Sunday, August 3, 2008

Guilt.

She comes in more often than she should.

Her body is a mass of bedsores and contractures. She is permanently folded into the fetal position.

She doesn't speak. She simply moans. Sometimes I'm glad that I don't know what she's saying. It's easier for me to pretend that she doesn't know what is going on around her, even though I always talk to her as if she understands me. I'm afraid that she does.

She has a PEG tube keeping her alive. She hasn't eaten a bite in years. The staff at the nursing home forgets to keep her head elevated. Most of the time she comes in because she has aspirated, and she has pneumonia, again.

She is the reason I question the existence of God.

About six months ago she came in with the worst GI bleed I've ever seen. She was pooping blood. She was puking blood. When we turned her, blood poured out of her stoma around her PEG tube. She was laying in a puddle of blood.

We stuck her for a line at least 10 times. The doc made two attempts to put in a central line. He couldn't get it. There was no way to even try for the groin because of her leg contractures, and we couldn't straighten her shoulders out enough for a subclavian. Her H&H was in the basement. Her vitals sucked. She was trying to die.

She doesn't have a DNR. In almost three years of taking care of her, I've never seen a family member. But she doesn't have a DNR. So we kept doing everything that we could.

We were moving her around to clean her up when I spotted a vein on the inside of her arm. Somehow I got an IV into it. I told myself that she really needed pain meds. But that IV was the portal through which all of her lifesaving interventions were pushed.

We shipped her to the Real Hospital in the Big City. I watched the obituaries for months. I never saw her name. But I didn't see her in our ER (or ED, if you're WhiteCoat), either.

She came in tonight.

Her bedsores are bigger.

Her contractures are tighter.

She has two 100 mcg Fentanyl patches on. She is still moaning. And awake.

She didn't aspirate this time.

Now she has a necrotic foot.

After I took her upstairs, I cried in the elevator all the way back down. And all the way back to the ER (or ED if you're WhiteCoat).

I wish that I hadn't gotten that IV.

The guilt is crushing.

32 comments:

LadyBugCrossing said...

It is sad...
It is sad that her family doesn't care for her.
It is sad that the facility isn't doing their job.
It is sad that because of this, she is suffering.
That said, if she was ready to go, there would be nothing you could do to save her.
She just isn't ready. She must be waiting for someone...
The fact that you care - says so much.
xo
LBC

Holly said...

I am so sorry. What a hard hard place to find yourself.

hugs to you

Nurse K said...

or ED, if you're WhiteCoat

*Snort*

In nursing school, I helped to resuscitate a post-whipple for pancreatic ca ARDs patient with minimally-detectable brain activity. I looked for her name in the obits for at least two years afterwards and never saw it. She's probably balled up in a nursing home somewhere on TF with MRSA pressure sores. Sorry, ARDs lady.

sara said...

your post made me cry. after working in the ICU for only a few weeks, i have already cared for several patients who would have possibly been better off if their initial injury had been fatal. i hate to think that way, and give them the best care i can, but it still breaks my heart.

sending you hugs today.

Matt M said...

Thank you for how much you care.

If she had a DNR, would this have included no transfusions? What care could have been withheld under a DNR, in these circumstances?

One of these days I am going to write down how I do not want to live my end days, so that my family will know enough to provide me with a DNR order. One of these days...

Joeymom said...

****HUGS*** You do what you have to do. I like that you speak to her as if she understands you. She probably does- and probably appreciates it.

Anonymous said...

Don't apologize for doing your job. You did what you could to ease her suffering.

It's not your fault that she never took the time to write down her wishes. Probably thought this would never happen to her.

Lots of people who ask that everything be done to save them (or their family member) have no idea what everything actually is.

betty said...

Sorry you had to go through this. So glad it was you and not someone who didn't care. Don't spend your life second guessing your decisions. It will eat you up one small piece at a time. Wish I could give you a hug.

CountyRat said...

I am sorry, MG. I wish I could write something to ease your pain, but that is not possible. If nothing else, you are not suffering alone. Many of us have been there, and know how you feel.

