NR 305 Discussion Case Study or Share an Experience
NR 305 Discussion Case Study or Share an Experience
This is my area of nursing. I work in hematology/oncology and hospice. I have had a lung cancer patient tell me, “Kelly, I think tonight’s the night”. I said, “Tonight’s the night for what, patient X?” And she said, “Tonight is the night I would like to pass on and see Jesus. I am ready.” And I said, “OK, patient X. Should we call your daughter and have her here with you?” She said, “Yes. Let’s have her come.” Cue the hand holding and smiles. That was that. She passed later that evening by removing her oxygen and being given morphine for comfort.
I have ordered patient’s last meals before sedating them to a comfortable coma-like state. I feel good about what I do when someone is ready to be at peace and be comfortable.
Option #1; Ann & Michael:
I would ask if Michael would mind stepping out of the room and talking to me. Unfortunately, during the pandemic, my hospital has strict end of life visiting policies and I might have to be asked these questions over the phone.
I would ask Michael if Ann had ever mentioned what she would want in this type of situation? Had she ever said things like if I am unable to do xyz, I would want xyz to happen?
What are your reservations to the surgery, Michael? What worries you? Do you feel like you understand the benefits versus the risks fully?
If Michael wanted Ann to just be comfortable in her remaining time on the earth, I would feel comfortable discussing hospice care. Often, in hospice care, we can provide a patient with oxygen for comfort purposes and medicate to make breathing more comfortable and restful. Sometimes we do remove the oxygen and only medicate. We would discuss options of taking Ann home or keeping her under the hospital’s care.
Let us say that Michael wants to understand more about inpatient hospice care, I would discuss all his and his wife’s “physical, psychological, spiritual, and practical” needs could be addressed by the hospice team (Hill & Hacker, 2010). Michael could determine that psychologically, Ann would not have a good recovery after a lobectomy although he does not want her to suffer with dyspnea. Physically he knows that Ann’s dyspnea is exhausting and giving her also sudden anxiety and restlessness. She has become incontinent. Spiritually he believes in God and does not want his wife to suffer, but also does not feel it is right to choose her life or death – chaplain or priest may be asked to step in here. Practically speaking, he feels he has already said goodbye to the Ann that he knew before, but he questions whether hospice is giving up on his wife.
I would reassure that we could really make Ann rest well and relieve her suffering. We could give medications like Ativan for her anxiety, dyspnea, and restlessness. We could also give medications like morphine or dilaudid for dyspnea. We can give robinul and scopolamine patches to dry up lung secretions. We can suction to clear the lung secretions as needed and as comfortable. All the while, we will keep her skin clean and dry, provide oral care and repositioning as tolerated. We will be happy to play spiritual music or biblical readings. We can involve music therapy and chaplains as often as possible. We are here to ensure you have support to through nursing and social and spiritual services.
All these struggles and concerns can be attended to by the right department and nurses play a big role in rounding up those departments as well as communicating with the medical team to relay the patient’s/family’s wishes (Weber & Kelley, 2018).
Hill and Hacker (2010). Helping patient with cancer prepare for hospice. Clinical Journal of Oncology Nursing 14(2): 180-188. http://dx.doi.org.chamberlainuniversity.idm.oclc.org/10.1188/10.CJON.180-188
Weber, J.R. & Kelley, J.H. (2018). Health assessment in nursing (6th ed.). Philadelphia, PA: Wolters Kluwer.
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Thank you for sharing. I really enjoyed reading your post. In your post, you mention Michael’s conflict with his spiritual beliefs and not wanting his wife to suffer but also feeling it is not right to have to choose between her life or her death. This a good point because family members often feel conflicted between religious beliefs and what is right for the individual. Weber & Kelley 2018 mentions, religion as a practice that affects healthcare regarding dying, acceptance of life, death prolonging treatments and withdrawing life support (Weber & Kelley, 2018, p. 190). I believe identifying these conflicts as they arise are crucial to both the patient and family during end of life care. I feel that when conflict is recognized we can then offer services such as pastoral care as mentioned in your post to help the family work through these challenges.
Weber, J.R. & Kelley, J.H. (2018). Health assessment in nursing (6th ed.). Wolters Kluwer.
The first patient who passed away on my shift was the one that made the most impact. I was in my second month out of orientation, working on a Vascular Surgery unit. Most of our patients were post surgical, but we were also one of the few Telemetry floors at the time, so we often had a mix of other specialties. It was Father’s Day, and I had buried my own father two months prior. One of my patients was an elderly woman with metastatic cancer. She was scheduled to go to Hospice the next morning. She was alert and oriented times one or two, but that morning she was more confused than normal. She’d been in our care for about a week, and was getting palliative radiation treatments to help with the pain from her tumors. That morning, she refused. The transporter came out to let me know, and I went in to make sure. She was agitated, and told me she absolutely was not going. None of her family was with her at the time. I believe they were still getting things in order for the move the next day.
