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Topics About 'Death And Dying'.

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Found 113 results

  1. Chancub

    ICU - not for the faint of heart

    I am just trying to hold myself together, often I am in pieces, and I feel like I am scrambling to keep everything in one piece. Is this what life is like? That was a question I asked myself last Thursday night, it was the second night that I had this patient, and his family was amazing. Often times it's the good ones. Of course it's the good ones that always lose the ones they love the most, and it seems like ones that are terrible nasty and mean stick around forever. You think that in two nights you wouldn't get to understand and know another human being, but you would be wrong. In my position as a nurse we really get to know people, possibly it is because it is when we meet people, in their most vulnerable moments. In the middle of my week I admitted a patient who had had a cardiac arrest, he was being flown in, as I've mentioned before we get patients from all around the state, the sickest of the sick. I get report from the nurse from where he's coming, and I knew this was going to be a bad one. What I did not apprehend is how incredible his family was. When I left that next morning, he was on a couple medications to keep his blood pressure up....but no big deal often times people are on that unit, when I came back the next night he was on three blood-pressure medications, and he was not able to keep his pressures up, and I knew it was over. It was only just a matter of time, now my job was to support the family. They were such a great family, I knew that they would not hesitate to make him a DNR if they had known that there was no hope, and in his case there was no hope. Why as the human population, do we continuously try to expand the lives of the people we love to the very end of time, even if it is not possible? We beat ourselves up for these people that die, when in reality we do not know if they really do die? Their souls can continue to live on, but we are so scared of death that we cling to them, even if they're willing to go. We will save that topic for another day, I have plenty of stories. Well his family was not like that, they were willing to let their loved one go, knowing there was no hope, but they were going to be there and love him until the very end which was soon to come. Throughout the shift as I got to know the family, I learned this hopes, his dreams, how many kids he had, what he did for a living, what he wanted to do with life, where he was coming from and why he was here. I learned his family's hopes and dreams, the ages of the children, his siblings, how his parents passed, anything else you can think of that you want to know about a human. Throughout the night the daughter, the son, the sister, and the ex-wife, never left the bedside. I have an odd name, but they sure did remember it from the night before when I admitted him, I felt so grateful that they would actually remember my odd name in their time of chaos and dismay. As his blood pressure started to trend downward, I knew it wouldn't be much longer, but the thing about that is, we never quite know when they're actually going to go. He had a son who lives in LA, who was attempting to get there, and you never know if that's what they're waiting for. Well he lasted my entire shift, and passed right before shift change, and an hour before his son was about to land. People choose when they want to die, he chose that he had wanted to die and hour before his son had got there, we will never know why. At one point in the night the daughter had continuously tried to be closer to him, I grabbed another coworker of mine who helped me scoot him over on the bed, and told her that she could lay next to him if she would like, she was so happy with tears in her eyes, knowing her father would soon pass. Thankfully he had just walked her down the aisle a month sooner, she had placed little crystals on his chest, I asked her what they were for? She said; "to keep him grounded, keep him with us." She was beautiful, there was tears in my eyes I had tried to hide, and I smiled; he will always be with you - I didn't say it, but thought it. She did not leave the bed again, until I was long gone and he was long passed. I will never forget that morning, I had given report to the nurse that had had him the day before, suddenly his heart had gone into a rhythm that was lethal, I notified the family and told them that it was only a matter of time now, he was no longer perfusing. They all stood around him, crying, and letting him know it was ok to go, and he was loved. I stood in the back, there for support, if they had needed me, or any other questions they needed answered. Before I left, and after he had passed I hugged them, and cried. They told me, which is a moment I will never forget; "you were our angel last night" ....their angel, wow...As she hugged me with tears streaming down her cheeks, and thanked me for everything. The one thing I've realized about this job is how much love their is in the world, and how people can always be thankful for anything you do, even if they're in the worst circumstance. I guess I never really realized that, I was just doing my job, but my job isn't normal...my job entails being there for people in their most raw and vulnerable state, people are so humbling. I left that day in tears, crying for this amazing family. I also realized how incredibly grateful I was for being able to be in their lives for that moment, for the moments when they needed someone the most, I was thankful it was me. I am grateful I met you, even in these circumstances, thankful for you, for changing my life, I will never forget these times, even if I don't do this job forever, so much will never be forgotten.
  2. It was shortly after labor day when I walked into the emergency room to see a client who had been found unresponsive and rushed to the hospital. I walked to the front desk, identified myself, and requested to see him. The woman behind the desk smiled kindly at me and asked: "Are you family?" I opened my mouth to respond and closed it again I did not know how to answer. This client, who had I known for 5 years, had no family. When a coworker visited him in the hospital weeks before, she had been present when a staff member asked him about family members. He had been very clear on the fact there was none. Was I family? When my normally calm administrator called me, her voice broke when she asked me to go to the ER to check on him, as she had just gotten a call from a very upset and worried aide. She had known him for much longer than I had, had gone to see him recently in the hospital, and was genuinely upset. It was her that had visited him a few weeks ago in the same hospital. Clearly, she was his family. Was I family? His aide was upset because she cared for him and had been with him more often than her own child. He has suddenly declined, and he needed her. She had come at all hours of the day and night, paid and unpaid, to care for him. She was scared. Of course she was family. Was I family? I had spent my drive there thinking of him. But I had also thought just as much about the girls in my office, all who had gotten out of their beds to care for him late at night, supported him when he was sad and angry, and loved him through it all. Girls who answered the phone at 1 am when he needed something, who talked to him during the day when he called for reasons that weren't really reasons. Of course, they were family. Was I family? She asked again. Yes, I replied. I am part of his family. And after the kind liaison sat me down and handed me tissues, I sat with him til it was time for me to go tell our family he was gone. When I arrived back at my office, I hugged, cried with and held our family, as we mourned one of our own. I don't say this enough, but I thank God for our family I wonder sometimes if other nurses or medical professionals go through this. I know we are taught not to form intense attachments to patients as it could cloud our judgment. I feel like my attachment to some has actually helped. Knowing them as well as I do has let me pick up on little things I may not have otherwise. These bonds have allowed my staff to care for patients in a way they normally wouldn't be able to. For patients like this one, who had no one but us, how does one walk into his home on a regular basis and not feed the basic human need for human connection? Isn't it part of our job to care for the client both physically and emotionally? Mental health and physical health can and often do go hand in hand. No one should be alone in the world. Especially not when so many people go in and out of their home every single day. Honestly, I feel like many nurses and medical professionals do. Doesn't everyone have that "one patient"?
  3. nutella

    There is nothing we can do

    When I entered the nurse's station, I immediately felt the typical business of a weekday morning. The morning rush during which everybody tries to get a handle on all the tasks for day was unfolding. One of the nurses looked at me briefly and said, "Good that you are here - Something needs to happen - This patient has cancer from head to toe and the family is in denial. The patient is not a full code but there is nothing we can do." Sounds familiar? Working as a palliative care nurse in a hospital is like no other nursing job. My job is to look at the patient and their family in a holistic way, to look at the bigger picture and to address nursing needs or general care needs that are related to serious illness and frequently at the end of life. Nowadays, many of our patients in the hospital have specific needs related to serious illness and require a different skill set. I carry around a small bag with papers and informational material - my stethoscope is neatly tugged in there as well - it lives in a zip lock bag ready for use together with all the information brochures and papers. My work outfit does not include scrubs, I am mostly a conversation nurse, although there are times I do "hands on" nursing care. The patient I was asked to see to assess for palliative care needs appeared very sick when I entered the room. Only half awake, the face sunken in, breathing shallow and faster than normal, the skin glowing in this yellow-greyish undertone that tells you right away something is wrong. A variety of drains and intravenous lines around him. His wife who sits next to him in the recliner chair is hesitant when I introduce myself. She agrees to talk with me and points out that her husband has been confused the last days and tried to pull out IV lines and the Foley catheter, which is the reason she stayed overnight. My biggest and most important tool is listening - I have the luxury to provide "time" while patients and their families tell me their "story." His wife tells me a typical story and tries to sum up neatly. The last several years that have been consumed by the initial cancer diagnosis with all the usual tests, surgery, radiation, chemotherapy. Uncounted visits to the city teaching hospital close by that is known for expertise in cancer treatments. Many days sitting in the hospital and waiting for lab results to show up, waiting to hear from the oncologist, waiting to know what comes next. Months on end with frantic activity in which being a cancer patient's wife turned into an unpaid full-time 24/7 caregiver job. True - there were also some months during the last years when things seemed better but life never returned back to where it was before he was found to have cancer in an advanced stage. Instead of traveling for fun, visiting family, and getting together with their group of friends to play cards, they were now experts in navigating the large hospital in the city, knew all the different times during which traffic is unbearable, developed preferences for one of the food courts and got to know the oncologist, nurses, aides, lab technicians, and the cashier at the food court. His wife continues to paint the picture that reflects their journey for the last years. The change of identify from the "retired couple with grandchildren" to a member of the "cancer tribe" with specific rituals and unwritten rules. The many talks she had with other spouses in a room united in hope but also united in the unspoken fear and worries. "We did everything they told us to do. Never missed an appointment, faithfully showed up for lab work, scans, check-ups." The last two months, she noticed that things were changing. Granted, they had been going to the cancer center for years and were now very familiar with what it means when the doctor tells you "I have bad news - we found something on the scan that does not look good" or "I am afraid that the chemotherapy is not working." It never meant to her that things might now be going into a different direction overall. To her, it meant that there will be "something they can do", although she realized that the cancer was slowly taking over his body. "He is definitely much weaker now, he has not gotten out of bed in weeks, it was already very difficult at home the last weeks. I have to do everything for him, he sleeps a lot." Her face gets sad and for a second I can feel the desperation when she continues to outline what has bothered her the most for the last weeks: "You know, you are good enough as long as they can treat you, while they are doing surgery, giving you chemo and radiation. But when there is nothing left and the cancer spreads they just throw you away. One day I called to talk to the new oncologist to tell that there were problems and that we had gone to the local emergency department because the city is too far for him now that he is so sick. I was told to talk to hospice. Just like that." We talked some more and she made it clear that she appreciated everything they were able to do for her husband. But it bothered her that there was no transitioning period, that the oncologist she had trusted and who was empathic had left the teaching hospital - she never connected with the next one. And she felt "passed off", "thrown away" and obviously abandoned. They never had a sit down about what would be important in case the illness progresses and spread further or what could lie ahead. "Of course they talked about do not resuscitate but you just don't know what comes next or what to do." It did not help when it was suggested to her to talk with hospice. "They want me let him die." It also started a whole chain of other reactions and events all based on the sudden feeling of abandonment by the department and institution that had been their second home for the last years. Obviously, there were many missed opportunities for conversations. When he became unable to tolerate food and TPN was started it was helpful but it was a milestone and would have been a good time to sit down. When they found metastasis after the extensive surgery that left him with a variety of bags and attachments it would have been a good time to talk about "what if" and "how much are you willing to go through for gaining more time." The patient's wife felt not prepared for what her husband had been knowing for a while. His continued functional decline and the continued unwell feelings including pain, nausea, vomiting and general discomfort were clear signs for him that he was not doing well and he became tired of being sick and unwell. For his spouse, his decline meant mostly more activity and more "things to do" but did not connect her with the fact that he was approaching the end of his life. When she realized, it was like the moving universe suddenly came to a full stop. Caring for him and taking care of all medical appointments, managing his illness and drains had moved her along like a conveyor belt where "you just keep going." She pointed out that she was not in denial, she knew that death would come but it did not have much meaning until the physician said "hospice". The constant activity shifted all her focus and thinking towards "doing" with no reflection about the bigger picture. When she was not busy with his 24/7 care and coordinating providers and treatments, she was so tired that she would just sleep or distract herself watching TV. Now that her main caregiver activity was to sit with him and talking to his care team, her emotions and thinking were catching up. From non-stop activity to full-stop. Her mind and heart re-connecting what had been mostly an intellect based experience for her. I validated her feelings and expressed sadness. As human beings, we want to feel connected and we want to know that the other person cares. People want to tell their story; they need to talk about how they feel and do not want to feel "thrown away." Many transitions do not go well because conversations happen too late and do not include "what if" talks. I sometimes hear "come on - they must have realized he is dying" - but reality is that our society does not view dying as a normal part of living and physicians view their job mostly as "treating" and have a lot of discomfort when they need to talk about the fact that dying is not optional - which is why many tend to have conversations that are not effective or hurtful. "Your cancer is progressing despite the 3.line treatment - There is nothing else I have for you". And when the patient and family starts to show distress followed by "do not lose hope - there is always something new, it may be just around the corner and I will look into clinical trials" while knowing very well that all of this is not an option and this is the time to prepare and do ensure that the time that is left can be spend in the most meaningful way. Sounds familiar? Physicians often feel that they are taking away hope - but what does that really mean? Often enough, the helplessness and the lack of skills to have a conversation that does not "turn bad" leads to passing the bucket to a different provider or the hope that "the family will realize." Some providers have become skilled in avoiding a conversation and elevate the "having a purposefully vague conversation" to an art so they fool themselves and others that "I have put it out - they are not ready to hear what I am saying." Obviously, I am advocating for earlier and better conversations. It is not about "taking away hope" or "stop fighting." When somebody has a serious illness that very well may turn terminal, it is important that the physician sits down and has a conversation that focuses on goals, values, preferences, trade-offs, strengths. It is important to stop the conveyor belt of "treatment" and to pause early on to reflect, build the relationship in a different way and guide patients and their families along. Thinking needs to shift from considering all treatments possible to pause and evaluate the benefits and if the treatments and care plans are actually congruent with the patient's overall wishes and goals if "time left" is limited regardless of maximizing treatment. When death is not avoidable in the near future, we should focus on finding out how much the person is willing to go through and what are acceptable trade-offs for gaining more time. Those structured conversations do not have to be long, when done early on and regularly they might be only 20 minutes long. It helps the family to understand what their loved one wants and opens the room to discuss what is important at a given time and which treatments and care plan match that goal. Instead of focusing on "what we cannot do" focusing on "what we can do" as a healthcare team. There is actually a lot we can do when somebody approaches end of life: We can help you to find out which care plan and treatments match your needs and preferences. We can help you to maximize your comfort and allow you to spend the time that you have, however long that may be, with more quality especially when comfort and avoiding suffering is most important to you. We can still hope and fight - not for a cure or to maximize the lifespan - but for the most comfort and quality to make the time that is left most meaningful. We can give the gift of time and listen. We can care and sit with patients and their families throughout this time. We can re-assure them of their choices especially when they feel ambivalent about comfort care. There is actually a lot we can do! There is nothing we can do-article.pdf
  4. spotangel

