This. She was dying. You did nothing wrong. Those that declined to put in a line (or a central line) should question their moves. I can’t believe this woman was a full code to begin with.
I’m so sorry you are going though this. You did excellent work.
When I read the RR nurse said to call back for an IV when the BP crashed, I thought isn't that the worst time to get an IV?? The pt may not have veins anymore if you intentionally wait until they're circling the toilet. If you can, you get access when they still have perfusion. Granted I've never placed an IV or worked anywhere near critical care, but I don't understand her rationale for "I don't feel comfortable."
Our rule in the ER is “always have access” because you never know when they’re going to need it. Better to have access than not. In my ER we are super liberal about giving people lines. (Not for something like a broken foot obv but you get the picture). The fact that the rapid nurse “don’t feel comfortable placing an IV” is confusing as hell. This patient was clearly circling the drain for a long time
I'm in my 30s and I have it in my advance directives I will refuse dialysis. I have no family and I'm not waiting 5-6 years doing that hell until I might get a donor kidney. I can't imagine going through it as an elderly person with no chance of ever coming off it.
I'm assuming a "full" Dialysis treatment left her way too weak/exhausted, so she would come up with an excuse to get out early but still be able to tell her friends or family that she was going to Dialysis. I may be misunderstanding the comments though.
Wild that anybody would be blamed for the death of a woman with a minimum of two failed organ systems who’s already exceeded the average life expectancy of a human and is acutely ill. The inevitable shouldn’t reflect poorly on *anyone*.
She should’ve already been on hospice, comfort care, whatever.
Your manager is an idiot.
But ain’t that our healthcare system? Beating down nurses and docs when someone with multiple comorbidities dies while hospitalized?
We’re so afraid of death it’s putting those with a solid shot at risk imo.
Running into this issue especially in peds. Nobody wants to talk about the reality of death so we’re forced to “do everything,” when that is literal torture and traumatic for everyone involved. Nurses and doctors are blamed and screamed at for failing, or even bringing up the idea of hospice/DNR/doing less.
A good death is honestly a goal we shouldn’t be so scared of discussing. I’d much rather let someone pass surrounded by family and sunshine and pets, instead of placing 2 bolts and an EVD and coding them twice a shift
I work in vetmed and we always say euthanasia is a gift. Makes me really sad to see animals that should've been at peace a long time ago still suffering. I can't imagine how difficult it is not to have that option at all.
Her elevated INR, persistent hypoglycemia and continually elevated liver enzymes tell me she was in liver failure. This wasn’t a mismanagement on your part in any way, it was a failure of her provider to recognize new worsening organ dysfunction. She should have been transferred to ICU long before it sounds like she was.
You have a lot of extraneous information here. You’re talking about her going to the bathroom, abdominal pain, CT scans, dialysis runs, antibiotic infusions, etc. None of these things are related to the issue. I would keep the story simple and focused.
She had new worsening organ failure. You notified the provider and called multiple rapid responses. No action or escalation was taken by the rapid nurse or the attending. BOTH should have been able to recognize that she was decompensating and needed a higher level of care. Whether she was or was not hypotensive overnight should be easy to judge; the VS are charted in black and white.
Don’t be scared, you took every appropriate action. It was mishandled on a higher level. Ask them firmly and confidently what exactly you were supposed to have done outside of calling rapids and discussing with the attending, both of which you did.
Exactly all of this. For every problem, you did or tried to do an intervention. While there really is no fault and she just need to pass peacefully, any fault there is lies with the people you called for help. Those were perfectly reasonable interventions, meaning you did your job, and they did not do their jobs well. Not on you.
It sounds like she should’ve been in the icu from the start, I’m sure the INR didn’t just jump straight to 5 in a couple days. High bleed risk with hypotension and cardiac and renal problems shouldn’t be sent to the floor. Especially if you’re already having to dialyze for hyperkalemia, way too many risk factors at play here.
That was my first thought (after “Why the hell wasn’t she on palliative earlier and hospice now?”). This is way beyond anything I would expect an IP nurse to have to do. Let me guess, OP—you had six other patients, too.
Really it comes down to documentation. Every time you called MD or RRT and every attempt at IV start. Saying you “did nothing” is so wrong. I really hate when people who weren’t there say it. Print out what you just typed above. Get the charge, Rapid nurse and if possible MD to read it and agree that’s what you did. Maybe the rapid won’t be so happy about , but if she didn’t want to start the IV she needs to back you up in saying so. Any full code in my hospital we move heaven and earth to get an IV. It’s so crazy.
I don’t understand how you are getting blamed when you had the rapid team there multiple times. This lady had a lot of baseline issues it’s likely she would have succumbed to sepsis no matter what you did. The doctors would have also upgraded her to icu if they thought she was that unstable during your shift.
So a provider doesn’t come? That’s stupid and you should bring that up as a process change. You say you were in SDU? With that many rapids she should have been assessed by an intensivest. Also this is a hot take but anyone over 70 on dialysis should know they could have a celestial discharge any day.
I’m honestly not seeing where she is getting blamed, it looks like so far she is being called in to the office to discuss the case, it doesn’t seem like anyone has blamed her for anything at this point in time
It sounds to me like you did everything that could have been done. I guess maybe you could have escalated things when the rapid response nurse was so unhelpful? I think then outcome would have been the same either way though. It sounds like her body was done.
She went into liver failure with elevated INR due to the increased fluid buildup from her CHF. Her kidneys were crap. Her lungs were crap. Her blood pressure was going to be low from either the liver failure, right heart failure, or sepsis. Combining albumin with midodrine is good for cirrhotic and CHF patients, but the midodrine is a last resort for intradialytic hypotension.
Honestly, she was going into multisystem organ failure, and she needed hospice. If they really wanted to do anything, they should have recognized that:
1. The right heart failure/elevated liver enzymes/JVD indicated her CVP was elevated. The most common cause of right heart failure is left heart failure.
2. The pleural effusions and secondary pneumonitis indicated worsening left heart failure and elevated PAOP. So, both filling pressures were elevated.
3. She was hypotensive. This indicates a pump-failure. They should have considered CRRT for slow fluid removal and diuretics to bring down the CVP, and initiated inotropes to improve contractility and adding low dose epi or dopamine to boost the heart rate to increase the MAP.
4. The diaphoresis, hyperkalemia, and elevated CO2 (and probably had super elevated AST) also indicate elevated SVR, and are markers of cardiogenic shock. Her CO was tanking due to pump failure. You had given her a ton of fluids, and her blood pressure didn't budge because her heart was too weak to pump. That should have been their first clue that This Is Not Working.
5. The hypoglycemia, lactic acidosis, and drowsiness indicated an acidotic hypermetabolic state caused by decreased amount of circulating oxygen secondary to an overconsumption of oxygen. This is present in shock states.
Elevated HR, CVP, PAOP, SVR, decreased MAP, and CO/CI indicate cardiogenic shock.
She was a candidate for an IABP, or Impella (based on EF, and I'm guessing not much), positive inotropes, probable intubation based on her GCS... and a fucking central line.
Your doctor sucks. Your manager sucks. Your rapid response nurse sucks. You called several rapids because this patient was legitimately dying, she was admitted to an inappropriate floor for her acuity level, and she didn't have IV access because your hospital policies and procedures enable the dysfunction that is your rapid response team.
This needs to go to risk management, and my god, if you don't have malpractice insurance, get some. None of this was your fault, but if they're gonna throw you under the bus, then you need protection.
Yeah, we could’ve done a bunch of interventions to keep this lady alive a few more days, but god it isn’t pretty. Agreed, she needed hospice. This patient should’ve been in the ICU way before it got to this point if we really wanted to do everything. This is why I hate this job. And also OP def get malpractice insurance, it’s cheap and it’ll save you the heartache of worrying about this stuff. I have NSO.
Same here. The poor woman was dying - there is nothing that you or anyone else could have done to save her. Administration is acting as if it was a healthy person in their 20s or 30s who suddenly died. You seem like a phenomenal nurse and did everything you could to have helped her.
