A month since I met Resident XX he was not eating. Handed over to me was the fact that Mr. XX had in his healthier age wished that in the event of deterioration he is not to be prompted nor be subjected to intervention that would prolong his life. At one stage when I was only starting to care for Mr XX, I found a bowl of pudding on his tray – I pointed out to him how he was not eating. He replied he was on diet. I told him, it is not too much it is okay and I fed him and he ate everything. I shared the thing about motivating the resident to eat unfortunately after the family meeting it was agreed that the resident is not to be shown nor offered food. The resident was to be asked if he wanted to eat but should be allowed to say no which he consistently did.
In one of the doctor’s visit, a can of thickener was found in Mr XX’s room. It was pointed out that the product is to be taken out of the room as it contained calories and was against the wish of the resident. Everyday Resident XX deteriorated to his fate.
My week starts on a Friday and goes straight to Tuesday. When I did my shift that Friday Mr. XX was definitely frail after prolong starvation. His voice was deep and faint and was speaking intelligibly. He held my hand and struggled to say – “I want to keep going help me”. I was for a moments caught at a loss for words to say anyway I asked him, are you hungry? do you want food? He said, no.
At medication round I noted the resident was increasingly having difficulty sucking water with the straw. He liked cold water though and would always say “thank you that was lovely”. I shared my observation to the other Nurses. At our discretion we can withhold oral medication for some reasons but the doctor has to decide the appropriate route and form of the drug as substitute.
On Saturday, the wife came to visit. The resident held on her hand struggling to say something. I can tell the wife was in some kind of discomfort not being able to understand what the husband was saying. I stayed for a while but the attention of the resident was more on the wife. I asked if he was in pain – the resident shook his head. I told the wife the resident is saying something maybe only the two of them can make sense. I suggested that she try to figure it out. We were aiming to sit the resident on his chair but decided that he is too exhausted and weak to be left alone. He was in bed for the afternoon with priorities on oral cares and repositioning.
Sunday, Mr. XX was handed over to me as fine but a bit restless. The morning nurse withheld his medication and gave PRN Morphine. Another dose was given shortly before the morning nurse signed off that I had to sign the drug out with him. The resident was mildly restless and weak. By the look of it he was ready to leave mortality but when his own physical body will give up no one knows. The resident was on a gradual decline. At about dinner time the wife came and we were doing our usual routine. My staff went in to do his oral care; I dropped in to check as I passed through giving medication to the neighbouring rooms. Sometime after dinner, while I was assisting a confused resident I heard noise. I went out of the room to check, nothing was happening. It could be just the television at the lounge. Walking along the hallway was Mrs XX who casually said she is ready to go. I replied “fine you take care “and she was gone.
I checked on Mr. XX who was lying on his bed and he was as he has been. I moved to check on the other residents. Of particular watch for me that day was a COPD resident who was increasingly coughing and breathless so with the two hallucinating and wandering clients that usually play up at such time. My staffs went for a break and I was left with a short shift staff. I walked one resident back to her room and tried to convince her to stay in bed. I checked on another resident who at about the same time would start calling out annoying the other residents. I checked the residents who were in bed that they were safe, ensured that room exits and windows were locked. Shortly, my staffs walked back to the floor and were looking shocked and reported Mr XX was not breathing.
I went in to check – Mr. XX was pale and lifeless. He was not responding and was wet. I knew he was dead. Being new to the workplace, I rang the other nurse to make sure that I follow the facility protocol re: deaths. She guided me through, ringing the family, the doctor on-call and went back to the room to wash and clean the resident. I personally took lead in the clean up with the help of my staffs after which they felt alright to finish the aftercare. It was time to do the two of the final medications. I went to the treatment room to take the pill – I met the family on my way out.
I told the wife, I am very sorry. I have washed and cleaned him up. He was not breathing and I cannot feel anything gesturing finality with my hands. The doctor was on her way. The family sounded fine, the son tapped my shoulder and said “that is fine; you did a good job, thank you for that. I walked the family to the room. The resident was pale and lifeless on his bed already cleaned and dressed. The wife moved to touch his face and cried. The son obviously overcame with emotion. I held the wife’s hand told her kindly – I will give you space and will be outside. She agreed and the son looked understandably. I went out while my staff was finishing the clean up.
I went straight to administer my medication. While I was away something I least expected happened. According to my staff the son checked for breathing and pulse and rang someone on the phone. He attempted resuscitation. Panic and confusion ensued in the room. At one stage he ordered my staff to call the nurse and when the staff could not find me she went straight to the next nurse who came with an ambubag. By the time I was out of a resident’s room my HCA urgently pushed me to call the ambulance. Staffs from the adjacent wing flocked at Mr. XX’s room. With an RN in the room I was thinking it was a valid demand and was driven by the urgency of the demand. Surprisingly, the ambulance did not go through the usual questioning and just asked for a staff to meet them at the main entrance to direct them the way. For a moment I was lost and I was thinking the son did not trust my decision and wanted a confirmation. The RN came out and told me that finally the son has accepted that the father is really dead. It was too late to stop the ambulance, the ambulance people was at the hallway with the on-call doctor who I have called earlier.