    I wish I could see you!

    Mr. Francis Ross's eyes were closed, his breathing shallow. I walked into his room. He was surrounded by his family. To the outside world they looked like a very close knit family. I knew better, bearing witness to the daily infighting inside and outside that hospital room. The reason was very simple. Francis was dying, was a DNR and the family stood to gain a lot of money. There was a tiny hitch. The ex-wife Clarissa had showed up now professing undying love for him. She claimed that he was going to get better and that she would nurse him back to health. Francis clung on to her and her words. His children could not stand her; calling her a fake, gold digger. They felt that he could not see past her honeyed talk. Matter of fact, he could not see as he was blind now. The diabetes had claimed his eyes. Francis had left his wife to marry Clarissa when he was a hot shot lawyer. His wife died a few years later and their children held that against him. Later when his luck and money were down Clarissa left him, divorced him and got married to someone else younger and richer. Francis realized his mistake, reached out to his children and mended his fences. For the next 20 years as he got sicker, his kids took turns to bring him to the hospital. This seemed to be his last visit as he was in multi organ failure. No medical treatment was working. Somehow, Clarissa found out and was back in his life. The evening before, I heard that there had been a bedside wedding. The children had found out that Clarissa was back in their father's life and were livid. Looking at the fatigue on Francis face, I gently herded the group out of the unit and went back to him. His BP was low and his labs had looked real bad. Since he was on palliative care we were giving comfort measures only as per his wishes. "Annie?" "Yes, Francis?" "I need your help." "What can I do to help you?" "I need a priest. Can you get me one?" "May I ask why?" "I want to get my last sacraments and confess. I know I am dying .Aren't you Catholic?" "Yes! Let me see what I can do. How do you feel about dying?" "What can I do? I can't change it. I want to talk to a priest." I called our hospital page operator who had all the on call and on duty pager numbers. The priest had gone on vacation to Africa and would not be back for 2 weeks. The backup number went to a message center. I called the Nursing Supervisor and asked for help. She made a few calls but could not get anyone. I then thought of calling my local parish priest who looked like a Chuck Norris double. Father Nick aka Chuck Norris, was a young and energetic priest. Bless his heart; he made that half an hour ride in 15 minutes and got preferred parking by the hospital entrance as I had called security at the front desk. Father gave him his last rites and he was at peace. I thanked father and he left. I allowed the family to take turns to visit and then leave. Clarissa left saying that she would be back after a quick shower. Four hours passed, no Clarissa. Francis condition was worsening although he remained alert throughout. It was almost time for me to leave. I gave report to RN Joan Wallace. Also updated her that Clarissa may return after her shower! I went to Francis's room. "Goodnight Francis! See you tomorrow!" "Annie will you come in here please!" I stepped closer. "Can I give you a hug? Thank you for calling father Chuck Norris (I had told him that Father Nick was a Norris double!). I feel so peaceful". We chuckled softly in perfect accord. "Sure, Francis, I love hugs! You are very welcome!" I hugged him gently as he was all skin and bones. "I wish I could see you child!" "You never know Francis, you just might! Remember our motto; never lose hope. Bye Francis!" "Bye! Annie! Bless you!" Hoping to see him the next day, I left. It took me half hour to reach home. Thankfully I got a parking on the street after a couple of drive arounds. Walking into the quiet apartment; I let a sigh of relief. The day was over. As it was summer, the sky was still bright and there was plenty of sunshine in the room. My husband had taken the older two who were toddlers then, in the double stroller for a walk in the park and was not back. As I sat down in my living room and untied my shoe laces, I froze. I could feel a presence in the room but could not see anyone. The air was still and expectant. In my bones, I felt, I knew it was as if someone was watching me. Strangely, I was unafraid and it felt peaceful and not scary. I instinctively looked at the clock. The time was 8.42pm. "Francis, if that is you, go in peace to God! I guess you can see me now! Glad you got me with only my shoes off!" I was unaware of the tears trickling down my face as I smiled at my weak joke. Just as it came, it was gone. I hurriedly removed my shoes, washed my hands and picked up the phone. I called my unit and asked for Joan Wallace. Joan picked up the phone. "Annie, you won't believe this!" she said in a rush. "Remember Francis, that sick guy in room 684?" "Yes?' "He just passed. The Nursing Attendant went to take his vitals and found him pulseless. The doctor pronounced him. He is calling Clarissa and his children now." "What time was he pronounced?" I asked quietly. "Around 8.40pm" How on earth did he know where I lived, I wondered. I sat and said a prayer for his soul. As I pondered on the visit, I realized that he had made his wish come true as anything was possible now that he no longer was burdened by his earthly body. As I opened the door to welcome my noisy family back and hugged the kids and their dad, I whispered to the still air, "It was good to see you Francis! Remember, never lose hope! With hope, all things are possible!"
  5. curlygirlie3

    Caring Vicariously

    It has been two weeks since I found out that my grandmother was in the hospital, ten days since her surgery, five days since I last spoke to her, four days since she moved to hospice, two days since the last time she was awake. For 81 years my grandmother has been a vibrant, healthy woman. Bike riding, swimming, square dancing, crafting, and enjoying time with her boyfriend filled her days in her small Florida retirement community. She must have known that she was sick. Colon cancer does not reach stage IV without a person experiencing symptoms. Waiting, ignoring, and deferring treatment was her choice; I respect that. The difficulty comes with the swiftness of decline - a sudden drop on the carnival ride that leaves one's heart in their throat. As a nurse, as a granddaughter, and as a person I want to be there for her. I want to swab her dry lips, arrange her pillows, and hold her hand. The gulf between me and her bedside is filled with geography, time, money, and obligations to my family and work. The guilt at not being there to care for her is enormous. After all, I work with cancer patients daily. I do all of the things that I want to do for her for strangers. Wait...I do it for strangers. Another family recently experienced a profound loss. I first met Ms. Smith when she was recovering from cancer surgery on my unit. She was beautiful, kind, generous, and funny. She was a gentle soul and I could tell that she had worked with children for most of her life. When I meet patients like her, my fondest hope is that I will never see them again. Don't take that the wrong way. If I don't see them it means that they are doing well. Ms. Smith was readmitted to the unit more times than I can remember with complications from her treatment. Despite losing her hair, appetite, and eventually her physical mobility, she never lost the qualities that made her so special to the staff and so loved by her family. In her last days I was her nurse. I swabbed her lips, I kept her dry, and I gave her medications to keep her comfortable. When she passed I paid my last respects as I placed her in the shroud. Unsurprisingly Ms. Smith has been on my mind for the past two weeks. I believe my memories of caring for her are helping me cope with the fact that I cannot be there for my own grandmother. I also believe that there is a nurse somewhere in Florida who is caring for my grandmother in the same way that he/she would care for their own family member. Providing nursing care for the sick and dying requires a sort of suspended reality. That is not a stranger in that bed, that is your mother, father, grandparent, or child. As a profession, we have a collective belief in the Golden Rule. This belief may be tested daily by the stresses of the job but we must never let it waiver. Somewhere out there a family member is holding out hope that you are treating their loved one as your own. To every nurse that reads this, please keep the belief in the Golden Rule alive because, one day, as I have, you may find yourself in a similar situation.
  6. ICU/CCU

    I See The Light ... Lift Me Up.

