A first time for everything

I went to work Monday night hoping for an easy night...and I sort of got my wish fulfilled.  Physically - it was a very easy night.  Emotionally - well, that's another story.  I started out the night with only two patients & only got one admit...two of which were med/surg status, which "usually" means they aren't as guarded or critical as PCU patients.  Unfortunately for one of my patient's..."usually" wasn't accurate that night.

To quote the patient's doctor..."I don't think he'll make it through the night."  Huh?  That doesn't sound good.  Don't say stuff like that.  I've had plenty of sick patients...even some that have gone on to die...but never have I had one in which the doctor was predicting the amount of hours he had left.  This gentleman was in his mid-70's & had suffered a CVA (stroke).  I was reading back through the nursing notes since he had been in the hospital for nearly a week.  He came in agitated, swearing, pulling out his NG tube...he had to be restrained.  By the time I got him, he was non-responsive, couldn't even open his eyes...I don't know if he even knew anyone was there with him.  His wife and daughter were at bedside, I could tell they had been crying...a lot.  I would be too if that was my dad.  The doctor had discussed with them quite a few times over the past week about this patient's grave prognosis.  They were in denial, hoping for a miracle.  I can't blame them.  I'd be doing the same.  Hospice had been consulted twice, the family just wasn't ready to give in & let go.  He had seemed content, non-responsive, but content...until the day he was my patient.  During the day he had difficulty breathing, his oxygen was increased from 3 liters to 5 liters.  It helped his O2 sat (98%), but it did not change the agonal breathing pattern he had developed.  I don't believe I've ever had a patient with agonal breathing...it's something I won't soon forget.  Basically, he looked like he was trying his best to breathe...sometimes it would be multiple, shallow respirations mixed in with this slower, somewhat gasping noise...I can't even really describe it.  If that isn't enough to convince his family that it's time to get out of denial & start making decisions, I don't know what is.  I hope that doesn't sound mean...cause I'm not brutal like that.  I really felt for them & tried to provide them with answers to their questions...but there comes a time when you have to look at his condition & see that what he needs is medication to ease the pain while at the same time, stopping other medications that are not necessary (IV fluids, tube feedings...things that are just overloading his already tired out body). 

The wife kept asking me to give him medication to help him breathe easier...I tried to explain to her that there was nothing we could give him to improve his breathing pattern.  At this point, all we can do is provide comfort care.  She asked what was available on his medication sheet...all I had to relax him was Ativan IV.  I gave him 2 mg and did not see any difference in him, although his wife swears he seemed more relaxed.  The breathing was no different.  She began to ask me about hospice...what do they do to make him more comfortable?  Not realizing she had already had two consults in the past week with Hospice nurses...I told her more than likely he would probably receive morphine.  I truly didn't know the answers though other than knowing they do provide medication to ease suffering.  I've never had a patient that needed hospice.  So rather than continuing to guess, I brought in my clinical leader since she was an experienced ICU nurse also.  She pretty much said the same stuff I did.  It was then that we discovered that the wife knew exactly what Hospice would provide & it was the same information we were giving her.  Later, my clinical leader told me that the wife was probably hoping for a different answer...some type of hope.  It breaks my heart.  The wife then asks if I can get the doctor to order morphine for her husband.  We got the order as well as an order to turn off the fluids for the night.  He was already having a difficult time breathing & he's a dialysis patient, no reason to overload him with fluids.  I alternated through the night of giving him Morphine & Ativan.  I could see that he was more relaxed, his breathing didn't appear so labored, he wasn't making those grunting noises that he had been making earlier.  His wife told me he was all sweaty & she didn't know why.  He didn't have a temperature...I told herhe was sweating because he was having a hard time breathing...his body was working hard to get oxygen. 

His wife wanted to stay the night, which I totally understood...I know if it were my parent or loved one, there is no way anyone is kicking me out of that room simply because they have a "family cannot stay over" rule.  Luckily, our floor was pretty empty (the other bed in the room wasn't occupied) & I got the approval from my clinical leader & the charge nurse.  They weren't happy about it, but I really don't see how anyone would have the heart to go in there & tell her she had to go home because of our stupid rule.  I made sure to find her a recliner & she spent the night at his bedside...holding his hand.  I heard her earlier in the night make a comment to her daughter about how she wished she could lay down next to him.  I was hoping she wouldn't because I know that wouldn't go over too well, but at the same time...I could understand why she would want to. 

She got up around 5:30 am as I was hanging an antibiotic IV.  She told me she was going to go home for a few hours...that this is the time of day when she usually would get out of bed & leave him to sleep a little longer.  She smiled, but I can't imagine the pain she's feeling.  I tried to clean him up the best I could, straightened up the room, put the flowers he had received on display so you saw them when you walked into the room.  The respiratory therapist came in to give him a breathing treatment...it was then when we discoved his O2 sat was only 77%...most likely a combination of him getting tired out with that labored breathing and the medications relaxing him...especially Morphine - one side effect is that it can decrease respirations.  The respiratory therapist decided he needed a non-rebreather mask...she started him out at 35% & predicted that by noon it would have to be up to 100%.  He didn't have much time left.  I stood & watched him for a little while...when that mask was put on him, he began those grunting noises again...like he was gasping for air. 

A first time for everything & I'm sure it won't be my last.  I haven't stopped thinking about him since I left work.  During my workout, before falling asleep, upon waking up & through the night...I kept wondering if he was still alive.  I haven't decided if I'm going to work tonight or not...I'll decide later.  For now, I'm gonna go do my 60 min work out again & be thankful that I have a choice when it comes to labored breathing...unfortunately, my patient does not.  :(