Life Death and Other Matters of Consequence: Part I

I've been a nurse for a long time, but I still can't wrap my mind around people who consider their own needs before those of their frail, elderly loved ones, especially when the loved one in question is clearly in physical, emotional, and/or spiritual distress due to a terminal condition. And while it can be said that life itself IS a terminal condition, most folks don't really believe it until they themselves are faced with an end-of-life situation.Letha, for her part, was declining with as much grace and dignity as possible, even if her daughters did refuse to give up the fight. We continued aggressive rehab and treatments, even though there wasn't a single part of her body that wasn't already bruised (thank you Coumadin), disfigured (rheumatoid arthritis), or painful (decubs on the coccyx and left hip, plus several old fractures due to osteoporosis). Through it all, Letha kept her sunny attitude and never resisted care, even when her daughters nagged at her to eat her dinner when she hadn't been able to keep breakfast OR lunch down. One night, though, after I'd received report of yet another bout of nausea and vomiting, I intercepted the daughters as they marched into Letha's room and, seeing her still in bed, began to lecture her about the necessity of getting up for the evening meal. I will never forget the look of gratitude on her face when I finally put my foot down:"No, your mother is NOT getting up for dinner. She has been throwing up all day, and I will not make her get out of bed if she doesn't feel like it," I said, firmly, but kindly. "She is clearly ill, and she needs to rest. I don't think you'd rather have her stay sick longer, and perhaps get dehydrated."Ironically, the daughters seemed to back off a little after this incident. Actually, they did more than back off---in fact, they became rather friendly with me, and even began to ask me for advice on occasion.......in particular when they wanted an honest opinion, rather than sunshine blown up their noses. I still thought they were being selfish in wanting "everything" done for Letha, up to and including a feeding tube and a ventilator along with CPR, but when push came to shove, it wasn't my place to judge what was in another person's heart; and I knew that if the situation ever arose, I would do everything in my power to save Letha. Then, the lesions showed up.Just a couple of scabby-looking growths on the scalp, barely noticeable at first, but within weeks they had turned black and red, grown to the size of quarters, and were threatening to spread further. The daughters conferred, and the son---a lone voice of dissent who had long since understood that he was outnumbered---agreed that the lesions needed to be biopsied. A tiny pilot light of dread sprang to life beneath my usual calm demeanor; instinctively, I sensed that the outpatient procedure was a terrible idea, and that it would be far better for all concerned for Letha to go on hospice and be kept comfortable instead. What was the family planning to do if the lesions were cancerous, as we all believed them to be? Make her go through chemotherapy? Radiation? More surgery? At NINETY?!Letha, herself, seemed resigned to whatever fate had in store for her. "I'm tired, and I'd just as soon go home and be with Henry (her long-dead husband). But Judy, she and the others make those decisions, and I just stay out of it. I know they do it because they love me."The day after the melanomas were removed, I saw on the 24-hour report sheet that Letha had had a low-grade temp on day shift, but no other concerns were noted, and nothing had been said in report. I normally didn't go in to see her until around 1700 to do her fingerstick, but just as I was preparing to go check on her, two of the CNAs came tearing up the hall to the nurses' station to report that she was minimally responsive and had a fever of 101.6 degrees Fahrenheit. I ran in to assess her and felt my heart drop like a stone: she was in septic shock!Now, having worked ICU more than a time or two, I've seen firsthand how fast such an illness can overwhelm even the relatively young and healthy. Letha was old and frail, and she wasn't going to make it if she didn't get to the hospital, STAT. I never hesitated. As much as I would have wished for Letha to be allowed to slip away quickly and quietly, it wasn't my choice to make, so I called 911. I called the primary care physician. Then I called her family. It was the right decision. No more than ten minutes elapsed from the moment I'd walked into the room until the EMTs bundled her into the ambulance, but her BP was already down to 70/30 and she was no longer responsive even to painful stimuli. I thanked my aides profusely for their quick action and made a mental note to mention their contributions in an Above and Beyond slip on the employee bulletin board; then I went back to my usual duties, more or less certain that we'd seen the last of our sweet Letha, and whispered a short prayer that all would be well with her, regardless of the outcome.~Continued~