    My mother also received high doses of narcotics in these end stages to keep her comfortable. As a result, she had been unresponsive for two days. I was sharing the night shift with my stepsister who gave the thorazine at 2 a.m. and told me that she would stay up while I took a nap and then we would switch. At 3 a.m. I woke up when my mother suddenly sat up in bed and quite lucidly asked for a cigarette. I looked at my stepsister and asked if she should be awake to which Kathy, shock evident on her face, simply shook her head "no". My mother told me that she was dreaming of "better places" and asked why she couldn't just go there. She remained completely awake, without shaking, without pain, until around 9 a.m. when she found excuses for each of her six children to leave the house and then she closed her eyes and died. Four years later, I was a nurse and the first shift that I was off orientation happened to be the first night shift (11pm-7am) I ever worked. I had been oriented to ICU, but was floated to the telemetry unit that night. In report, the nurse was telling me about a patient who was end-stage for some type of cancer. I no longer remember what type of cancer she had. The nurse told me that the patient would likely not live through my shift. She said that for palliative care she was receiving 10mg of morphine every few hours, which had kept her quite sedate for the nurse's entire shift. In fact, the nurse said the patient had been completely unresponsive for her. She reported that while the patient was unresponsive, she gave the morphine based on the patient's respiratory pattern, rate, blood pressure, etc. When report was finished, I went into the room to assess my patient. I put a small nightlight on by the door that cast an eerie illumination across the room. As I approached the bed, my patient said in a soft, sing-songy voice, "I see the light." I was scared to death that my patient was speaking and I felt nervous just being on my own. I shakily mumbled a quiet, "Hmmm?" Again, she said in the same sing-songy voice, "I see the light." Fear was rising quickly in me. My mind raced with thoughts back to when my mother was dying. I said nothing and walked to the patient putting on my stethoscope to do my assessment. As I leaned over my patient in the bed, she said in the same high, floaty voice, "Lift me up". Her eyes were closed and she barely looked alive! I remember taking off my stethoscope and looking around the room to see if anyone was there to witness what I was about to say. With nobody around, I mustered up the courage I needed. Again she said, "Lift me up..." With my heart pounding, I leaned over the patient and quietly said, "To the Lord?" Suddenly the patient opened her eyes and said in a strong, completely normal voice, "No! I want to sit up in bed!" I laughed until I cried!
  7. NutmeggeRN

    Choosing the 4th Option

    As a school nurse for 20 years, I have had more than my fair share of kids who have been diagnosed with cancer. I have had kids win the battle and lose the battle. Some had intensive therapy regimes, with every side affect possible and some blew through treatment with little side affect. Some have survived and some have not. I live in a little town that is seemingly overwhelmed with pediatric cancer diagnosis but when I try to clarify numbers with epidemiology, I find we are not higher than we should be statistically. Tell that to a parent and child whose whole world has been turned upside down. And now it is personal. My grandson to be (my sons soon to be stepson) has been treated for a brain tumor since he was 6 months old, he is now 5 �. Multiple surgeries, countless rounds of chemo, radiation, a shunt..... Recently there has been increased growth of the tumor. We met yesterday to discuss the results of his latest MRI. I was able to meet with the team from his Children's Hospital. What an amazing group of people. I have interacted with them over the years, as a school nurse, but this time it is personal. After his appointment 2 weeks ago, they were given several options to consider. Radiation, oral chemo at home or a six week clinical trial at St Jude''s. Or do nothing. An unimaginable choice. They sought out pastoral counseling, and spoke with parents who have been down this road with their child. They wrestled with putting their child through intensive disease based therapy, knowing the end result will not change. Or suspending treatment. Worrying they were giving up on their child. These are young parents. She has been a single mom her whole adult life, with an 11 year old who has clearly been impacted by his younger brothers illness. My son stepped into this situation early last year and has been a bedrock for her. They were friends in high school and now have a new relationship as adults. But he, MY (32 y/o) baby, hurts as well. He lost his dad at a young age and really struggled from the time he passed the age his dad died at, until about a year ago. They have not had it easy as young adults. They have become a strong force and a united family. And now it is going to change. She (and he) have chosen to enjoy this little man as long as they can. And they had the blessing and clear support of the team at the hospital. They were reassured they can change their mind at any time, and they will ALWAYS be a part of the Children's Hospital family. As a health care professional, I was moved by their empathy and understanding. As his grandmother, I am devastated, but strengthened, by their clarity and comprehension that this lil' guy has a limited time with us and it is up to us to give him the life a normal five year old. We will move forward from here, with periodic visits to assess growth of the tumor. They will now start to consider end of life care decisions.DNR, POLST, MOLST...there are too many acronyms to be had in medicine. These are by far the hardest decisions any parent should ever have to make. I applaud the team for being forthright and not sugarcoating that this is an issue to be dealt with. And I applaud my son and his fianc� for not backing away from the difficult conversation and inevitable decisions. We will be strong as a family but, There should never have to be a 4th option. EVER.
  8. b a nurse

    A Perfect Ending to a Perfect Day

    The window curtains were wide open. I kneeled down beside her where she could hear me and I grasped her hand into mine. I closed my eyes and I began to pray for her. The hall smelled of urine and that fecal odor that always permeates every breathable space in the facility. It was usual at this particular facility. There were loud TVs and call lights on above every other doorway. Through all this hallway madness my mind was on my time constrained day. It was filled with my usual patient load plus five. I had covered for a fellow co-worker who called in sick that morning. Up until that afternoon, my day had been filled with many hurries up and wait for situations but this next assignment would put time into perspective. This particular room had two patients, both separated with a curtain. I came to her around the curtain in the second stall. My eyes fixed upon her and I instantly surmised that she didn't have much time. I lay my backpack down at the foot of her bed. I reached to grasp her hand and could only feel cold. Her eyes were half open and her mouth was drawn open. I quickly felt her forehead and it felt hot. Raising my hands up I quickly said a prayer. My hand then caressed her face and went to work. The wash basin, soap, and hot water were in hand as I began to look around more closely. There on the nightstand and dresser were religious deity pictures accompanied by small statues of the Mother Mary. A thought quickly came to mind. I instantly turned on the TV to the all Religious channel. I knew she could hear even though she had labored breathing and half-closed eyes. I was on a mission. I had to get her comfortable and ready it seemed. I didn't stop but to only clean up from my procedures. Then I settled into bathing her. Methodically I began to clean her and I could tell as she seemed to become more relaxed as I progressed. Each part of the body received its individual care. I would rinse ever so carefully and then dry. First her face, then hands, and thirdly her body. Just as I started to care for the lower half she moved her hand and pointed to the window. After a few attempts to understand her, she spoke in a very mumbled and slurred tone, "Open the window." I dropped the towel and did as she told ending a prayer once more. She went back to her unconscious state of labored breathing and rest. I then was moved to comfort her. I wanted her to be calm and the best thing I could do was hum the hymn, How Great Thou Art. Once again she seemed to not respond and didn't seem to mind that I was humming the most comforting music available to her. I soon finished up with the bath and dressed her in a gown trying to do so with little to no extra movement all the time humming to her. My clean up took little to no time. I still felt compelled to comfort her more and more. Her breathing became more shallow. The time was coming close. I finished up and went to her side. I placed my hand into hers and I bowed my head. I began to pray to the Lord on her behalf. I felt better now that she was comfortable. I could read no pain in her face or body. I exited the room to start my "end of visit" paperwork and I returned no longer than five minutes later. She had passed. She was at peace. Many days after I could only think about her and how God worked his perfect timing. Throughout my entire day with all of the schedule changes, hurries and stops I was in perfect timing to be present for her on her journey home that late afternoon.
  9. RobbiRN

    A Tale of Two Deaths

    There is a story in Japanese folklore that goes back into an era in which they practiced "Ubasute," the abandonment of the elderly. When there were too many mouths to feed and not enough food to go around, impoverished farmers would take the oldest, most decrepit member of the family deep into the forest and abandon that person there to die alone. In one version of the story, a heavy-hearted son is carrying his mother deep into the woods. Through his tears, he notices that she is reaching up and breaking branches from the trees and dropping them onto the path behind them. He asks what she is doing, and the old woman replies, "Omae ga, kaeru toki no michi shirube da - They are markers to guide you when you return home." Even as she is being carried to her death, she is not angry or thinking of her own dilemma. Her only concern is for her son's well-being. Despite the pathetic context in which the story plays out, I'm profoundly impressed by this mother. She is sacrificed due to the lack of resources, but her final hours are marked with unselfish love. My own mother died suddenly of an aneurysm at the age of 57. I don't remember her ever being sick a day in her life. She was a nurse for years before getting two Master's degrees and becoming a nursing instructor. Between classes, she took a fellow instructor and some students out to her car to give them some boxes of apples. She collapsed while lifting a box from the trunk. Her best friend and her own students started CPR before EMS arrived. She regained consciousness briefly before coding again in the ER. Our family was aware of her general wishes, and we made the decision to stop life support soon after brain death was confirmed. Advance directives were relatively unknown in those days. Ironically, a few months before her death, Mother made a single entry in a journal, reminiscing about her life so far. The last paragraph closed with these words: "If I ever get into a situation where I would need to be dependent on machines, I do not want to be kept alive. Please be sure there is a 'no code' on my chart." We found the journal a few days after she died and took some solace as her words confirmed that we'd made the right decision. The story of Ubasute and my mother's death strongly influenced my thinking before I went into ER nursing where I see death on a regular basis. There are some who argue that it is also courageous to struggle, to fight for life until the last breath, even when we have been reduced to a persistent vegetative state. They readily avail themselves of the full force of our medical prowess. On the far end of the spectrum, others see life as more than sustained physical functions, more than a heartbeat and the ability to consume nutrition and produce excretion. They want, or need, a certain level of quality to continue. For them, letting go is courageous and possibly unselfish. While I don't judge those who believe differently, I won't try to hide my bias as I share the stories of two of my patients, each representing opposite extremes in decision making about the end of life in a health care setting where "everything" can be done: Glen The crumpled little figure lying on his left side is a sad reminder of the frailty of our humanity. Glen has a long, complicated medical history with multiple system failures and corresponding medical interventions to prop him up for another round. His once healthy five-foot nine-inch frame is down to ninety-two pounds. A plugged J-tube protrudes from his abdomen, with some yellowish liquid soaking through the dressing. Duoderm covers a massive stage three sacral decubitus. A pastel plaid pair of bulky heel protectors hide chronic foot ulcers. His extremities are severely contracted. A Foley catheter drains a scant amount of thick, dark urine. He hasn't spoken a word since a stroke six years ago. He responds to noxious stimuli, but he does not follow commands or assist with his care. He makes no eye contact. A long-term care facility sent him to the ER be evaluated for possible aspiration pneumonia. A woman who appears to be about sixty bustles into the room. She looks flustered and anxious. "Is he alright?" I'm a little taken back when Michelle looks the visitor in the eye and says, "No, ma'am. He's not alright. Is there anything here you see that is alright?" Michelle is not unkind. She is simple and more honest than most caregivers would be in answering this question. She's right of course, but many will judge her harshly for telling the truth. The visitor does not seem offended, but she doesn't respond. Instead, she goes to Glen's side and pushes his hair from his forehead, saying "I love you poppa." He does not respond to her. She produces POA papers and states "they" want everything done. We initiate an aggressive sepsis workup, including a D-dimer which prompts a VQ-scan to rule out a PE because his renal function precludes the coveted CT thorax. Two hours later, sepsis and pneumonia are his primary admitting diagnosis as he goes to ICU with several infusions running. Despite continued aggressive care, Glen does not recover. A code blue is called six days later. The first few compressions break his ribs, and his detached sternum floats freely. Frothy blood running up into the ET tube suggests that broken bones have punctured a lung. After 20 minutes of ACLS, five rounds of epinephrine, and two defibrillations for a possible "fine v-fib," the unsuccessful resuscitation effort ends. Esther An eight-six-year-old female arrives from home in a wheelchair. She's on 2 liters of oxygen via nasal cannula and clearly in respiratory distress. Esther's daughter-in-law, Jennifer, is her primary caregiver. Her only son, Jake, has an hour drive ahead of him to get to the hospital. They produce a living will and a valid DNR. The patient clarifies that she is open to medications and oxygen therapy, but she does not want bi-pap, intubation or resuscitative measures, including emergency drugs like epinephrine. We tell her that without aggressive treatment, she may die very soon. She answers, "That's why I went to the trouble of getting these papers. I've lived a good life. I've already had the bonus round. We've talked this over, and if this is my time, then it is my time." She agrees to basic labs, a CXR, IV solumedrol, IV fluid, and increased oxygen, but refuses any kind of a mask because she wants to be able to talk clearly. Jennifer is the most courageous family member I've ever seen at the bedside of a dying patient. There is no way to improve on what she does. She silences her phone and puts it in her purse, giving Esther her undivided attention. When Esther gets too weak to talk, Jennifer keeps her engaged, reconstructing meaningful moments of her life for her, telling story after story. "You were so good with the kids granny. The will never forget all the days you were there for them in the early years. You gave them so many happy memories, like that blow-up pool you got Jason when he was six. Jessica still talks about the weekend you took her and her friend Emily over to St. Pete Beach for her 8th grade graduation. She came to me that night and said you are the coolest grandmother ever." We are nearing the hour mark, and I can see that Esther may not be able to hold out for her son to get here. Jennifer tackles this obstacle too with incredible poise and grace. "It's okay, granny. I know you are trying to hold on for Jake to get here, but you know he loves you. It's okay if you need to go now. He'll understand. We all love you, Esther." Esther tries to smile as her head slumps forward, and Jennifer quickly steadies her back on the pillow. She quietly runs her fingers through Esther's hair. There are only a few agonal respirations before the breathing stops altogether. I silence the alarms, feel for a carotid pulse, and confirm what Jennifer and I both already know. I shut off the oxygen and removed the nasal cannula. Esther's face is peaceful. I hug Jennifer and tell her she is incredible. I've seen hundreds of deaths. Calm, anticipated and accepted deaths usually happen at home or in a hospice facility. Death in the Emergency Department is usually intense, arguably brutal, and sometimes frantic. Some deaths are shocking and tragic when a child or healthy adult dies unexpectedly. Most people, like Glen, die for really good reasons. I've seen so many like him, they are soon forgotten. I'll never forget Esther, and her last hour filled with courageous love on both sides. If it is even permissible to put the two words together, Esther's death is beautiful. I won't judge those who chose differently, but I already have an advance directive. The people in my life know where I stand. When my time comes, I will be honored to follow my mother's conviction and Esther's noble example.
  10. CheesePotato

