What to do when.....?

[Darknights]

I am an RN working in an extremely remote hospital in outback Australia. We are generalist nurses caring for a patient population ranging from psych to acute stroke, chronic care to palliative care. Unlike other places our nursing has the RN's out on the ward doing as many showers etc as the LPN's. I can't remember a time in nine years when we haven't been shortstaffed, or have been given adequate resources to do our jobs properly. But we do our best, and we really do care about our patients. They are mostly elderly and have endured horrific conditions in a harsh desert, while the men did dangerous work in the mines.....they are tough and resilient, and grateful for everything we manage to do for them.

Three weeks ago a patient was diagnosed with terminal cancer. This was a shock to her and her huge loving family. Two days later she was unconscious. Not an unusual story out here.

On the day I am writing about I was working with the family for the first time. They weren't coping so I was trying to provide as much support and education as possible. The patient had a death rattle that was becoming louder and more distressing to the family, despite multiple doses of anticholinergics and morphine. It was a bad situation just becoming worse.

I asked an LPN to help me give the pt a wash, check her incontinence pad, and try some postural drainage. As tipping a dying patient so their head is much lower than their feet is not a very dignified act I asked the family if they'd mind stepping out of the room for a short while. They were reluctant as they wanted to be there every minute until the patient died. I said we'd be quick and just wanted to make sure the patient was comfortable and dry. So they left.

We tipped the bed and noticed an instant decrease in volume of the death rattle. When I rolled the patient towards myself I commented to the LPN that sometimes repositioning and drainage is the best intervention. I rolled the pt back and was horrified to see dark blood pouring out of her nose and mouth. I grabbed the suction and started suctioning the blood, but it soon became clear that the patient was about to die and the blood flow wasn't going to stop. At least this event explained the worsening death rattle not responding to meds.

By then there was blood everywhere. I was doing my best to suction and to try to help the LPN change the linen, hindered by her having to run out of the room for linen and other supplies. I could see my patient's life ebbing and wanted to get her cleaned up so I could get the family back before she actually died. Our frantic efforts to change her clothes, keep suctioning and change the linen meant the yankeur had sprayed blood up the wall and across the floor, so we were trying to clean that up to.

I felt totally hopeless. I didn't know what to do. I wanted the family to be able to come back in to be with the patient, but how could I confront them with an image of her drowning in her own blood? And with every second I was thinking about it she was one more breath closer to being dead. It ended with us getting her on her side, draining as much as we could, cleaning her face, throwing covers over the linen, then hoping she'd die before the blood built up and poured out of her face and mouth again. I got the family back in, telling them she was about to die. She took one more breath, then was dead.

Three weeks later I still haven't come up with an answer for this situation. What if it was obvious nothing was going to stop the blood flow and the patient was so close to death there was no opportunity to prepare the family for what they were about to see? Do you delay things until the patient is dead? Do you just let them in to witness the event, then counsel them afterwards?

I've seen some awful deaths. It was the first death the LPN had witnessed. She was so traumatised by it I took her out for a five minute coffee. My manager made a comment about our going but I said we were going for a few minutes to have a coffee. I was traumatised too, because I had been so stuck. The LPN cried while she drank the coffee and I got to explain to her that such a death isn't common. Then we went back to work. My manager came up to me later and I told her what had happened. She said perhaps in future when such things happen it is a good idea to take a few minutes to debrief as it seemed to be helpful. As it has never happened in the nine years I've been here that is one good outcome from a not good death.

Other staff have said that we might have to get red sheets for when patients have a bleed. I'm not convinced that families won't notice pools of blood on red sheets. This is going to happen again. We've recently had three patients with fungating tumours involving their necks and the doctors expected them to die from catastrophic haemorrhages. They didn't. My patient did.

Have others been in similar situations? What did you do?

After all that the family thanked me for the care I'd given their mother that day. I still don't know what I should think about it.

[Psqrd]

Darknights,

I admire nurses like yourself that everyday despite poor conditions continue to do the best they can every day for their patients.

