Fine Line, Three Things

how comfortable are you with . . . . . . being an agent of death? with being the one to push that last bit of morphine and ativan to send someone onwards from this life?

i'm still working on that issue.

one of the nurses i work with was telling me about a time that he, as we say, 'pushed' the death dose, and it has stuck with him ever since. even years later it hard for him to administer the big 'comfort care' doses that are usually prescribed for end-of-life situations.

there are three things that we do at the 'ospital.

thing one that we do; everything we can. if your heart starts to go, we can hit you with drugs, drips, and electricity. and cardiologists, cardiology hospitalists, or heart surgeons/thoracic surgeons. we can give you meds to keep your heart steady, increase its contractility, keep your blood pressure low or high. if your kidneys fail, we gots nephrologists, we can give you meds for high potassium, clean your blood with dialysis machines, and replace your electrolytes. we try to prevent clots. if your throw a clot anyways, we can pull it out or try to dissolve it with TPA. if you have infection we have some pretty big-time antibiotics. if you are bleeding we can stick tubes with video cameras and grabbers down your throat or up your pooper pipe. we can make you swallow a 'pill-camera' that will take pictures of your whole GI system, transmit it to a receptor on your belt. wow. there are LOTS of things that we can do to prevent death, turn back illness.

and unless you tell us otherwise, we do all this and more. to and for everybody. that's the baseline.

thing two that we do, is almost the same as the above, except for DNR/DNI. those letters stand for 'do not resuscitate,' and 'do not intubate.' which means, like i said, we do all of the things above (and more, by no means was that an exhaustive list of all the things we can do), EXCEPT FOR breathing for you (DNI) and doing chest compressions (DNR) on you, should your heart/lungs just up and quit.

the last thing that we do is comfort care. it's pretty simple-we just do stuff to make you comfortable. this is reserved for people who have reached the end of the medical rope, so to speak. people who have no chance of recovery, or who are too frail/weak/broken/old to survive whatever procedures we have left that might 'prolong life.' for some people, that means withdrawing support. if you are already on a ventilator and can no longer breathe on your own, removing ventilator support will send you on your merry way very quickly. those decisions are not mine to make or to carry out. first of all, i work nights. decisions like that are for day-time awake doctors and social workers and family members. occasionally, support will be withdrawn and the patient will last a little while, like into night shift. my turf.

it happened to me one night. the room was full of family, and the patient had no chance for a recovery. the patient had ackshully been undergoing some kind of treatment and not tolerated it well. it was then discovered that instead of being checked, the disease process had advanced considerably past the point of expectation for a reasonable recovery. by the time the patient got to us, he was in pretty bad shape. losing pressures, heart arrythmias, things we recognized as Circling the Drain. the family recognized this and, in accordance with the patients' previously expressed wishes, it was decided to withdraw the care we were ready to provide.

one family member did have a special request. he sat at the patients bedside, held his hand and told him that he just had to hang on for a little bit longer, because the family needed to gather to say a proper good-bye. now, this was a patient that was so far gone, he had not responded to painful stimuli of any kind for a while. we weren't sure he was even still 'in there,' if you know what i mean. however, when his nephew made his request, a funny thing happened......

the patient's blood pressures stabilized. his heart quit doin' funny things. and his breathing settled down.

it was amazing.

he stayed that way, too, until the next night shift. when he did die, he was in the room surrounded by tons of loving, grieving family members.

here's where it gets tricky. before he died he started to breathe funny. not unexpected, but disturbing for sure to the family in the room. and struggling for air. and rattling in his throat.

comfort care means making the patient comfortable. in this case, we had large doses of morphine and ativan ordered. morphine is a narcotic, and ativan is a benzo. together, they have a synergistic effect, increasing the others power. morphine, by itself, depresses your drive to breath. combined with ativan........it is very effective. basically it stops you from breathing. you s-l-o-w-l-y breathe slower, and then, you don't breathe at all.

the patient had some family members in the room that were in the medical profession, and i felt doubly awkward walking in to the room with enough morphine and ativan to, essentially, stop this man's breathing. worse, the patients spouse asked me what i was giving the patient as i was giving it.

well, this is to make the patient more comfortable.........

sure enough, the patient slowly, quietly died a few minutes later. stopped breathing funny first, though.

now, cause of death was not listed as 'Nurse J.'

i didn't kill him, the cancer did.

at least that's what i keep telling myself.................

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our hospital has tons of crap on the walls about 'mission statements' and catchphrases to remind us to be better nurses.

it is all a bunch of crap.

i don't have any of the cute sayings mesmerized, nor could i repeat any of them to you. i'm a good nurse (or trying to be) because i want to be. i come to work everyday with the expectation that my patients deserve the best care possible, as if they were my family. if that was my uncle/brother/sister/wife/aunt what have you, how would i want them treated? keeps it real simple for me. it works too, because everybody has difficult family members. have a patient that's a lying sneaking thieving drug addict? hey, so's my dear old Uncle Bobby, i'll just pretend that's my patient and care for him like family. have a fat, outta shape patient that poorly manages their diabetes and is in the hospital every other month in DKA? hello Cousin Jodi! and so on and so forth.

plus, i am invested. this is a career, not merely a job. i care about my success, and the success and well being of my co-workers and my hospital in general. that is how i operate. i smile because i'm a smiley happy guy dammit, and if smiling is appropriate, i'll smile because i want to, not because i saw it on some silly poster of five things to do every shift in all my 'patient interactions.'

which brings me back to my original question. how do i feel about being the one to push those last deadly doses? if that really was my mother/brother/aunt, would i want this same care?

now, cause of death was not listed as 'Nurse J.

i didn't kill him, the cancer did.

at least that's what i keep telling myself.................................