    Dear Nurses: Please Forgive Me

    Dear floor, ED and ICU nurses, Please forgive me. I know he's dying. I get it. I do. We were told five years. Five years on an outlier and he would be gone. We were told transplant was an option but with the dismal survival rates, we opted for rehab. He is now eight years post diagnosis. We know we are lucky have had him this long. It doesn't make this any easier. Please don't say it like it's a mantra of comfort. For reasons I don't know or even fully understand, it only makes the sting more sharp. We see it, you know. The mental status changes. The lack of control. The shuffling gate. The use of accessory muscles. We see it. And we know exactly what it means. When he can't remove his bipap to eat, we know. When he can't lower the head of his bed past thirty degrees, we know. When he can't talk, we know. We know. Forgive me, please, my many sins. Forgive me the overbearing stare and raised eyebrow. Forgive me for repositioning him and demanding another pillow for under his heels. I'm helpless, you see, to stop the very shadow that will claim him and I have nothing else to cling to. I have nothing else but what now feel as tedious, miniscule scraps of knowledge that amount to nothing. No cure. No hope. I'm lost. I'm lost. You must understand that when I nearly demand to read the orders or see the chart, when I loom over your shoulder, it is not that I don't trust you...it is that I don't trust myself. I don't trust myself to be cope, to make all the right choices, to advocate, to deal with the loss and reconcile the feelings of guilt, of doubt, and pain. I beg you to understand that I'm scared to death and helpless and a control freak and for once I can't make it better. Understand that I glare instead of cry, laugh instead of scream, and go silent when angry. It's dysfunctional, but it's my way. And I don't want to be up later at night, pacing a hole in my carpeting, consumed by nausea and a feeling of coulda-woulda-shoulda. So when you see me wandering the halls, wringing my hands, biting my lip and growling under my breath, please don't be afraid to offer a kind word. It is what I need to hear. Even if I do not acknowledge that I heard it at all. Trust me, it got through. And I will remember. You must understand that this man is precious to me--that I want to guard him the way he guarded me from myself. That when I call every two hours to demand a neuro status check it is because I am not there and I am struggling to convince myself that I really do need to sleep even after being up for nearly thirty six straight hours and you are my eyes and ears and everything else. Please see what that cranky, demanding creature is to me. He wasn't always this way--a brain sitting in an acid bath is a terrible thing. I can't control what's happening to his body but I can control the flavor of his Jell-O and so, you know what? If that means raising holy hell with Dietary so I can get red Jell-O for him, then I will. Because it's all I have. Be genuine with us. We can handle it. Know that he is the first man, since my grandfather, who treated me with kindness, and god help me, love, even though I was a crazed woman-child dwelling in a familial household, riddled with hormones and a gloomy past, laden with baggage, sociopathic tendencies and unable to form any sort of bond and yet he never left. I lived years without that bond. Years without feeling the need for the guidance and protection only a father could give. Some part of me missing that bond and loathing "daddy's girls" everywhere. But he's trying to leave me now...I survived nearly a lifetime without him and suddenly I 'm not ready. I'm not ready. I'm not ready. Know that I never encourage him to use me as some kind of threat...some unholy boogie man that will get you if you don't help him right this very second. Because, "my daughter is a trauma nurse and she will know what you haven't done right." Know that when I come in and acknowledge that, ::sigh:: yes, I am a nurse and then talk a little shop with you, I am not trying to be in your business but show you that I understand what you are trying to accomplish and understand what you are dealing with on a day to day basis. I am nothing without you and neither is he. But he is my dad. Please understand.
  11. Jesikanikole82RN

    The Little Girl in Room 421 (creepy)

    Mae was a 72 year old congestive heart failure patient who was sharp as a tack and always making jokes. She was what we called a frequent flyer, since her chronic condition flared up frequently landing her in the hospital. She was a sound sleeper and always in good sprits, which is why her current less than happy state on this sunny morning caught me off guard. I asked her how she was felling and she snapped, "fine but tired!". Like any good nurse I asked her if she was having difficulty breathing and laying down to sleep. She knew the drill and responded back no my hearts doing fine today! It was all the giggling that kept me awake! I was puzzled by her statement since I was unsure who was giggling on a unit full of elderly cardiac patients so I brushed it off, and assured her I would make sure to let everyone know they needed to keep it down at night. She nodded and we went about our day. The next morning I returned and had Mae on my assignment list. I enjoyed caring for patients I knew so I happily started my day by checking on her. Mae again insisted that someone was in her room at night giggling. This time I mentioned her complaint to my charge nurse who laughed at me and said is Mae in 421? I shook my head and quickly tried to figure out how my charge nurse knew Mae's room without me telling her. Within a few minutes I had 3 senior nurses and my charge nurse trying to convince me that room 421 was haunted by a child from the pediatric unit who died a slow lonely death by cancer. The child was a foster child who only knew nursing staff as her family. Families tried to care for her but her illness always proved to be too much to handle and they gave her up time after time. That did not keep the little girl from fighting a long hard fight before passing away. I was not sure how I felt about hearing this story or if passing this information on to my patient was a good idea. Later that day I received discharge orders for Mae. So lips sealed about the story I sent Mae home. About 2 months later I agreed to work midnights for a few months until a nurse returned from maternity leave. I had long forgotten the story of the giggling girl in room 421 but I was quickly reminded. I was making my 3 am rounds checking on all of my patients. I slipped into my patients room to ensure he was sleeping, safe, and not in any distress when I heard a rustling noise in his bathroom. I opened the bathroom door and did not see anything. Then I heard a little girlish giggle behind me. I turned around so fast I almost fell over. I could feel my heart racing in my chest and I could not get out of the room fast enough. I had not seen anything but that giggle I heard was plain as day. It sounded as if a young girl was standing right behind me giggling at me for falling for her bathroom noise joke and then getting scared. When I told the nurses in the station what had happened they all laughed at me and reassured me that the sweet giggling girls ghost would not harm me or my patients. They informed me that if my patient complains about the giggling they come up with an excuse to switch rooms. I have never been a believer of ghosts but I guess I have never been a non-believer either. I just coasted through life never having an experience that made me ask myself, do I believe in ghosts? Now that I have heard and met the giggling girl who makes 421 her home I know that I am a believer in ghosts. After doing some research to reassure myself I am not crazy I found that room 421 was once a room which isolation and critically ill children where placed. Many children took their last breath in that room. I believe at least one child is still alive and well in that room pulling harmless practical jokes on the nurses and giggling about it.
  12. Hope4us

