Question about dying patient

[Scrubby]

Hey fellow allnurses just want to discuss something that happened at work today which I found a bit disturbing.

An elderly patient was brought into the holding bay of our OR. Patient was to have emergency laparotomy, query ischaemic gut. It became apparent fairly quickly that the patient was cheyne-stoking, we couldn't rouse him at all to do an identity check etc. Within 10 minutes of him arriving to the holding bay he died. Very sad and not the sort of thing you see everyday in the transfer bay.

The nurse who brought him from the ward who I know is a first year nurse didn't seem to realise that he wasn't just sleeping he was actively dying. Although it's sad he was moved around the hospital while he was dying like that, before he was in 6 bed ward and at least when he died he had some privacy in the transfer bay. Thank goodness no other patients were around at this time because I think it would have been very upsetting for them and put them off having surgery.

So my question to you is, if you were the bedside nurse would you just take someone who is cheyne-stoking to the OR? Would you call an MD before taking them to surgery? Would a laparotomy even be appropriate in this situation because correct me here if I'm wrong but once a patient reaches the stage where they're cheyne-stoking is it true that not much that can be done except make them comfortable?

I'm not trying to appoint blame on the first year nurse either because I'll admit I haven't seen cheyne-stoking before, my knowledge of palliative care is limited. I was more concerned that he was unrousable, which I must admit the first year didn't seem to be concerned about. But I'm just interested to hear your opinions.

[iluvivt, BSN, RN]

Was this pt a no code or were they going to do everything they could? At what point did the pt have a sudden change in condition/ b/c it sounds like it was a very sudden change in the pts condition ,which could have happened en route to your dept b/c I would find it difficult to believe that a nurse would not notice a pt that could not be aroused. Did this pt come in through ER? Maybe it was a sudden event such as a ruptured AA...bowel maybe? Would I have transferred an unstable pt to OR....that depends...sometimes that is their only chance...I would have to know more of the circumstances involved. I once had a pt transferred to me from the ED and the pt literally died when I was transferring them from the gurney to the bed.

[tewdles, RN]

how unfortunate....

It is my experience that physicians are not all that great at recognizing the signs of imminent death either...so I wouldn't be too hard on a first year nursing grad.

[Scrubby]

I asked the nurse who brought him in how long has he been unrousable and she wasn't sure. According to the anaesthetist he was semi conscious the night before when he was doing the anaesthetic consent. He was cheyne-stoking as soon as he came into the holding bay. Anaesthetics seem to think that his death was most likely shock leading to multi organ failure from having dead gut. I know they were against doing the surgery in the first place because of his extensive cardiac problems, lack of urine output and general state of health. I guess I will find more out tomorrow.

He was not for resuscitate so we just put him on monitoring and stayed with him. I don't think he was there for 10 minutes before he was dead.

[WalkieTalkie, RN]

This may sound terrible, but the patient dying prior to surgery may have been the best thing that could have happened to him. He was probably very acidotic with all that dead bowel. He would have been sliced opened and likely in extreme pain post-operatively had they intubated him, done a surgery, closed him, and then left him on life support for any amount of time.

Obviously the manner in which the patient's death occurred wasn't ideal or proper. It is very sad that he was left in this state as well, without family being notified. However, in the grand scheme of things (without knowing his code and family status), I think there are worse things that could have happened. The chances of this poor guy making it were basically about 0.00000000001%, if you catch my drift. It sounds like he already had MODS with impending septic shock.

What were his pre-op vitals? I can't imagine he had much of a blood pressure prior to arriving in pre-op.

[Zana2]

Scrubby, I'm sorry you had to go through that. We're not really used to this, are we? Are you alright though?

Try not to be angry . I'm sure she's a good,compasionate new nurse. Maybe she didn't realize the poor man was dying. I bet you next time she'll know, we tend to make 'mistakes' like this once.

Feel powerless, I know. And upset. Try and see the good part of it, though, little as it is. Hugs.