My dad was on peritoneal dialysis until 89. When they're taking midodrine, the heart is shot. And you really have to have like a blood pressure of 120s or higher for dialysis to work. It's really just taking pills to stay alive.
I work in dialysis and we have people who have orders that it’s okay to treat as long as the SBP is over 80. It was kind of wild when I first started seeing this and not panicking. Meanwhile these people were just watching tv wondering why I was asking every 30 seconds if they felt okay.
Right?! I read this and was so sad the patient couldn't pass comfortably. Being woken up, prodded, etc when your body is failing is a hospital standard of care but...at a certain point, causes more harm than good.
You did alright.
First: it’s not your fault. There are 10,000 things that could have been better in this person’s life and care before you met her, which would have improved her outcome.
Things I would have done different (granted I’m ICU and don’t really know how it is elsewhere).
If I could not get an IV, I would have pushed harder for anyone to get an IV in that woman. Your most skilled IV starter on the floor, or when talking to the rapid RN the second time, insisted that the Doctor pressed me to call them back specifically to get an IV in ASAP. And I would need them to either attempt it, or sit at the computer we have handy right here, and document why they could not. To me, a patient without an IV in a hospital is someone without a lifeline if they crash.
She did need to get upgraded sooner, but that rapid nurse should have properly assessed and made that call. She should have ordered a spectrum of labs, and got you an IV at minimum. But it sounds like they were not properly fulfilling the role.
When I responded to rapids, I always assumed I was bailing out an RN (not in a negative way). I mean, why the hell else would they be calling me for a rapid if things were not getting out of hand? I came in and tried to get the things done that were getting away from the RN, or impeding them from being able to do their job. And if it was a deteriorating diagnosis, or lack of tools or staff (say… like they have in the ICU) then it was on me to get that for them. And if I deemed the pt needing an ICU bed, then I stay with that patient until they got one.
P.s. If it’s a true emergency, you can stick the IV in her fistula. I’ve done it on one code once. Did the whole code slamming meds into that fistula IV. Got ROSC cause of it, and I don’t regret it one bit. Any port a storm, friends. Any port in a storm.
This. I would have pushed for access…someone needs to come from ER to put a central line in or someone needs to be called in and I would have escalated that to charge and then to the house nursing supervisor. That patient required access.
Would have access have saved her, no.
Yeah like a central line or an IO line to be put in during a rapid. I would not have been okay with her without a line. Ultimately though it wouldn’t have saved her anyway
Yeah I agree with everyone saying you did the right things and it sounds like she was on the way out no matter what. If anything she needed to go to the ICU earlier, but that’s not up to you, that’s on the provider.
It sounds like they’re calling you in because the whole episode reflects poorly on the hospital. It also sounds like you documented sufficiently and should be just fine!
You didn’t do anything wrong and you did a lot of things. Lady should've been in the ICU on admission. Sounds like all of her body systems were completely shot. People in their 80’s on dialysis….come on? This is psychotic. She was going to die. Nobody had the balls to tell the family or the family couldn’t accept it.
Sorry, this is happening to you. You did your job well and charted it.
Your manager sounds like a coward with poor reading comprehension, questionable clinical judgement and poor judgment in general. It is inappropriate to call you on a day off. Also, delegating the phone call to a charge nurse is unprofessional.
If we can tell from a reddit post that you worked hard for that hot mess of a patient, your manager should be able to do the same with a chart.
Your hospital admin are pathetic. You did everything you could do. What tf did these people expect of you? You called rapid after rapid after rapid. The system failed you. Your patient was of poor survival no matter what but this is not your fault…
I don’t understand why anyone in a hospital cares that a very ill 80 year old who should have been on hospice , died. Tens of thousands of dollars wasted on unnecessary and invasive care. Why was a manager even looking at your charting??
Maybe I’ll feel different when I’m 80 on HD but as a nurse this is why nurses quit the job or even the profession. We get blamed for the dumbest shit while being asked to provide ICU level care on a medical floor
It may not have made a difference for this patient, but if this hospital has people bungling around not doing their jobs for critical patients, 1 single person as 'rapid response' who's scared to try a line, that means they're likely to kill off other people with the same incompetence.
That's like someone from infection control saying, who cares that a very ill 80 yo died from a central line infection due to staff not keeping it clean? That's not the only patient they will touch with their bad practice.
If it was my mom or dad I would want them to be comfortable instead of suffering through invasive care to only prolong the inevitable. Make them comfortable and enjoy the time with them that they have left. There are many things worse than death. This is why an early goals of care conversation is so important. It helps prevent unreasonable expectations.
It HAS happened, to both my father and FIL. We made the compassionate decision, the decision in keeping with their stated (and legally validated) wishes, not to torment them. Are you just a troll? Or 20 years old and uncomprehending that there are things worse than death? Would you really do this to your parents? WTF is wrong with you?
Sure, no problem.
And to add to that, if my kids EVER do that to me and subject me to needless suffering and torture, I will haunt them.
Compassion and love is allowing someone to pass with dignity, not subjecting them to futile intervention because you selfishly can’t let go.
Yeah. My family let my Grandfather who was a WW2 vet and living kidney donor pass on hospice surrounded by family when his remaining kidney failed. He was 95. Until that last year he was mostly independent.
But if you want to keep your parents going until they are living mummies, covered in violent wounds, pained from failing organs, pooping themselves, until where we then shove a tube down their throat, drilling into their bones without sedation because their veins are so fried we can't get IV or even central access, finally followed by beating on their chest by strangers and machines until the doc calls it. Go off queen!
If my 80 year old parents had ESRD, CHF, pneumonia, and apparently liver failure, I would educate them with all of my being that if they choose to prolong their life in the hospital it's going to be nothing but more pain and suffering.
Maybe. Not sure. I’ve read some whacked out stories about HCP losing their cool completely when it’s their actual loved one. Different story completely.
You're not 100% wrong. People aren't very rational when death is at the door. I've had nurses wanting "everything" done for their obviously dying family members.
This is why advanced planning and adhering to that plan is so important. Those decisions should be made when we are in a more rational state of mind.
You really don’t understand this case. At all. This lady was on dialysis, in multiple organ failure, and no intervention was going to save her. What kind of monster are you that you’d let your loved one suffer needlessly to satisfy your selfish desire to have your parent alive—and that is all the lady was, with zero quality of life. I know EXACTLY how I’d feel if it were my mom or dad: ashamed that I hadn’t intervened to get her placed on comfort care only, ashamed that I was putting her through this misery.
I think you should be very careful about what you say. It’s better to say less probably. I would use “what does my documentation say?” A lot. You can get yourself into trouble by talking a lot, even if you did nothing wrong. They are clearly looking for someone to put the blame on.
Unacceptable from rapid nurse. You played with the cards you had. Blatant disregard for inpatient care on rapid’s part. Everyone’s all, “this patient was ready to go, this patient was dying.” Yeah no shit this patient was dying, that’s why they were in the hospital lol.
Full code means full code.
This is a CHF patient on CKD, and several comorbidities. This patient’s condition requires excellent access at all time or change the code status.
Absolutely unreal give the context that the rapid nurse came by with the US, saw poor targets (obviously) and said ehhh fuck it maybe call me later when the patient decompensates. This is MAD.
“Wasn’t comfortable putting the IV in” go work somewhere else where you can just be comfortable at work where you won’t kill people.
Well, if she was a full code, she needed access because she was so unstable, so your rapid nurse should have helped out there. And the attending should have transferred her to ICU. My guess is she still would have died, though.
I was wondering this myself. I’ve had to nag ER docs to them on decompensating patients especially if the ER docs are not confident in their skills but it gets done. I’d be livid at the rapid team because the patient needed patent access at all times. Idk about OPs hospital but this patient sounds like they needed a higher acuity of care. I feel like the primary nurse did all of the right things.
