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.
