Examplars
Critical nursing incidents where you made the difference
Helen Calabretto
School of Nursing, University of South Australia, SA
PP: 094 - 096
Article Text
Lessons from a dying client
Gaynor Keenihan RN BN
The experiences related here gave me insight into the special needs of a client learning to relate to death. The understanding and knowledge I gained from this relationship have had a lasting impression on me and continue to influence the way in which I approach other clients in the end stages of living.
I have worked with many terminal care clients throughout my nursing career. I met Kead (the client's nickname is used throughout), when I was doing a stint on an oncology ward during a hectic phase of my life. It was a time of personal questioning and searching. I thought I had death all sorted out, and I was fairly comfortable with the steps of the process that I had witnessed as clients and families struggled to come to terms with the limits which life imposes on us. I am grateful to Kead for straightening me out. He didn't have family or friends with whom to share his deeper feelings and consequently all the staff were very aware of his need to explore and talk. We made every effort to get him through the stages, and would spend entire team meetings debating which stage he was in and rationalizing our opinions. Some members would not only become fixated on the stages of the process, but also on the idea that clients should progress through them in a logical, sequential manner. We had great models to work with, and no reason to suspect that there would be exceptions to the rule. Most clients did fit the framework in terms of their progress towards acceptance of death.
Kead knew a fair bit about dying and was learning each day about the reality of its parameters. He would have convoluted discussions with the staff about everything. A favourite theme was to turn theories upside down. 'What if we're on the base of the evolutionary pyramid, instead of the insects?' 'Do you think human beings learn to feel pain?' He challenged everything and everyone, all the time. There was a sense of stillness and a yearning in him that I hadn't seen other people express in quite the same way. Kead rarely discussed or acknowledged his physical deterioration, but negotiated all his care, read everything about his condition and treatments and asked challenging questions.
The staff had quietly come to a consensus about the 'inappropriate' behaviours which Kead continued to exhibit. He was referred to as a 'bad' patient, and sometimes treated differently by the staff who accepted this categorization. He would question and challenge staff and make them feel uncomfortable about the 'care' they gave, when he perceived coldness or detachment or delays in answering his call-bell. We now recognize the rights of the individual and the need to explore all client issues, however, in the time and place I write about these were radical and threatening ideas.
I was inspired by Kead's energy, and I loved his expression of life. We had a trusting nurse-client relationship throughout his final days. Many times I have found myself past Kead's room in case he might call out for something or invite me in for a thought-provoking conversation. The accepted behaviour from nurses was to control emotion in front of clients and others, and to be 'professional' at all times. In the face of this confining model, I did however learn to listen, support, and share my thoughts and tears with a wonderful human being. The time we spent exploring his issues and concerns was unique because he would never hesitate to express himself in honest terms, and I learnt to do the same. When Kead died the staff went into a kind of collective grief, and I think we felt devastated because I had stepped beyond the limits of my role and become attached to a 'patient'. I grieved for a long time, even though I knew I had done nothing wrong.
Time helped me to see the experiences with Kead in a new light; the parameters of the models we use changed, the role of the nurse evolved, identification of clients' rights and individuality became high art forms in nursing care. Things still change. My work with clients who are dying has developed and evolved as I strive to connect to others with an honest, empathic approach.
I am very grateful to Kead for teaching me his steps and for letting me walk with him for a time.
My expression of nursing changed forever, when I walked into his room and talked with him all those years ago.
Night shift in ICU
Pamela van der Riet RN ICU/CCU Cert DipEd(Nsg) DipRemedMass BA Med
I am rung at 8.15 pm and asked to do a night shift in the intensive care unit. I'm not that keen. Don't they know I've already worked a shift this week and I have my usual lecturing job, plus a family to look after? I also have a dissertation to complete. However, I'm the third person they have rung tonight, and it is really busy in ICU with five patients, so I agree to work.
11.30 pm: Driving to work it is freezing cold and it is sleeting and raining. I wish I was home in my warm bed. As I walk from the car park of the hospital I look up and see the lights on in ICU and think to myself 'They are busy'. I receive handover and am allocated Mr D. The evening nurse in charge of the unit suggests I look after Mr D as 'Everyone has to have their turn of looking after this difficult patient'. He has cardiac failure and has been in the unit for over three weeks. I now remember him from two weeks ago when I last worked a shift in ICU. He was on the buzzer literally every 10 minutes and calling out 'Ice, nurse', 'Bottle, nurse'. My thought is one of 'Oh well, this patient will keep me busy'. I ask, 'Is he for resuscitation?' The reply is 'No, he isn't and it is documented in the notes'. I also ask 'Is his wife aware?' The reply is 'Yes, and she left not long ago'.
