Tuesday, May 10, 2011

Nurse Follies: The Impossible Situation

Mr. Pickled arrives to the hospital on a Friday, sporting a yellow skin tone that makes him glow in the dark. The family, brags that he has come in for a liver transplant that will take place the following Wednesday. Nurses are puzzled. Liver transplants generally aren't scheduled in advance as they are transplanted within hours of retrieving it from a donor. Donors aren't exactly something you can predict. Not to mention that the Transplant Gods refuse to give a new liver to someone who can't put the bottle down for six months before the transplant and promise not to drink after.

The disease process of a crapped-out liver runs its course, and inevitably we come to the part where Mr. Pickled is going to die, and the family has decided that they have no choice but to let him go. Wife and sister hold a beside vigil while Mr. Pickled prepares to transfer to the Eternal Care Center.

Now, palliative patients are near and dear to me. I find it rewarding to help in this transition. To help the patient be comfortable, to help the family cope with the impending loss. It's a highly personal experience, and I am honored that family members trust me enough to share in their journey. It's an area of nursing I am very good at, but have no inclination of doing it full time.

Sadly, I'm not taking care of Mr. Pickled, and get to wear the charge nurse hat. A friend and colleague (Salty) gets to care for the Pickled Family (because it Palliative Care, the focus is just as much on the family as it is on the patient). She is a newer nurse, and somewhat uncertain, so I help her when I am not dealing with the phantom toilet flushing in the staff bathroom that's causing the other nurses to freak out.

Mr. Pickled goes into his agonal breathing pattern, which is to say his breathing becomes shallow and slows to 2-4 breaths a minute. The first time this happens, the family assumes it's his last breath and begin the emotional release that comes with the death of a loved one. Then he takes a breath. The family stops crying, blinks their eyes, and the vigil resumes. This happens three other times. The crying stops and starts like a faucet. Emotions are raw. It's as if you relive the death of a loved one over and over again.

Death is different for everyone. Some go quick. Some like to hang out for a while. Mr. Pickled is unpredictable and no one can be sure how long he's going to keep this up. The family asks us to give them a time frame. We can't.

Finally, Mrs. Pickled cries, "Can't you do something to stop this? Can't you give him more Morphine to end this? I can't take it anymore!?"

Salty and I look at each other, speechless. Narcotics are given to keep the patient comfortable, alleviate air hunger, pain management. Yes, there is an unspoken understanding that it could hasten the inevitable, but never before has a family outright asked us to expedite the process.

Finally, Mr. Pickled passes away an hour or so later, without further nursing intervention. Mrs. Pickled crawls into bed and spends the rest of the night sleeping, for the last time, by her husband's side. It freaks out the younger nurses, but we just let them be until morning. When the wife leaves, she thanks the staff and makes no mention of her previous outburst. I wonder if she looked back upon it and kicked herself in the ass.

There are medications that some patients take that are life sustaining. Any cessation of these meds will result imminent death. Some patients, after a while, opt to stop the drugs, which results in their imminent death. The patient knows that this will be the end result because doctors and nurses make sure they know it. Would this be considered the same as an assisted suicide? Why is this more acceptable than giving someone a high dose of something that is going to hasten the death of a terminal patient? Euthanasia is not legal, but it also encompasses a HUGE gray area that no one speaks of.

Maybe, folks need to start talking about it. And not in the final hour when you want the nurse to do it.

1 comment:

bobbie said...

At least the Pickled family didn't freak out and decide to nix the DNR order!

You're so right about the huge grey area... and dox are SO terrified about bringing it up.

I had a lovely doc write me an order for 2-4 of MS IVP q5 min prn air hunger. I made sure the family understood ALL the possible consequences of the dosing, and they were all for it.
Made for a 'nice' transfer to the ECU.