A Nurse’s Reply

What do we see, you ask, what do we see?

Yes, we are thinking when looking at thee!

We may seem to be hard when we hurry and fuss,

But there’s many of you, and too few of us.

We would like far more time to sit by you and talk,

To bath you and feed you and help you to walk,

To hear of your lives and the things you have done;

Your childhood, your husband, your daughter, your son.

But time is against us, there’s too much to do –

Patients too many, and nurses too few.

We grieve when we see you so sad and alone,

With nobody near you, no friends of your own.

We feel all your pain, and know of your fear

That nobody cares now your end is-so near.

But nurses are people with feelings as well,

And when we’re together you’ll often hear tell

Of the dearest old Gran in the very end bed,

And the lovely old Dad, and the things that he said.

We speak with compassion and love, and feel sad

When we think of your lives and the joy that you’ve had.

When the time has arrived for you to depart,

You leave us behind with an ache in our heart.

When you sleep the long sleep, no more worry or care,

There are other old people, and we must be there.

Sp please understand if we hurry and fuss –

There are many of you, and too few of us

Liz Hogben

~

He was a child before he was born

Now he is helpless, old and forlorn.

He was a husband, long years ago

He walked with his wife, their cheeks all aglow.

His wife was a mother, she had babes at her breast

Caring for others and giving her best.

He was man, salute him for this

Now he is withered and harder to kiss.

Speak to him gently and nurse him with pride

Now as he waits to sail with the tide.

Ours are the last hands he’ll ever hold

Let him know love now he is old.

Kathy Doyle

~

~Act Thirty~

  • To recant what mum was given on the 7th:
  • 7-9am mum was given:

2G Ceftriaxone IV

1G Paracetamol Calpol

40mg Furosemide Oral

5mls Carbamazepine Oral

5mg Salbutamol Neb

0.5mg Atrovent Neb

  • At 12-2pm mum was given:

500mg Clarithromycin IV

7500units Dalteparin SC

1G Paracetamol Calpol

5mg Salbutamol Neb

0.5mg Atrovent Neb

  • At 4-6pm mum was given:

1G Paracetamol Calpol

1000mg Vancomycin IV

  • At 5.10pm mum was given:

40mg Furosemide IV

  • At 7pm mum was given:

1G Paracetamol IV

  • At 10-12pm mum was given:

1G Paracetamol IV

  • Now for the 8th!
  • At 7-9am mum was given:

1G Paracetamol IV

40mg Furosemide  (Oral but patient couldn’t swallow therefore not given)

5mls Carbamazepine (Oral but patient couldn’t swallow therefore not given)

5mg Salbutamol Neb

0.5mg Atrovent Neb

  • On the 8th!
  • Notes from the ward manager in Large Writing:

W/R  Sb Dr …..

For 12. IVI’s.

For 20mgs IV Furosemide

General condition very poor.  Daughter has been in attendance all night and morning.

She has been informed of the gravity of mother’s condition.

M………..has been offered the full hospitality of the ward – she has refused.

This is So, So Boring!  And pathetic for an adult to write such drivel!

The truth was that I was offered a cup of tea or coffee, and gratefully said ‘I wouldn’t mind a cup of tea thank you.’

Two nurses (one of which was the disgruntled one earlier) also offered me a mattress in the day/props room if I wished to lie down, and I thanked them politely and told them I was not leaving my mother.

There was absolutely no haughtiness on my part, I merely wished to be with mum!

What if she had opened her eyes again, which she never did!

  • The ward manager also wrote in Huge Writing on my mother’s Oral Intake Assessment Chart:

8/2/…N.B.M. Remains Very Unwell.

8/2/… N.B.M. – Unwell. Unable to eat.

  • At 11.30 the chart read:

B.P. 139/78, pulse 109, O2 78% on 10L, resp. 26.

The chart has an increase written sideways up 15L 90%.

  • At 12-2pm mum was given:

1G Paracetamol IV   (Written by other doctor)

20mg Furosemide IV (Instructed by Consultant)

7500units Dalteparin SC

5mg Salbutamol Neb

0.5mg Atrovent Neb

  • On 8/2/… the Consultant came round to ‘explain the gravity also’ and wrote in his doctors notes:

W/R

Very poorly

Creps throughout (R) lung

(L) lung – good air entry

Continue antibiotics

Which antibiotics did he refer to?

The fact that he writes this in plural denotes that he had more than one in mind, therefore which antibiotics were these?