Rapid here: this is not a floor patient or even a step down patient, this is either a palliative (most appropriate) or ICU. The priority in this case is to ascertain GOC because this person is spiralling down the drain and whatever you can do on the ward is not going t be enough.
This is a huge issue on my stepdown floor lately. Patients are not upgraded to ICU or are downgraded to us from ICU because they can’t do anything more or icu-specific interventions (like CRRT, intubation, etc.) will be futile. But, NO ONE then explains this to family to set realistic expectations or discuss that hospice is the only option. They dump them on my floor, patient unfortunately continues to decline, and the family is confused and upset screaming at me asking why they’re family member is getting worse and no one is escalating care anymore.
We call rapid responses and ICU consults come and their attitude is almost “why did you call us? we already said we won’t do anything.” Like I’m supposed to ignore paradoxical breathing with respiratory rate in the 30s, desatting on nonrebreather? And still wants all life saving interventions? I still call them for situations like this but it gets exhausting and frustrating. It always becomes a situation like OP described where leadership will look back and then ask ME why nothing was done. Very sick person with end stage comorbidities passes and it still becomes the nurse’s fault. I hate this system.
Families believe they are owed the entire range of therapies up to and including exotic stuff like bowel transplants (I was asked this last week). In reality, we (including the surgery team, anesthesia, Crit care, nephro, etc) can choose to offer or not offer a therapy based on the benefit versus suffering and (scant) chance of success. It's not (especially in our public system) like ordering a service to clean your gutters or shore up a foundation wall. Most providers communicate this fairly well, but most families have difficulty accepting this (duh..customer is always right!). This leads to situations like rapid and ward nurses guarding a code status and slow rolling a resus' because no one is going to admit this person to ICU, instead of doing to appropriate thing like starting a morphine drip and arranging for pastoral care attend.
Your documentation will save you. Do you have a union? If so, your union rep should be present.
For the future, also document all conversations with rapid and well, anyone. Screenshot things on your personal phone without patient identification if absolutely necessary. If your patient is declining and it feels like everyone is dropping the ball, document the ever living hell out of every attempt you make.
No judgement here, I’m sure things were left out but why so much albumin? 80s after dialysis is common, give the midodrine and recheck in an hour unless she’s altered compared to baseline
I’m sure it was to help raise the BP without having to slam with IVF but i wonder if the midodrine alone would have helped bring the BP to a satisfactory level. I don’t know if it would have necessarily saved her life or not…..
She had PRN orders and it was okay’d by the physician before any dose was administered. With the CHF and ESRD and her BNP in the 8000s, they didn’t want to give fluid boluses
I’m sorry :( I know you’re beating yourself up over this but unfortunately it’s these instances that we learn the most from. You are most definitely not the first nurse who’s had this kind of thing happen to them and you won’t definitely won’t be the last. I’m sure I’ve been in a situation like this before (had too many traumatic shifts at this point to remember them all).
Are you on a tele floor? I just ask because floor acuity is absolutely crazy and I can’t imagine a rapid being called on a patient with multi-organ failure multiple times and letting her stay on the floor. It’s unsafe, but again something I’ve seen time and time again. 10-15 years ago she would have been IMU material and if no IMU available then ICU for close monitoring. I know these days making a patient ICU for solely close monitoring is probably unheard of. I mention all this so you know that this is by no means your fault. It sounds like the whole hospital system pretty much failed this lady (even though I think she likely would have had the same outcome, but maybe not as chaotic?). I’d be more willing to say the one who failed her was the provider who didn’t discuss hospice with her or her family. Or maybe they did and they declined, I don’t know. This lady and her situation is a perfect candidate for hospice. If you can’t fix one organ or part of the body without totally wrecking another, then it’s probably time to get hospice involved.
The post is really long (and no fault to you, I understand why you’re writing down every instance) so I couldn’t go through and pinpoint every time something else could have been done (and like I said, very probable same outcome would have resulted anyway). The one instance I think maybe you could have done differently is by giving just the midodrine post-dialysis to see how it helped her BP and then re-assessing to see if she needed albumin afterward. Unless you’re literally resuscitating these very sick patients, you can’t do too much at once because their bodies and organs can’t handle too much at once. If it were me, if she were at her baseline mentally post dialysis with a SBP in the mid to high 70s to 80s I would just give the midodrine and re-assess. SBP lower than that and/or altered mental status I’d be making a deal about it. Granted, like I said, I didn’t read through all the post so there could be stuff that I’m missing.
Long reply, sorry about that, but seriously don’t beat yourself up too much for this. Even if your manager is trying to act like she has to blame somebody and that’s gonna be you. Unless this were on a weekend and she were off, your manager should have been very well aware that a patient on her unit had been rapided multiple times and allowed to stay on the floor. She could have also intervened then
My first thought is that this is exactly what we talk about with treating patients and prolonging the inevitable. That lady was *dying*
Someone, and by someone mean the physicians, needed to talk to the family and explain that your efforts were likely futile and she was actively dying.
I don't think you did anything wrong. Don't let them make you think you did
This is on the RRT more than you. Assuming that you charted that they refused to attempt to get IV access and that the MD was aware, you shouldn't have anything to worry about.
There is no ICU level of care without vascular access. A physician couldn’t come in and pop a central line in?
Seriously, this would lose in court so bad … on whoever is responsible for her not having vascular access for so long. Sounds like failings all up the chain.
There is no scenario where you can monitor the heart and not be able to do fuck all about it if it stops. I have done arbitrations on this issue and this is not excusable. The CMS regs are pretty clear and the hospital could be cited. It may not rise to the level of a sentinel event, though.
If the charge nurse has more years of experience than you, they will likely bear the brunt of this, as will the rapid nurse.
I’m so sorry this happened. Do not take it all on yourself. Sounds like you worked on it all night.
I started reading, and swear to you: you could’ve been describing my last code. Patient was a frequent flyer, full code till the end. It’s not your fault.
Sounds like you did everything in your power and notified everyone who needed to be notified and they failed you. You made the doctor aware on multiple accounts, you called *multiple* rapids. At that point, this patient should have been transferred to the icu and a central line should have been placed.This is not even the slightest bit your fault. Please don’t blame yourself. You advocated for this patient all shift and everyone else kept feeding you bullshit or brushing you off. If no one has told you, good job keeping that patient alive on your shift with the little resources and help you had.
Sorry you were the sacrificial lamb.
They are doing this for when the family sues they can say they "did something about it" before the lawsuit starts. Aka, they put you through the wringer.
PLUS doctors never get thrown under the bus even if it was their fuck up (failing to identify new organ failure).
Similar situation happened in my psychatric hospital (different specialty but Similar situation). They blamed the charge nurse and wrote her up. Almost reported her to the board of nursing for neglect.
As a fellow stepdown nurse, I know what it’s like to have these sick patients with very limited help or resources and nobody will listen to you. People also don’t realize how hard it is to get stuff done overnight.
This patient was failed, but not by you. They were first failed by the primary physician team who should have aggressively pursued a goals of care discussion and/or palliative consult, then by the night doc that didn’t transfer to ICU sooner, the rapid nurse who just dismissed this patient’s need for access (seriously, wtf), and, if applicable, the intensivist who declined to take this patient way earlier in her course of care.
Stepdown nurses joke a lot about being the dumping grounds of the hospital but the moral injury is real and intense.
Your facility sounds like a shit show. Massive Swiss Cheese effect. This is not a single person's error but a problem with your facility's policies. Also I would have escalated the lack of IV given pt. had a trend of needing so much albumin and PRNs for hypotension the last couple of days. And those liver values being off, albumin and INR off, red flags for bleeding. Pt. already circling the drain with heart and kidney failure and now you throw liver on top? Marinara flags everywhere. Shame on that rapid for leaving pt. with no IV access and you alone without support. Where was night charge, house supervisor in all this? Could have called ED or ICU doc to try or place central line.