In hindsight, I probably should have seen some of the signs, and asked more questions. She was more agitated than usual, and it was in my head that she was Hospice, and end of life, but I had no idea that she was actively dying until one of the palliative doctors came out to find me later that afternoon. He told me that I should call her family and get them to the hospital as soon as possible. I hadn’t noticed in the morning, but her hands were mottling, she hadn’t eaten, and by the afternoon her blood pressure was dropping. (Signs and Symptoms of Approaching Death, n.d.) I called her family, and calmly asked them to come up. They were surprisingly calm, given the circumstances, but I assume it was because the Hospice plan was already in place. The palliative doctor called pastoral care to consult, and I was to call when they arrived. We moved the patient’s roommate out of the room, and I attempted to make her comfortable with pillows. At that point, the patient was no longer speaking. She didn’t appear to be agitated or in pain. When the family came, I called Pastoral care to come to the bedside. He gave her last rites and spoke with the family. Shortly after he left, a family member came out to ask me if she had passed. Her breathing had stopped. When I walked in the room, it had become more of a death rattle type breathing pattern. (Providing Care and Comfort at the End of Life | National Institute on Aging, n.d.) I knew what this was. I stroked her forehead and started to cry. I explained what the breathing pattern meant. They asked me if I’d had a chance to speak with her that day, and I told them how feisty she had been about not going to radiation. This put smiles on their faces, because she was a small woman, with a big personality. A few minutes later, she passed away. I excused myself and gave the family time to themselves.
If the same situation happened today, I don’t know that I would have done anything differently. I might have called the family sooner had I been more aware of what to look for. I might have offered to get a radio, or tune in to a music station for some calming music. (Providing Care and Comfort at the End of Life | National Institute on Aging, n.d.) I felt like the family appreciated what we were able to do to give them time, and comfort. I think that my father’s recent passing helped me to be more empathetic to their situation. They actually told me that they were touched to see me cry, and hugged me as they left.
Providing care and comfort at the end of life | national institute on aging. (n.d.). National Institute on Aging. Retrieved August 21, 2020, from https://www.nia.nih.gov/health/providing-comfort-end-lifeLinks to an external site.
Signs and Symptoms of Approaching Death. (n.d.). Hospice Patients Alliance. Retrieved August 21, 2020, from https://hospicepatients.org/hospic60.htmlLinks to an external site.
During my clinical rotation in the ICU, a young man in his 20’s was shot multiple times in the torso, neck, and back of the head. He made it through the initial period and even discharged to an acute care nursing facility. At the time of his discharge, he was able to open his eyes, grunt in response, and every once in a while, able to indicate yes or no. He was paralyzed from the shoulders down as one of the bullets lodged into his spinal cord and could not be removed. However, he was only in the nursing facility for about two days when he became unconscious. He was transferred back to the ER and admitted to ICU.
I participated on the doctor’s round in the ICU and received an update on the status of this patient. The family was in denial about their loved one’s prognosis and wanted everything done for him, including resuscitation protocols. The doctors had multiple conversations with the family in person and on the phone, trying to advise them of the poor prognosis. During this discussion, I asked if the Gift of Life has been notified of the patient’s condition. The doctors, including the residents, nurse, and pharmacy, just stared at me for what seemed to be an eternity and went back to discussing the plan of care. As the doctor’s moved on to the next patient, the alarms in the young man’s room activated, and he went into cardiac arrest. I was there for the resuscitation, and after a few minutes of CPR, two Epinephrine’s 1 mg IV push, the patient’s pulse returned. However, once the Epinephrine would wear off in 3-5 minutes, he would go back into cardiac arrest. After about 20 minutes of cyclic cardiac arrest protocols and return of spontaneous circulation, they started an epinephrine drip, and for now, the patient pulse remained. During that time, the doctor’s called the family on the phone a requested a family conference. The family arrived in about an hour and was escorted into the family room. I was not allowed to observe but was informed that the doctors were attempting to make the patient a Do Not Resuscitate (DNR) order. While all this was happening, I heard the one RN asking for the number for the Gift of Life. I was ecstatic that they did listen to my suggestion even though they did not acknowledge me, but I was also confused as to why the Gift of Life was not contacted sooner.
As the family conference ended, they still could not believe that nothing could be done for their loved one, so the doctors ordered a brain death protocol. Two doctors had to perform the assessment. I was able to observe the neurological exam, including pupillary reflexes, cranial nerve reflexes, and the caloric test, where they place ice water in the ear canal to assess for pupillary responses, and the apnea test. All the tests were positive for brain death criteria, so the final step they performed was to test the cerebral blood flow to the brain with contrast. The examination revealed that there was no blood flow to the brain. As they advised the family of the test results, the patient went into cardiac arrest, and eventually, the family decided to stop resuscitation efforts with no organ donation.
