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Difficult Conversations

Arroyo, Vanessa BSN, RN-BC, CCRN

AJN The American Journal of Nursing: August 2019 - Volume 119 - Issue 8 - p 72
doi: 10.1097/01.NAJ.0000577472.38134.52
Reflections
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With time running out, a nurse makes sure a family answers a crucial question.

With time running out, a nurse makes sure a family answers a crucial question.

Vanessa Arroyo is a nurse at Tampa General Hospital, Tampa, FL. Contact author: vmikla@tgh.org. Reflections is coordinated by Madeleine Mysko, MA, RN: mmysko@comcast.net. Illustration by Gingermoth.

Figure.

Figure.

On a Monday morning, Mr. P, a bilateral lung transplant recipient, was admitted directly to the medical intensive care unit (MICU) from the lung transplant clinic for shortness of breath and high fevers. His differential diagnoses were pneumonia versus acute lung rejection. We see many pneumonia admissions in the MICU, and I knew his symptoms didn't match that diagnosis. As his condition quickly deteriorated, Mr. P began panicking and calling out for his wife, who was on her way to the hospital.

After three bedside bronchoscopies and an hour of me holding Mr. P's hand, we were able to get some samples to send to the lab. When Mr. P's tests showed a critically high donor-specific antibody level, the physicians quickly realized he was going through an acute lung rejection. Shortly after his wife arrived, I was informed that Mr. P needed to be intubated because he was not oxygenating properly. Two hours later, the patient I had been comforting and conversing with was laced with drains, lines, and tubes. I calmly explained to his wife what every line was for and promised to do my best to keep Mr. P comfortable on the ventilator.

Before I knew it, my shift and workweek were over, and it was time to give report to the oncoming nurse. But I couldn't keep this patient and family out of my mind. They were genuine and easy to talk to, the kind of people you can't help rooting for.

Mr. P remained on our unit for over a week. I wasn't assigned to him, but I would stop to talk with his wife in the hallway. Mr. P had been extubated and was working with physical therapy, which appeared to be a sign of healing.

Then on a Friday, I was assigned back to Mr. P. It was his 12th day in the MICU. He had become increasingly anxious over the past few days, intermittently confused and with higher oxygen demands; he was on heated high-flow oxygen via nasal cannula and now had a chest tube for a partial collapsed lung. On first glance into the room, I saw him taking quick shallow breaths and using his abdominal muscles; he was working hard to breathe and seemed extremely uncomfortable. I had a gut-wrenching feeling that I needed to have a difficult conversation with this family and it needed to be today.

During my assessment, I placed my stethoscope on Mr. P's clammy chest and listened to the coarseness of his breaths. I asked how he was feeling, and he said he felt anxious. When I asked if he was scared that he might be put back on the ventilator, he answered adamantly, “No more ventilators!”

I looked over at his wife. “Did you hear that?” I asked her.

“I did,” she said. “We had a talk about this.”

Then I asked if they had discussed whether he would like to be resuscitated with compressions and medications if his heart stopped. She said that they did not want him to suffer needlessly and that he had already been blessed with three additional years following the transplant. It takes a strong person to stick to the promise they've made to their loved one regarding end-of-life wishes, and I immensely respected her for this.

I notified the attending physician of their decision to become a full DNR. The physician came to the bedside and reassured Mrs. P that a DNR did not mean we would stop treating her husband—we would continue the current rejection regimen over the weekend and reassess the plan on Monday. This regimen was tough on Mr. P. The long hours of plasmapheresis and chemotherapy injections were taking a toll. The rest of that day was full of ice chips, hand holding, and hugging—which, I've learned, are some of the most important “tools” in the MICU.

The following morning, Saturday, Mr. P was more lethargic, and more peaceful as well. He deferred any questions I asked him to his wife and spent most of the day in a somnolent state. You did not have to be a medical professional to know Mr. P's time on earth was coming to an end. I spent that shift chatting with his wife and keeping Mr. P as comfortable as possible—the same promise I made to his wife on the day he was admitted.

Before I left, I hugged Mrs. P tight, and gave Mr. P's hand a hard squeeze. I would be off the next day, and felt uneasy saying goodbye, but told them I would be back on Monday. Mrs. P said, “We'll request you. You've been with him from the beginning.” Mr. P did not make it through the night; his heart slowed, and he went into asystole. It is never easy having difficult conversations with patients and their family members, but I am comforted that Mr. P was able to leave this earth with dignity.

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