[Scrubby]

Hey I'm not angry with this new nurse. It's not her fault that the patient had to wait so long before he was taken to surgery. It's not her fault the fact that people are waiting days to be operated on at my hospital. Perhaps she should have rang the MD about his detiorating condition but the outcome would have been the same. At least he died in a private area. It's a shame his family didn't get a chance to say goodbye though.

The fact is he was one of 'those patients' that the surgeons were keen to 'get done' and anaesthetics didn't really want to do given his chances were zilch.

Can't recall the exact specifics of his vitals but they were pushing 2000mls of iv fluids over 2 hours and only 30mls of urine an hour. His BP was low ( can't recall) and we couldn't find a radial pulse. SaO2 were in the 70's.

I sometimes wonder though why we go to these extreme measures in elderly patients with so many co morbidities and poor chances of survival. Is it so hard to let people die in peace?

[talaxandra]

It is my experience that physicians are not all that great at recognizing the signs of imminent death either...

That really strongly reminded me of a night shift many years ago - I had a patient who was deteriorating, NFR but for full ward management. I had the resident up examining him, more a pro forma exercise than anything else; the resident was a bit stressed out and needed to do something, so he started preparing to take blood. I tried gently to point out that the patient would be dead before the results came through, without actually saying it in a way that the unconscious (but possibly still hearing) patient could understand.

I think I said something like, "I don't think the lab will be able to process those in time to be useful." Whatever I said, it clearly wasn't explicit enough, because he went around to the patient's other arm, haivng failed with the first one. He got the tourniquet on and said, "I don't understand why I can't get a flashback."

Me: "That's because he just died."

Poor baby resident: "Oh. Oh! Oh dear, if I'd know it was that close I never would have put him through taking blood."

And that's when I realised that most doctors so rarely see patients who are dying that what was obvious to me (imminent death) looked different to the doctor (very ill).

[tencat]

Such a sad story. Why, why, WHY do we keep doing this to people who are clearly not going to make it through? We as a society need to accept that we do DIE. We can do it comfortably, or we can go kicking and screaming, but the end result is the same. I don't see it getting better, though, as the current Baby Boomer generation who IS getting older is fighting it tooth and nail and not accepting it...sigh

[TigerGalLE, BSN, RN]

Hey I'm not angry with this new nurse. It's not her fault that the patient had to wait so long before he was taken to surgery. It's not her fault the fact that people are waiting days to be operated on at my hospital.

That is exactly what I was going to ask. Why wasn't he taken emergently to surgery once they realized he may have dead/perforated bowel? Obviously he chance of survival was extremely slim. But putting the surgery off is just going to increase mortality. Maybe that was the surgeon's/anesthesia's goal. (for him to die before surgery was even done).

Anyway, like someone said earlier. His death is probably the best thing that ever happened to him. At least he didn't end up on a vent with multiple pressors and a huge open gut.

I took care of a poor lady once who was post-op a mesenteric arterial bleed that led to a dead gut. She was intubated, on multiple pressors, and the surgeon couldn't even close her abdomen. Can you imagine the pain? We initiated hospice care after the surgeon reopened her on the 3rd day post op. Her entire bowel was dead. She was in so much pain. The amount of pain she was in still haunts me today.

You should feel proud. You are a good nurse and you were there with him when he died. If he was still up on the ward he may have died alone.

[rn undisclosed name]

I sometimes wonder though why we go to these extreme measures in elderly patients with so many co morbidities and poor chances of survival. Is it so hard to let people die in peace?

To answer your question maybe they asked this patient and he said he wanted to have everything done.

I work oncology and it is amazing to me the differences in what people want done. Even with having cancer (and late stage at that) some people still want everything done. It is such a personal decision and I've asked that same question many times. It's hard not to let our personal belief into this.

Some people want NOTHING to be done. Others are ok with treating an infection with antibiotics.

Then you have to wonder what the docs said to the patient or family. Sometimes the patient is done and is just ready to die. Then there is the family to consider. Some just have a real hard time letting go and make the final decision to just make them comfortable.

[PostOpPrincess, BSN, RN]

The process of dying cannot be stopped. It can only be delayed.

The "what if...should I have...and if only..."

Is an expenditure of energy....

I wouldn't be wasting...