    The Little Round Thing

    When I started that day it seemed the paramount thing to me just to get rid of the dress bypassing my state board exams. My clinical rotations had become routine stuff after two years. My mentor hardly bothered to check on me anymore. I thought I was ready to be released into the real world of nursing, until that day! Hectic! Four call lights were ringing and they were all my patients. The aide on my rotation was taking extra long time to give a bed bath when I needed her help, it seemed to me. I had a pain shot in one hand, but I looked into room 369 on my way past to say, "Sylvia, I'll be right with you." I turned off her call light. When I came out from giving the shot, Sylvia's light was on again. I stepped in. She was sitting on the edge of her bed with her arms on her raised side table, gasping for breath as she had been for the eight days she had been in the hospital. She was what we called a frequent flyer with advanced COPD. She usually rallied after a week or two in the hospital and went home again. "I need a little round thing out of this drawer," Sylvia told me. The drawer on her nightstand was open and I fumbled through it, wondering when the aide was going to be available to do this stuff I didn't have time to do. I couldn't see anything round in the drawer. After eight days the drawer was quite full of papers and silverware, jam and salt and pepper packets, whatever Sylvia wanted to hang onto. It was so hard for Sylvia to get air to talk that all conversation with her had to be yes, no questions and I was in a hurry. I told her I'd be back. I turned off her call light as I went out the door. When I came out from giving the next pain shot, three call lights were ringing. One of them was Sylvia's. The aide was nowhere to be seen. I felt a little impatient. I put on my smile and stopped to wash my hands as I entered the room. A deep COPD grunt of disapproval came from Sylvia. She did not have time for me to wash my hands the grunt said. "Now," Sylvia gasped, "you find it!" I began to ask questions as I dumped the drawer on the top of the stand. I showed her as I put each thing back in the drawer, one at a time. "Is it a pen or pencil?" No, her eyes said. "Smaller?" Her eyes registered frustration. "Shorter than a pen?" Yes her relieved eyes told me. "Wider?" Yes. By then I was to the bottom of the stack. The only thing in the whole drawer that could be called round was her glasses case, and it wasn't really round. I held it up. Sylvia motioned for me to put it in the drawer and flipped her hand towards the door as if she was the queen and I was a disobedient servant whom she had no further use for and she was sending me out of the room. "Your breathing is much worse," I told her, "I checked and you have taken everything you can take but the nebulizer. I'll bring it to you right away." I was surprised how much air and energy Sylvia was able to muster to spit out a very decided and upset, "No!" "You don't want your nebulizer?" I asked with genuine surprise. "No!" This time it was louder and more determined than before. "Just find the round thing," Sylvia hissed at me with a gasp between each word. "I'll be back after I give another shot," I told her. I had to work to keep the impatience out of my voice. By the time I had the shot ready, Sylvia's light was on again. It was still on when I was done. The aide wasn't back yet. I stepped in the room again and went to Sylvia's closet telling her, "I'll look some more, but I don't really know what I'm looking for. It would help if you could tell me more about it." "Yellow." I came up with nothing round and I had gone through the whole room now. I could see nothing yellow anywhere. Tears came to Sylvia's eyes, and I understood see she was trapped in her body and helpless and didn't even have enough energy to cuss at me. I softened as we stared at each other. I told her, "There is a very patient man down the hall who has been waiting for a pain shot. I need to take care of him, and then I will come and ask you some more questions and try to understand what you need unless the aide can come first. One of us will come, okay?" It was not okay. She shook her head. She grunted about the man who didn't need me as much as she did. She was serious and she was helpless. As for me, I was starting to feel like maybe I did need my uniform and it seemed to fit a little better than it had earlier in the day. It took more than a change of dress and passing exams to make a nurse I was thinking. After I gave the next pain shot there was only one light ringing. It was Sylvia's. I heaved a very big, impatient sigh and tried hard to remember the lesson in class on how to deal with difficult patients. Cooled down, I went to Sylvia's room more relaxed. It was quiet. Nobody was waiting for me this time when I went in. I could spend some time with her. She was lying back in her bed! "Sylvia!" It was extra quiet. It wasn't just because I turned off her call light. There was no wheezing sounds - no difficult breathing sounds. In a flash, I was at the bedside taking Sylvia's carotid pulse. It was barely there. I grabbed at the automatic BP cuff, put it on her arm and hit the button with one hand while I got the bed ready for CPR with the other. I had heard a faint breath when I put my ear to her nose. As I picked up the phone to call for help the BP read 30/10. Then it hit me with a repulsive shudder that rocked me from head to toe. DNR. Sylvia was a do not resuscitate patient. I quickly checked her pulse again. Nothing. I hit the blood pressure button. As my mentor flew through the door into the room, the blood pressure monitor read nothing. No heartbeat. No breath. No blood pressure. I have never felt more frustrated in my life in twenty years than I did at that moment when I was not allowed to start CPR. I even thought of trying it, just in case, for a split second. My mentor looked like she felt about how I did. The doctor came in right away. The family was called. The mentor, aide and I cleaned Sylvia of her incontinent bowel and bladder mess and got her all ready for the family visit. We put on crisp clean sheets and combed her hair and made everything look as natural as we could for the farewell. We were in a hurry to have it done, knowing the family was rushing to get there to say their good-byes. "Why rushing?" I wanted to know. They were the ones who didn't want her resuscitated. They had all agreed. Now they were rushing to see her when it was too late for anything but good by. "How could they do a DNR?" I asked again. It was so upsetting to me. I looked at the mentor as we left the room. "The only other thing I feel bad about is that I didn't find her little round thing," I told her. "Her nebulizer?" my mentor asked me. "What!" "Sylvia calls her nebulizer a little round thing. She always sneaks one in from home. The doctor knew her condition would improve with the new stuff and he also knows she didn't take hers as it is prescribed so she wasn't supposed to have any at the bedside, but she always gets one smuggled in from home. She doesn't like the new stuff. Last night the aide found her contraband and put it in her glasses case. We were going to ask the doctor what to do this morning." I stayed behind in the room as the mentor went out. I opened the drawer and took out the glasses case. I shook the little round thing out of the case. It had a yellow band around it. It seemed to me my student uniform fit me perfectly. I had an examination to make before I ever faced nursing board exams. I had to examine me and what life is all about. What rights do patients have? What rights did I have? Why didn't we start CPR? If I had found the nebulizer what would I have done? How would I have treated the patient? If she had found it, would it have given her a little more relief? Would it have given her minutes to live? Would it have held her over to her IV dose? Would she be wheezing away right this minute? "I'm sorry Sylvia. I'm sorry I didn't find your little round thing. I'm sorry you died in here all alone. Your need was more important than the patient man down the hall waiting for his shot just like you told me with your eyes. I didn't believe you and I am sorry, Sylvia." Name changed
  13. tammysmithlvn

    Daughter vs. NURSE: Moral Courage

    Reflection: Moral Courage Moral courage is sometimes a shared experience. I have always had the realization that sometime in my Nursing career, I would be faced with the task of assisting my patient while they receive a terminal diagnosis. Allowing the patient time to process such information, and to make personal decisions based on their preferences and needs, is just a small part of nursing care. But never in my wildest dreams, did I ever think, that it would be my very own MOTHER... sitting next to me, And while I gently held her hand... Hearing the doctor say... "YOU HAVE TERMINAL LUNG CANCER" As you can well imagine, it was such terrible news to hear. And of course many questions surfaced. You know those "What If" questions...What if we did surgery. ... What if we did radiation? BUT all we heard back from the doctor was more negativity... "IN-OPERABLE and TERMINAL"!! This diagnosis was not at all what we expected to hear. As the daughter of the patient in the room, I remained quiet, trying to simply process the news, allowing my Mother to ask questions that I knew she had. But then... the Pulmonologist began insisting that she return to the hospital and undergo a Bronchoscopy procedure. Momma looked at the Doctor and simply asked him... "WHAT IF I DON'T WANT ANY TREATMENT FOR THIS CANCER"? The response from the Doctor was.... "WELL, I think you are being very SELFISH at this point" As you can imagine I abruptly abandoned the Daughter role and "NURSE TAMMY, LVN" went into action. I quickly reminded the Doctor that this was not his decision to make. The patient has the right to be educated about her diagnosis and treatment options, and would require more time to come to reach a decision. I told him the he had No RIGHT telling any patient that they were being selfish!! He angrily stood up and left us alone in the room. It seemed like we sat there together for an eternity..on the 12th floor of the office building, studying the Houston skyline. The ride back home was so quiet. There was a lot of thinking and soul searching going on that day. The Pulmonologist's office called the very next day, with the arrangements that had already been made for the Bronchoscopy. (This doctor was persistent!!). Two long days went by, and then one day after class I sat down in Momma's room to visit. I could tell she had been really battling this decision. As her daughter, I just could not give her an answer...."permission to die". BUT approaching this situation as a NURSE... I simply looked into her beautiful face and said... "DO YOU REALLY CARE WHAT KIND OF CANCER CELLS ARE GROWING IN YOUR LUNGS"? She looked up at me, eyes wide opened, and shook her head NO... I then simply smiled at her and said.... "I THINK YOU HAVE YOUR ANSWER"!! Such a tremendous release poured from her face at that point. She quickly began living the rest her life, spoiling her family with as much LOVE as she could. She never regretted her decision. As Nurse's... we are taught to become the patients advocate. We are there to offer teaching, protection, and to offer support... taking into consideration the wishes of the patient. We must find that inner moral courage and strength to be able to help our patients...and yes, even sometimes our very own MOTHER ... make the best choices and decisions regarding their personal care and spiritual well-being. In Memory of my Mother, Sandra J. Smith 01/04/1942 - 12/22/2010
  14. YelenaV

    Singing with the Angels

    There are times, however, when the patient can't improve. To our frustration, we all remember times when our patients were terminally ill. Some we didn't know very well, so the feelings inside were sadness and reverence. Some were our favorites, and we cried together with their families. Yet I learned that death is not always a failure on the part of a patient or his medical staff. There is a powerful event which when happens is able to make peace between life and death. This event is called reconciliation. After graduating with my B.S. in Nursing I worked in a small hospital in eastern Kentucky. Being born and raised in Russia, it took time for me to get used to the local accent. However, I found people delightfully simple and friendly - they tried their best to understand my Russian accent and I was often telling them funny stories about how people live in my country. That day was my regular day shift. I had 9 patients, but they were unusually stable and therefore I was rather cool, calm, and surrendered. At the end of my hallway was a room for just one patient, and earlier in the day the patient was admitted there by another nurse. I was walking down the hallway in the afternoon when I heard this patient's IV beeping. I went in to see if it was just kinked and maybe could be easily fixed. A man in his late fifties was lying on the bed with Dr. E seated by his side and a lady about 40 years old standing in the room. I was surprised to see Dr. E because it was long after the doctors' rounds were finished and this doctor was pregnant, so I knew she would not come out to the hospital unless there was a serious reason. While fixing the IV, and sure enough it was just kinked, I heard bits and pieces of a conversation. "... Unfortunately Mr. J, the picture we got a week ago and a picture we got today are drastically different... It grew to the size of a grapefruit... This is a very rapidly growing cancer..." The IV was fixed; I exited and went on to check on my own patients. 15 minutes later the IV began to beep again, and I went toward that private room, thinking about how unwise it was to give this client to another nurse, the majority of those patients were in another hallway. I quietly passed by Dr. E standing outside the room, holding the lady and talking to her quietly, trying to comfort her. The lady turned out to be Mr. J's daughter and right now she was sobbing inconsolably. I entered the room and looked at the man with some degree of curiosity, I'll have to admit. He was lying quietly staring at his sheets. I fixed the IV, but I couldn't just leave him. We both could hear his daughter crying in the hallway. I sat down and took his hand. What do you say to a man who just received his death verdict? "Are you scared?" I whispered. He looked at me and tried to smile or say something, but I don't recall that anything actually left his lips. He just looked lost. I was so young, only 21, and this was the first time I was witnessing a person's reaction to the news of his death. I felt the sacredness of this moment and I could almost hear the world pausing, waiting for his reaction. And then suddenly something broke the silence - to my ultimate surprise, it was my quiet singing. I often sang to patients: little funny songs, Christmas carols, Russian songs. But those were cheerful songs meant to brighten the day. I never sang to a dying man. And now in this room, touched by the shadow of death I was singing an old hymn: When peace like a river attendeth my way, When sorrows like sea billows roll... Mr. J closed his eyes and squeezed my hand, and to my dismay, the tears started rolling down his cheeks. Usually, I would have been afraid that I had done something wrong, but deep down inside I knew whatever I was doing now was right, and the song went on: Whatever my lot, Thou hast taught me to say: It is well, it is well with my soul... I don't remember how long I kept singing, but I remember the words that came out of his mouth finally: "Thank you! Thank you!" And I knew immediately he wasn't thanking me. When Mr. J opened his eyes, he looked straight at me and said: "I saw heavens open and angels singing. And now I know that God accepts me." This man from Eastern Kentucky probably didn't know that he practically quoted the great composer George Frederic Handel, who several centuries ago said the same very words after composing his famous "Hallelujah Chorus". His whole countenance changed. It was almost as if his confidence had returned. Chills ran down my back. I realized that I had just witnessed reconciliation between man and God. In the next several months I saw Mr. J quite often in the hospital. Sometimes I was his nurse, sometimes I would just stop by to say "Hello." When he would see me, he would say: "Here's my angel," but I knew I was no angel. I was only grateful for the privilege to be a small part of a miracle. His daughter called me when he died. Six years have passed since then. I moved back to Moscow, but in the rush of life in the capital, I still remember the lessons I learned from my encounter with Mr. J. I learned that each one of us longs for reconciliation with self, our loved ones and with God. But more important, I learned that God longs for reconciliation with us. I learned that God has a special way of talking to us, making a conversation that is understood only by Him and the person He is talking to. Other people may witness that conversation, just like I witnessed the reconciliation between Mr. J and God. One might even be a messenger of such a conversation, but this conversation is too intimate and cannot include a third person. What I remember the most is my feeling of gratitude and humility. What a privilege for a nurse to be an instrument in a healing process that is still possible even in the face of death.
  15. Spritenurse1210

    How I learned compassion.

