permission slips and field trips

My patients don't die, they go on field trips. I don't let them go on the field trip without a signed permission slip (DNR). At least that is the way it is supposed to be.

The most draining, exhausting, burnout inducing cases are the ones in which the patient has had their permission slip signed yet the family refuses to let them go. A 90+ patient is admitted with ischemic bowel, there they lie in their bed intubated, TPN, Levo, Vassopressin, bicarb infusing into the central line, a-line pressure indicates a MAP barely above 60mmHg, CVP 4 urine output looks like over seeped tea and a DNR bracelet on their arm. Or the 80+ patient that signed a DDNR but the witness signature in not legible the family insisted that the EMTs do something when they were called to the home and now there the pt. lies in an ICU with the family refusing to accept the grim prognosis.

What keeps me going when I want to walk away and never look back? I'm not sure, I whisper in their ear that it will get better...one way or another it gets better. Scenario 1: The family will come to terms with the wishes of the patient and give them permission to go to the other side. Scenario 2: No matter how much or how many hormones, pressors, and fluids we pump into their system their heart no longer conducts the electrical impulses to keep it beating and life on this earth ceases for them. They are finally able to board their plane, train, car, boat, helicopter, UFO, wings of angels or what ever mode of transportation that is provided to the other side. Scenario 3: They may get well enough to leave our unit or hospital; but at what cost? None of them has ever come back and told me "thanks for keeping me alive"...then again none of them has ever come back and told me "thanks for staying with me till the end" either.

Since I have been a nurse (5 years) I have only had 2 of my OWN patients code (one lived on life support for a few days the other we were never able to revive). I do not know if it is luck, skill or because I let them know right up front that field trips are not allowed without a signed permission slip and their families permission; they are not to board the bus, train or plane. So far this has been an effective strategy for me along with a whole lot of prayer and diligence to keep them here until the next shift. Try it sometime and see how it works for you.

One is never prepared when a patient decides they are going on the field trip without your or anyone elses permission it can be devastating to one's confidence and moral. I personally still wonder if there is anything that I could have done better, diffrently, or faster to improve the outcomes for my patients.

Someday I will be on the other side and I will know the answer, but for today I have to have faith and courage to do what I do to the best of my ability.