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

[Eastern RN]

I read this just now and hope you have now know that you did not fail the patient. Her family did. It seems one family member did not respect her mother's wishes, and once she was resuscitated and procedures to "save her" had been started, the remaining family members could not get it together enough to recognize that this was NOT what their Mother wanted and make the decision to have her made a DNR - and have their Mother placed in a Hospice or at least a palliative care environment where her wishes for end of life care would be respected and carried out.

I see this ALL the time. In our province of approx 500,000 people - the 2011 census had the # of people that were age 65 and over just shy of 100,000. That's 20% of our population. How many of these people have advance care directives? From what I have seen over the years - VERY FEW. And - as the poster said - it only takes one family member to challenge that - and BAM - the ball starts rolling..... downhill.

To be fair - if someone presents in ER or the EMS arrive at a scene and there is no family present and it's not immediately known that the patient does not wish any advanced life support measures - well - in most cases we are going to try to save that person. Unless of course they are cold and blue, or they are obviously already dead or near dead. And who makes that decision - depends on the EMS, depends on the physician. We try to do what is ethical.

BUT - I cannot tell you how many times in my 32 yrs of nursing that I have heard a doctor have a discussion with a patients family about a DNR - and put it something like this - "If your Mom's heart stops or she stops breathing do you want us to do everything we can to save her?" For real - if the doctor is having that discussion with the family - generally it means the **** is about to hit the fan so to speak.

People who are not in the medical profession have no idea what that "everything" is. So many times over the years I wished someone had produced a video that shows exactly what goes on in a code, shows exactly what happens when people are placed on ventilators and remain there for extended periods of time - and basically just rot in the bed. Just pop in a CD for people to see - the good, the bad and the ugly - all of it. I would imagine families would make some different choices for their loved ones. I'm not saying that no physicians I work with explain and present the "DNR" issue properly. I have seen the issue of making a patient a "DNR" explained to many, many families in a clear, easy to understand manner - and families have been able to make informed decisions that they are comfortable with.

Another thing that irks me - patient comes in who has had the DNR discussion with family at some point already. The family they live nearest to. The patients wish is to be DNR. BUT - there are other family members as well who do not live close by - and are unable to get there quickly. So then it's "Well, Mom said she didn't want to be on life support - but I can't decide that on my own - I have to wait until - my brother - or whoever the rest of the family is - gets here. So lets put her on the breathing machine for now until the rest of the family gets here and then we can make a decision" . I have heard this more times than I care to remember. And anyone who had read my rant this far knows what happens when the rest of the family does get there. No one wants to be the bad guy and be to one to suggest that life support be discontinued. Every now and then it does happen. But rarely. Poor old Mom usually stays on the vent and slowly deteriorates - sometimes quietly, sometimes dramatically - and I would expect not without discomfort. Which does not leave us nurses with a warm fuzzy feeling.

There may just be something to having a DNR tattooed on your left chest. It can probably be done quite elegantly. Anyhow - peace out - my rant for this month is done. I hope.

[RNBillieBSN]

This happens more than you can imagine. I have cried

over these patients while providing their care....and at

home as well. So sad.

[Ryn RN]

Unfortunately so very true and occurs way too often! So very sad.

[MarieG]

wow. what an ethical disaster! I would refuse risking the loss of my job. I commend you for being able to face this.

[Bill Levinson]

The initial decision to give CPR was correct because a living will takes effect only if the person is terminally ill. In other words, if somebody with a living will but no terminal illness collapses from a heart attack, CPR is given. The living will takes effect only if there is a condition such as incurable cancer that makes interventions futile, and serve at most to prolong the dying process.

E.g. my father should not have been given CPR when his heart stopped, but he was suffering from a neurodegenerative disease (Lewy body disease). Unfortunately, none of his doctors had rendered a diagnosis to the effect that he had less than 6 months to live, so his living will never went into effect, and he did not receive hospice care from Medicare. (I did have a private duty nurse supplementing his care in the nursing home, but perhaps hospice could have done more for him.)

In Pennsylvania, at least, a living will does not take effect unless its writer is diagnosed with a condition that is expected to be fatal within six months. This means that, if you don't want to be revived, it is important to get this diagnosis.

[CiaraLopez]

Brought tears to my eyes. So powerful. Great job in such a tough circumstances. Nurses truly are angels

[MahzieLPN, LPN]

I, too, believe you did not fail this patient. You provided her with the deeply desired dignity that was allowable, no thanks to the Selfish Daughter. She must have been some piece of work that the other children didn't band together to over-ride her. . .and at least this dear patient suffers no more. I shudder to imagine holidays in that family. . .

[m.keeton]

I watched the same scenario play out with my grandmother and her 3 surviving children. My father and aunt were ready to let her go, but my uncle was sure she was going to pull through. She kept telling us she was ready to be with her husband, her mother, and her family and friends that had passed. She knew it was time, and was ready to greet the afterlife like an old friend. I can't fault my uncle for wanting to keep her for just a little bit longer. I know I sure wanted her to stay around, and he had known her 25 years longer than me. Finally, the decision was made to let her sleep and the staff made her comfortable. over the course of a week, the family got to know the hospital staff like extended family, and it was as a family that we all saw her to her final destination. I am thankful to the staff for allowing us a little extra time with her, and caring for her as much as they could.

[RNBillieBSN]

This type of thing happens so much more than people realize. Children override mom or dad's wishes to perform CPR rather than let their parent (s) go. They have no earthly idea what they have done...or are doing to their parent. And yes, I think there should be a special place in hell for these children if, after the physician has explained exactly what their parent is experiencing and they continue to want "everything done" and "don't want them to have any narcotics for pain".

[ryan2]

We need to stop this, ethics demands that the pt has a say in their treatment. If we can tell a family their mom signed to be an organ donor and it's no longer up to them what happens to the pts organs why can we not tell family we are abiding by the written wishes of the pt for their living will.

[Dragonnurse1, ASN, RN]

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

I have had a few of these patients when I was in the ER. I have performed CPR on an elderly woman and have broken those frail ribs and I have listened to Doctors try to get the family to abide by the living will to no avail. Do every thing possible they said. Vent, pacing, we did it all and once the family arrived an hour later they wanted it all stopped. It took 3 hours for all the stimulants to clear her system so that her heart would register a flat line. She came from a nursing home and the family had "forgotten" to give the no code order to the staff. Many of the doctors that admit to the nursing homes here will not admit a patient without a no code order being signed by family and the above case is why they have started this practice. Some of the Doctors in the ER would run slow codes rather than torture the elderly. I have no understanding of family that will insist on "all measures" when those measures amount to torture of their parents.

My Dad made sure that I had both his and Mothers living wills and Medical Power of Attorneys as he knew my sister would not follow his wishes. (But Dad learned this the hard way when my Aunt died. He overrode my aunts wishes and she was given the entire treatment. When I got to the ER he was asking what to do. It took 2 days for her to pass but he never forgot what happened.) I was tending to Dad at the end and I ran into the problem with the pain relief. He was in very severe pain (at home) but the Doctor did not want to give him morphine because it would "compromise" his breathing. He was dying! I basically threw a fit until I got him some pain medication.

You did what you had to do but that does not make it any easier, just know that you did everything with as much tenderness as you could and for that she would thank you. I have one son that will have my medical power of attorney so that there will be no "family" problems if/when something happens to me.

[directive]

Saw too many of these in my 50 years of nursing, have two sons and if either one of them ignore my wishes they will be removed from my will. Problem solved!!!