    "When he saw him, he was moved with compassion, came to him, and bound up his wounds, pouring on oil and wine. He set him on his own animal, and brought him to an inn, and took care of him." The parable of the good Samaritan, Luke 10:34 There comes a time in every nurse's life when they must go against society's social norms and care for what I call "society's undesirables." My definition of society's undesirables is the homeless, the mentally infirmed, the physically handicapped as well as criminals. In short, the kind of people that every day Americans would consider beneath them. In the course of my short career I have cared for all of the above. One patient had particularly touched my life both personally and professionally. Her name was Reva and she was a convicted felon. She lived for a year after she was paroled in her 17th year of a life sentence for the murder of her infant daughter. Reva came to my unit after being admitted for pyrexia, low white blood cell count and end stage lung cancer. Her emaciated cancer-ridden frame barely even made a dent in the hospital bed when my fellow nurses and I helped her off the gurney. Her husband, a formidable man with an air of arrogance loomed in the doorway as we helped her get settled in. "Do you know who I am? I am a pastor at the state penitentiary." He stated, "I'm a man of God. Don't think you can mess with me because God will punish you for persecuting me." I looked over at my patient, who by this time had began to clutch her side and gasp softly, "Reva, enough of that, you're not getting anything for pain. The nurse is here to make sure I'm comfortable. You need to just be quiet." Calmly I stated "Sir, I'm here to make sure she is taken care of. She is my patient. If you insist on preventing me from caring for her then I will have you escorted out of the hospital by security." He slammed his massive hand on my shoulder and yanked me closer to him by my scrub shirt. "You better not talk back to me you little heathen, or I will show you how God deals with disobedient women." I quickly pressed the staff emergency button located on the tracking device that was issued to me at the start of my shift. The sound of thudding sneakers became louder and louder as he threw me into the wall. Three security guards stormed in with our house supervisor and my charge nurse in tow. The charge nurse helped me up as security escorted the screaming husband out of the room. I dusted myself off and with only minor bruises I continued with my assessment. "You're the first one to actually stand up to him" Reva said, teary-eyed. Her unkempt appearance and strong body odor as well as bruises in various stages of healing explained everything. "I suppose I deserve it, because of what I had done in my life. I'm just not worth anything to anyone." Placing my hand in hers I continued to listen to the confessions of a dying woman. "I killed my baby girl. She was just so beautiful. I never imagined anything so beautiful would come from me. After years of hooking, cocaine and heroin, I had been given a gift from heaven, and I destroyed her!" Huge tears rolled down her cheeks as she described to me how in a drug induced stupor she killed her daughter. Hysterically crying she looked at me, "I was afraid I would corrupt her, and sentence her to a life of drugs and prostitution. I am so sorry, I'm so sorry! Forgive me Father, oh sweet Jesus forgive me!" Wiping her tears, I told her that I would care for her, and that I am not here to judge. After medicating her for pain, anxiety and starting her IV fluids, I stroked her hair while she drifted off to sleep. Later that night she became unresponsive. Searching through her chart I found her DNR orders and living will that stated she only wanted care and comfort measures. I closed her chart and shut myself in the staff bathroom to have a good cry and talk to God on her behalf. "Please dear Lord, forgive this poor woman, who I'm sure that was shown no kindness in her lifetime. Please show her what a loving Father you are. Greet her with open arms, give her peace. Amen." After washing my face and hands I continued on with the rest of my shift. About 0400 Reva began Cheyne-Stoking. Sitting at her bedside after finishing my rounding I brushed her forehead with the back of my hand. She fixed her eyes on the ceiling and raising her arms up she whispered, "Oh Jesus, Jesus!" Her face softened and she had passed with her lips curved upwards in a slight smile. My prayer had been answered. I called her husband to tell him that she'd passed. "I'm not coming back up there after how you people humiliated me. You just do whatever you have to do with her. I will have your job by the way." He continued on, "Why don't you call her scum-bag mother, maybe she will have more sympathy for her." Her mother was just as devastated by her death. "Oh she's finally dead, is she? Send her to Degraff Funeral Home. I will identify her body there. Do you know if it's expensive to cremate someone?" Disgusted, I hung up the phone. Bryan and I bagged and tagged her and sent her down to the morgue. The rest of the shift continued on without incident. After giving report I made my way down to the cafeteria for a much deserved breakfast and hot cup of tea. I learned that night that no matter what, it is my duty as a nurse to provide holistic, unbiased and professional care to all members of the human race. I'll save the judgment for God. Name changed
  16. Death is the reason why I decided to become a nurse. I know, it's a rather strange thing to say and I probably don't mean it in the way that most would. I don't see myself as a caped avenger, fighting death. In fact, in many cases, Death is welcome. The journey to me becoming a nurse all started with an end; I got laid off from a factory job. Where I live, the government had an initiative that would pay for your education and some expenses if you had been laid off. When I first applied to school, nursing seemed like an okay option: it fit the requirements of the financial assistance program. But then, my grandmother started failing. She had been in a long term care facility for approximately three years at this point. Her doctor had called my mother to say that she would likely not last the night. Of course, my family being how we are, we all rushed to the nursing home and were at her bedside. My grandmother's nursing home was a small one; only about 50 residents lived there. When she made it through the first night, the staff moved her into their family room. It was there we stayed, keeping vigil. The room was small and my family is fairly large. But we spent the last week of my grandmother's life in that room. I say that this experience made me decide to become a nurse for several reasons. Sure, I had already applied to school and had been accepted but I had no real concept of what the word "nurse" really meant. Watching my grandmother and the people who cared for her was the way I began to understand its meaning. When my grandmother was hot, they would give her a cold compress. If she was in pain, they would give her medication. If she was cold, they would adjust her blankets. If my family was concerned about something, they would talk with them, teach them and simply comfort them. When the time came that my grandmother took her last breath, they came in to take care of her. They talked to her as though she was still there and they had tears in their eyes when they said their own goodbyes. Since then, I have graduated nursing school and have passed my licensing exam. I am working as a nurse at a local retirement home. In the two years that I have worked there, there have been 15 deaths. I remember each one. Death is not a battle that is fought, because there can never be any true winners. But for each of those residents who have died, I have been there. Death can be many things to different people: friend or foe, adversary or companion, silent partner or looming threat. I believe that the most important thing about being a nurse is how you help others deal with death and how you can help them go through it. You are there for the dying person as well as the living.
  17. danegerous

    Room 827 - Nursing Ghost Story Article

    I have the rare and distinct honor of working in the ICU of one of Chicago's most prestigious and longest-standing hospitals. Don't get me wrong, I busted my backside getting here, with a large helping of luck along the way. When I started this past February, I noticed a nice change of pace in the orientation process. There was a clever mixture of history in with the standard Rules and Regulations type stuff, just enough to keep my interest. One bit of information I found particularly interesting was that our hospital had undergone many changes in the unit structures before reaching it's current layout. As a matter of fact, before we built a dedicated children's hospital next door, our current Med/Surg floor fulfilled the Peds role. On our last day of orientation, right before our short Friday came to an end, our education liaison came in to deliver one additional little nugget of lore to our information-beaten brains. Maybe she was trying to see who was paying attention, or maybe it was a reward for those who possessed the cognitive fortitude to make it through those last five minutes...I'll never know. She came in to tell us a story, one that had been developing over the last 40 some years. It was the story of a little girl, her name since forgotten, who once called that eighth floor pediatrics wing home, room 827 to be exact. She was in for something common at the time, although the story-teller didn't know exactly what. This little girl was loved by the whole unit, because no matter how sick she got, she always just wanted to play. The doctors would tell her, "Now you need to stay in bed, that's the only way you will get better" and the nurses would always find her by the window, sitting on the ledge, begging for them to come play with her. One cold November night, an extra chill blew through that dusty unit as the cries of a young mother rang throughout the halls. It was the girl, she had succumb to her illness. The nurses, orderlies and physicians all knew it was coming, but they never expected tonight would be the night, and it broke their hearts. Shortly thereafter the unit was shut down for remodeling. The peds unit was then moved to the other side of the hospital for it's eventual transition to the new children's building. In the old unit's place was a brand new, state-of-the-art Medical Surgical unit. Although the structure was still the same, the walls had been painted, and the amenities all updated. Shortly after the new unit opened, something very interesting started to happen. Stories started to spread of patients telling nurses of seeing a little girl near the window in their room, always followed by a sudden turn for the worst, ending in a code blue and ultimately their death. The stories were so regular, in fact, that the manager on that floor began keeping records of when the stories occurred. Now, as an ICU nurse, I have a decent amount of brains in my head, even if I am relatively new. So, I took this story with a grain of salt. I knew it was just a neat old story, no matter how intriguing it seemed. Then it came, my first day off orientation. A code blue was called through the overhead speaker during our pre-shift conference. Being the aggressive young (male) nurse that I am, I run to just about every code there is, and this was no exception. When I arrived at this one, it was pretty standard with nothing out of the ordinary. It was an 84 year old male with a surprisingly small health history, his heart had just seemed to give out on him. So, like most codes, we began compressions and started our ACLS protocol. I have always been a compressions guy, never really getting into the charting of pushing meds during the code. At this particular time, we had just reached about 13 minutes of CPR when we regained a pulse, with me currently kneeling on the bed next to the patient for leverage. I knew better than to get down off the bed, since I already had established my positioning, so I sat and waited while the patient was assessed. Just then, as if someone flicked on the lights inside this old man's head, his eyes opened. Bright. Wide. He looked directly at me, perched over him like an ancient gargoyle. Then, defying medical possibility, he opened his mouth and said to me with a smile, "I'll come and play with you", then he turned his head, looked at the window, and his heart stopped. We tried for at least 30 more minutes (the entire time with a my stomach in complete knots), but there was nothing we could do, he never regained a pulse. As part of the code paperwork, I was required to sign my name on the record sheet. I had noticed that someone left the room number off, so I called out, "Hey, what room is this anyway?", and at that moment everyone looked at me as if I should have already known, and at that moment I did...it was 827.
  18. TheCommuter

    Death Happens. Get Used To It!

