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Friday, March 4, 2011
A Day at Hospice House - Part Three
My patient in Room 412 is a sweet little man who took himself off of dialysis a week ago. It is unlikely that he will live another week. When I arrive at his bedside to do his assessment, he is having dramatic tremors of both hands and arms. He is been medicated with Ativan every four hours, and he is still restless and agitated, the toxins that should be filtered by his kidneys building up in his system.
I manage to get him assessed, then I visit with his very anxious family, his wife and daughter. I wonder out loud to them if our sweet man is in pain, though he denies having any. Thinking about it, I note that his tremor gets much worse if we touch him - anywhere on his body. I suggest to them that we might want to give him some hydromorhone (Dilaudid), which is ordered for him to receive every three hours for pain.
Back to the med room for an injection for him. He has a subcutaneous infusion site, a soft catheter inserted under the skin around his belly button, and when I return to the room at 10:10, I inject the diluted drug slowly and flush the site. I sit at his side, talking softly with the family, and wait to see how the hydromorphone will affect his pain. Ten minutes pass, and he is asleep. I touch his hand, and it remains still. He is snoring loudly when I leave the room.
(Aside, I love subcutaneous infusion sites. They are much easier on the patient, need to be changed less often than IV sites. There is little chance that the patient will pull it out - a win/win for patient and nurse).
At 10:15, later than usual, I open the electronic charts for all three patients, quickly making notes. The doctor has visited, and I check my charts for new orders. There are none, thank goodness, so I slurp on my cold coffee and go back to see about my man in 406.
I find him still sleeping and spend some time with his family, answering questions and encouraging them. We give all of our families a booklet that explains the dying process, but most of them cannot absorb at first reading. I go over the signs with them and encourage them to go back to the booklet and read it again.
Returning to Room 411 to find my little lady having longer periods of apnea. More family is in the room, a daughter and a son and daughter-in-law. I look at her feet. They are cold and mottled and her legs are cool to the knees. Her nail beds a cyanotic, and she is approaching the end of life. More family is on the way. I sit with them and offer support, trying to field questions like: “How long will it be?” “How long can she go on like this?”
Some questions are impossible to answer, but I tell them I believe the end is imminent, that if they want to give my sweet patient permission to leave, they should do it now. Sometimes, patients need to be assured that their families will be all right, and if they need to leave, they can. Hearing is believed to be the last sense to go at end of life, and even though she is now in a coma, I encourage them to talk to her.
They each in turn take her little hand and whisper how much they love her and that if she is too tired to live, it is all right to go to the light.
I tiptoe out of the room and find my little man in Room 412 snoring away. I touch his hand, his arm, his face, and he continues to sleep without tremors. We are all relieved, the family and I, that he is peaceful.
Returning to Room 411, I sit with the family as their dear loved one takes in her final breath. I put my stethoscope to her chest and hear no heartbeat. She is not breathing, and I pronounce her time of death at 11:15 AM. I quietly tell the family to take all the time they need to be with their dear one, to call me when they are ready for me to call the funeral home. They want her to stay until other family members can come.
Back at the desk, there are forms to be filled out, and I enter a death note into my patient’s chart.
Then it’s back down the hall to check on the two patients I have left. Returning to the desk, I learn that I have an admission coming..............For the conclusion, click here.
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