The Patient I Failed

[nerdtonurse?]

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.

Quote

"I do not wish my heart to be restarted through usage of any chemical, mechanical or physical intervention..."

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.

Quote

"I do not want any external device to be used to maintain my respiration if my body is incapable of sustaining it on its own."

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.

Quote

"I wish to die a peaceful, natural death."

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.

Quote

"I do not wish artificial means of nutrition to be used, such as nasogastric tubes or a PEG tube."

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.

Quote

"I wish nature to take its course, with only medication to prevent pain and suffering."

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."

Quote

"Allow me the dignity we give to beloved pets. Let me die in peace."

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.

Quote

"Thank you in advance for helping me in the last moments of my life to have a gentle, peaceful passing."

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

[fdorgham]

Oh my goodness... All that pain... All that suffering... All of it d/t the fact that we have such a hard time letting go... In that moment, I don't want to suffer and I don't want my loved ones to suffer with me. That is so heartbreakingly sad.

[JoMark06]

Also the author mentioned putting a peg tube down the patient's throat. Peg tubes are placed thru the abd wall... These details almost killed it for me, however, I absolutely understand why this was written.

"

You must have misread the original piece. She did not say the PEG was placed down the pt's throat. Here is the specific paragraph you refer to:

"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."

Just wanted to point that out since you say certain details killed the piece for you. I have seen DNR's rescinded at the request of the family when the patient, who had capacity before being vented, had asked the DNR be in place. I have seen patients who shouldn't be coded, coded time and again at the families wishes. I have seen a nurse request her husband be a full code when she knew, in her head, that her 80+ year old husband (who was frail, contracted and alert to self only from a CVA) would not survive a code. It happens more than you think.

[LonKieffer]

This article is an excellent example of the Caregivers Dilemma (the basis of my program "Defending the Caregiver!" This Caregiver is exhibiting a classic example of COGNITIVE DISTORTION #10: PERSONALIZATION, where the Caregiver sees herself as the cause of some negative external event which in fact she was not primarily responsible for... this Caregiver failed no one! Instead, she executed her duties no matter how difficult and rather than feel proud of her actions she feels guilty for providing a service that few others could perform.

[gtmahar]

I'm not normally so negative, but this was horrible! As a previous SICU RN and current CRNA, I have to say that multiple people dropped the ball here. As an RN your job is to be patient advocate-speak to the family that know what her wishes are and empower them.

[LonKieffer]

to GTMAHAR: You are correct in your comment regarding the role of the RN as being a patient-advocate, however, you are incorrect in one regard. This article is written from the perspective of a nurse, a Caregiver, taking care of this patient NOW! Well after the advanced directive decision was poorly executed previously. I understand your perspective but to voice it so succinctly only ads to the Caregivers Dilemma NOW.

This nurse has not failed anyone! Not only is this nursing PERSONALIZING the situation you are perhaps LABELING it; COGNITIVE DISTORTION #9LABELING AND MISLABELING: An extreme form of overgeneralization. Instead of describing the situation, you attach a negative label to yourself (FAILURE): "I'm a loser." When someone else's behavior rubs you the wrong way, you attach a negative label to him: "He's a goddam louse." Mislabeling involves language that is highly colored and emotionally loaded.

This article should be entitled... "The Patient I Took Care of Competently and with Passion tho Personally Difficult After Something Bad Happened Before I Ever Came into the Situation!"-- not very sexy but much more accurate! As a "Defender of Caregivers!" I feel compelled to point out that; this Nurse is dealing with a very emotionally difficult scenario she did not create; to attach a LABEL of FAILURE or NOT AN ADVOCATE makes it worse and more emotionally laden and is unfair to the Caregiver.

[sharonaz]

thank you for this powerful story. This is the kind of healthcare reform we need. We need to honor a person's wishes for death with dignity. This would save thousands of healthcare dollars and show respect for the dying. How many family members would insist on heroic actions if the fee came out of their pocket?

[NC29mom, ASN, LPN, RN]

unfortunately, this happens all the time.

[nrse_06lpn]

this article is so true to what happens when a family doest respect the wishs of their loved ones, so many people are hurt by the actions of one or two that just cant let go. in the end it tears the family apart and makes the medical staff go against what we are taught and trained to do in the end breaking everyones hearts.

[bogdana]

I disagree vehemently with the usage of comparing human beings to "beloved pets". We put pets down because they are PETS. Humans are not to be put down. Obviously this woman's time was nearing an end and a DNR was appropriate, but comparing DNRS to euthanasia is dangerous. I know that had my pet had the same injuries my husband received from a drunk driver, my pet would be put down. THANK GOD my husband was not. I know there are some ignorant people who think he'd be better off dead than deal with a spinal cord injury, including people in the medical field. He disagrees! Luckily euthanasia is still illegal... for now. Don't let stories like this cloud your judgement about euthanasia (which is what happens to PETS, not humans)

[jenniejenius]

Having worked with cancer patients and their familes for a number of years, I have seen this same scenario carried out on family/friends who did not wish to be cared for in this manner. It is indeed a heart breaker and we all need to view this as a reminder for ourselves and others to have these sometimes very difficult conversations with our family and friends as well as our lawyers and physicians, so they will know our wishes and will comply with them. Please...have that conversation this weekend! We never know what is in store for tomorrow...

[lulurnbsn]

I agree, this was beautifully written. What I don't understand is how you feel that you personally failed the woman in the story. As a nurse, you are a patient advocate and you are also bound to the laws that, let's face it, bind us in many ways. Had you carried out the wishes of this woman, you would have surely lost your license. I can almost promise that she wouldn't have wanted you to do that. It was her daughter who clearly failed her, for letting her suffer while knowing what her mother had requested. There is nothing you could have done differently. The fact that you apologized to her was probably gratifying and soothing for your patient.

[grannyNan]

Yes, I agree it is nicely written. However the nurse in me wonders if anyone ever really stood up for this patient? She had a living will which is a legal document that was ignored by the family, nursing and the medical staff. Does this facility not have an ethics committee or a risk management department? Were they not concerned about the legal issues the other family members could raise such as assault charges on the staff? The author only speaks of the one daugheter but clearly there are other family members involved. We as nurses must stand up for the patient especially when they cannot protect themselves from harm, and let's make no mistake that harm did occur here. Sometimes being a patient's advocate means you stand a hard fast line against those who would do harm to those whose care we have been entrusted to. I commend the author for her caretaking abilities as the life of this woman slipped away. The bigger problem is why do we fear death so? Why do we in the medical field feel we have failed when our patients die? We say things like we lost her or she expired, like we could have renewed her life if only we had sent the payment on time. The health care system is what ultimatelty failed this woman and the author. We have built up expectations that we can not live up to. Life and death is not really in our hands as much as we like to think it is, we are only instruments used by whatever higher being you belive in. Let's face it all of us have a limited time on this earth we should accept death as we except birth, a part of life.