    Here's a truthful horoscope for you: we're all going to die! Before we get started, ask yourselves the following question: What exactly is it about death and dying that disturbs you? Once you pinpoint the source of your fears, keep in mind that other people who once had the same reservations have moved on to become stellar nurses with solid careers in the nursing profession. If you cannot identify what it is about death that makes you fearful, that's also okay. It's probably a sign of our modern times. Let me explain further. In previous generations, death still remained a sad and dreadful time for people who saw family members die. However, the main difference between the past and the present is the fact that death and dying used to be highly visible, very out in the open, expected, and an accepted part of life. During yesteryear, 'passing away' was a personal event when people died at home encircled by loved ones who said their goodbyes. The surviving kinfolk lovingly gave post-mortem care at home in the hours after death. In the modern 21st century, the vast majority of death now occurs in healthcare settings such as hospitals and nursing homes. In other words, death has mostly been removed from intimate home settings, so many people fear what they have not seen. American society now does too efficient a job at hiding death from view and this contributes to making death seemingly creepy to some. Is it bad for you to fear dead bodies? No. Your fears are actually normal due to the society in which you were probably born and raised. Regrettably, death is all around us, and you will need to become acclimated to it if you plan to work in most areas of nursing. Don't worry, because you'll start to become more familiar with death as you get more exposure. You'll actually be relieved by some deaths and saddened over others. Although death will never be easy on you, it will get easier over time. What do you do if a patient dies? It depends on the code status, healthcare setting, and situation. You would immediately call for help if you find a dead or dying patient who is a full code at a hospital. Press that code button, call the rapid response team (if available), lay the patient on a board or hard surface, initiate CPR, and so forth. The sooner you summon assistance, the quicker your patient's room fills with people to help with the resuscitative effort. Patients who have current DNR/DNI orders are dealt with differently. We want to notify family promptly if the patient is in the process of actively dying. In an ideal textbook world, someone would remain with the dying patient until family arrives to ensure the person doesn't die alone. Dying patients who are on hospice or end-of-life care receive comfort care such as frequent turning, bed baths, pain control, oral care, and other measures to maintain dignity before death. When the patient dies, someone makes a pronouncement of death. In the state where I practice nursing, pronouncing death is within the RN's scope of practice. Some families want to spend time with the body, so we give them time for that. What happens with the dead body? The nursing department is usually responsible for post-mortem care such as cleaning the body and rendering the patient fit to be seen by any family members who may want to say goodbyes to their loved one at the bedside. At many hospitals, the nursing department is also assigned the tasks of placing the deceased inside a body bag, attaching toe tag identification, and transporting the body to the morgue. The mere thought of dead bodies might send chills up and down your spine right now, but I assure you that dealing with death will become easier with the passage of time and the accrual of more exposure. After all, death is a natural part of the circle of life. Don't let your fears deter you from nursing.
  19. maryloufu

    A different perspective

    When the ambulance rolled up to the ER, I could see the EMTs doing chest compressions on my dad. I remembered a guy his size who had coded when I was working on the floor- that guy did not make it. I started to shake and sob loudly. The ER nurse came over- I told her I would not interfere but I did not want to scare people in the waiting room- she said, "just give us a chance to work on him." She took me inside to the family room. About an hour later I stood at the nurse's station and listened to ER code him for what seemed like forever. He could not keep a good heart rhythm going. I felt sure that they would quit trying to save him at any time. I could see the lack of hope on their faces. They were very kind to me but I have given that look before and I knew what it meant. After some time he went from no rhythm to critical. He was moved up to CVICU (cardiovascular intensive care unit). After they got him settled in they let the family come back to see him. I felt bad for crying and asking 1000 questions that were politely answered. I know how busy the nurses are but I shamelessly asked everything. I could plainly see the bottom line every time I mentioned how long he was down at home and that he had to have prolonged CPR- they shocked him 10 times. They worked to keep his heart beating and tried to get rid of the PVCs and keep his blood pressure at the right spot. I just wanted to hide under the desk in the corner. So many people told me if I needed anything to let them know- but what I needed was someone to fill the emptiness that burned from my clavicle to my stomach- an emptiness that is still there burning me alive. I have always been a proponent of having a good cry as a cathartic experience- but the cleansing will not come. Now I just have a sore face and really cloudy contacts. My dad was on a vent and many meds to keep his heart beating, his pressure up, one for sedation, a paralytic. Later he would have to have meds to get his blood pressure down, potassium, magnesium, antibiotics. He never once woke up- I stood at his side until late in the night singing him songs, telling him that I wanted him to fight and stay alive to watch his grandchildren grow up. I thought about telling him that if he needed to die that I would understand- but I just could not say the words. One night I stayed until 5 in the morning, convinced that if I left he would go into Afib and he would die without any family at the hospital. On day three the doctor told us that there was no brain activity and asked us what we wanted to do. There is no clever acronym for the steps to follow when you are going to take your Dad off of life support- they just tell you to take all the time you need. Well, how much time should we take? What is proper and respectful? They are making you set the timeline for when his heart will stop and his breathing will stop and the color will leave his face. Then all you want is one more hug that is returned or one more I love you from his lips- but that is not going to happen. When you are ready you go up to the nurse's station and tell them - just like you were at a restaurant and it is time to pay the check and clear out. At some point, after it is over you are going to leave your father's shell in that bed waiting for the funeral home to come to pick it up. This is especially hard to do when all you really want to do is lay down on the floor and cry. You know that you are acting like a fool holding his hand and telling him that you love him. This is the last time you will see those eyebrows that look just like your own and the shoulders that used to carry the whole world for you. And then you leave the hospital, confused and empty. It is definitely a different perspective- I hope you never have to be on this side of the bed.
  20. jeastridge

    How Much Time Do I Have?

    How much time? She looked up at me with pleading eyes, her head resting on a freshly laundered pillow case and her hair, still damp, laid out against the white expanse to dry. Her voice was firm as she asked the question that was on her mind. Taking a deep breath of the oxygen that ran to her nose she said, "How much time do I have?" She was not old. Certainly not old enough to die. Just in her late 60's, recently a new grandmother again, she found herself with much to live for and yet with each deep cough she knew the lung cancer was getting ahead of her. As I wrapped up my hospice visit, I sat back down beside her, to focus in on her question and to carefully think through just what to say-and what not to say. Whether you work in the emergency room, in a doctor's office, on a med-surg unit or hospice-whatever your field is-the critical question about how much time remains comes up from time to time. How we answer or don't answer that question can have a profound impact on our patient's well-being. Admittedly, with hospice patients there is at least some expectation, given clinical parameters, that the patient has six months or less to live. But that time frame varies widely and despite our best efforts to meet guidelines that outline expected decline, each person is an individual case where death can creep up unexpectedly or sit coyly in the background long beyond its expected arrival. Answering this particular question well requires sensitivity, knowledge, and honesty. When any of us faces a shortened life-span, we want to know what to expect. Terminal illness is accompanied by a host of unknowables. Measuring the time left is difficult because of each person's individual disease and progression. We expect the lowered immunity, potential for infections and complications that come along but those are often countered by deep wells of resourcefulness in the individual, and a love and zest for life that triumphs over all expectations. So what do you say? Probably the #1 answer to that question is, "I don't know" While this is technically and existentially true, it can be an easy way out for us as professionals. I think a more complete answer involves telling the patient that while we cannot predict with certainty, we pledge ourselves to let them know if we see a change that would indicate the time is near. We can add to that teaching about what generally happens as the time of death nears: increased fatigue, loss of appetite, less time being alert and a gradual shut down of body systems.For family members, there are many books that describe in more details the dying process and what to expect. "What do you think about how long it will be?" A second way to address the question involves reflecting it back to them and asking them what they have been told, what they are most concerned about, what is bothering them in particular at this time. This may sound like an evasive maneuver, but it truly does help to clarify the issue, and often what we are hearing is not what they are really asking. When it comes to death, most of us don't want to know specifics as much as functionality-how long will have have with my loved ones? Will I be able to talk/communicate? Will I be in pain? As nurses, we cannot promise total freedom from pain or discomfort but we can offer our commitment to work hard to alleviate symptoms to the best of our ability in conjunction with our health care team. "Ask you doctor" This is certainly not recommended phrasing, but sometimes, when all the tests are not in, when the biopsy is still pending, when treatment options are uncertain, we do the patient a disservice by trying to address this end of life question too directly. It can be especially true when dear Aunt Sue has breast cancer and so-and-so died of breast cancer and "I just know I am going to die of it too." The underlying tone of the premature question is one of fear and panic. Sometimes, what is most helpful to to ask the patient (or relative) to wait until all the tests are in, the treatment options are laid out, then resume the discussion. It is not helpful to lay awake at night worrying about something that hasn't happened and may never happen. In these cases, our role becomes one of comforter, of listener, and of encourager. Try to be as honest as possible And, no, this does not mean laying on the unvarnished truth with a heavy stroke. There is no such thing as "false hope." Hope is hope and we all need it to continue to survive for even a day or an hour. During admissions, I often tell patients, "Coming into hospice does not mean that you have given up. It means, instead, that modern medical science doesn't have any great treatment options to offer you and your family at this time. But miracles do happen and they can happen even in the context of hospice." This is completely true and I have seen patients "graduate" from hospice as their condition improves. Honesty is the best policy always and at this critical juncture, people really need someone who will maintain eye contact, extend a caring hand, offer a hug, and say truthfully, "I don't really know how long this journey will be. But I do pledge that our team will walk with you through this time and do everything that we can to help you on the journey. We will be with you." Those words can cut to the heart of the fear of being left alone, of suffering without relief. We always need one another, but when it comes to dying, the gift of presence is the best gift their is. I tried to address my patient's question as honestly as possible. In the course of the conversation, I found out that her new grand baby was due to come for a visit in a week. Her question centered on wondering if she would be here then, and more importantly, would she be able to hold the little one. I told her we would do our best to help her marshal her strength for that event and that we would do everything we could to help her be alert enough to enjoy some grandmother time. What about you? Have you found some particular wording that helps you talk with patients about this difficult topic? How do you answer the question, "How much time do I have?"
  21. VickyRN

    Skin Changes At Life's End (SCALE)

    The skin is the largest organ of the body and can become dysfunctional at life's end, with loss of integrity, just like any other vital body system, with reduced ability to utilize nutrients and other factors necessary to sustain normal skin function. The manifestations of this dysfunctional state are called skin changes at life's end (scale). These end-of-life skin changes stem from ineffective skin and underlying soft tissue perfusion, increased vulnerability to external insults (such as minimal pressure), build up of metabolic wastes, and local tissue factors. At end-of-life, a person may develop skin breakdown, despite multiple appropriate interventions and optimal care, as it may be impossible to shield the skin from insult and injury in its compromised state. The acronym scale describes clinical phenomena in skin and soft tissues that occur when the dying process compromises homeostasis, resulting in skin failure. Skin failure is defined as the localized death of skin and its underlying tissues due to decreased blood flow secondary to dysfunction of other body systems, often multiple system organ failure. This failure of the largest organ can be classified as acute, chronic, or end-stage. Clinicians need to have a realistic understanding of what can be achieved, in terms of prevention and treatment of wounds, due to the declining health status of individuals with multiple comorbid conditions and/or terminal illness, as they approach end of life. As stated earlier, not all pressure ulcers at end-of-life are avoidable. A common manifestation of scale is a phenomenon known as the kennedy terminal ulcer (ktu), which is a special type of pressure ulcer that forms suddenly in dying individuals. A pressure ulcer, also termed a bedsore or a decubitis ulcer, is a lesion that develops as a result of unrelieved pressure, shearing force, or friction or a combination of these factors. It usually develops over bony prominences. The damage consists of areas of tissue ischemic hypoxia, necrosis and ulceration. Pressure ulcers are most often seen in elderly, immobilized, or emaciated patients. The sores are graded by stages of severity, from stage i through stage iv. Research is limited, but the ktu is an unavoidable pressure ulcer that develops in some individuals as they are dying, usually within 2 weeks of death and in conjunction with impaired skin perfusion. This unique type of skin failure or skin breakdown is typically found on the sacrum or coccyx, occurs suddenly (usually within hours), and is shaped like a pear, butterfly, or horseshoe. The ulcers may be red, yellow, black, or purple in color, and tend to progress rapidly to stage iii/ iv. The treatment for the ktu is the same as for any other pressure ulcer of the same stage. This has been an overview of scale, a topic that is just beginning to be researched. Not all pressure ulcers are avoidable at end-of-life, especially the kennedy terminal ulcer.
  22. nerdtonurse?