To second guess what you could have done different in this situation is very tough indeed, as you were only thinking of what was best for the patient. In my own experiences I have learned to move or disturb a patient as minimally as possible at end of life. Faced with your situation I believe you did the best thing possible which was to cover the blood on the linens and wipe the patient as best you could...the only other thing if possible would have been maybe move the patient to clean room if available.

You did the best you could for your patient to move from this life to the next as easy and respectfully as possible and no fault can be found in that. Keep up the good work your doing down under, and know for what it's worth, I would be proud to work with you any day!

Psqrd.

[msjellybean]

Almost exact same situation happened to myself and another nurse. We laid the pt down to put in a foley and that was it. Family had stepped out of the room for a few minutes. Very traumatic for everyone involved. This pt however, didn't appear to be as far advanced in the dying process as yours did.

[K+MgSO4, BSN]

you poor thing. That is a horrific thing for anyone to have to deal with but to be pretty much on your own and supporting your EN as well it is hard. I am going to assume that you are working in the public hospital system. There should be some sort of employee support program, even if they can't get out to you give them a ring and talk to them. None of this is your fault, you were doing what you thought was going to make your pt more comfortable, you were not expecting a haemorrage of that size. Talk to someone. If work can;t provide a number call the ANF & ask them to put you in contact with someone to talk to. take care of yourself.

[cav5]

I worked ICU and the first patient who died in my care was very similiar to this. He did not bleed but we had the family step out while we changed his linens and cleaned him up. He actually died while we were turning him. One of the very best nurses I have ever worked with did exactly what you did- we turned him over, got him cleaned up, made the room look as presentable as possible, and called the family in as quickly as we could. The patient's father was a doctor and not one of them was upset over what had happened. It was traumatic. At the end of the day all you can ask yourself is "if that would have been my father, mother, sister, or me on the bed would I have wanted that?" If your answer is yes then you have your answer. If your answer is no-I would've wanted this....then you have your answer. I know that if it had been me on the bed I would've wanted a nurse to do exactly what you did-dying is hard enough- you took care of not only a patient who was sick and dying but also shielded her family from the worst of it when she couldn't do it. To me, as a nurse and mother, that is your answer.

[OldNurseEducator]

I am an RN working in an extremely remote hospital in outback Australia. We are generalist nurses caring for a patient population ranging from psych to acute stroke, chronic care to palliative care. Unlike other places our nursing has the RN's out on the ward doing as many showers etc as the LPN's. I can't remember a time in nine years when we haven't been shortstaffed, or have been given adequate resources to do our jobs properly. But we do our best, and we really do care about our patients. They are mostly elderly and have endured horrific conditions in a harsh desert, while the men did dangerous work in the mines.....they are tough and resilient, and grateful for everything we manage to do for them.

Three weeks ago a patient was diagnosed with terminal cancer. This was a shock to her and her huge loving family. Two days later she was unconscious. Not an unusual story out here.

On the day I am writing about I was working with the family for the first time. They weren't coping so I was trying to provide as much support and education as possible. The patient had a death rattle that was becoming louder and more distressing to the family, despite multiple doses of anticholinergics and morphine. It was a bad situation just becoming worse.

I asked an LPN to help me give the pt a wash, check her incontinence pad, and try some postural drainage. As tipping a dying patient so their head is much lower than their feet is not a very dignified act I asked the family if they'd mind stepping out of the room for a short while. They were reluctant as they wanted to be there every minute until the patient died. I said we'd be quick and just wanted to make sure the patient was comfortable and dry. So they left.

We tipped the bed and noticed an instant decrease in volume of the death rattle. When I rolled the patient towards myself I commented to the LPN that sometimes repositioning and drainage is the best intervention. I rolled the pt back and was horrified to see dark blood pouring out of her nose and mouth. I grabbed the suction and started suctioning the blood, but it soon became clear that the patient was about to die and the blood flow wasn't going to stop. At least this event explained the worsening death rattle not responding to meds.