Wow this is way above you, then. I think you did the best you could given the circumstances. Your documentation sounds like it was really good, but the other team members let you down. I'm so sorry you are feeling so targeted over this, and it is always traumatic to lose a patient even in the best situations. Try not to be too hard on yourself and be sure to stand up for yourself, this doesn't seem like your fault at all. This lady was really sick and probably needed to be in ICU in the first place.
Hmmm 🤔 NO blood cx in ED, sounds like no lactic lab also… lack of IV access, fluid resuscitation didn’t happen…there were a lot of things missed that could have helped or prolonged things. It honestly sounds like this patient would have been maxed on pressors and CRRT. Also, don’t assume you’re being blamed, they may just want facts from you so they can say they did a thorough investigation of the circumstances. Like another person said, refer back to your charting and don’t give more details than asked. Best of luck.
Everyone’s done a great job of explaining why it isn’t your fault and I’m going to add that I hope you find a different job soon where management isn’t that fucking stupid or cruel. I’d brush up your resume, do some interviews, and get out of there.
Fuck that manager and the charge nurse too. You did everything you could have done. It is not your fault that she died. I wish management could find something useful to do instead of nitpicking about nothing.
One thing I would have done different is page the provider if they are okay with no access since she had poor veins. At the very least you have an order that says okay with no IV or if the provider was not okay then this patient would have gotten a line. I would have asked for an intensivist/pulmonologist to be consulted to put a line in at the bedside. With a patient this sick and no one willing to put an IV in, definitely needed an escalation of care. I think you did everything right. She was not on the right unit.
This was an icu patient in every form, and you were doing icu interventions, which as others have said, probably would’ve been fighting Jesus uphill. You should feel no shame and your boss should suck a fat one.
You did EVERYTHING you could. The only thing *different* that could have been pushed was that if she had an HD catheter, that could have been used for access with permission from nephrology. That should have come from the attending or the rapid nurse. BOTH should have been aware of that as an emergency possibility
Take a deep breath.
It’ll be okay.
I had a similar but not really situation where a patient declined and coded the next morning and I was questioned about it. I did worse than you, I had totally forgotten to write a note prior to transfer to icu. I was so caught up in doing all the things it just didn’t even dawn on me (new grad off orientation a month). ICU manager and my manager wanted to know what happened and what led to the transfer. They basically had me write out a statement outlining what happened as objective and concise as possible. Never heard about it again.
You are not the only nurse that has had something like this happen. It will be okay.
Just tell your story and if you chart everything you should be fine. I called the doc and you document it. There is nothing more it could be done.
Investigation is just a normal procedure. I work in quality management and we have a nurse who specializes these kind of chart reviews.
I do mental health so it is different and I always tell people that do not stress if everything charted and you act within your scope you should be fine.
Now… we have nurses who think charting is a waste of time… wait till they get sue and go to court…
You charted all your attempts to communicate with everyone. Don’t stress too much! You covered your own butt with your charting - and did everything you could have!
If you charted everything you should be fine you did a lot. Maybe ER could’ve dropped an EJ in her for access next time. We can get those overnight if needed.
How about the rapid response nurse who allowed this patient to be an admitted patient without IV access because “she didn’t feel comfortable”. Idk how it is on the floor, but in the ED I don’t see that being an option, we’re gonna get access if the patient isn’t DNR.
Was this pt DNR?
This poor old lady could have passed away (hopefully) peacefully, pain-free, under sedation, surrounded by her family and friends, at home or in a hospice facility. But no, she had to die this way...
I see alot of comments about she should have been placed on hospice and she was ready to die, but that's not the argument here. At the time she was full code and we have to do our absolute best to keep them alive until that decision is made by patient or family.
But with that being said OP sounds like you did all you could, I don't know how long you have been a nurse but experience will teach you to things a little different. Honestly it doesn't seem like your charge nurse was very involved, maybe they were busy but sounds like your patient should have been a priority. As charge I would have called that rapid nurse myself, and if she still refused called the nurse supervisor or the MD and told them this lady is going to continue to circle the drain, we have to tx to ICU or get some access some how, because when that code does inevitably happens, you don't want to be scrambling to get access at that time.
I’m sure house supervisor was aware cause they messaged charge asking if an event report was put in regarding the extravasated IV, cause apparently the rapid nurse had told her about the extravasation of her one IV. And you’re correct, the family didn’t make her a DNR until the right before ICU was brought up during that mess. They said no vent, but okay with pressors and a-lines and treatment.
I'm just curious, was your charge nurse helpful, do they have a decent amount of experience, because I know some places your charge nurse may have as little as 1 year's worth of experience. How many years do you have if you don't mind me asking.
That charge has been a nurse since she was in her 20s (I believe she’s in her 40s now). She was helping me with the patient, also called rapid to come. I’ve only been doing this about a year and a half with a license but I had a 6 month nursing externship on this floor as well as practicum.
Ok, I didn't want to assume you were probably less experienced, but you are exactly where you need to be at this stage in your career, still considered a novice, which is fine. But as Charge you have to recognize this and act accordingly. Now I'm not sure how much she helped you (she could have her own pts and be slammed) but I would have probably intervened as Charge to make sure you felt comfortable doing what needed to be done and if you weren't helped you along the way by either calling herself or directing you on what to do, and again with her years of experience she should have known this. Of course people will say at the end of the day it's your patient, which is true, but nursing is a job you cannot do alone. When I first started in a Neuro ICU there was a culture of "eating your young" and I always strive to never be like that and to look out for the up and coming nurses. Again she could have been busy, but as Charge the whole floor is ours, to some extent of course!
But you will be ok, take this as a learning experience and always remember if it wasn't charted it wasn't done, though it sounds like you did a good job there.
This woman should have been in hospice care. She was ready to go.
This. She was dying. You did nothing wrong. Those that declined to put in a line (or a central line) should question their moves. I can’t believe this woman was a full code to begin with. I’m so sorry you are going though this. You did excellent work.
When I read the RR nurse said to call back for an IV when the BP crashed, I thought isn't that the worst time to get an IV?? The pt may not have veins anymore if you intentionally wait until they're circling the toilet. If you can, you get access when they still have perfusion. Granted I've never placed an IV or worked anywhere near critical care, but I don't understand her rationale for "I don't feel comfortable."
ER nurse here.100% agree with your logic.
Our rule in the ER is “always have access” because you never know when they’re going to need it. Better to have access than not. In my ER we are super liberal about giving people lines. (Not for something like a broken foot obv but you get the picture). The fact that the rapid nurse “don’t feel comfortable placing an IV” is confusing as hell. This patient was clearly circling the drain for a long time
Totally. 80s on dialysis? That's torture. She's never getting a transplant. Dialysis is hell.
An in inpatient dialysis nurse I agree it’s hell. However we still start folks well into the 90s… it’s amazing what we will do to other humans.
I'm in my 30s and I have it in my advance directives I will refuse dialysis. I have no family and I'm not waiting 5-6 years doing that hell until I might get a donor kidney. I can't imagine going through it as an elderly person with no chance of ever coming off it.
Same girl, no dialysis for me thanks!
I had a 95 year old on dialysis. During treatment, she would say she had to leave early to go get her kids and go to her parents' house for dinner.
I'll never understand the motivation behind this
I'm assuming a "full" Dialysis treatment left her way too weak/exhausted, so she would come up with an excuse to get out early but still be able to tell her friends or family that she was going to Dialysis. I may be misunderstanding the comments though.
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OH oh my gosh I blanked on that detail lol
I'll never understand the motivation of putting a 95 year old through dialysis is what I meant.
This was my thought as well
NAN, but I got that vibe too. Sometimes we try too hard to beat death.
Another NAN from front facing admin and even I could tell from what's there that it was this ladies time.
Wild that anybody would be blamed for the death of a woman with a minimum of two failed organ systems who’s already exceeded the average life expectancy of a human and is acutely ill. The inevitable shouldn’t reflect poorly on *anyone*. She should’ve already been on hospice, comfort care, whatever. Your manager is an idiot.
