The Dreaded Death Bath and a Moral/Ethical Dilemma?

[Be_Moore]

So my coworkers and I were discussing a patient who had died recently during bathing. Well, let me clarify..patient didn't actually die during bathing, but the stress of bathing caused a chain of decompensating events that we colloquially call the "Death Bath." This is a pretty common (and anecdotally well known) event in ICUs. With this specific patient another nurse (mind you jokingly) responded "WHY DID YOU BATHE HER??" to which the nurse taking care of said patient replied "She was dirty!"

This made me realize a very interesting moral/ethical dilemma within nursing. With insurance companies, medicare/medicaid cutting reimbursements for patients who recieve HAI's/pressure wounds, should you or should you not perform preventative wound care on patients who are terribly hemodynamically unstable?

One point you could bring up is that the patient who is so unstable that turning/bathing ultimately leads to their demise is statistically not likely to survive long anyway. But one case we have is a patient who went from horrid septic shock crashing to..."recovering" who is now still in our ICU on day 28, but hemodynamically stable. So, had we been doing q2 hour turns on him during his bad phase while he was on multiple pressors and CRRT, we could've possibly killed him (The Death Turn, the evil cousin of the Death Bath). On the other hand if we don't turn him and he gets a decubitus and survives, we don't get reimbursed.

Now, I hate to make you guys think that this is all about money...buutttt....I work in a Level I trauma center which also happens to be the safety net hospital. Money is a huge issue at our hospital and with the increasing costs and reimbursement cuts in healthcare...it's a semi-valid point argument. We're kind of backed into a corner on this one.

[cardiacRN2006, ADN, RN]

For pts who are so hemodynamically unstable that a turn will kill or harm them I try to tilt them ever so slightly.

Even if it's just a folded bath blanket under one hip. I'll try.

For the ones who are soooo unstable that they may die if you look at them wrong, I don't turn. They lie flat until they stablize. I'm talking the 20 units of blood products, 5 pressors, multiple drips kind of pt. The s/p codes who are on thier own kind of hypothermia protocol. The ones who are already dying, but we are interferring and just prolonging the inevitable.

Those, I don't turn so much. Although, I'm sure a tilt won't hurt there either.

However, these guys aren't going to be getting any decubs anytime soon anyway.

[Be_Moore]

And to sum up my OP in the form of a question (one question, two parts): Would you say that with the new policies of cutting reimbursements for patients who recieve HAI's / wounds during hospitalization a (probably) unintended side effect of such policies would be that "killing" a patient with a "Death Bath/Turn" would be the financially intelligent move? And second part, is this something that needs to be considered at the level of these companies who are cutting reimbursements?

[nkara, CNA]

I've been told that technically if you "pull" on the draw sheet it's considered a turn...

[Mommy_of_3_in_AL..RN]

Actually, we faced this situation recently. Very unstable patient with severe pulm edema, ascities, very unstable respiratory wise, on multiple pressors, CRRT and a no code at that (actually, no compressions, no intubation..chemical code only.) He was a day bath so we got everybody in there to help (as he was also a large person), and started bathing. Mind you, we were trying to do so efficiently but carefully, as he was so unstable. After about 5 mins or so, we were almost done, securing the sheets and getting him situated, his O2 sat dramatically went down to about 30% on a non rebreather and HR decresd to the 20s as well. We bagged him for about 45 minutes, in order to see if he would recover without any other intervention. The doc was at the bedside and witnessed the whole occurance. He did recover and is still kicking on the pressors and CRRT, but now we have specific doctor orders to not turn. We can bathe him, but only the exposed areas that we can get to without turning. We were told that covers us in the event of breakdown, etc.

[8jimi8ICURN]

As a new grad in a level 4 MICU, how long do you think it would be before I get a patient like that!?? :shudder:

[cardiacRN2006, ADN, RN]

When you are ready.

Ideally, your charge nurse should give you this kind of pt when you are ready, and there is proper support to be with you and guide you. A day where it's not short staffed, or crazy. A day where there might be extra nurses.

Those days are hard to come by, but when they happen, we need to take advantage of them to guide our newbies into caring fo these type of pts.

[pebbles, BSN, RN]

Nobody ever died from not having a bath.

Really. If they are that unstable, it may be a bit distressing as nurses to not bathe, turn, etc. But we have to keep remind ourselves why we're doing it, or not doing it.

Pt's that are too unstable to be turned, you can change the angle of the bed by even 5 degrees, and it helps to change the pressure points. Or as someone said, tuck a flannel under a hip for a bit of a difference.

[pebbles, BSN, RN]

I've been told that technically if you "pull" on the draw sheet it's considered a turn...

Whoever told you that was wrong and possibly lazy.

Remind me of when I was a new nurse and one of the "senior" nurses told me that if the 02 sat reading is 94 or greater, that means the chest is clear, you don't *really* have to listen.... :icon_roll

If you can't turn your patient for any reason, you have to make small changes in his position and not just leave him. Do your best, SAFELY. But the most appropriate action is to document why you are unable to turn - not to pull on a sheet, and "call that a turn".

[meandragonbrett]

As a new grad in a level 4 MICU, how long do you think it would be before I get a patient like that!?? :shudder:

A level four MICU? Care to explain?

[8jimi8ICURN]

OOPS!! Typo!

My hospital is a level 4 trauma center. I'm in the MICU. sorry about that!

[dorimar, BSN, RN]

This was an excellent post!!!

I would hope that the vital signs and required aggressive therapies alone would demonstrate why the patient could not be turned frequently. However, my guess is that CMS will require some sort of form and official documentation of stated reason why it was not done-- despite the obvious evidence of vital signs, etc.

Another fact that has bothered me since the institution of "never events" and "pay 4 performance" is that some factors, not related to nursing care, impact these outcomes (extraneous variables). For example, in your patient who was so horribly hemodynamically unstable- not only was perfusion to his vital organs lacking, but to his skin as well. What do they expect from us? Magic???? Then if you looked at his nutritional status and immune status before arrival to ICU, it probably plays a part as well....