Since FY2 who was Not On Duty on the 7th, signed off the 2G Ceftriaxone after 7-9am, and 500mg Clarithromycin after 12-2pm on the 7th which accords with writing the prescription for 1G Vancomycin in time for the pharmacist to dispense same, (proving that she most certainly was about on the 7th yet wrote No Doctors Notes At all about her Plans) and since this Vancomycin was only to be given every 48 hourly, Which antibiotics was he referring to?

Risk of further PE>>

  • Where did this come from?   And When?
  • Had there been a PE no-one had written about previously?

risk of recurrence of I.C.H. (Intra. Cerrebrael Haemorrage) => continue anti-coagulation.

=> balance of risk explained daughter + ‘serious’ chest infection.

Not taking oral med.

=> monitor re: LVF => may need IV Furosemide.    Signed by the Consultant.

  • At 4-6pm mum was given:

5mg Salbutamol Neb.

5mg Atrovent Neb

FY2 wrote a prescription on the page which she had previously left blank numbered (F) for *20mg Furosemide IV on the 8th, and after this was given at 12-2pm she signed this off?

This * was instructed by the Consultant and written on the ward manager’s notes only!

What if more had been required?

What was the rush?

FY2 also stopped the fluids which were instructed by the Consultant after writing a fluid prescription and giving this once at 12pm!

FY2 was Never diligent about signing off prescriptions before so why now?

FY2 also signed off the prescription above this number (E) after the 1G Paracetamol had been given at 12-2pm!

This necessitated the doctor at 7pm writing a Once Only prescription for 1G Paracetamol IV?

This was despite the fact that when FY2 also informed me about mum’s situation she told me ‘They would keep her comfortable with Morphine!’

I said Morphine? Why Morphine? Is she in pain?

The reply was, ‘The blood clot in her leg, may have or could travel to her lung.’

I asked her why mum could not have Paracetamol instead, and she said ‘it’s possible!’

I also asked her what would happen about fluids since her Venflon had tissued,

Her reply was that ‘they could do a sub-cut,  (Subclavian Cut)  ‘it’s easy!’

‘What is that?’

‘We cut the vein just below her neck at the collarbone and put in a line’.

FY2 was very emphatic that giving my mother fluids ‘wouldn’t do any good’.

Had I known about the bronco-pneumonia I would probably have agreed, but was told Nothing!

I asked, ‘Is there a remote possibility that if my mother was to receive fluids that her throat would be lubricated?’

‘It’s Possible’.

‘Then I’d like that please.’

A Precipice In Front

Wolves Behind

Oscar Wilde

What I did Not Know was the fact that when FY2 was telling me ‘fluids wouldn’t do any good’, that the Consultant had already instructed this to be given and that FY2 had complied by writing a Parenteral Fluid Prescription Sheet to start at 12.oo.

Why was FY2 trying to stop the giving of fluid, as she stopped this after one dose?

  • This has echoes of the Liverpool Care Pathway where people are taken off fluids and food to hasten their death!
  • A Further Question Arises?
  • What was in the IV bag given to my mother by sub-cut and removed at 4pm by a nurse?
  • FY2 had stopped the Fluid, the Paracetamol and the Furosemide after 12-2pm!

Unknown to me FY2 wrote a prescription for 2.5mg Morphine, route S/C, indication agitation, Max. Frequency PRN.  (as and when required).

There was no chance of Paracetamol instead! (More Blatant Lies!)

This left nursing staff No Alternative but to give Morphine!

Therefore FY2 signed off the Furosemide prescription after one dose at 12pm, signed off the Paracetamol after the 12-2pm dose, only gave one dose of Fluid at 12pm, and wrote a prescription for Morphine!

FY2 Did Not sign off the Dalteparin after the 12-2pm dose on the 8th!

FY2 Did Not sign off the Vancomycin after the dose on the 7th as it would be due on the 9th and presumably mum would require this if she had lived.

FY2 Did Not sign off the 5mls Carbamazepine Oral on the 8th after 7-9am could not be given (Patient couldn’t swallow as she was in a Coma).

FY2 Did sign off the Furosemide 40mg Oral on the 8th after the 7-9am could not be given.  (Patient couldn’t swallow as she was in a Coma).

FY2 Did Not write another prescription for Furosemide IV to replace the Oral one!

FY2 Did write (at the Consultant’s instruction) a prescription for 20mg Furosemide IV for 12-2pm then signed this off!

Why the rush to sign this off, rather than leave it open?

