Every now and then, though, we get to care of someone who shows us exactly why we do what we do. Those cases, those patients, provide us with the inspiration we need to do our jobs despite how taxing they can be. I had the pleasure of taking care of one of those patients just the other day.
I was orienting a new nurse to the floor who, at that point, was ready to be on her own. It was her second to last day, so she was doing her thing and I was there for support. She took an entire load of patients so when the ICU wanted to send me a palliative care case, I took her as my "only patient". I love being involved in end of life care and was glad to have the opportunity to be able to devote all of my attention to this patient and her family.
She was an 89-year-old woman who had come in for pleural effusion in the right lung. Her condition on arrival was grave enough that she received a chest tube and was sent to the ICU. She was placed on BIPAP where she stayed stable for a week, but with no improvement. On the patient's 90th birthday, the family decided to remove her from the BIPAP. The ICU staff took her off with the family gathered around, but to everyone's surprise, she kept breathing on her own... effectively. She required oxygenation, but only with a nasal cannula. She was still unresponsive at this point. The decision was made to transfer her to the floor and put her on palliative care. Her transfer orders were for diet as tolerated, (she was unresponsive), NS @ 10cc/hr to KVO for Morphine 2mg hourly as needed, 02@2liters, and q2 turns. The chest tube was put to water seal and that was that.
When they brought her up, I took one look at her and just knew that the transfer from the ICU bed to our bed would be it. Transfers on patients that looked that bad were always it. But she survived the transfer. During her fourth scheduled turn of the night, she opened her eyes. I stayed in the room and did a neurological eval on her. She was not verbally responding to me but she would follow me with her eyes and could nod her head. The Hospice nurse had already been in to talk with the family about expectations at the end of life, so they understood that there is often slight improvement before the final decline. But something felt different to me about this one. I let the rest of the night ride out just taking care of her but not pursuing anything aggressive.
When I came back the next night, the nurse reporting to me said: "I just don't think this is it for her." I had that same feeling the night before. I took her as my only patient again that night. When I went in to do my assessment, she was in a semi-fowlers position and alert, looking around the room. I asked her how her day had been, not expecting her to respond, and to my surprise, she said: "I feel terrible, honey." !!!
Granted her speech was VERY garbled and difficult to understand (she had been lying for 10 days with her mouth open, was dehydrated, and didn't have her teeth in) but I could make it out. I proceeded to talk with her and ask her some neuro check questions and she was oriented. She was a little confused about the dates obviously and a little foggy on EXACTLY what hospital she was in, but was easily oriented!! When I asked, she told me that it was 2008 and Bush was in office. She even asked me if she had had a stroke!! I was flabbergasted at this level of improvement. I explained to her what had happened and gave her a rundown of her stay with us so far. The family had no idea what to think. They couldn't understand her speech at all. This was very frustrating to them and to her, so I spent a lot of time just interpreting things that she wanted to say. Everything she said was so appropriate and she even joked around and told me stories about her late husband and the gardens they would plant. She told me all about her canning vegetables and baking pies. When I would tell her family the things she was saying, they were amazed that she was so lucid! I sat in there all night. She was stiff from lying in bed so long, so I exercised her legs. She had a firm belief that Aloe Vera was the "cure all" so I rubbed nearly a whole bottle of the stuff over every ache and pain she had. After the "aloe massage," you could see how much more relaxed she was. She thanked me extensively for that. We talked and laughed and I fluffed and puffed her for hours.
We were all surprised when she expressed an interest in her daughter's ice cream a little later that night. She hadn't eaten in close to 2 weeks! She (very slowly) ate a half cup of vanilla ice cream and drank some water. Then she wanted some Pepsi. Her hand-eye coordination was very poor. I tried to assist her with the cup, but she insisted that she do it herself. She did, too. Slow and sure, with a few spills, but she did it. I just couldn't believe what I was seeing!
We tried to get her teeth in so we could understand her better but her mouth was so dried out and they wouldn't stay in place. I sent her son-in-law out for a new bottle of aloe and some Fixodent. We had a good laugh about the last time she used a denture adhesive.
"I guess I used too much," she said. "I couldn't take them out to clean them for 4 whole days!!"
Even with the Fixodent, her dentures were a bad fit. Her poor lips were cracked and her gums were so dry, they just wouldn't stay.
But with me there to interpret, she was able to voice things that made her uncomfortable, tell us how to turn her, tell me and her family that she didn't want so much Morphine. I was so excited and felt so relieved that she was able to take part in her care. And I can't express how good it felt to be able to pamper her that night and spend so much time with her and the family. Closer to morning, she told me to go to her house and get her tan shoes ("they are the only ones that fit right") and her rolling walker because she wanted to walk!!!
Now, keep in mind, ALL we are doing for this woman is 10cc of saline per hour and iv morphine. Her family and I, after a good talk in the hall, decided that it was time for action. They all agreed that they still didn't want to be "aggressive", but that supporting her was a must.
I was on the phone all morning with case management and with the docs getting her fluids increased, getting the surgeon who put the chest tube in back on her case, getting things ordered to support her if she was gonna turn her bus around and head back our way!
As I left that morning, she was sitting up in bed eating cream of wheat and thickened OJ. I told her that I was going to be off a few days (going on a weekend trip) and she squeezed my hand tight and said: "Thank you, precious, for taking such good care of me." I teared up like a baby. She teared up, the daughter teared up... It was so touching. Her family expressed their sincere thanks. Many hugs were shared.
I figured that when I got back to work case management would have already had her home. When I got back from my trip I dropped in to see if she was still there. She was. I walked back in the room and she had her little rolling walker and was sitting in the chair in her tan shoes eating oatmeal. It took her daughter a minute to realize who I was. I guess I look different in my street clothes. But the second my patient saw me come through the door, her face lit up like Christmas. She beamed at me, pointed down to her tan shoes and walker, and gave me a wink. "How was your trip, morning glory?" she asked.
She had finally gotten her teeth in and talked as plain as you or me. We chatted for a while. I asked her how she had done since I left. She showed me that her chest tube was gone. She was very happy to be rid of it. "No more Morphine," she said. "I get the pain pills now!"
"And guess what the best news of all is?" she said.
"I'm going home today!!"
I can honestly say that taking care of this woman and witnessing her amazing turnaround has changed the way I view my job. Even though her outcome was positive, caring for her has strengthened my interest in the palliative care aspect of nursing. I plan on teaming up with other nurses in my facility and improving and educating people on the way that we take care of the dying patient. Being her nurse has also highlighted the importance of spending that extra time and going that extra step for my patients. You never know how much difference a little time and a little aloe vera can make.:wink2: Finally, taking care of this woman made me a better advocate for the needs of my patients. She made her comeback all on her own. But being there for her and her family, and making sure that she had the support that she needed was one of the most rewarding things I have experienced. To be a part of her story is an honor. People like her are unforgettable and taking care of them is why I love my job.