Sad, how this patient was injured in the first place. As far as if it was a “peaceful” death, I do not know. I know that the hearing is the last thing to go as I have had patients tell me when they return from being resuscitated. Some have reported an out of body experience and said they could see us working on them. For this patient, I am not sure. During this experience, I could tell that the doctors were displeased with the family because the family could not understand, or perhaps it is the hope that their loved one will pull through, that the prognosis was poor. Even though the doctors disagreed with the family’s decision not to make the patient a DNR, the doctors still abided by their wishes.
On the other hand, I feel that it was tough and tragic for the family to be faced with this decision since he was such a young man. There were no discussions about the end of this patient’s life as it never occurred to the family that it needed to be discussed. Trying to make decisions for an older person that one has not addressed their wishes is difficult. Still, I cannot even imagine the family trying to decide on such a sudden tragic event. Finally, it appeared that the whole family of this patient wanted to be there and involved as there were about 10 in the family conference room. Perhaps they could not agree on a decision as a family (National Institute on Aging, [NIA], n.d.). Because the doctors abided by the family’s wishes, discussed the “end-of-life care approach,” and provided the information that the family required to “prove” that their loved one was dead helped in the family’s decision process. In the end, the family was able to make that decision to stop resuscitative efforts (NIA, n.d.).
However, I am deeply saddened that the Gift of Life seemed to be an after-thought. In my Gift of Life class, Tameka Childs-Wolfe gave a lecture in 2019 and emphasized several times that if you, as a nurse, have a patient that is vent-dependent with a non-recoverable neurological illness or injury to call. Also, request the Gift of Life before the first formal brain death examination, before talking with the family about DNR status, or if the patient has a traumatic brain injury, anoxia or CVA to call (Childs-Wolfe, personal communication, October 21, 2019). The sooner Gift of Life is notified, the sooner they can arrive at the facility and start assessing the patient even before discussions begin with the family (Childs-Wolfe, lecture, October 21, 2019). This way, when brain death is confirmed, they can start to “preserve organ function to maximize successful organ procurement” (Anwar & Lee, 2019, p. 15). There are approximately 110,000 people who are waiting for an organ transplant. Only 2.5 percent of patients qualify to donate organs (Gift of Life, n.d.). One of the benefits of notifying the Gift of Life is that they meet with the family and explain everything about the process, what it means, and how it can be “life-transforming” (Gift of Life, n.d. Authorization Process section). Even though this young man’s life has ended tragically, I think about all those other lives he could have saved and perhaps comfort the family that their loved one continues to “live on.”
Anwar, A.S.M.T., & Lee, J. (2019). Medical management of brain-dead organ donors. Acute Critical Care, 34(1).https://dx.doi.org/10.4266%2Facc.2019.00430Links to an external site.
Gift of Life. (n.d.). About organ donation. https://www.donors1.org/learn-about-organ-donation/Links to an external site.
National Institute on Aging. (n.d.). Understanding health-care decisions at the end of life. https://www.nia.nih.gov/health/understanding-healthcare-decisions-end-lifeLinks to an external site.
When responding to Michael I would try to address his psychological needs without giving him any false hope. I would want to make certain that Michael understands the current stage of the disease process Ann is facing in addition to her advanced dementia and that both are progressive illnesses, helping him to understand that this procedure would not be a “cure” but would possibly slow the cancer’s progress and possibly give Ann a little more time and better quality of life that she may have left. I would then ask him to tell me about the concerns he is having about the procedure and try to answer any questions he may have. I would also offer to have the provider come back to explain the procedure and its risks/benefits again if needed and/or answer further questions Michael may have. As caregivers we can enable our patients to have a higher quality of life by initiating palliative care to optimize the management of their progressive illnesses by allowing them to die in comfort and with dignity (Evans et al., 2014). I would also explain what palliative care or end-of-life care is, advocating this as an alternative treatment plan that also focuses on quality of life, maintenance, prevention, and symptom management and how that could address Ann’s pain and keep her comfortable (Weber & Kelley, 2018). Palliative care can be used alongside life prolonging treatments (Merlane & Cauwood, 2020). If Michael decided to move forward with the procedure, palliative care would most likely be the focus of Ann’s treatment afterward.
Evans, N., Pasman, H Roeline W., Donker, Ge A., Deliens, L., Van den Block, L., & Onwuteaka Phillipsen, B., (2014). End-of-life care in general practice: A cross sectional, retrospective of ‘cancer’, ‘organ failure’ and ‘old age/dementia’ patients. Palliative Medicine 28(7), 965-975.
Merlane, H., & Cauwood, L., (2020). Core principles at end-of-life care. British Journal of Nursing 29, (5) 280-282.
Weber, J.R., & Kelley, J.H. (2018). Health assessment in nursing (6th ed.). Wolters Kluwer.