Wednesday, 28 January 2009


In this profession you standardise you're level of success or failure based on how many patients are alive when you leave the ward. If you have worked a shift and none(or in critical care very few) of your patients have died then you mentally tick that off as a successful shift.

Many wards at any one time have patients who are palliative, they are dying and there is nothing that can be done medically to prevent this. Fortunately there are care pathways(protocols) in place for any patients who meet very specific criteria. This takes a lot of the difficult decisions out of the hands of doctors, nurses and the patients family. The standard care pathway in my trust is the Liverpool Care Pathway. Once a patient has started on this care pathway their treatment is purely for comfort. Analgesics, Anti-emetics, etc are administered
more or less constantly via a syringe driver. A device that slowly injects medications over a given period so rather than a patient getting a dose of morphine for their pain at 1300 and needing another dose at 1500, the driver releases the same dose into the body constantly over x amount of hours. This not only means the patient is constantly receiving pain and sickness relief but the nurse doesnt have to wake the patient up every three hours to administer the drug.

Once a patient is on the LCP and non-essential medications are discontinued(pretty much anything they wont die immediately if you take them off) and their observations are either ceased or taken only once a day as it is an uncomfortable thing to do to a patient but absolutely necessary for a patient who has a chance of recovery. In patients with no chance of recovery whats the point of waking them up at 0500 every morning to take their blood pressure, pulse, oxygen levels, etc. On a regular basis the patient is assessed for pain, agitation, nausea,
breathlessness, etc and if there is any variance on these then the medication the patient is on is adjusted so that they are as comfortable as possible.

This phrase always made me laugh "as comfortable as possible". The patient is dying, they are scared, exhausted, probably in pain. What we make the patient isnt anywhere near comfortable. And to add to the discomfort we take them off fluids and food and of course they are bed bound so they will be cathatarised. Ethically is this the right thing to do? they are dying and food, fluids, etc will prolong this however do we want their last hours to be spent, thirsty and hungry?

And back to my original point when you leave the ward and one of these patients has died how do decide if it was a success or a failure on your part?


Sage said...

That is such an awful dilemma, you can't pick one or the other.. just that they died without pain is a success, but it isn't a way I would choose for myself to have every amenity taken away. I don't envy your job at the moment, you must sometimes have a heavy heart.

asclepius' wife said...

the point of the liverpool care pathway is is indeed to make the patient comfortable. what else are you doing??

Some patients are alert enough to know what is happening around them in these cases you offer them food but in many cases they feel too poorly to actually eat and will refuse. There is no 'protocol' to say you stop altogether its the patients choice!

In other cases where the patient is not alert enough to swallow food it is infact dangerous to even try feeding them!!

There are many many research articles exploring the fact that giving patients within 72 hours of death fluid is in fact cruel as your are just prolonging the inevitable. They also suggest that the patients do not feel hunger or thirst. I suggest you may want to read some of these before deciding whether it was a success or failure.

As i believe it is a failure if that patient is made to live and suffer longer just because you dont want your patient to die!
Because there is only one inevitable thing in this life that is we die if i can go in peace with out having cannulas, nasal gastric tubes, bags of fluid and obs machines around me, but have my family there who have had time to say goodbye that would be a sucess!