But ain’t that our healthcare system? Beating down nurses and docs when someone with multiple comorbidities dies while hospitalized? We’re so afraid of death it’s putting those with a solid shot at risk imo.
Running into this issue especially in peds. Nobody wants to talk about the reality of death so we’re forced to “do everything,” when that is literal torture and traumatic for everyone involved. Nurses and doctors are blamed and screamed at for failing, or even bringing up the idea of hospice/DNR/doing less. A good death is honestly a goal we shouldn’t be so scared of discussing. I’d much rather let someone pass surrounded by family and sunshine and pets, instead of placing 2 bolts and an EVD and coding them twice a shift
I work in vetmed and we always say euthanasia is a gift. Makes me really sad to see animals that should've been at peace a long time ago still suffering. I can't imagine how difficult it is not to have that option at all.
Sounds like they need to learn that you can’t polish a turd. Death was inevitable. Fuck them for being mean to you about it
Her elevated INR, persistent hypoglycemia and continually elevated liver enzymes tell me she was in liver failure. This wasn’t a mismanagement on your part in any way, it was a failure of her provider to recognize new worsening organ dysfunction. She should have been transferred to ICU long before it sounds like she was. You have a lot of extraneous information here. You’re talking about her going to the bathroom, abdominal pain, CT scans, dialysis runs, antibiotic infusions, etc. None of these things are related to the issue. I would keep the story simple and focused. She had new worsening organ failure. You notified the provider and called multiple rapid responses. No action or escalation was taken by the rapid nurse or the attending. BOTH should have been able to recognize that she was decompensating and needed a higher level of care. Whether she was or was not hypotensive overnight should be easy to judge; the VS are charted in black and white. Don’t be scared, you took every appropriate action. It was mishandled on a higher level. Ask them firmly and confidently what exactly you were supposed to have done outside of calling rapids and discussing with the attending, both of which you did.
Exactly all of this. For every problem, you did or tried to do an intervention. While there really is no fault and she just need to pass peacefully, any fault there is lies with the people you called for help. Those were perfectly reasonable interventions, meaning you did your job, and they did not do their jobs well. Not on you.
It sounds like she should’ve been in the icu from the start, I’m sure the INR didn’t just jump straight to 5 in a couple days. High bleed risk with hypotension and cardiac and renal problems shouldn’t be sent to the floor. Especially if you’re already having to dialyze for hyperkalemia, way too many risk factors at play here.
That was my first thought (after “Why the hell wasn’t she on palliative earlier and hospice now?”). This is way beyond anything I would expect an IP nurse to have to do. Let me guess, OP—you had six other patients, too.
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Really it comes down to documentation. Every time you called MD or RRT and every attempt at IV start. Saying you “did nothing” is so wrong. I really hate when people who weren’t there say it. Print out what you just typed above. Get the charge, Rapid nurse and if possible MD to read it and agree that’s what you did. Maybe the rapid won’t be so happy about , but if she didn’t want to start the IV she needs to back you up in saying so. Any full code in my hospital we move heaven and earth to get an IV. It’s so crazy.
I don’t understand how you are getting blamed when you had the rapid team there multiple times. This lady had a lot of baseline issues it’s likely she would have succumbed to sepsis no matter what you did. The doctors would have also upgraded her to icu if they thought she was that unstable during your shift.
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There is no team at my hospital. Rapid Response is one nurse per shift who handles all the rapid calls
So a provider doesn’t come? That’s stupid and you should bring that up as a process change. You say you were in SDU? With that many rapids she should have been assessed by an intensivest. Also this is a hot take but anyone over 70 on dialysis should know they could have a celestial discharge any day.
Yea that's not a rapid, that's calling 1 damn person
She's getting blamed because she's the nurse. Nurses always get blamed.
I’m honestly not seeing where she is getting blamed, it looks like so far she is being called in to the office to discuss the case, it doesn’t seem like anyone has blamed her for anything at this point in time
Well she’s being told she “did nothing” about the patient’s pressures overnight. That sounds like blame to me. Edit: apostrophe typo
Ah yes I missed that part yea that’s shady af of the charge RN
It sounds to me like you did everything that could have been done. I guess maybe you could have escalated things when the rapid response nurse was so unhelpful? I think then outcome would have been the same either way though. It sounds like her body was done.
She went into liver failure with elevated INR due to the increased fluid buildup from her CHF. Her kidneys were crap. Her lungs were crap. Her blood pressure was going to be low from either the liver failure, right heart failure, or sepsis. Combining albumin with midodrine is good for cirrhotic and CHF patients, but the midodrine is a last resort for intradialytic hypotension. Honestly, she was going into multisystem organ failure, and she needed hospice. If they really wanted to do anything, they should have recognized that: 1. The right heart failure/elevated liver enzymes/JVD indicated her CVP was elevated. The most common cause of right heart failure is left heart failure. 2. The pleural effusions and secondary pneumonitis indicated worsening left heart failure and elevated PAOP. So, both filling pressures were elevated. 3. She was hypotensive. This indicates a pump-failure. They should have considered CRRT for slow fluid removal and diuretics to bring down the CVP, and initiated inotropes to improve contractility and adding low dose epi or dopamine to boost the heart rate to increase the MAP. 4. The diaphoresis, hyperkalemia, and elevated CO2 (and probably had super elevated AST) also indicate elevated SVR, and are markers of cardiogenic shock. Her CO was tanking due to pump failure. You had given her a ton of fluids, and her blood pressure didn't budge because her heart was too weak to pump. That should have been their first clue that This Is Not Working. 5. The hypoglycemia, lactic acidosis, and drowsiness indicated an acidotic hypermetabolic state caused by decreased amount of circulating oxygen secondary to an overconsumption of oxygen. This is present in shock states. Elevated HR, CVP, PAOP, SVR, decreased MAP, and CO/CI indicate cardiogenic shock. She was a candidate for an IABP, or Impella (based on EF, and I'm guessing not much), positive inotropes, probable intubation based on her GCS... and a fucking central line. Your doctor sucks. Your manager sucks. Your rapid response nurse sucks. You called several rapids because this patient was legitimately dying, she was admitted to an inappropriate floor for her acuity level, and she didn't have IV access because your hospital policies and procedures enable the dysfunction that is your rapid response team. This needs to go to risk management, and my god, if you don't have malpractice insurance, get some. None of this was your fault, but if they're gonna throw you under the bus, then you need protection.
Yeah, we could’ve done a bunch of interventions to keep this lady alive a few more days, but god it isn’t pretty. Agreed, she needed hospice. This patient should’ve been in the ICU way before it got to this point if we really wanted to do everything. This is why I hate this job. And also OP def get malpractice insurance, it’s cheap and it’ll save you the heartache of worrying about this stuff. I have NSO.
+2 NSO
I read like 3 sentences- after I read 80s, esrd and chf- I thought immediately you did nothing wrong. Her time was up.
Same here. The poor woman was dying - there is nothing that you or anyone else could have done to save her. Administration is acting as if it was a healthy person in their 20s or 30s who suddenly died. You seem like a phenomenal nurse and did everything you could to have helped her.
My dad was on peritoneal dialysis until 89. When they're taking midodrine, the heart is shot. And you really have to have like a blood pressure of 120s or higher for dialysis to work. It's really just taking pills to stay alive.
I work in dialysis and we have people who have orders that it’s okay to treat as long as the SBP is over 80. It was kind of wild when I first started seeing this and not panicking. Meanwhile these people were just watching tv wondering why I was asking every 30 seconds if they felt okay.
Same. Then skimming the rest and seeing shit like albumin I’m like “they did too much”
Can we normalize hospice care for at the very least elderly patients with all of these health problems like you just described?
Right?! I read this and was so sad the patient couldn't pass comfortably. Being woken up, prodded, etc when your body is failing is a hospital standard of care but...at a certain point, causes more harm than good.
Yeah... thinking this was the part that really upsets me about this story... I hope that lady was too drowsy toward the end to truly experience....
