The Art of Letting Go

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Specializes in Acute Care Cardiac, Education, Prof Practice.

Exhausted.

That is the only word that comes even remotely close to how worn out I am after last night.

Classic case of 85+ fragile patient, malnutrition (spouse has early dementia yet they refuse to leave their home or accept assistance, so my patient isn't getting medications or even food sometimes). Family has attempted to intervene but are having a hard time with "we don't want to force them into something they don't want to do" situations. If they offer too much help the couple gets agitated and forces them to leave.

For over seven hours of my shift last night I wracked my brain, my heart and soul trying to figure out how to handle this patient. Now a DNR with family wishes to minimize invasive care the patient is circling. BP skyrocketing despite several IV and PO medications (painstakingly crushed in tiny bites of pudding), increasing hospital aquired agitation, with no end in sight.

This case kills me a few ways. One is the utter helplessness in making this patient comfortable. Nothing I could do, positioning, bathing, pain meds, anxiety meds, NOTHING could make this patient comfortable. Watery eyes looking up at me, asking me, "why are you doing this to me?" alternated with "help me, something is so wrong" is nearly bringing me to tears thinking about it.

I think what made this worse was the family, but not in the typical way. The family, initially was very compassionate to the patient, progressive in getting the situation at home resolved and understanding in end of life care. However as the night wore on and the family grew weary it just seemed as though the patients pleading eyes suddenly became the same eyes the family wore. Looking at me, pleading and panicking over every moan and cry.

I am a firm believer in the aura of surroundings. I don't mean cheesy color coded voodoo, but the essence of calm or havoc having a very vital impact on patients, and people in general. I do feel this patient was severely overstimulated. I believe that the majority of the issue came from too many people in the patients "face" per se, and too much activity. I attempted to explain this to the family and was met with "oh you think so, I don't know" polite nods.

Nothing helped, and I left this patient in the very capable hands of the oncoming shift and took my grievances to my mother on the ride home. I was of course met with her normal "lets think this through" mentality and found myself irate. I didn't want to argue about end of life care, death and dying etc, but I found myself there. I quickly shut down the conversation stating mental duress and went on to talk about my leaky roof instead.

It is really hard as an RN, at least for me, to believe in "doing everything you can" after a certain age. My mother is a woman who rehabs stroked dogs, and after over 30 years of raising every kind of animal, only in the last five years can manage to take an animal in to be put down herself. She wants them to live forever, while I just want to let them go.

I once had a patient of about 94 y/o admitted for some form of mild pneumonia. Her completely dependent husband was admitted with her and laid in another bed in her room. She looked at me late one night and said "I am ready for this to be over. I have had a good life, but I am just tired now."

I hear that a lot.

Tired

I think what frustrated me most in my conversation with my mom was the argument that "tired" isn't a reason to die. That 80/90 years of life isn't a reason to want it to be over. She argued depression, chemical imbalances etc with me as reasons my current patient was in her state. I just wanted to scream "when is it good enough to let go?"

I am rambling now, and there are so many more details, but I guess I am just...venting.

Tait

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Specializes in Correctional, QA, Geriatrics.

Letting go is rarely easy. I think sometimes it is because we, perhaps, unconsciously, view it as a defeat instead of what it is in reality: the last stage of life. It is inevitable for us all, not necessarily something to rushed into per se but I think that word tired sums it up pretty well. The individual is tired of not being independent, tired of chronic pain, tired of not being able to participate in activities that used to bring pleasure, tired of feeling isolated because no else around them has shared their life experiences, tired and ready to die. Their bodies are tired, their minds are tired and their spirits are ready to move on.

The heartbreak part for me is when they are ready but something or someone blocks the process from happening. Perhaps if we as a culture did not fear death or dying so much we would be able to respect that word tired and help that person through the process. Dying, like living is an art and not the enemy.

No I am not advocating euthansia. I am advocating for a peaceful dignified death. As I have shared with families before my mothers illness was awful but her death was peaceful and beautiful even. The best gift I have ever given to anyone was to honor her when she told me she was tired and ready to go. Once I got past my issue with her leaving me by dying I was able to see the dying experience as something that doesn't have to be awful. She gave me that gift of knowing that dying and death are not things or enemies to avoid but just part of the journey. I still mourn her. I mourn the pets that I shared my life with that have died and left me behind. I have mourned patients that burrowed their way into my heart but I no longer view their deaths as a failure or a defeat on my part. I can deal with the mourning and the grief. It comes with the territory of being involved.

I hope when I come to the point in my life when I am tired and ready to die that my loved ones honor my request to be allowed a peaceful dignified death and not try to avoid it because they fear to be left behind or that to let me die is a poor reflection on their love for me. Rather realize that letting go is OK and grief is bearable. For I will be tired and ready to move on.

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Specializes in Derm/Wound Care/OP Surgery/LTC.

You're right, Tait. Sometimes, we have to just "let go and let God". It's never easy to watch a patient in the midst of what you described. I definately know the heartbreak you were feeling. Sadly, it becomes all too familiar for most of us.

Just know that you have provided her with good care and a nurturing environment. That's really all we can do when the family intervenes and the doctors turn a deaf ear on our recommendations.

Your frustration is palpable. I am sorry you had such a rough day today.