Another doctor wrote a Once Only prescription for 1G Paracetamol IV on the 7th (which constituted an overdose) and also wrote a regular prescription for 10-12pm on the 7th, 7-9am on the 8th, and 12-2pm on the 8th. 

FY2 then signed this Paracetamol on the 8th after the 12-2pm dose, despite mum lasting until 8.45pm!

Why the rush to sign this off, rather than leave it open?

This meant that mum had No Paracetamol since 12-2pm until she died at 8.45pm?

Yet, FY2 wrote a Morphine prescription in case of distress.

  • This was clearly deliberately Pre-meditated!

Since the Doppler after 5pm on the 7th had shown mum to have a clear indication of a Clot, then why would Paracetamol suffice for this by the SHO on the 7th

Would mum not require a Morphine prescription (just in case of distress) after the SHO saw the report from the Doppler on the 7th?

Yet this FY2 thought she would require Morphine on the 8th?

  • It doesn’t Add Up!
  • N.B. Agitation can be caused by many things which do not necessarily require Morphine.
  • Patient was showing No Signs of Pain!
  • FY2 Review:  (Taken from SHO’s notes).

Sats down to 82% on 60% O2.  (Where did this come from?)

90% on 15L via trauma mask  (Taken from chart at 11.30am)

Sweaty & Clammy.  (Taken from the SHO’s notes)

Cheyne stokes breathing.

Up RR.  Chest with a small sketch.

poor (R) sided entry + creps (L) basal creps.

No signs of failure.

On 12. IV fluids.  (Instructed by the Consultant and written on ward manager’s notes, with a Fluid chart written for this by FY2 to start 12pm – only given once despite writing this for Three times with Dextrose in-between).

Imp/Very unwell 2. infection + – PTEs.

not likely to improve.

‘I have explained this to her daughter.  We are doing as much as we can.  I also explained that at this stage we feel it is best to keep her comfortable and will give her Morphine if agitated.

  • She understands this.’
  • What a Blatant Lie!

This was the Second occasion this FY2 wrote ‘She Understands This’.

Both occasions resulted in telling me lies!

The first time was when she told me about her proposal to give mum Heparin on the 4th, when she ‘explained’ this as if she was going to give this for the first time.

The second time was this tale about ‘Morphine’ despite my stating that I wished to have mum given Paracetamol and was completely unaware that FY2 had already signed off the Paracetamol Before she told me ‘It’s Possible’!

Also discussed with (Consultant).

Plan:

15 O2.

Keep comfortable with Morphine.

The IV bag was removed at 4pm*** and shortly after this a nurse came in and without even acknowledging mum or I, proceeded to ***remove the urine bag (which was half-filled with deep yellow urine), so presumably any fluid was to either gather in my mother’s bladder, or fall onto the floor, or perhaps onto the blow-up mattress which they had moved her onto; when I asked a male nurse? if they were going to take her bed into the ward  ‘to be nearer the nurses station’ and he said ‘Yes’ (More Lies, but hey it’s just her daughter, so what does it matter!, just tell her any old patronising story) but when the curtain was drawn around her bed I saw the sheets thrown onto the floor and knew they were shifting her about again!  Her poor little body was through the mill.  I was unaware at this time that she was being lifted onto this blow-up mattress!

As for being nearer the nurses station, this was sheer baloney as not one nurse came to see how mum was. 

Not once!

  • Nurses notes at 6.30pm:***

Now for S/C fluids as no IV access.***

I am reminded of Shakespeare here who said:

~All The World’s A Stage ~ And It’s People It’s Players~

Only thing is, most people like to watch Stars, not stand-ins feverishly trying to please in order to get more parts!

  • How is it possible for an SC to be done at 6.30pm when the IV bag and the urine bag had been removed at 4pm?

Family want to discuss Mrs……..case to date.

  • Nurses notes from Communication with Relatives:

Mrs…. daughter and grand-daughter asked staff if they could speak to doctor.  Advised that only ‘covering’ doctor on duty, but they would be paged.  Asked if I could help them in any way.

Asked if getting fluids changed to S/C meant it was ‘like switching off life support’ (my daughter’s reaction).  Explained it was absolutely nothing like that and the only difference would be that sub-cut is less invasive and she would be getting some volume of fluids – only over (possibly) longer times.  Also explained that as condition very poor, IV Paracetamol was discussed and PRN Morphine is possible to control pain.

Was she aware that the Paracetamol prescription had already been signed off?

Asked about oral meds. – explained all discontinued as condition too poor for oral diet. (My daughter’s question) Again explained that medication received very carefully (Did this include the Vancomycin perchance?) and medical staff decide.