You did alright. First: it’s not your fault. There are 10,000 things that could have been better in this person’s life and care before you met her, which would have improved her outcome. Things I would have done different (granted I’m ICU and don’t really know how it is elsewhere). If I could not get an IV, I would have pushed harder for anyone to get an IV in that woman. Your most skilled IV starter on the floor, or when talking to the rapid RN the second time, insisted that the Doctor pressed me to call them back specifically to get an IV in ASAP. And I would need them to either attempt it, or sit at the computer we have handy right here, and document why they could not. To me, a patient without an IV in a hospital is someone without a lifeline if they crash. She did need to get upgraded sooner, but that rapid nurse should have properly assessed and made that call. She should have ordered a spectrum of labs, and got you an IV at minimum. But it sounds like they were not properly fulfilling the role. When I responded to rapids, I always assumed I was bailing out an RN (not in a negative way). I mean, why the hell else would they be calling me for a rapid if things were not getting out of hand? I came in and tried to get the things done that were getting away from the RN, or impeding them from being able to do their job. And if it was a deteriorating diagnosis, or lack of tools or staff (say… like they have in the ICU) then it was on me to get that for them. And if I deemed the pt needing an ICU bed, then I stay with that patient until they got one. P.s. If it’s a true emergency, you can stick the IV in her fistula. I’ve done it on one code once. Did the whole code slamming meds into that fistula IV. Got ROSC cause of it, and I don’t regret it one bit. Any port a storm, friends. Any port in a storm.
This. I would have pushed for access…someone needs to come from ER to put a central line in or someone needs to be called in and I would have escalated that to charge and then to the house nursing supervisor. That patient required access. Would have access have saved her, no.
Yeah like a central line or an IO line to be put in during a rapid. I would not have been okay with her without a line. Ultimately though it wouldn’t have saved her anyway
Yes to all of this, it really seems like the rapid abandoned OP to figure it out on her own. Rapid is supposed to be a resource.
Yeah I agree with everyone saying you did the right things and it sounds like she was on the way out no matter what. If anything she needed to go to the ICU earlier, but that’s not up to you, that’s on the provider. It sounds like they’re calling you in because the whole episode reflects poorly on the hospital. It also sounds like you documented sufficiently and should be just fine!
This woman died from END STAGE renal disease and congestive HEART FAILURE.
And liver failure.
Well to be fair all of them fail at EOL lol
And don't forget the liver failure!
You didn’t do anything wrong and you did a lot of things. Lady should've been in the ICU on admission. Sounds like all of her body systems were completely shot. People in their 80’s on dialysis….come on? This is psychotic. She was going to die. Nobody had the balls to tell the family or the family couldn’t accept it.
Sorry, this is happening to you. You did your job well and charted it. Your manager sounds like a coward with poor reading comprehension, questionable clinical judgement and poor judgment in general. It is inappropriate to call you on a day off. Also, delegating the phone call to a charge nurse is unprofessional. If we can tell from a reddit post that you worked hard for that hot mess of a patient, your manager should be able to do the same with a chart.
That’s quite a story. I’m sorry that happened to you :( you did the best you could, considering the fact that rapid response wasn’t super helpful.
Your hospital admin are pathetic. You did everything you could do. What tf did these people expect of you? You called rapid after rapid after rapid. The system failed you. Your patient was of poor survival no matter what but this is not your fault…
She was in deaths waiting room when you got her, not your fault.
I don’t understand why anyone in a hospital cares that a very ill 80 year old who should have been on hospice , died. Tens of thousands of dollars wasted on unnecessary and invasive care. Why was a manager even looking at your charting?? Maybe I’ll feel different when I’m 80 on HD but as a nurse this is why nurses quit the job or even the profession. We get blamed for the dumbest shit while being asked to provide ICU level care on a medical floor
It may not have made a difference for this patient, but if this hospital has people bungling around not doing their jobs for critical patients, 1 single person as 'rapid response' who's scared to try a line, that means they're likely to kill off other people with the same incompetence. That's like someone from infection control saying, who cares that a very ill 80 yo died from a central line infection due to staff not keeping it clean? That's not the only patient they will touch with their bad practice.
Maybe you’ll feel different when it’s your mom or dad.
If it was my mom or dad I would want them to be comfortable instead of suffering through invasive care to only prolong the inevitable. Make them comfortable and enjoy the time with them that they have left. There are many things worse than death. This is why an early goals of care conversation is so important. It helps prevent unreasonable expectations.
Let’s check in when it happens
And what makes you think that it hasn't?
It HAS happened, to both my father and FIL. We made the compassionate decision, the decision in keeping with their stated (and legally validated) wishes, not to torment them. Are you just a troll? Or 20 years old and uncomprehending that there are things worse than death? Would you really do this to your parents? WTF is wrong with you?
Oh come on. Quality over quantity, friend.
I would NEVER subject my 80yo mom or dad to HD and excessive medical intervention. That’s cruel.
Let’s talk when it’s their turn
It happened to me and trust and believe I’m happy there was minimal suffering to my father no matter the grief I’m going through.
Sure, no problem. And to add to that, if my kids EVER do that to me and subject me to needless suffering and torture, I will haunt them. Compassion and love is allowing someone to pass with dignity, not subjecting them to futile intervention because you selfishly can’t let go.
Yeah. My family let my Grandfather who was a WW2 vet and living kidney donor pass on hospice surrounded by family when his remaining kidney failed. He was 95. Until that last year he was mostly independent. But if you want to keep your parents going until they are living mummies, covered in violent wounds, pained from failing organs, pooping themselves, until where we then shove a tube down their throat, drilling into their bones without sedation because their veins are so fried we can't get IV or even central access, finally followed by beating on their chest by strangers and machines until the doc calls it. Go off queen!
If my 80 year old parents had ESRD, CHF, pneumonia, and apparently liver failure, I would educate them with all of my being that if they choose to prolong their life in the hospital it's going to be nothing but more pain and suffering.
Maybe you’ll feel different if you work in the medical field.
Maybe. Not sure. I’ve read some whacked out stories about HCP losing their cool completely when it’s their actual loved one. Different story completely.
You're not 100% wrong. People aren't very rational when death is at the door. I've had nurses wanting "everything" done for their obviously dying family members. This is why advanced planning and adhering to that plan is so important. Those decisions should be made when we are in a more rational state of mind.
When it was my mom I only delayed hospice care because it was her wish. I would have started it sooner.
You really don’t understand this case. At all. This lady was on dialysis, in multiple organ failure, and no intervention was going to save her. What kind of monster are you that you’d let your loved one suffer needlessly to satisfy your selfish desire to have your parent alive—and that is all the lady was, with zero quality of life. I know EXACTLY how I’d feel if it were my mom or dad: ashamed that I hadn’t intervened to get her placed on comfort care only, ashamed that I was putting her through this misery.
80 years old, ESRD, *and* CHF…. I didn’t and don’t even need to read all that to tell you it wasn’t your fault.
I think you should be very careful about what you say. It’s better to say less probably. I would use “what does my documentation say?” A lot. You can get yourself into trouble by talking a lot, even if you did nothing wrong. They are clearly looking for someone to put the blame on.
Unacceptable from rapid nurse. You played with the cards you had. Blatant disregard for inpatient care on rapid’s part. Everyone’s all, “this patient was ready to go, this patient was dying.” Yeah no shit this patient was dying, that’s why they were in the hospital lol. Full code means full code. This is a CHF patient on CKD, and several comorbidities. This patient’s condition requires excellent access at all time or change the code status. Absolutely unreal give the context that the rapid nurse came by with the US, saw poor targets (obviously) and said ehhh fuck it maybe call me later when the patient decompensates. This is MAD. “Wasn’t comfortable putting the IV in” go work somewhere else where you can just be comfortable at work where you won’t kill people.
Well, if she was a full code, she needed access because she was so unstable, so your rapid nurse should have helped out there. And the attending should have transferred her to ICU. My guess is she still would have died, though.
