comfort care

i've mentioned this before, but did you know?  nursing is a strange profession!

on wednesday, i arrived at work.  my patient assignment included a 43 year old, heavily tattooed man whom i had admitted on monday.  and a 69 year old woman on comfort care, dying of pancreatic cancer.

to top it off, i also had a nursing student assigned to work with me; she is sweet and religious and competent, but in a shy, nervous way.  she lost her dad in 2006 to cancer at my hospital (which likely prompted her interest in nursing).  and wednesday was her last day on my unit, her last day of clinicals while in nursing school; in fact, she graduates TODAY!  it would have been nice to help her end her nursing student career in a FUN, HAPPY, POSITIVE way.  but instead, i anticipated and warned her that we would likely see a woman die on our shift, that we would complete post-mortem care, and zip a once-living-loving woman in a body bag...

i haven't cared for someone on comfort care in a LONG while.  which, in some way, is too bad considering i think i'd still like to be a hospice nurse some day (and could use the experience).  and considering how many people die on my unit, you'd think more people would be on comfort care.  but sadly, people die suddenly on our unit, with codes, and CPR, and everything but peace and quiet.

anyhoo, i was not surprised to hear that my patient was on a morphine drip; but i was surprised to hear that she was on 40mg an hour.  that is a HUGE dose.  enough to sedate, if not kill, a large elephant.  not surprisingly, when i assessed her in the AM, her respiratory rate was 4 breaths per minute.  my nursing judgement told me from that and from her cool, mottled skin that she was nearing death.

BUT...  the plan of the day shifted when her team of physicians approached me and asked in a rather gruff, concerned way, "how did we get to 40mg of morphine per hour from the 2mg we started on just yesterday afternoon?"  let me explain.  nurses have the authority, based on an algorithm, to titrate drip rates to patients' comfort.  if a patient is in pain, nurses can give a bolus and increase the drip rate at increments.  but there had been NO documentation of the patient's pain; in fact the previous nurse charted that the patient was calm and comfortable.  it seemed that the nurse prior to me increased the drip rate rather willy-nilly, perhaps expediting the patient's death - which is ILLEGAL.

so, for the first time (and hopefully the last) in my nursing career, i was asked to decrease the rate of the morphine drip.  in essence, to reverse the comfort care orders.  to possibly wake a woman peacefully dying and perhaps cause her pain.

i hated the idea.  and told the team this.  i agreed that perhaps the way in which her morphine drip was handled the day before was inappropriate.  but the fact of the matter is, it hadn't killed her.  and now, she was comfortable.  and i didn't want to play any part in changing that.

after much discussion with one of my managers, and further discussion with her provider, i turned the drip down.  i monitored my patient more closely, with peace of mind, knowing full well that if my patient showed the slightest bit of discomfort, i had the authority, based on MD orders, to bolus the patient with morphine and increase her continuous pain medication.  thankfully, the patient remained calm. comatose. obtunded.  and to my surprise, almost horror, the patient survived my entire 12 hour shift.

and yesterday's.

it's strange to want a person to die.  to hope that the two breaths i counted in one minute were someone's very last two breaths.  but at the same time, it's hard to see a woman, barely clinging to life, hang on.