PS: The reality of human suffering causes us to question the existence of a shallow, fairy tail god; an imaginary god. The reality of human compassion, and the fact that we are allowed opportunities to reduce one another's suffering points us to the existence of the true God who exceeds all of our poor attempts to understand, yet still allows us mercy and joy amidst the suffering.

Rogue Medic said...

You were attempting to provide relief for her pain. That is what you do. This is good.

Her pain has been allowed to continue, because of your attempt to ease her pain. This is bad, but it is not your fault. You shouldn't stop trying to help people, that would be worse.

If I were the patient, I would be thankful for your honest attempts to ease my pain. I would also hate all of the sadists who cause me to be tortured.

Family - what kind of family inflicts this kind of pain? Her doctor - you make is clear that even with 2 - 100 mcg fentanyl patches on, no small dose, she is in pain. Staff at the nursing home - some decubiti are unavoidable, but this strongly suggests neglect.

This is nothing but torture. How can the family encourage torture? How can her doctor encourage torture?

Torture is not a sacrament.

You are not the one causing the torture.

WhiteCoat said...

Welcome back to the blogosphere, Big Sis.
I feel your pain with this one. We have several patients just like her.
On another note, I'm going to give you and Nurse K an e-mail smackdown if you keep up this "ER" hooey.

Intubate Em!!! said...

Soon she will be vent dependent, then I will take care of her. I will pray that the family withdraws care, but until then, I will take care of her as best as can with as much compassion as I can give.

That's what we do, even if we know it is wrong.

I know, the guilt is awful.

Anonymous said...

Sometimes the old ways worked better. Around 30 years ago I was a nurse in a small southwestern town. One night I was caring for an elderly lady who was post stroke and nonresponsive. Her family couldn't accept that Mama was going to die, and wanted everything done for her. I was in the room - with the family - when she went into respiratory arrest. She still had a heartbeat. As I very reluctantly picked up the phone to call the code, her doctor entered the room. I quickly and quietly explained the situation to him. He walked over to the bed, listened to her heart and said to the family "She's gone".

The doctor and I never spoke of that night. I've always believed that it was the kindest thing we could have done for the patient.

A couple of years later in a different job, my nursing instinct caused me to call the resident in the middle of the night because someone just didn't seem right. It turned out the patient was just begining to crash, and by the time the doc got there, she was nonresponsive and was shipped off to ICU. She survived two weeks longer in ICU.

I know which way I hope I go.

girlvet said...

the girl is back - yeahhhhh!!

Jamie said...

Your post made me cry. I am so glad to know that there are people like you in the medical field. Your heart for your patients is absolutely wonderful, but don't let it eat you up. You did what you had to so that you could do all that was possible to relieve her pain.

mojitogirl said...

I feel your pain MG. I've made sure my immediate family members get their wishes down in writing and I hope to be around so they are ENFORCED. As for me, I'm seriously considering the over-the-boob twin tattoos "NO" and "CODE" . NO JOKE.

But I'm happy to see you back!!

Jeff said...

Sad. Very sad.

The unwritten part of the story is the SOB down the hall who can't understand why everyone's taking so long to get to his sore throat. So we just pick up the pieces and move on to the next patient.

Ninja Medic said...

I'm a medic, and I work for a hospice. I feel your pain.

I'm sorry. It's not your fault, but I can understand why you'd feel like it is.

911DOC said...
This comment has been removed by the author.
911DOC said...

your objection is the classic atheist objection to the existence of a good God.

if you are interested in looking for answers read cs lewis 'the problem of pain'. it won't make you happy, but i believe he answers this objection the best of anyone i've read.

do not bust yourself up over this. you saved her life, such as it is, and i do not think it at all unlikely that while she may be experiencing pain, that she doesn't experience it like you or i do. cold comfort i know. the family should be forced to come and see her in this state. assholes. cowards.

Mother Jones RN said...

This isn’t your fault. It’s hard to imagine why God allows good people to suffer in unremitting pain, but I believe that everything happens for a reason.

MJ

ERP said...

