yours,

    Fran
  12. by   BanoraWhite
    OP, You are an Angel
  13. by   joanne28
    I really agree with those people who commented above.. You are such a good nurse.. You made the last days of that man a wonderful one.. Your story really touched my heart.. I am a nursing student and I also experienced some heart wrenching stories about my patients which motivated me more to pursue my studies.. Thank you for your story.. This inspired me more to pursue my profession..

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