pepper_rn

Thanks to everyone who has responded so far. I wanted to answer some of the really good questions that have been asked. When the patient was extubated the first time and began to recover she was lucid and compentent enough to make the decision to have a DNR status. She told everyone who would listen that she didn't want "that tube" again. Luckily we have a copy of that legal documentation on her chart. For the second intubation, she was pretty much unresponsive as a result of the renal failure for anyone to ask. My biggest problem is that I feel that if she has already expressed her wishes not to be intubated, then the physicians should not be allowed to even offer that to the family as an option for treatment. Essentially, the family shouldn't be able to over-ride a decision that she made when competent to do so. And yes, I really feel that she is telling me that this needs to stop. And no, the doctors are not interacting with her at all. The tell me to give her more of the morvan slam (morphine and ativan) "to keep her more comfortable". To me, it's disgusting and this is not the first patient it has happened to. Luckily all my co-workers support me 100%, so no problem going toe to toe with doctor, which I will continue to do. I will turn this over to the Ethics commitee at my facility. Unfortunately to my knowledge this will be the 7th case turned over and nothing has been done so far:sniff: thanks again, Pepper

First, let me begin by saying that I do not believe that DNR should translate into "Do not treat." There are plenty of people out there with active DNR orders or living wills in place who can and should be treated effectively. But I had a case last night that really made me question the line between following those orders and patient advocacy. Some back story, this patient has been in and out of the ICU for 6 weeks. The patient had a surgery that went badly, went septic, into renal failure, exacerbated CHF and eventual respiratory distress requiring intubation and dialysis. After recovering somewhat, the patient signed a DNR order and expressed wishes to NEVER be "put back on the tube again." But the patient never addressed dialysis. Once transferred from our unit to the step-down care area, the problems started again BUN rising, output all but stopping, respiratory distress. The doctors approached the family to begin dialysis again, but suggested that the patient be intubated and ventilated prior to placing the dialysis catheter. The belief was that she would "wear out" before dialysis treatment could begin. The family, after being told that they "had to give this person a chance" by the doctor, agreed to elective intubation. Basically because they were led to believe that it was for a procedure and not resuscitative. But the truth is, she would have died before we could've begun dialysis again so I do believe it was resuscitative. The patient had been re-intubated for several days without the benefit of sedation. It was thought by the doctor that the patient was so far down on their own already that we shouldn't need to sedate with anything other than prn Morphine or Ativan. As I am giving the bath, suctioning and repositioning the patient woke up several times. Each time the eyes opened there were huge tears rolling down the cheeks. The patient would swing her head from side to side, bite down on the OETT and would mouth, "no, no, no" around the tube. It was so heart breaking. I went to the doctor with this information (and documented it thoroughly). His reply was to try and wean her from the vent, which of course she failed. This poor woman, who is so edematous that even her stretch marks are fluid filled, she is in pain and winces every time I touch her. Everything that I am doing to her, she has said she doesn't want and because the family agreed under false pretenses, I have to keep doing it. I tried speaking to the family, compassionately of course, to try and educate them on what was happening. But the doctor has them so hopeful that this will work that it is prolonging the inevitable. I wouldn't even consider this a growing problem if I hadn't seen it so many times. I've heard doctors use the excuse, "well it's for a procedure, it's not her lungs that are killing her". And while there is some small truth to that, it's not the whole truth and families are left with the burden of not trying everything they could, or thinking that a parent could still be here if only... I'm wondering at what point do we stop the doctors and become the patient advocate? How many different ways can you say and legally document what you don't and do want done and still have the expectation that someone will carry out your wishes? I know this is long, but I am truly heart sick over it. I was to the point last night where I really considering untying the restraint from her very swollen hand and letting her extubate herself. Which I know is wrong, so I decided to rant about it here instead. Anybody else have an experience like this. Pepper

Ok this story is from my mom who worked ER for several years. One night around 2:00am this young man comes in with a horrified painful look on his face and asks to be seen by the doc (male, at the time all female staff). The nurse informs him that he will have to go through the whole triage, assessment part first. He demands to be seen by the ER doc, not the nurses. He then gets angry and leaves... A few hours later he's back, says he can't take it anymore, agrees to see anybody. In the exam room the nurse discovers that this man has a very lovely 1 karat diamond ring stuck over the shaft of his member. :imbar Turns out he was proposing to his girlfriend and thought this would be a unique way to do it. (AH, the romance) All I have to say to that is my ring finger is a size 4, no wonder he didn't want the nurses to see what he had done. Pepper

I consider myself a person of faith but not really into a specific religion and I did clinicals and worked at a wonderful Catholic hospital. Like other posters have said, this hospital did daily prayer over the PA. I live in a pretty small area without alot of religious diversity so no-one, to my knowledge ever complained. I believe that a persons over all healing has alot to do with their faith (just my opinion). So whatever your religious affliation, or none if the case may be, if it helps out the patient's then I am all for it. What's that old poem that says, "Embrace God, whatever you concieve him to be?" Best of luck to you Pepper :)

Hello all, I'm looking for some input on how different facilities respond to codes. (That is code 10, code blue, cardiac arrest, whatever you call it in your area) My hospital's policy needs some tweaking. Right now it is: 1 nurse from ICU, 1 from CCU, 1 from ER, Respiratory, IV therapy, Chaplain, Nurse supervisor and the doctor. That would be fine in theory, but our codes have turned into major spectator sports. The last three that I have been on (I'm the ICU nurse that goes) there have literally been 30 people standing around, blocking the way. It looks like the Ringling brothers circus and I'm wondering, who's taking care of the other patients if everyone on the floor is huddled around this particular doorway? The doctor has even had to yell at people to get out of the way so that we could move the patient to the unit. It's insane! I know it's human nature, or maybe nurse nature to want to help or just see what is going on, but when it is delaying treatment, isn't that a problem? Anyway, if someone has suggestions or advice on how they handle these situations, that would be great. Thanks, Pepper

New here, but sorry to hear about your ear. That must have been really scary. I only nearly fainted once in nursing school and that was watching one of our open heart docs put in a triple lumen. I had seen several and had even assisted with a few as an LPN but for some reason that day, it just really hit me wrong. I was holding the patients hand, black dots were swimming and I thought, "i've got to get out of here now!" I got a nice long lecture from the doctor about eating breakfast before I came in. But thankfully it has never happened again.:imbar Take care, Pepper