“Maggie” commented on the last post and had several questions. Since she didn’t leave an e-mail address, I figured I’d answer them here.

Hmmm. Hi. Interesting. There are somethings I don’t understand. Maybe you could help me understand, geena? Thanks.
1. He had “some acute renal failure.”
He was being dialyzed.
The dialysis machine then went kaput.
So he he must have been getting more swollen with fluid.

Well… in a matter of speaking. The machine was only off for about 2 hours, and it wasn’t like I was taking off a whole lot anyway; he wouldn’t have tolerated normal dialysis, which is why we were doing gentle dialysis. Gentle dialysis means that we could only take off a small amount of extra fluid each hour. So he WAS getting more swollen with fluid, but it wasn’t causing his current problems. The machine clotting off is just something that sometimes happens.

Then he started having breathing problems…why? Was this related to his kidneys or something else?
It sounds like he was “bucking” the ventilator if that is the right word. That is the reason for the paralytics, no?

He was kind of bucking the ventilator (which means the patient tries to exhale at the same exact time that the ventilator is attempting to give a breath, and it’s all out of sync). He was creating an auto-peep, or “stacking breaths.” Basically, he wasn’t exhaling completely before the vent gave him the next breath. He wasn’t overbreathing the vent, which was the wierd thing… it was just that for some reason, he wasn’t letting out all that was going in.

It sounds like he had a breathing problem aside from the kidney problem.

His lungs, remarkably, were clear. But the pH of his blood was extremely acidic, which made him do the “guppy breathing” we see in this case – almost a gasping, even though they’re being ventilated and are well-oxygenated. It’s weird, and a little hard to explain.

2. Once the dialysis machine was fixed, you were getting ready to put him back on, and the wife said stop?

It doesn’t sound like the medical team had decided that the patient was “unsaveable”. Did the wife really understand? Ie. was this an informed decision?

Yes, it was an informed decision. We did actually think that the patient was unsaveable, but it is not usually our place to stop treatment just because WE think that it is futile. In this day and age, there are a LOT of things that we can do to people to provide treatment, even though the medical team thinks it won’t ultimately save the person. The family makes those decisions and we try to guide them as best we can, in an honest and objective manner.

3. When the wife asked you if he was getting better, you replied you didn’t think he was. Then she said go ahead and disconnect, and you did.

When the wife decided to disconnect apparently based on what you had told her, how is it possible to immediately do that? Shouldn’t such an order come from the medical team, or specialist, or someone? Can the nurse decide to disconnect without any physician/team input, based on what the nurse felt about his medical condition?

Such important issues ARE discussed with the physicians!! When families ask me if their loved one is getting better or worse, I ALWAYS want to tell them that they’re getting better. But I also believe in honesty, and the family needs to know what’s going on. I think sharing my assessment with her was just a mere piece of the puzzle in terms of her decision. She could see him swelling with fluid, she could see his color getting worse… I was merely confirming for her what she already knew deep-down. I didn’t feel as though telling her that I thought he was getting worse was a big revelation for her and I don’t think that she based her entire decision on it. He had been fighting for his life for about a week and we had done everything we could to save his life, but it just wasn’t going to be.

Having said all of that, it is NOT within a nurse’s scope of practice to initiate OR withdraw medical treatment from a patient without a physician order. I didn’t mean to imply that that’s what happened. Since all of this occured on the day shift, 2 of the patient’s doctors were readily available in the unit. After I told the patient’s wife about her husband’s condition, she talked it over with other family members and then talked it all over with both physicians. Both doctors fully supported her decision (as they had fully supported her decision to initiate all of the treatments were were doing) and they gave me the order to start a Morphine drip and extubate the patient, stop all other medications, and stop dialysis.

I hope that answered your questions (which were great, by the way!)