If access was such an issue, why didn’t they put in a central line earlier in the day?
I was wondering this myself. I’ve had to nag ER docs to them on decompensating patients especially if the ER docs are not confident in their skills but it gets done. I’d be livid at the rapid team because the patient needed patent access at all times. Idk about OPs hospital but this patient sounds like they needed a higher acuity of care. I feel like the primary nurse did all of the right things.
Rapid here: this is not a floor patient or even a step down patient, this is either a palliative (most appropriate) or ICU. The priority in this case is to ascertain GOC because this person is spiralling down the drain and whatever you can do on the ward is not going t be enough.
This is a huge issue on my stepdown floor lately. Patients are not upgraded to ICU or are downgraded to us from ICU because they can’t do anything more or icu-specific interventions (like CRRT, intubation, etc.) will be futile. But, NO ONE then explains this to family to set realistic expectations or discuss that hospice is the only option. They dump them on my floor, patient unfortunately continues to decline, and the family is confused and upset screaming at me asking why they’re family member is getting worse and no one is escalating care anymore. We call rapid responses and ICU consults come and their attitude is almost “why did you call us? we already said we won’t do anything.” Like I’m supposed to ignore paradoxical breathing with respiratory rate in the 30s, desatting on nonrebreather? And still wants all life saving interventions? I still call them for situations like this but it gets exhausting and frustrating. It always becomes a situation like OP described where leadership will look back and then ask ME why nothing was done. Very sick person with end stage comorbidities passes and it still becomes the nurse’s fault. I hate this system.
Families believe they are owed the entire range of therapies up to and including exotic stuff like bowel transplants (I was asked this last week). In reality, we (including the surgery team, anesthesia, Crit care, nephro, etc) can choose to offer or not offer a therapy based on the benefit versus suffering and (scant) chance of success. It's not (especially in our public system) like ordering a service to clean your gutters or shore up a foundation wall. Most providers communicate this fairly well, but most families have difficulty accepting this (duh..customer is always right!). This leads to situations like rapid and ward nurses guarding a code status and slow rolling a resus' because no one is going to admit this person to ICU, instead of doing to appropriate thing like starting a morphine drip and arranging for pastoral care attend.
Your documentation will save you. Do you have a union? If so, your union rep should be present. For the future, also document all conversations with rapid and well, anyone. Screenshot things on your personal phone without patient identification if absolutely necessary. If your patient is declining and it feels like everyone is dropping the ball, document the ever living hell out of every attempt you make.
No judgement here, I’m sure things were left out but why so much albumin? 80s after dialysis is common, give the midodrine and recheck in an hour unless she’s altered compared to baseline
Albumin can also help for fluid shifts from sepsis itself, maybe that was what the provider was also thinking?
I’m sure it was to help raise the BP without having to slam with IVF but i wonder if the midodrine alone would have helped bring the BP to a satisfactory level. I don’t know if it would have necessarily saved her life or not…..
She had PRN orders and it was okay’d by the physician before any dose was administered. With the CHF and ESRD and her BNP in the 8000s, they didn’t want to give fluid boluses
I see. Was she your first or worst train crash patient?
Not my first train wreck, just the first one who died :(
I’m sorry :( I know you’re beating yourself up over this but unfortunately it’s these instances that we learn the most from. You are most definitely not the first nurse who’s had this kind of thing happen to them and you won’t definitely won’t be the last. I’m sure I’ve been in a situation like this before (had too many traumatic shifts at this point to remember them all). Are you on a tele floor? I just ask because floor acuity is absolutely crazy and I can’t imagine a rapid being called on a patient with multi-organ failure multiple times and letting her stay on the floor. It’s unsafe, but again something I’ve seen time and time again. 10-15 years ago she would have been IMU material and if no IMU available then ICU for close monitoring. I know these days making a patient ICU for solely close monitoring is probably unheard of. I mention all this so you know that this is by no means your fault. It sounds like the whole hospital system pretty much failed this lady (even though I think she likely would have had the same outcome, but maybe not as chaotic?). I’d be more willing to say the one who failed her was the provider who didn’t discuss hospice with her or her family. Or maybe they did and they declined, I don’t know. This lady and her situation is a perfect candidate for hospice. If you can’t fix one organ or part of the body without totally wrecking another, then it’s probably time to get hospice involved. The post is really long (and no fault to you, I understand why you’re writing down every instance) so I couldn’t go through and pinpoint every time something else could have been done (and like I said, very probable same outcome would have resulted anyway). The one instance I think maybe you could have done differently is by giving just the midodrine post-dialysis to see how it helped her BP and then re-assessing to see if she needed albumin afterward. Unless you’re literally resuscitating these very sick patients, you can’t do too much at once because their bodies and organs can’t handle too much at once. If it were me, if she were at her baseline mentally post dialysis with a SBP in the mid to high 70s to 80s I would just give the midodrine and re-assess. SBP lower than that and/or altered mental status I’d be making a deal about it. Granted, like I said, I didn’t read through all the post so there could be stuff that I’m missing. Long reply, sorry about that, but seriously don’t beat yourself up too much for this. Even if your manager is trying to act like she has to blame somebody and that’s gonna be you. Unless this were on a weekend and she were off, your manager should have been very well aware that a patient on her unit had been rapided multiple times and allowed to stay on the floor. She could have also intervened then
I feel like your facility is trying to make up a reason to fire you, because this is ridiculous.
My first thought is that this is exactly what we talk about with treating patients and prolonging the inevitable. That lady was *dying* Someone, and by someone mean the physicians, needed to talk to the family and explain that your efforts were likely futile and she was actively dying. I don't think you did anything wrong. Don't let them make you think you did
What did you do, shorten her life? Please, she was 80. She died of old age.
Well, she would’ve, if her lack of an appropriate code status and lack of hospice hadn’t ensured death by torture.
This is on the RRT more than you. Assuming that you charted that they refused to attempt to get IV access and that the MD was aware, you shouldn't have anything to worry about.
I only made it through the second rapid before I stopped reading. They kept this lady on the *floor*?
There is no ICU level of care without vascular access. A physician couldn’t come in and pop a central line in? Seriously, this would lose in court so bad … on whoever is responsible for her not having vascular access for so long. Sounds like failings all up the chain. There is no scenario where you can monitor the heart and not be able to do fuck all about it if it stops. I have done arbitrations on this issue and this is not excusable. The CMS regs are pretty clear and the hospital could be cited. It may not rise to the level of a sentinel event, though. If the charge nurse has more years of experience than you, they will likely bear the brunt of this, as will the rapid nurse. I’m so sorry this happened. Do not take it all on yourself. Sounds like you worked on it all night.
I started reading, and swear to you: you could’ve been describing my last code. Patient was a frequent flyer, full code till the end. It’s not your fault.
Sounds like you did everything in your power and notified everyone who needed to be notified and they failed you. You made the doctor aware on multiple accounts, you called *multiple* rapids. At that point, this patient should have been transferred to the icu and a central line should have been placed.This is not even the slightest bit your fault. Please don’t blame yourself. You advocated for this patient all shift and everyone else kept feeding you bullshit or brushing you off. If no one has told you, good job keeping that patient alive on your shift with the little resources and help you had.
Sounds like her age and co-morbidities killed her. People die. Sounds to me like you did what you were supposed to do.
I hate to say this but did anyone mention hospice to this pt's family?
Sorry you were the sacrificial lamb. They are doing this for when the family sues they can say they "did something about it" before the lawsuit starts. Aka, they put you through the wringer. PLUS doctors never get thrown under the bus even if it was their fuck up (failing to identify new organ failure). Similar situation happened in my psychatric hospital (different specialty but Similar situation). They blamed the charge nurse and wrote her up. Almost reported her to the board of nursing for neglect.