    The Patient I Failed

    She knew what she wanted. She'd watched her husband of 52 years die on a vent, and followed his wishes to remain a full code. But she knew that was not what she wanted for herself. So, she wrote a Living Will, had it notarized, gave it to her personal physician, told all her friends and family what she did not want. She wasn't eligible for a DNR, as she was a healthy 89-year-old, but she knew what she wanted. Of her 6 children, one fought against her mother's decision, and it was this child, this one desenting voice, who found her mother collapsed on the kitchen floor. The daughter told EMS her mother was a full code, and they intubated her on the floor of her kitchen. Once at the ER, her heart stopped, CPR was performed, and her heart was shocked back into a beat. Under the hands of those trying to follow the daughter's wishes, the woman's ribs cracked and broke. She was then sent to ICU, where her heart tried to stop 3 more times. Each time, the broken ribs jabbed and ripped into the fragile muscle and skin as CPR was performed. Electricity coursed across her body and her frail heart was restarted a 4th time. By this time, the other children were there, but the act had been done, over and over. No DNR was written, and the Living Will fluttered impotently at the front of the chart. Her swallowing ability was lost in the storm in her brain that had left her with no voice, no sight, no movement. A scan showed she still had brain activity; she was aware of what was being done to her. Including the PEG tube sank down into her stomach, and the trach in her throat. The daughter who wanted the mother to remain a full code also refused to allow narcotics to be given, stating she did not want her mother sedated, since she would "wake up" when the correct medical procedures were performed. Her nurses begged the doctor to write a DNR, and he said, "the family can't get it together, and I'm not getting into the middle of it." I met her one Tuesday night, and spent that night pouring Jevity into her tube, only to suction it back out. Her legs were cool and mottled, her bowel sounds were non-existent, and her blue eyes stared blindly at a ceiling she could no longer see. The MD refused to terminate feedings, but I held them since there was no digestion taking place. The woman was turned and repositioned every 2 hours, and each time, she moaned and gurgled as her lungs slowly filled with fluid. I whispered my apologies as I did the very things to her she tried so hard to prevent. Suctioning improved her lung function, but would make her body tremble. Over the next 2 nights, she slowly died, all while the daughter demanded more interventions, and maintained that her mother wanted to be a full code. We had read the Living Will. We knew better. She had another stroke, and went back to the ICU, where she was coded until there was not enough surviving heart tissue to maintain a beat. Finally her heart was broken. And so was mine. The-Patient-I-Failed.pdf
  23. Chancub

    Through the Eyes of An ICU Nurse

    Everyone copes with things differently, but often times I write to help me cope with the difficult woes of my job. I often don't share, but this time I thought, why not let some of you guys have some insight into the life of an ICU nurse? If it wasn't for the outpouring of love and emotional support from my coworkers, I often don't think that I could do it, and I think as a team they are incredible and mean so much to me and have taught me so much, so thank you. 10/8/16 You'll never know how much you affect me. You'll never know that I had to step out to get some air and call my own mother, just hear her voice, and be thankful that I still have her in my life. You'll never know that I went home and cried my eyes out in my shower thinking about the struggle and loss your family is going through. I bring you water and tissues, you thank me.... it's the least I can do. I stand by you and hold your hand, and hug you as you sob. Your selfless decision to let your mother go peacefully is the most beautiful and difficult decision you could've ever made...I wish you could believe and understand how incredible and courageous that act of love looks like from the outside, even though you're broken and shattered on the inside. You stand by her side as we turn off life support. She was loved. You'll never know how much that sad look in your eyes and the glisten I notice on the verge of tears, eats me up inside. You offer me food, with a cracking voice, because you're incredibly selfless and have no appetite. You sit next to your son and read him a story knowing this may be the last time. You beat yourself for not being there, blame yourself for his disorder. I tell you it wasn't your fault, it's genetic, as you look away from me with tears in your eyes. You ask if he will ever be able to breathe again on his own, I wish could tell you yes, but his muscles are deteriorating and his disease is unforgiving and undeserved. You hold his hand wishing for these final moments to last forever, you try to cherish them. 8/16/16 Your youngest daughter was rolled onto our unit unresponsive. She was pronounced brain dead by the attending; you fall to the floor, a blubbering mess, demanding to have the test redone because you swear you saw her eye move; it didn't. I help you off the floor as you are bawling into the blanket that she used to sleep with every night. I am left there by the attending to pick up the pieces of families' and friends' broken hearts. You have a large family, I keep explaining what just happened to each person that re-enters and asks questions. They are all so thankful for the honesty, even though it's the last thing anyone wants to hear. You so desperately want to understand why she is dead if her body is still functioning on life support. I re-explain, but you can't comprehend, you keep asking yourself why? Each time a little piece of my heart is with you, I wish desperately that she could just wake up and be your baby girl again; but she can't, she never will be. I watch you as you stroke her head gentle as tears roll down your cheeks; "just one more day," you wish you could talk to her just one more time. You yell at her to "Wake up! Please, please wake up", you beg and plead. I give you your space, you need these final moments with your daughter. I secretly cry in the bathroom for you. I am there for you, I support you, and my heart hurts for you. I will never forget you. You'll never know how much you affect me. You'll never know how privileged I feel to be your ICU nurse.
  24. I recently spent 45 minutes talking about death, and hospice, with my husband's sister in Maryland. Her mother -a delightfully quirky 91-year-old activist who still spends her days faxing her congressmen-just signed on with the local hospice. I'm a hospice nurse, by far the most rewarding work I've done in 35 years in the profession. I'm doing my best to help them navigate these new waters. Why is hospice nursing challenging? I understand so well what she's going through-teetering on that invisible line between wanting to cheer someone on to keep trying, and allowing them to decide that it's OK to stop fighting what is inevitable for all of us. Esther has, by my estimation, months, maybe a year left in her increasingly frail body. Although she's still very sharp, mentally, she forgets things more, has to stop more often to catch her breath, and can't really muster any enthusiasm for exercising with her walker. She spends more time in bed or on the couch, wakes up later, goes to bed earlier. I see the familiar signs of someone looking beyond this mortal coil. Considering the quality of those months is, to my mind, far more important than wringing out more of them by pushing her to eat more and take more walks. There comes a time with an aging parent when you have to stop trying to make things better, and decide to just love them, respect their wishes, and be present. I think that time has come with Esther. At this stage, it's important to distinguish between what COULD be done and what SHOULD be done. Still, it's hard. Damned hard. As I remember well with my own Dad, it's easy to decide in an abstract way that you don't want to prolong life unnaturally, to trade quality for quantity. Yet, when my rapidly declining father broke his hip, I was heartbroken to hear that he decided not to have surgery (in retrospect, this would have been a miserable experience he might not have survived). I wanted to let him go peacefully, without a lot of high-tech, dehumanizing interventions. I just didn't want to do it YET. No matter how clear we are, in a theoretical way, about wanting a peaceful, dignified end for our loved ones, we're never ready for this moment to be the last we have with them. That pain is something we sign on for when we let ourselves love someone or something impermanent. Which is, alas, everyone and everything. Loving the impermanent is one of the necessary pains included in this beautiful, untidy package we call life; I've decided to learn to live with it. The alternative, to harden ourselves and not get "too attached" (a concept that has taken much of the heart out of medicine, in my opinion) is not one I care for. This is what I love most about working for Hospice-we get attached to, and often fall in love with, our patients; it's a given. And although I'm aware of how much we bring to patients and families we care for-comfort, supplies, clarification of what's important, understanding of what they're going through and what's ahead-I always feel I've received more than I give. It's an honor to be with people who are facing their own mortality. Somehow frivolous concerns seem ... frivolous; the specter of death has a way of distilling what's important in life. And being reminded of our universal mortality reminds me not to squander this life I have on resentments, or worries, or acquiring more things. I'm more aware of the beauty, and the fragility, of the world and our relationships. So, I answered the questions I hear so often. Joining hospice does not generally cause people to give up and die-often the support we give causes them to rally and live longer and more comfortably; sometimes they even "graduate." Pain medicines, used appropriately, do not cause addiction or hasten death, but the need for them often coincides with a decline that has already begun to accelerate; ideally medications relieve pain and air hunger in patients' last months, even sometimes increasing activity. And yes, there are always gray areas: How long is it safe to leave her alone? How much should we push her to eat and exercise? As always, I suggested she answer these questions from her best understanding of, and respect for, Esther's wishes, and by exploring them with the hospice staff. We'll fly out over winter break; I look forward to spending some bittersweet, heart-ful time with my beloved mother-in-law. And I hope to make sure she's comfortable, and help love her out of this life. That's the best any of us can do, and what we all hope for in our last days.
  25. greenergrass

    Lives Forever Changed - I am Glad!

    Tom was 35 years old when he got sick. A strong police officer, Tom never expected to be diagnosed with Acute Myelogenous Leukemia. One day he was on the SWAT Team, breaking down doors, gun in hand, fighting the bad guys. That afternoon, he went to his regular blood donation appointment. By evening, he was admitted to the hospital. In 2 days he was told his career was over & maybe his life. With his version of AML, Tom chances of surviving 2 years were 19%. His entire life was changed. Thin, active, married with a young stepson, Tom had a plan. Cancer was NOT in the plan. Tom's wife was a nurse, his doctor was her friend. Together, they broke the news. No more police work, chemotherapy would start immediately & continue over the next year. Major life changes would occur. Plans would have to be made. Tom did not react, he was incredibly stoic. His friends rallied. Two shaved their heads. The biggest blood drive in Central Florida was organized, bone marrow was collected. Tom got sicker. His wife began her research. The doctor worried. One day, Tom's wife decided she could no longer tolerate the idea of 19% survival rates. Her research revealed that a stem cell transplant had the potential to improve Tom's survival odds to 50%. The fight began. Without the doctor's knowledge, she submitted Tom for transplant at the best center for AML in the country. Blood was secretly sent. The wife waited with bated breath. She prayed. The doctor found out. An angry confrontation ensued. "Why did you do this behind my back?" the doctor accused. "Why didn't you offer us all the options?" the wife pleaded! "I couldn't stand for you to be disappointed when there were no matches," the doctor admitted. Everyone waited. September 11th, 2001 brought the news. The very day and the very moment of the attacks on the World Trade Center - I got a call saying that my husband & his sister were a 100%, 6 allele match for a stem cell transplant! I couldn't stop crying! Tom, my husband, might live! Frantically, we began making arrangements. Immediate action was needed if we were to stop this disease and reclaim our lives. Somehow, we were able to board a plane on September 13th and fly to Seattle Cancer Care Alliance for Tom's intake assessment. We made every connection - while all planes were grounded, we traveled with flight crews being repositioned throughout the country. Tom is now 7 years cancer free. My husband is the patient who changed my life & my nursing practice. I now know what it is like to be afraid at the bedside of a patient. I now know what it is like to wait, uncertain, desperate for information. I know what it feels like when someone you love has life hanging by the very thread. I know what it is like to have options withheld. I know the pain of having to leave & go to work, not knowing if my loved one is being cared for. Now, I know. I will never be the same nurse. I am glad.
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