final breath

Throughout my final semester internship I had multiple opportunities of exposure to palliative care patients because my unit at UCSF has two rooms dedicated specifically to palliative care.  During my final week on the unit, my preceptor and I were assigned a patient who had illeocecal  cancer and had not had a bowel movement in over a week.  She had lost her fight with cancer, but had not yet been moved to palliative care because the husband was not yet ready to let go.  During the morning shift report, the night nurse indicated that the patient and her husband, who was staying with her, had not slept much over the night and that they requested to not be disturbed until the 9 am medication time.  Despite this report, my preceptor and I discussed all of this woman’s comorbidities and decided that it would be inappropriate to wait until 9 am before checking on this patient.  I quietly entered the room to simply check her respirations to find that she was in the middle of moving from the bed to the chair.  Falls are of course a great concern, especially since her orientation was altered, so I helped her to her chair and checked her respirations.  She had a respiratory rate of 36, using many of her expiratory muscles.   This is incredibly high and a sign distress, since normal respirations are between 12 and 20 per minute.  The husband was awake at this time and I introduced myself, apologizing for interrupting his sleep.  He was thankful that I was there because the patient had not had much sleep and was uncomfortable.  I indicated that I was concerned for her respiration rate and that I would return with her ordered dilaudid and to take a full set of vital signs.  After the vitals were obtained and I discovered that her BP was 65/40 and her heart rate was 115: I knew that her physician needed to be notified immediately.   The physician and I discussed her vitals and determined that despite the husband’s concern, the patient was best suited to be placed on palliative care.  A meeting was conducted with the husband and palliative care was initiated.  Dilaudid boluses were administered continuously as we waited for the pharmacy to provide the PCA, but she passes away by 11 am, before the PCA ever reached the unit.  The dialudid brought her comfort. but unfortunately, her passing was not peacful.  Her obstructed bowel came up in a vile vomit of repose.  The husband, who was beside her during her final breath, through a blanket over her face out of shock from her final breath.  Surprisingly, the husband handled the situation well, despite the grim image of his wife’s passing.  The husband was very thankful for the attentiveness I provided for his wife, providing the comfort that she needed, and after I assisted in cleaning her up due to emesis that occurred upon dying, the husband hugged me for my assistance and care.  It is a delicate skill of attending to the family of the patient as much as the patient because illness does not only affect the patient; it affects all of their loved ones as well. What was most striking to me about the situation was that if I had simply taken report and not entered the woman’s room until 9 am her discomfort in her last hours would have been so much greater; she could have fallen in her transfer to the chair and she may have died before palliative comfort measures were ever started if vital signs were taken 2 hours later. The incident reaffirmed that in all of my patient care activities I must be diligent in conducting assessments continuously because patient status can change dramatically between shift changes.

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