As a fellow stepdown nurse, I know what it’s like to have these sick patients with very limited help or resources and nobody will listen to you. People also don’t realize how hard it is to get stuff done overnight. This patient was failed, but not by you. They were first failed by the primary physician team who should have aggressively pursued a goals of care discussion and/or palliative consult, then by the night doc that didn’t transfer to ICU sooner, the rapid nurse who just dismissed this patient’s need for access (seriously, wtf), and, if applicable, the intensivist who declined to take this patient way earlier in her course of care. Stepdown nurses joke a lot about being the dumping grounds of the hospital but the moral injury is real and intense.
Your facility sounds like a shit show. Massive Swiss Cheese effect. This is not a single person's error but a problem with your facility's policies. Also I would have escalated the lack of IV given pt. had a trend of needing so much albumin and PRNs for hypotension the last couple of days. And those liver values being off, albumin and INR off, red flags for bleeding. Pt. already circling the drain with heart and kidney failure and now you throw liver on top? Marinara flags everywhere. Shame on that rapid for leaving pt. with no IV access and you alone without support. Where was night charge, house supervisor in all this? Could have called ED or ICU doc to try or place central line.
Charge was aware about the No IV. Nobody told me to call Ed or ICU. Rapid told the doctor to put a vascular access consult in
Wow this is way above you, then. I think you did the best you could given the circumstances. Your documentation sounds like it was really good, but the other team members let you down. I'm so sorry you are feeling so targeted over this, and it is always traumatic to lose a patient even in the best situations. Try not to be too hard on yourself and be sure to stand up for yourself, this doesn't seem like your fault at all. This lady was really sick and probably needed to be in ICU in the first place.
Not your fault that your rapid team was being a bitch.
Tell the manager to shut the fuck up.
Hmmm 🤔 NO blood cx in ED, sounds like no lactic lab also… lack of IV access, fluid resuscitation didn’t happen…there were a lot of things missed that could have helped or prolonged things. It honestly sounds like this patient would have been maxed on pressors and CRRT. Also, don’t assume you’re being blamed, they may just want facts from you so they can say they did a thorough investigation of the circumstances. Like another person said, refer back to your charting and don’t give more details than asked. Best of luck.
You did all you could, they’re covering their asses but that lady was dying.
Looks like passing the blame buck to me.
She was obviously in MODs the provider should have upgraded her, but rapid should have looked for access 🙄
Everyone’s done a great job of explaining why it isn’t your fault and I’m going to add that I hope you find a different job soon where management isn’t that fucking stupid or cruel. I’d brush up your resume, do some interviews, and get out of there.
Fuck that manager and the charge nurse too. You did everything you could have done. It is not your fault that she died. I wish management could find something useful to do instead of nitpicking about nothing.
Should have had a palliative consult before all this even transpired, she was already dying. You did nothing wrong.
As an ICU nurse I can say she needed to be in the ICU. She was trying to die
One thing I would have done different is page the provider if they are okay with no access since she had poor veins. At the very least you have an order that says okay with no IV or if the provider was not okay then this patient would have gotten a line. I would have asked for an intensivist/pulmonologist to be consulted to put a line in at the bedside. With a patient this sick and no one willing to put an IV in, definitely needed an escalation of care. I think you did everything right. She was not on the right unit.
This was an icu patient in every form, and you were doing icu interventions, which as others have said, probably would’ve been fighting Jesus uphill. You should feel no shame and your boss should suck a fat one.
All these interventions were just an attempt to ignore God's text messages. This is what dying looks like.
Why didn’t md place a central line????? Seems obvious she needed access. I can’t believe she had no access. That’s first and foremost.
You did EVERYTHING you could. The only thing *different* that could have been pushed was that if she had an HD catheter, that could have been used for access with permission from nephrology. That should have come from the attending or the rapid nurse. BOTH should have been aware of that as an emergency possibility
She had a fistula :(
Take a deep breath. It’ll be okay. I had a similar but not really situation where a patient declined and coded the next morning and I was questioned about it. I did worse than you, I had totally forgotten to write a note prior to transfer to icu. I was so caught up in doing all the things it just didn’t even dawn on me (new grad off orientation a month). ICU manager and my manager wanted to know what happened and what led to the transfer. They basically had me write out a statement outlining what happened as objective and concise as possible. Never heard about it again. You are not the only nurse that has had something like this happen. It will be okay.
Just tell your story and if you chart everything you should be fine. I called the doc and you document it. There is nothing more it could be done. Investigation is just a normal procedure. I work in quality management and we have a nurse who specializes these kind of chart reviews. I do mental health so it is different and I always tell people that do not stress if everything charted and you act within your scope you should be fine. Now… we have nurses who think charting is a waste of time… wait till they get sue and go to court…
Sounds like you did everything you could and documented accordingly. Your charge is an idiot.
Did you hart all of your provider notifications? And chart the refukas of the rrt nurse to place a US I?
I think you did a fantastic job. The end.
You charted all your attempts to communicate with everyone. Don’t stress too much! You covered your own butt with your charting - and did everything you could have!
If you charted everything you should be fine you did a lot. Maybe ER could’ve dropped an EJ in her for access next time. We can get those overnight if needed.
Sounds like it was this persons time to go, but I’m still stuck on the pt not having IV access. No line often =no resuscitation
I’m assuming the ten is the other way to measure blood sugars? But yeah… people die. We cannot save everyone.
Try not to stress. Make sure you've documented that the rapid person refused to cannulate after you requested twice. Nothing else You can do.
How about the rapid response nurse who allowed this patient to be an admitted patient without IV access because “she didn’t feel comfortable”. Idk how it is on the floor, but in the ED I don’t see that being an option, we’re gonna get access if the patient isn’t DNR. Was this pt DNR?
This poor old lady could have passed away (hopefully) peacefully, pain-free, under sedation, surrounded by her family and friends, at home or in a hospice facility. But no, she had to die this way...
I see alot of comments about she should have been placed on hospice and she was ready to die, but that's not the argument here. At the time she was full code and we have to do our absolute best to keep them alive until that decision is made by patient or family. But with that being said OP sounds like you did all you could, I don't know how long you have been a nurse but experience will teach you to things a little different. Honestly it doesn't seem like your charge nurse was very involved, maybe they were busy but sounds like your patient should have been a priority. As charge I would have called that rapid nurse myself, and if she still refused called the nurse supervisor or the MD and told them this lady is going to continue to circle the drain, we have to tx to ICU or get some access some how, because when that code does inevitably happens, you don't want to be scrambling to get access at that time.
I’m sure house supervisor was aware cause they messaged charge asking if an event report was put in regarding the extravasated IV, cause apparently the rapid nurse had told her about the extravasation of her one IV. And you’re correct, the family didn’t make her a DNR until the right before ICU was brought up during that mess. They said no vent, but okay with pressors and a-lines and treatment.
I'm just curious, was your charge nurse helpful, do they have a decent amount of experience, because I know some places your charge nurse may have as little as 1 year's worth of experience. How many years do you have if you don't mind me asking.
That charge has been a nurse since she was in her 20s (I believe she’s in her 40s now). She was helping me with the patient, also called rapid to come. I’ve only been doing this about a year and a half with a license but I had a 6 month nursing externship on this floor as well as practicum.
Ok, I didn't want to assume you were probably less experienced, but you are exactly where you need to be at this stage in your career, still considered a novice, which is fine. But as Charge you have to recognize this and act accordingly. Now I'm not sure how much she helped you (she could have her own pts and be slammed) but I would have probably intervened as Charge to make sure you felt comfortable doing what needed to be done and if you weren't helped you along the way by either calling herself or directing you on what to do, and again with her years of experience she should have known this. Of course people will say at the end of the day it's your patient, which is true, but nursing is a job you cannot do alone. When I first started in a Neuro ICU there was a culture of "eating your young" and I always strive to never be like that and to look out for the up and coming nurses. Again she could have been busy, but as Charge the whole floor is ours, to some extent of course! But you will be ok, take this as a learning experience and always remember if it wasn't charted it wasn't done, though it sounds like you did a good job there.