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I'm curious to see what the future holds.

My parent's generation is the "baby boom".

A lot of these folks have no intention of getting old, slowing down, or becoming marginalized.

My mom once said she didn't want to live her mother's life or her death.

We'll see if this generation changes the way we handle end of life care.

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Specializes in LTC, assisted living, med-surg, psych.
Letting go is rarely easy. I think sometimes it is because we, perhaps, unconsciously, view it as a defeat instead of what it is in reality: the last stage of life. It is inevitable for us all, not necessarily something to rushed into per se but I think that word tired sums it up pretty well. The individual is tired of not being independent, tired of chronic pain, tired of not being able to participate in activities that used to bring pleasure, tired of feeling isolated because no else around them has shared their life experiences, tired and ready to die. Their bodies are tired, their minds are tired and their spirits are ready to move on.

The heartbreak part for me is when they are ready but something or someone blocks the process from happening. Perhaps if we as a culture did not fear death or dying so much we would be able to respect that word tired and help that person through the process. Dying, like living is an art and not the enemy.

No I am not advocating euthansia. I am advocating for a peaceful dignified death. As I have shared with families before my mothers illness was awful but her death was peaceful and beautiful even. The best gift I have ever given to anyone was to honor her when she told me she was tired and ready to go. Once I got past my issue with her leaving me by dying I was able to see the dying experience as something that doesn't have to be awful. She gave me that gift of knowing that dying and death are not things or enemies to avoid but just part of the journey. I still mourn her. I mourn the pets that I shared my life with that have died and left me behind. I have mourned patients that burrowed their way into my heart but I no longer view their deaths as a failure or a defeat on my part. I can deal with the mourning and the grief. It comes with the territory of being involved.

I hope when I come to the point in my life when I am tired and ready to die that my loved ones honor my request to be allowed a peaceful dignified death and not try to avoid it because they fear to be left behind or that to let me die is a poor reflection on their love for me. Rather realize that letting go is OK and grief is bearable. For I will be tired and ready to move on.

I am right there with you, and couldn't possibly have articulated it better. Thanks to you and Tait for putting things so eloquently. :yeah:

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Specializes in Acute Care Cardiac, Education, Prof Practice.

Update: Patient is headed to home hospice in the morning. I signed off on her for the night and gave her to another nurse. I am glad I did because it is the same pitiful moans tonight but fortunately for the RN tonight no family is present.

Sometimes my heart just can't take it.

Tait

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Specializes in Med/Surg.

Unfortunately, our society doesn't give dying with dignity the emphasis needed. I often think we're kinder to our animals than humans. Who would want to be kept alive solely because of the tube in thier stomach or the trach in thier neck? too many people suffer like this for years. It's sad really.

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Specializes in Med/Surg.
Update: Patient is headed to home hospice in the morning. I signed off on her for the night and gave her to another nurse. I am glad I did because it is the same pitiful moans tonight but fortunately for the RN tonight no family is present.

Sometimes my heart just can't take it.

Tait

Hugs to you. :cry:

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Specializes in Med-Surg.

My mom (a nurse as well) and I just had this same converstation yesterday. A patient just passed on our hospice ward after awaiting death for several weeks. His family just couldn't let go, and every time he started circling the drain they demanded we "save him". Save him, for what?, I wanted to ask.

By the end, he was having IV's restarted daily to keep the PPN going "so he wouldn't just starve", which I found cruel just on its on. 40-50 people remaining in the room at all time, gawking at him. Some that admitted had not seen the patient or family in decades.

The patient suffered when he should have been allowed a peaceful death. The other patients on the same hall could not rest for the constant noise. Their families could not sit with them, becuase all the chairs continued to walk off into the other room. Staff was constantly harassed the "refresh the coffee pots" and "get more cups". They even went into another patients room and stole the bedside tables to have something to set their stuff on. Anyway, I ramble off the subject.

It is heartbreaking to watch someone try to pass, and not be allowed to do so with dignity. I hope my loved ones will be strong enough to just let me go when the time comes.

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Specializes in Vents, Telemetry, Home Care, Home infusion.

from the new yorker: august 2, 2010

letting go

what should medicine do when it can't save your life?

by atul gawande

wonderful articles about the benefits of hospice and asking the right questions when currative not working in end stage illness...."if time becomes short, what is most important to you?". karen

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Tired of living..after 90 years of breathing, heart beating, muscles moving, bones forming and dying and liver detoxifying and regenerating than dying and kidneys etc etc. I like the word tired that the 90 year old used, it is justifiable.

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thank goodness they got this man on hospice... and shame on his family and physician and anyone else for not doing it six months ago.

a reminder of the applicable hospice criteria:

failure to thrive

palliative performance scale equal to or less than 40% (mainly in bed, requires assistance with adls)

body mass index below 22kg/m2; bmi=703 x (patient's weight in pounds) + {height in inches)2

the patient declines or is not responding to enteral or parenteral nutritional support

non-specific terminal illness

recent rapid clinical decline and disease progression

decline in functional status

weight loss

dependence on assistance for two or more adls

recurrent aspiration

increase in er visits, hospitalizations or physician contact

progression of cognitive impairment

progression pressure ulcers in spite of optimal care

dysphagia with recurrent aspiration

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