This was the (previously disgruntled) nurse who then asked Again:

Explained again that they do not want Mrs….. resusitated.  This has already been discussed and decided by family and medical staff.

Why the constant need to verify this?

This was the Third Time!

Mum died at 8.45pm that night, so the amount of Morphine she had been given must have been sufficient in her body from 2pm – WoW that must have been some amount – for no distress for Almost Another Seven Hours !

It doesn’t matter that the prescription for Morphine was never signed as the mandatory sheet for Vancomycin was never completed.

Also since mum had been on a Constant bombardment of Paracetamol since she arrived there, are we to expect that after the scenario at the Doppler she could just be taken off this completely after the 12-2pm dose?

That is unless it was known that the Vancomycin dose had done the trick and put her into a Coma, then if ‘Agitated’ there was always the convenient top-ups of regular Morphine which, when given sufficiently will stop the heart!

  • At 8.45pm Mum Passed Away!
  • Within seconds a yellow palor (like someone painting her) passed across her entire face and body!
  • The Jaundice swept over her like a wave!
  • The speed this was exceptional!

The fact of the Jaundice is the only slight comfort I have in knowing I was right in not allowing mum to be resusitated, as she would have been in agony, and the only recourse would have been lots of Morphine, which may not have been sufficient by that time.

The fact that I was put in the position of deciding to allow my own mother to die because of taking her into that place shall never be excused.  I Do Not take  any comfort in the fact that all of this was deliberately brought about, and I talked my mother into going there initially!

I sat with mum to be sure she was gone and put my head out of the curtain, where two females were changing a bed at the farthest away corner while talking non-stop to each other – eventually responded to my saying ‘nurse’.

Another FY2 was sent for and she was so gentle and kind toward my mum talking to her as though she could hear her (possibly just in case she could).  She did various tests and said time of death 9pm which I corrected at 8.45pm.  She acknowledged this with sympathy and left us both alone.

This FY2 was asked to certify death!

-No breath sound one minute.

-No respiratory effort one minute.

-No pulse one minute.

-Pupil fixed and dilated.

Time of Death:  8.45pm

Cause of Death: Bronchopneumonia.

  • Nurses notes:

Patient died at 8.45pm.  Doctor notified.

Daughter will collect Death Certificates today.

Disgruntled nurses notes again from Communication with Relatives:

Mrs………….  died at 20-45hrs.

Her daughter was in attendance.

Following Mrs…….. death the daughter said that she didn’t want her mother to go down to the Mortuary.

She wanted to take her mother’s body home with her.  Myself and S/r ……….. explained that this was not possible.

The daughter then said she wanted an undertaker to take her mother to the chapel of rest right away.

I did not say ‘right away’, I merely thought that they would not want mum staying in the ward with other patients; understandably; and I wanted mum to go somewhere nicer than a mortuary!

S/r……. explained that it would be unlikely that an undertaker would be willing to come out at that time of night.

Eventually after telephoning an undertaker from the ward Mrs…….. daughter was satisfied that her mother would go to the mortuary.

Daughter and friend in attendance at this time.

I asked if mum could go home with me, or if a Funeral Parlour could be contacted, but was told that was not possible because she would have to remain there until the doctor certified her death in the morning.

The two nurses told methe Mortuary was a nice place’!

Can you believe this?

FY2 notes:

8/2/…..  Death Certificate Issued.

Cause of Death   

1a –  Bronchopneumonia                                      

1b – Pulmonary Embolism

FY2  Could not know that mum died of a Pulmonary Embolism as there was no way of telling it had moved from the Femoral Artery.

Only a Post Mortem examination would show this for certain!  It possibly never moved, especially with Morphine numbing the body, and no movement from mum at all apart from breathing with the Trauma Mask!

Since two doctors are required to sign this Why was this not seen?

  • I did not know at that time that doctors are paid to sign Death Certificates!

That’s Terrific!

So the people purported to be looking after you get paid by you when you die!

Mum had been sitting watching a film on Television the night I noticed her heart racing a bit when she retired for the night, and if it had not been for my stupidity in asking that G.P. about occasional oxygen -if and when she required it for occasional use – my mother would have been safe at home, and when her turn came to leave, she would have been able to die in her own bed.

  • Certainly Not by Involuntary Euthanasia-so don’t fool yourself as this is exactly what happened.

Do Not Be Like Me! 

Do Not Trust Blindly! 

Ask Questions All The Time!

Get The Right Answers!

I’ll be back in two or three weeks with Curtain!

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