11.00 pm-1.00 am: Mr D rings only four times, and I think 'He is unusually quiet, perhaps he will go tonight'. During this time I'm busy with other patients checking observations and intercostal catheters, giving intravenous medications, doing pressure area care and totalling fluid balance charts. I change Mr D's dopamine infusion line since the evening staff ran out of time to do this. I also wash his back and change his position. I note that he is slightly incontinent of faeces.
1.00 a.m.: Mr D rings his buzzer. 'Are you okay I ask?' His voice is very faint as he replies 'No, will you stay with me?' 'Of course', I gently reply. I look at the monitor and note that it corresponds with my gut feeling that he may not make the night. His blood pressure is low and his breathing is erratic. My thought is 'No one should die alone'. I sit with Mr D for over an hour, stroking his head and hands until he settles.
5.40 am: I attend to Mr D's pressure area care. His breathing is laboured, his blood pressure is still very low at 84/38 and he is no longer rousable. I ring his wife and tell her that her husband's condition has deteriorated. I apologise for waking her at this hour. Five minutes before Mrs D arrives, the RMO decides to increase the dopamine infusion. I am annoyed at this added intervention, however I didn't take the phone order. Mr D's wife, a very dignified woman, arrives. She says 'He is not conscious sister. What do I do?' I reply 'Just hold his hand and talk to him'. I make her a cup of tea. She responds 'His hands are so cold and he keeps pushing me away'. I start to load the new dopamine infusion and the male patient next to Mr D wants a pan. He has had a pulmonary embolus, is heparinized and weighs 80 kg. As we lift him onto the pan his intravenous line falls out. His Lv. site starts to bleed.
Mr D's wife is concerned that her husband is not getting any oxygen as 'the bottle is empty'. I explain that it is just the humidifier that requires filling and that I will fix it shortly. I check the dopamine rate with another nurse. The theatre staff want the CSSD keys and I haven't a clue where they are. I load the intravenous pump with the new infusion and alter the rate. Several minutes later the alarm goes off telling me there is a problem with the door in the machine. I check this and it seems okay. Two minutes later the alarm goes off again. I start to feel a bit frantic and ask for help. Mrs 0 tells me that when the same problem occurred the other night, the nurse taped the door shut. I now see why it is taped shut, but it is still alarming. Nurse S stretches the tubing and says 'This often works'. It does work and I am grateful for her help. At this stage I am thinking how ridiculous all this is, since this man is not for resuscitation and the situation is only prolonging everyone's distress.
6.45 am: The morning staff arrive and I give my handover about Mr D I am almost finished when I am interrupted by his wife who comes in crying and asks, 'Could you please come and sit with us? I just don't know what to do'. I find Mr D is Cheyne-Stokes breathing, his colour is mottled and grey. His monitor shows an idioventricular rhythm. Both of us cry and watch while he dies: somehow in that moment I re-experience all the pain in my own life and my unspoken grief is shared with his wife. I have one hand stroking the patient and one stroking his wife. It isn't particularly pleasant as Mr D seems to try and fight the inevitability of his death. He vomits and seems to gasp for breath to the very end. I suction him gently so that his death is dignified for them both. His wife says 'Do you think he can hear us?' I reply 'Perhaps, I am not sure'. After 10 minutes of what seems like an eternity, Mr D is dead. His wife says, 'I can't take any more of this'. I take her to the relatives' room and we are joined by other members of the nursing staff. They all give her a hug. Nurse R gives me a hug and I appreciate this comfort as I am also feeling rather fragile. I complete my paper work and leave the unit feeling physically and mentally exhausted.
7.45 am: I arrive home and my husband comments 'God, don't you look awful!'. I explain that I've just had a death, an older patient with cardiac failure, and that it wasn't very pleasant. My 8-year-old strokes my face and I appreciate her comfort. I ask for my son's calculator to check the dopamine infusion rate. I am worried that perhaps in my tiredness I have miscalculated the dose. I find that I haven't miscalculated the dose and am relieved. I instruct my husband to wake me later. I fall into bed exhausted and am woken by my husband at 11.30 a.m. 'It's time to get up'. He opens the curtains and says 'That could be us one day!' I reply 'I know!'
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