They proceeded to Mr. XX’s room and therapeutic as the paramedic approached the family they were asked what they wanted. The paramedic heeded to their request. The doctor went out of the room and read the resident’s chart. Mr. XX was not for resuscitation. The doctor confronted the son and an emotional outburst ensued. I was caught demoralized. Personally, I cannot stand shouting. I fully understand how the family specifically the son felt – I know he was the EPOA and that he was fully aware of the Advance Directive which is the major issue but at such emotional state people can be irrational. Some twisted allegation came out of the altercation that added to my demoralized state.
Much as I understood the feelings and actuations of the son; I also understood the point of the doctor. Somehow along the line, there was a better way of saying and doing things. The son was saying “how could you come and question me for my decision, he is my father. How could you be so callous to do that? Can’t you just give me time to settle myself?” The doctor insisted on her role as patient advocate and the legal implication of the document. The son repeatedly accepted his awareness of the contents of the document however he insisted on the human factor contributing to the incident.
Personally I evaluated my own lapses. I told them “I am sorry, I have washed and cleaned him, he is not breathing and I cannot feel any sign of life. The doctor is on her way “. Could it be that the family entertained some hope of reviving the resident? Yet, the family have always known and allowed to let the resident starve to death and they have understood the content of the Advance Directive. Very lately, a MDR has been done for the patient and it was well attended. The order was clear not to show food to the resident – what is there to be expected without nourishment for the body but death.
There was no reason to expect for such anxiety. A couple of days before it happened I have explained to the wife how her husband was deteriorating. I added that without food to nourish the different systems it was bound to fail at certain stage. When the wife was informed that her husband had stopped breaithing she sounded concern but not panicking – she came with her son and they were calm. With due consideration to their privacy I left and everything was seemingly in control. The daughter in law who was an RN came later to apologize to the doctor about her husband’s actuation. The daughter in law however directed her disappointment on me - she repeatedly said “the resident should not have been left to die alone and threatens to put me in trouble - adding end of story.” My mind refused to process what the daughter-in-law was saying. I was too tired and stressed by the incident.
Thoughts of my moments with Mr. XX replayed in my mind. Mr XX was a lovely man. He was obviously an achiever who still talked of his meetings and luncheon. If just to lift him from his depression I once told him – Mr X, you could have been good looking in your youth and how he smiled and replied “you are a sweet person, you are my friend for life “. And the resident in his more lucid times had emphasized “a friend is forever”. As a nurse, it is sometimes inevitable to get personally connected to the residents; think about them even outside the working hours. How I was more excited to motivate the resident back to health but the other side of the issue was his quality of life. As a nurse we tend to accommodate every stress and please everyone as if we do not have the right to be offended and be affected. I refused to argue and simply said, okay!
I dropped in bed when I got home. The argument kept ringing in my ears.
The next day, I went to work an hour earlier. I went straight to the manager’s office. The manager was reading all the documentation on the resident’s chart. She was obviously disturbed. I tried to give a detailed and chronological order of events the best that I could. Everyone seemed to blame me for not saying the word “dead” and I expressed my view of the event. I knew that the incident provided insights to improvements that should be done in the execution of my duty as a nurse but refused to blame myself for what the daughter in law accused me of. My manager understood and offered to provide help to make me feel better. Different versions of the incident scattered around the workplace like wildfire but the best experience I had was when my fellow RNs came to me and said “it is not your fault. Some things can go wrong and offered ways to prevent the incident from recurring. I learned to appreciate the working environment I am in.
It took me weeks to shed the stress off my nerves. Time was when I woke up with my head feeling very light and I could not concentrate. I was obviously getting sick and I rested. Each day as I come to work, I can only gain reassurance from how the remaining residents relate to me. Even find comfort in the meaningless comments of one of our resident who would call out my name to say, “You are very good, you come to save me, you are my hero”. Another resident would ask me how I am doing with my gym work and would tell me how cool I appear. I was gaining strength from the cheeky smile of a resident who was aiming for his glass of wine and his apology every time I tell him off when he goes impatient for his second glass.
I tried to rebuild confidence from the approving smile of a resident for whatever simple reasons they have to feel pleasure. Generally, my rapport with most of the residents and their support system was not too bad and here I was blamed for not being able to witness the resident’s last breath and not being able to say the word dead. One family member did asked me how I could have managed to keep everyone calm when they have witnessed how times can go crazy with residents hallucinating, calling out, wandering and even falling.
The family came back to pick up the personal belongings of the resident. Something in me wanted to reach out to them, to say some words of comfort and see they were alright. I saw the son was trying to justify something to the other nurse. Memories of the night overcame me and I decided to just stay afar. Later I was told that what really triggered the confusion was the son was having the illusion of his father moving. He was talking to my staff who confirmed that she could feel some pulse. Yet despite everything, basing on the previous decisions the family agreed to manage the resident’s plan of care and the Advance Directive the time had come and they have agreed to abide by it. Besides I have told them the doctor was on her way and whatever doubts they must have could have been confirmed by the doctor. I was too tired to confront my Health Care Assistant named by the family. I trusted the management knew what to do and say. Weeks had passed, memories of the incident slowly faded and time and again some nurses give me a funny look as if I have done something ridiculous. I cannot be bothered anymore – we all learn from every experience we get. We meet different types of personality in different circumstances all for our growth and development.
The HCA from another wing approached the RN from the next wing to say: a daughter is on the phone wanting to talk to you and she is on our line. The RN busy with her evening routine had to walk to the next wing to pick the call.
