Tuesday, March 25, 2008

My Worst Easter

The following story has been altered in order to protect the confidentiality of the patient, and family members. This topic may not be suitable for young people.

This Sunday many have been my worst Easter ever. I worked in the nursing home that morning. I was assigned a 1 on 1 case. Before I walked in I received report from the Nurse on duty... "Joe is a dying patient. He had stopped eating, and drinking. Joe is in his late 80's, unresponsive, and had the death rattle, (chain stokes breathing), with slight modeling to one small area on one of his legs. He is DNR (do not resuscitate), and on hospice care." The Nurse added that she didn't believe that Joe would die on our shift.

The family was obviously grieving, but were as nice as could be. His daughter Julie came up to me immediately, and introduced herself, and her brother Sam. Throughout the shift they included me in the conversation, and even offered me some food that they had brought in. You could tell that they were both caring, down to earth people.

Throughout the shift I made sure that Joe received the best of care. I bathed him, put lotion on him, changed his gown, oral care, frequent repositioning. You know the works. When that family left to have lunch I read to Joe from his favorite book, and talked to him.

In my 20 years as a C.N.A. I have seen scores of dying patients. I have witnessed the death of about a half dozen or so. This was not foreigner to me. I noticed that Joe had some strength. He wasn't limp when I turned him. Also his breathing was very regular. I didn't need to count his reparations, but did often. They were always around 14 which was average. I concluded that Joe was to strong to die during my shift. I silently agreed with Nurse Julie's assessment. Of course I didn't tell the family that. Being an Aide, I was in no position to do so, besides it is all subjective.

Later in the shift the Nurse came in, and gave Joe his Morphine. I wish that I had looked at the clock, because that is when the change occurred. Minutes later there were several changes. Over a period of about 20 minutes Joe seem to weaken, his jaw dropped, his breathing changed. Breathing wise, he went on automatic. That's what I call it. It's the very slight difference between an unresponsive patient having some input into his breathing, to no input. It was like he was no longer in control, and part of him seemed gone. I can't describe it other then that.

The family had gathered around the bed, talking to him, and holding his hands. They were both crying. Joe soon stopped breathing, about 30 seconds later he was white as a sheet. Joe was gone. It happened so fast. I remember looking up just above Joe's head, half expecting to see his spirit, or feel his spiritual presents. It happened so fast, that I wondered if he was hovering over his body for a few seconds. But I saw/felt no ghost.

My eyes filled up. It caught me off guard. I didn't expect him to die. I muttered a few words to the family in a fruitless attempt to comfort. I have never been good at that. I never know what to say. My voice cracked as I spoke. I was on the verge of crying, but needed to get a hold of myself. I had learned professional distancing. Usually I could hold back the tears until I got home. That's something that you learn in this business, but still it is very difficult sometimes. Losing a patient is always hard.

Julie the Nurse came in. I couldn't help but wonder if she had killed Joe by administering the Morphine. I knew that the doctor ordered it, but she did administer it. There are some days that I am glad I didn't finish Nursing school.

Morphine is often given to dying patients in order to control pain. It can change breathing patterns, and decrease the respiration rate. It is somewhat controversial. I have heard discussions though out the years. Some Nurses refused to give the P.R.N. med, because they feel that it could kill the patient. Other Nurses give the Morphine to make sure the patient is comfortable.

When I was in my early 20's taking care of my mother who was dying of cancer, one of my mothers meds was Morphine. None of the hospice Nurses told me that it possibly could hasten my mothers death. They should have! The family should always know. Fortunately, I know from the circumstances that it was not the Morphine that killed mom. Otherwise I would feel guilt stricken even to this day. You would think that after all these years, they would have found a drug that could be effective for relieving pain without affecting the breathing. Yes, there are days that I am glad I am not a Nurse. They have to make some very difficult choices.

When I got home I received an e-mail from a friend. She had contracted a Superbug, and had to go into the hospital for surgery. Yes, this Easter was my worst Easter ever.

Additional reading:
Dying and Death in a Nursing Home


Anonymous said...

I'm really sorry you had to go through this, but it's the cycle of life.

I couldn't do what you do, but I'm glad there are people like you that DO it.