After Letha went to the hospital with lights flashing and sirens screaming, life back at the nursing home rapidly returned to normal. As the days passed with no word from either the hospital or the family, and no obituary announcing her passing, we all began to think she might have survived the sepsis after all, that she might even come back to us. Eventually, the good news came down that she had, indeed, successfully fought off the sepsis, as well as a nasty case of pneumonia AND a STEMI, and she would be coming home as soon as the IV antibiotics were finished.The bad news was, the family now understood that this was probably the end. Though Letha had won the skirmish with death, it had weakened her to a point where she was clearly losing the war, and as the tough-minded oldest daughter, Judy, told our admissions director: "We've got to think about what's best for Mom now."Hearing this second-hand, I began to question the actions I'd taken and the decisions I'd made on that fateful afternoon when Letha crashed. What had we 'saved' her for? I asked myself over and over. So she could suffer even more? So she could have another week, or two, or ten, of being sick and miserable? Of having no control over her life or even her surroundings? She would have been gone within a matter of hours if I hadn't intervened.........but I'd done what I was supposed to do, what I knew I had to do, and now we all had to live with it.I looked in on her every day after she returned, despite the fact that she was on a different unit and the daughter who was staying in the hospice room with her, Annie, was very cold to me during my visits. I thought she blamed me for everything that had happened since that day, and as the days passed into weeks, I felt more and more guilty. I'd sneak into the room and look at Letha's pale, shrunken face and think maybe I'd been wrong about her. Could it be that she was taking so long to die because SHE didn't want to be dead, not because the family was having such a hard time letting her go? Her daughters had always said she was a fighter.......The end came quietly yesterday afternoon, after almost five weeks of shallow, rapid breathing, bouts of agitation, the fever that nothing could break. Again, I wondered what it had all been for---I was glad Letha was out of her pain and felt relief for the family, but why had it been necessary for her to go through so many days of torment? The answer---as so rarely happens in real life---turned out to be as close as the oldest daughter, Judy, who had come to our nurses' station to let us all know that Letha's struggle was over at last, and to offer thanks for the care we'd given her. "You were the nurse who sent her to the hospital that day, weren't you?" she inquired, as much of herself as of me (having been orphaned many years ago, I know how difficult it is to keep time and people in perspective for awhile after such a profound loss).Oh, dear God, I thought, now it's coming. But what she said next still gives me goosebumps:"I wanted to thank you for what you did for Mom. As you know, we've all had a terrible time facing the fact that her time was coming, and even though we knew we had to, we just couldn't bear to let her go. Because you acted so quickly when things went wrong, we were given the extra time we needed to be ready to let go. We will never forget that."Then she hugged me, brushed a tear from her face, and walked out the door into the autumn afternoon, where red-and-gold leaves swirled madly as if in a rush to enjoy the last of their own glory before dying.

I love your last sentence. Incredibly evocative. As was the whole story, but that conclusion is powerful

So many times we question our actions, but always try to do what is best for the patient and family. I am working with a family now helping them make a decision about removing their mom from the vent. They have realized that she did not want to be on life support and they have been trying to keep her here for themselves, so she will be coming off on Friday. The docs would have wanted to do it sooner but the family was not ready so we had to sit doen with the doc and discuss everything and once he understood their reason for waiting until Friday, everyone was on the same page. I digress. Your story was so beautiful and loved your last line. :redpinkhe

Threads merged for continuity

Girl, you are some kind of writer. Get that book out!

Thank you. This story will be part of it, if and when I ever get it finished.Mercy, how perspective changes when you're older and have begun to figure out what really matters. So much of what we think is important in nursing, like perfect care plans and the 'right' treatments, doesn't mean squat when you're dealing with a precious individual person, a human being unlike any other who has ever existed or ever will exist. Sadly, we tend to forget that in our rush to get things done, finish the paperwork, tie up all the loose ends so we can keep our butts out of a sling and our facilities out of trouble with the State. I got pulled in yesterday during an investigation of an incident that occurred on my shift some months ago when a CNA didn't follow a care plan and a resident was injured, and I'm telling you, I was sweating bullets. No, I personally didn't cause the injury, nor would I have countenanced the CNA's not following the care plan if I'd known about it; but I was the shift supervisor and therefore bear some of the responsibility. The thing is, I'm not so upset about the legalities---we (the facility) were clearly in the wrong, there's no defense for that, and I feel very fortunate that both my job and my license are secure. What I feel TERRIBLE about is the pain and suffering the resident has experienced as a result of the injury, and you can be sure I'm going to supervise my staff more closely in the performance of their duties........not because I'm afraid of getting in trouble, but because I love my residents and I never want sloppy care to endanger them again. Not on my watch!

Loved your story-especially the line about the autumn leaves.You REALLY have the knack for turning a memorable phrase... Your subject is the most frustrating aspect of my job in LTC-we actually were cited a few years ago and the DOH determined that "We are obligated to consider the resident's needs ahead of family's demands"

Now I'm sitting here crying. Sometimes, I think half of this job is getting the families to the point where they realize there's something worse than Mom or Dad dying.Hugs to you for being the voice of the voiceless.:icon_hug:

Quote from ktwlpnLoved your story-especially the line about the autumn leaves.You REALLY have the knack for turning a memorable phrase... Your subject is the most frustrating aspect of my job in LTC-we actually were cited a few years ago and the DOH determined that "We are obligated to consider the resident's needs ahead of family's demands"

Marla ......... I think we're twins separated at birth!

I wish that in some way that would be PC so not to "offend" anyone this message would be posted in each LTC brouchure!! NOTHING and I mean NOTHING tears out your heart more that having someone say " I wish they would let me go ". I have seen this countless times over the years and because of this I don't believe as a society America is ready for health care reform. We don't want to make hard decisions. I have taken care of 2 cases of vegative state pts as a result of car accidents. No real responses to any environmental factors. Bodies falling apart and systems failing and listed as full codes by the family. One like this for 12 years and the other for 2 years. And we the tax payers are paying for it. Viva you hit the nail on the head!