By then there was blood everywhere. I was doing my best to suction and to try to help the LPN change the linen, hindered by her having to run out of the room for linen and other supplies. I could see my patient's life ebbing and wanted to get her cleaned up so I could get the family back before she actually died. Our frantic efforts to change her clothes, keep suctioning and change the linen meant the yankeur had sprayed blood up the wall and across the floor, so we were trying to clean that up to.

I felt totally hopeless. I didn't know what to do. I wanted the family to be able to come back in to be with the patient, but how could I confront them with an image of her drowning in her own blood? And with every second I was thinking about it she was one more breath closer to being dead. It ended with us getting her on her side, draining as much as we could, cleaning her face, throwing covers over the linen, then hoping she'd die before the blood built up and poured out of her face and mouth again. I got the family back in, telling them she was about to die. She took one more breath, then was dead.

Three weeks later I still haven't come up with an answer for this situation. What if it was obvious nothing was going to stop the blood flow and the patient was so close to death there was no opportunity to prepare the family for what they were about to see? Do you delay things until the patient is dead? Do you just let them in to witness the event, then counsel them afterwards?

I've seen some awful deaths. It was the first death the LPN had witnessed. She was so traumatised by it I took her out for a five minute coffee. My manager made a comment about our going but I said we were going for a few minutes to have a coffee. I was traumatised too, because I had been so stuck. The LPN cried while she drank the coffee and I got to explain to her that such a death isn't common. Then we went back to work. My manager came up to me later and I told her what had happened. She said perhaps in future when such things happen it is a good idea to take a few minutes to debrief as it seemed to be helpful. As it has never happened in the nine years I've been here that is one good outcome from a not good death.

Other staff have said that we might have to get red sheets for when patients have a bleed. I'm not convinced that families won't notice pools of blood on red sheets. This is going to happen again. We've recently had three patients with fungating tumours involving their necks and the doctors expected them to die from catastrophic haemorrhages. They didn't. My patient did.

Have others been in similar situations? What did you do?

After all that the family thanked me for the care I'd given their mother that day. I still don't know what I should think about it.

AWESOME job!!!!!!!! What a story.....:yeah::yeah::yeah:Thank God for nurses like you. You did a remarkable job. :heartbeat:heartbeat:nurse:

[Ruthfarmer]

Your care and concern for both the patient and the patient's family is a beautiful thing. Your priorities are certainly admirable.

Sometimes, as nurses, we find ourselves in just hard down wretched and impossible situations. Both life and death can be unpleasant and repugnant. Your actions were both kind and practical. You made the best out of a horrid situation. Don't second guess yourself for a minute. You are the nurse I would want caring for me or my loved ones. :redbeathe

[shhhh]

You are the nurse I would want caring for me or my loved ones. :redbeathe

I second this. You sound like an amazing nurse. Best of luck to you. :)

[Darknights]

Thanks everyone. I expected feedback on what I'd done wrong. I hadn't anticipated your positive comments. I really thought there was some answer on what I should do in such a situation and I just couldn't see what it was.

[sweetnepenthe]

You were also kind enough to care for your co-worker as well as the patient and the patient's family.

Good job.

[surferbettycrocker]

you know sometimes i wonder if the dying patients hang on by a paper thin thread when family is in the room. i have heard of and witnessed patients actively dyeing who give their last breath just as family stepped out of the room. you never really know. maybe even in the state of dyeing the patient feels a need to hang on for the grieving family.

i think you did the best you could with the situation at hand.

althoug iw ould not want my loved ones to die alone, i dont think i could sit and listen to a death rattle of a loved one..

[nurse2033, MSN, RN]

Holy cow! You had me gripped from the first sentence. Don't play what-ifs, you did the best you could do in a terrible situation, kudos. I don't think any family wants to see their loved one choke to death so it's probably for the best. My opinion, what you should think is- that you busted your a** to support your patient and her family in a time of great need, and did exactly what a nurse is supposed to do. That things didn't come out a fairy tale is not your fault. I'm hoisting a beer to you...