Ugh. What a sad but all to familiar tale. I had a demented, bedridden, pegged 97 year old two days ago who came in totally septic with pneumonia - no DNR. Thank God a call to the family got us one. He did not last two hours and died relatively peacefully just as the family arrived.

Mercgirl said...

I just want to hold your hand right now. You are such a good person. Thank you for caring. I know it has to be horribly hard, but it means so much that you do.

Angry Nurse said...

I've faced this type of situation far too many times so trust me when I say I share your angst in this regard.

Respectfully though I have to submit that God doesn't do these things, society at large does!

Society still has not figured out that quantity and quality of life are not equal measures of value and one does not necessarily mean the other.

I spend lots of time wondering how Society manages to ignore its own hypocrisy as it screams about the right to life almost as loudly as it endlessly complains about how much people cost to care for when they're chronically ill or dying.

That said even the Nuremburg defense (I was just following orders, or in this case so called standards) rings hollow in my ears.

In more theistic days I often wondered if I would go to hell for the things I had done to the elderly and infirmed with no one ever stopping to ask if this is what they really wanted.

Will the “right to die” ever be as important as the “right to life”?

I suspect that someday this issue will be decided once and for all, but sadly I also suspect it will not be because it’s the right or wrong thing to do, but because it’s economically more viable.

So much for society being civilized!

Lynn said...

A hospice nurse here--I often look at patients like this and ask them (in my thoughts) what took you so long to come to me.
It is a societal problem. The woman could have made decisions in writing when she was still of sound mind. Her family could make these decisions now. The nursing home could get the state guardian involved if the family did not take interest.
You, in your time with her, saw her as a person and made a human connection.
(She probably is too thin for the Fentanyl patches to work--they should move to MS Contin rectally or a SQ morphine button.)
I filled out my advanced directives at age 45. I can't get my mother at nearly 80 to do so.

Anonymous said...

St. Thomas More, in prison, waiting to be executed:

....let us remember Christ's painful agony, that he himself would for our comfort suffer before his passion... And then need we never doubt but that he shall either keep us from the painful death, or else strengthen us in it so that he shall bring us to heaven by it. And then doth he much more for us than if he kept us from it. For God did more for poor Lazarus, in helping him patiently to die for hunger at the rich
man's door, than if he had brought to him at the door all the rich
glutton's dinner. So, though he be gracious to a man whom he
delivereth out of painful trouble, yet doth he much more for a man if, through right painful death, he deliver him from this wretched world into eternal bliss.

Anonymous said...

Does your hospital have an ethics committee? Since she is seen in the ER on repeated occasions, and is admitted, that might be a resource for raising these concerns and "engaging" the family. Also,what protections exist for nursing home residents in your state - clearly they aren't working for her now, but perhaps you could (anonymously, perhaps?) contact the state agency responsible for residents' rights in nursing homes and get them on the case. In Massachusetts the nursing home ombudsman's program is under the control of the department of public health, the same state agency that surveys nursing homes for compliance with state regulations. There are federal regs. that mandate that every state have some form of protection of residents' rights, I believe. I know how much these situations hurt, and can only encourage you to take the hurt and anger and turn it to advocacy action for this lady, and others who are so vulnerable.

Anonymous said...

re: "Does your hospital have an ethics committee?"

In general, ethic committee's are worthless when decsions need to be made.

Rogue Medic said...

Anonymous said...

"In general, ethic committee's are worthless when decsions need to be made."

Isn't that true of all committees? They are used to delay a decision to the point that people either give up or water whatever-it-is down to the point of it being ineffective.

Committees are the antidote to initiative.

Jim said...

I hope a lot that people will take your compassion for others as an example of how they should behave.

Kimberly said...

I understand where you're coming from. I work in an LTAC ICU and 90% of our patients are like this. I've become numb to it. I have to... because I found myself depressed after a while and had to do something about it.

We do what we can, take care of the patient and try to educate the family.

Kimberly said...

I understand where you're coming from. I work in an LTAC ICU and 90% of our patients are like this. I've become numb to it. I have to... because I found myself depressed after a while and had to do something about it.

We do what we can, take care of the patient and try to educate the family.