The Patient was a Retired Nurse

[vmbennett, BSN]

The author was being oriented in intensive care units when she was assigned to her exemplary case. This case involved an elderly ventilated lady that was alert and oriented, capable of making her own decisions and facing the end of life decisions. The elderly lady had several comorbidities, including respiratory distress, diabetes, congestive heart failure, and a history of a stroke. The patient knew that if we took the ventilator tube out of her mouth, she would not be able to withstand life very long. She was a retired nurse and understood the ramifications and was prepared for the outcome.

Comorbidities

The patient’s respiratory distress had developed into acute respiratory distress syndrome (ARDS). Additionally, she had congestive heart failure, which causes fluid to increase around the heart, causing it to pump inefficiently. These symptoms made it harder to extubate this patient. The elderly patient also had diabetes and a history of a stroke. Although her diabetes was being controlled based on an A1C of six, and she had no deficits from a previous stoke, she was ready to see her husband again. The combined symptoms from her disorders and with the blessing of her family, this patient decided to be extubated.

The pathophysiology progress of ARDS was explained by palliative care as neutrophil activation due to inflammation, which is significant in the pathogenesis of ARDS. The patient and the family members verbally acknowledged the possibilities of multiple organ failure, pulmonary hypertension, and a high mortality rate. Additionally, palliative care explained that there are no single biomarkers to predict the outcome of ARDS in an elderly patient, but numerous different pathways are involved in the development, which increases the risks for a poor outcome at an advanced age. Although the family members were not agreeable with the patient's decisions and very tearful, they were all respectful.

Patient's Journey

The journey involved a retired ventilated nurse that was alert and oriented, capable of making her own decisions and facing the end of life decisions. She was writing messages on our communication board and texting with her phone to communicate. She had been in intensive care for several days, and we were unable to wean her from the ventilator during the daily spontaneous breathing trials. She had lost her husband several years earlier from cancer and wanted to be with him. Palliative care had been consulted and met with the patient and the family members. The patient kept her dignity, which included autonomy and control over the daily activities and circumstances. The patient's self-determination allowed her to feel that life still had worth and importance despite the current circumstances. The patient understood the meaning of comfort care and withdrawing care. She knew that if we took the ventilator tube out of her mouth, she would not be able to withstand life very long. She understood the ramifications and was prepared for the outcome.

To the author, this was a well-educated elderly lady with independence and dignity. The patient kept her dignity, which included autonomy and control over the daily activities and circumstances. The patient's self-determination allowed her to feel that life still had worth and importance despite the current circumstances. The author observed the elderly lady facing the end of life decisions had identified with her illness, age, and comorbidities. The cause of her death would be by her hand and decisions. The patient would determine the timeline, and the consequences were that she got to meet her husband again. Other consequences the patient thought about was leaving her children and grandchildren, but the patient expressed a weary life and determination to be pain-free again. The treatment the patient chose was comfort care to relieve her suffering.

After caring for this patient on many occasions, becoming a confidant to the family members and a friend to the patient, we withdrew care. As an orientee, the author was not fully aware of what comfort care meant. The author was instructed to get pain medications from the Omnicell to administer to the patient. As the author administered the medications, the patient's heart rate and respiratory rate began to diminish. As an orientee, this response was alarming, but as an intensive care nurse, composure was vital. At that moment, the author was confused, irritated, and doubted what she had just done as a nurse. We are taught to do no harm.

What had just happened? The author had been listening to the palliative care team for days talk about comfort care and peace, but details had not been explained. The author certainly had not expected to be the one pushing the final medication before the patient's last breath. As the author stood there holding the patient's hand, watching the monitor, passing out tissues to the family, and feeling as though she had done something wrong, the patient took her last breath. It was not a sudden death but a peaceful one. This incident made the author doubt her career choice, her faith, and the intention of the medical field. This situation was the most uncomfortable and spiritually confusing event of the author's life. As the author drove home that evening, tears of forgiveness rolled down her cheeks. The author went to the hospital chaplain and the palliative care team for guidance and clarification. The circumstance was explained as holistic care, focusing on psychosocial, psychological, and spiritual characteristics of care for the patient and family.

This experience was the author's first experience watching the role of a palliative care team, experiencing grief for someone that the author had not known very long, watching a person pass away, and witnessing a faithful family lose their mother. The family stated that medical treatment would have prolonged their mother's life without offering substantial benefits. Nursing incorporates numerous characteristics of care, including ethical decision making, supporting families and patients through the death and dying process and pain management. It is challenging to teach curricula on empathy, sympathy, the dying process, different healthcare system policies and practices, and the numerous interpretations of end-of-life progressions. As an orientee, effective communication skills from the leaders could have enhanced the experience, built trust, increased knowledge, and diminished career doubt.

Provider's Professional Role

A provider’s professional role when dealing with end of life decisions is to listen and discuss the wishes of the patient and family members. It should be routine as providers in a primary care setting to offer a living will/advance directive to every adult patient regardless of their age. Options and choices in the document should be read and explained so that the patient gets a clear understanding. A provider can educate the family and patients on who can sign as a witness, what is involved in decision making, and suggest someone who will respect their wishes. A provider should encourage the patient to discuss this decision with all family members involved before this document is needed. To prevent disagreements during the implementation of living will or advance directive, it is essential to begin the dialogue process concerning the end of life strategies early.

A non-crisis situation is an ideal time to have discussions about the end of life. The patient and family members can think clearly, discussing values, and ask questions. When approaching these conversations, the patient should feel safe, heard, and valuable. Autonomy should be given to the patient, and providers must explore cultural aspects and expectations of care with the patient and family. Providing information and education on what to expect, support groups, and discussing needs and expectations with the patient and family are vital.

Conclusion

Although the retired nurse passed away, a positive outcome was accomplished. The patient kept her dignity, which included autonomy and control over the daily activities and circumstances. Her quality of life was maintained until her last breath, and her family experienced a serene and peaceful passing. The patient's choices displayed her self-determination without external influences from her family, and her stress was limited due to managing and adapting to her illness. This patient demonstrated a journey of courage, love, faithfulness, kindness, and consideration. The retired nurse’s life story will forever be described as the author's epiphany in her nursing career and a hero. This encounter taught the author a deeper meaning of compassion, patient autonomy, understanding, and the true meaning of a hero.

[NutmeggeRN, BSN]

We should all have the autonomy and ability to make those decisions for ourselves.

[VivaLasViejas, ASN, RN]

This is why I made my own decisions regarding end-of-life long before I'll  need it. I have a POLST and I've made it known to my adult children that as much as I enjoy life now, I'll be happier when I join my late husband and if some illness comes along that has the potential to take me out, nature is to be allowed to take its course. I don't want to be ventilated, tube-fed, incontinent, or unable to care for myself in any way. I don't want to exist in a nursing home at the mercy of caregivers who may or may not give a damn. Of course, one does not ordinarily have a lot of control over whether he or she wants to die, but at least there is a choice of how to die. And comfort care is the way to go IMHO.