I'm also sorry you had to turn on moderation -- it really sucks when someone forces your hand like that on your own blog.

I was wondering if you were planning to attend the NewlyWed In New York celebration on April 26?

Awake In Rochester said...

Hi Pat,

Thank you for your kind words.

I did not turn on moderation because of any questionable comments here. So far I have been very lucky. It's because someone is trying sent another blogger a virus. And someone else is posing as a blogger that I know. Crap like that.

Um, what is NewlyWed in New York? I am out of the loop.

Anonymous said...

Sorry to hear you had a bad Easter .. :(

But I think Joe and his family appreciated the care you gave to him before his passing.

You're really strong to be in this profession and even though you were just an aid, I'm glad to have people like you in the world that care so much about their patients.

Anonymous said...

Thank goodness there are caring people like you in this world. This might have been a terrible day for you, but I would bet your patients family is very thankful that you were the one taking care of their father. It seems like they knew their father was dying and as you know, it's hard to say exactly when it will happen. But it was something they were expecting and since they probably don't know the signs of death as well as you do, the quickness of his death was probably not something they would ever think to question.

I'm an RN in a hospital and have taken care of many dying patients. The decision to give morphine really isn't too difficult. Sometimes the goal is to slow the breathing, if they are breathing very fast, because this is considered uncomfortable. If there are non-verbal signs of pain such as restlessness, facial grimacing, crying out, or increased BP then morphine should be given. Also, if you know the patient and you know that if they don't get their morphine every 4 hours they start to have these symptoms, it could be given in an attempt to avoid discomfort. Just as you would give any pain medication when pain starts rather than wait until it is out of control. I agree that it is hard to know if the morphine sped up his death or not, since death was the expected outcome eventually. If the nurse had a current order and reason to believe he needed it, then it was the right thing to do. It is NOT safe to give a medication just because the MD ordered it. The doctor wasn't there and it's the nurses responsibility to make the final decision based on her assessment of the patient as to whether it is appropriate and safe to give any medication. I am sure she did her own assessment of the patient and determined it was ok to give. In my own practice, I am careful to document the symptoms and reasons I give morphine (or any other pain medication) to my patients so if it is ever called into question, I have clear justification for what I did or didn't do. I only hope that nurse saw or knew something but she just hadn't verbalized it to you. It's situations like this that give morphine a bad name but it really is a good medication, when used correctly. Either way, this patient was lucky to have you with him at the end of his life. Maybe it was your presence that helped him to appear so comfortable, he knew he was safe and in good hands.

It is interesting how observant you are. You sound like you would make a great nurse. I rarely see people take such good care of a dying patient.

Out of curiosity, why was he on a 1:1? At the hospital where I work, we only get 1:1's for suicidal patients and patients who are so confused they are at risk of falling and injuring themselves. Maybe it's different in a nursing home...?

Feel proud that you took such good care of this man and know that he surely appreciated it.

Awake In Rochester said...

Hi -a,

Thanks for saying that. I honestly didn't think he would die on my shift, so it was an unpleasant surprise. Actually Easter isn't such a bad day to die if you think of it.

Awake In Rochester said...

Hello Anonymous and Welcome!

I was hoping that a Nurse would stop by. I hope that you come again.

Thanks for your kind words concerning the care that I gave. There are some 1 on 1 where I work. It was privet duty, so the family had money. Plus he was on hospice care.

I've heard pros, and cons on Morphine. Isn't there another pain med that could be given that is just as effective without slowing down respiration's? I gave Morphine to my dying mother over 20 years ago. You would think after 20 years they would come up with something better. I was never told about the side effects. I strongly believe that the family should be informed. I understand about careful assessment, and documentation. Still, I might hesitate to give that med if I where a Nurse. That's just me. I'm the overly cautious type, I guess. I would want to do no harm. Even unintentional harm.

Your job is certainly not easy. So many decisions. Nurses get crap from all sides- difficult patients, Doctors, family members, so on. C.N.A.'s get some of the crap, but Nurses get the brunt. Plus I don't like blood, or needles. I admire Nurses.

Well, I hope to see you again! You had some very good input!