Wednesday, July 24, 2013

You Tell the Tale: End of Life Dilemmas

Image courtesy of olovedog/

It’s that time again for another You Tell the Tale adventure!  Here’s where your hard earned wisdom and experiences can really make a difference, so please help us make this discussion worthwhile! 

How it works:

Nurseables will start with a fictional account of a difficult nursing situation to get the discussion going.  Then, you write a comment about how you think the tale should end.  Anyone is welcome to write in, even if you don’t have a nursing background.  So write a comment, tell us your thoughts, play the role of the granddaughter, the patient, management, the nurse or a fellow coworker.  Get creative, have fun and let’s learn from each other!

Just a couple of rules to keep in mind:

1.            Be cognizant of HIPPA, do not give any identifying information away in your discussion
2.            Be kind and courteous in your responses

(Disclaimer: This is an entirely fictitious situation and any similarity to the characters or patients is completely coincidental.)

As always, looking forward to hearing your thoughts, suggestions and comments!


                Slowly, Nancy walked up to the nurse’s station and handed the phone to me.  Her beloved father had been struggling with end stage lung cancer and wasn’t doing well.  It’d been a long road through chemo therapy and radiation, but they’d done everything they could to fight off the disease.  It just wasn’t working anymore…

In her I saw the look of a woman just trying to keep it together, to stay strong for the rest of her family that waited at their loved one’s bedside.  Just seeing her sorrow saddened me because I knew the struggle they’d been going through.  I knew because I’d recently lost my own grandmother and had been through the grieving process; it was never easy, no matter how you prepared for it.  Then, Nancy looked up at me, the nurse who’d been by her loved one’s side multiple times throughout the ordeal, and she said, “Ok Nurse Di, we’ve talked it over.  The doctor would like to speak with you now.”

                After receiving orders from the doctor for comfort care and a titrated morphine drip, I prayed that I’d be able to help comfort the family in their time of need.  Their loved one lay in the hospital bed and I was given the precious opportunity to be with them during this time.  I just wanted to help... but a morphine drip?  I knew my patient was at the end of his life, but I’d always heard from nursing rumor that as soon as I hooked up the drip, I’d basically be sending him off to the land beyond without further ado… but, I also had the doctor’s orders and I didn’t want him to suffer.

As I calmly and peacefully worked to set up the morphine, my eyes spoke the words that my lips couldn’t utter, “I understand.”  In nursing, you have to learn that there’s a fine balance between providing compassionate care and getting too involved emotionally.  Someone has to stay level headed and provide sound wisdom when dealing with difficult situations.  It’s just… some things hit very close to home.

Time went by and I checked on them frequently, sometimes providing tissues or a hand of reassurance on their shoulders.  I made sure they knew if there was absolutely anything I could do for them to just let me know, anything at all.  Then, Nancy asked to speak with me in the hallway. 

My heart sank because I had a pretty good idea of where the conversation was going.  Fighting back tears, Nancy calmly looked me in the eyes and said, “All he said when he was more with it was that he didn’t want to suffer…  And Nurse Di, we just really don’t want him to be in pain.  Should we, can we, give him more?”

And there it was, the question I’d been asking myself ever since I’d written down the doctors order for a titrated morphine drip… was I willing to increase the dose?  His respirations were already very slowed, around 7-8 breathes per minute last I checked, and he wasn’t responding to stimuli… but I didn’t want to hasten his death prematurely either.  When I looked at him, the FLACC scale didn’t indicate any distress to me other than maybe just a tiny bit of restlessness every now and then, but then he’d settle right down.  I knew the end was coming and that’s why the doctor had ordered comfort measures, but ethically could I administer the dose that would send the patient over the edge?

You Tell the Tale:

How do you think this story should end?  What should the nurse do next?  Have you ever sat by your loved one’s bedside and wrestled with deciding on the right course of action?  Have you ever struggled with deciding on the right level of medication in an end of life situation?   What did you do?


  1. Got a couple great comments on the Nurseables Google+ page that needed to be shared:

    I'm not a nurse, so she probably shouldn't take my advice, but I'd leave it where it is. Don't want to harm the patient more on accident. +TristanCook

    As an oncology nurse I've been in this situation numerous times and although each time is different my opinion on the right thing to do never changes.

    If my patient is in pain, agitated or nauseous, morphine, midazolam and an anti-emetic will help and it's titrated until each symptom is settled and my patient is comfortable, not dead. As a nurse nothing can justify 'that little bit extra' to help him along the way. Being there, being present, showing you care and MANAGING the symptoms of a dying patient should be all you need to do help your patient and their family through an experience that will stay with them for the rest of their lives.

    On a personal note, this is exactly how my gran died, comfortable, cared for by a veracious nursing team and loved. +Sarah Wetherop

  2. Another comment from Google+:
    There are no words that can be uttered, you responded correctly, I went to church everyday, and made sure that the family was comfortable as they waited for that time. I would give the family space to be with the patient. +Lisa Cristo


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