Let me tell you of an experience during clinical lab at a nursing home. My students were divided, two in each hall of the facility, and I had been systematically working from one student to the next. Three of the students approached me rather timidly, so I stopped what I was doing to find out the problem. They had been helping with the feeding of those patients who were unable to feed themselves when they came to Mrs. A. This patient was not assigned to any student, but they had been instructed to work with others as they could. They had successfully given her fluids on the previous day, so they were upset when she was unable to take the juice offered this morning. On assessment the patient was found to appear very frightened and apprehensive while choking and coughing and there were no breath sounds heard in the lower thorax. Her mouth appeared very dry and the few remaining lower teeth were very dark in color.
The LPN working that wing was notified of Mrs. A's condition and asked if perhaps suctioning was advised. She arrived with a suction machine about the same time the director of nurses arrived in Mrs. A's room. For a short period of time the LPN unsuccessfully suctioned the patient's pharynx. The machine was turned off, covered, and pushed against the wall as the LPN and director of nursing were quietly conversing between themselves. On approaching them, I was informed that Mrs. A's doctor and family had left instructions to give no artificial life supports so she could die peacefully and with dignity.
This situation was not my idea of dying with dignity, because I believe every person has the right to- comfort, patent airway, and hydration.
My students were extremely upset and in tears as they left the room along with the two staff persons. Left alone, I closed the door, pulled the curtain between the two beds and proceeded to gently and slowly hydrate Mrs. A using an asepto syringe and water. She was able to swallow and on command took some deep breaths. Gradually the secretions liquified and loosened. As she coughed up the debris, I suctioned it into the asepto syringe. Some large chunks of dried material came loose from the inside of her mouth and were removed.
The LPN came back into the room and asked if I were successful in getting her to take any fluid. I answered in the affirmative and asked if there would be any objections to my using the suction machine. Permission was granted. Mrs. A seemed to understand as I explained what I was doing. She didn't particularly enjoy the procedure, but I was able to successfully suction her nasopharynx so her breathing was unobstructed. I raised the head of her bed a little more and before leaving her bedside I said a prayer. "Please, Lord, if this lady is to die, let her die relaxed, comfortable, and free of pain."
She relaxed and continued to breathe quietly and easily for as long as we were in clinical lab.
Next came a conference with the students. They were still upset and tearful as we talked about caring for the dying patient. They asked, "aren't we as nurses permitted to do anything for a patient in this situation? Did we hear the wrong message?" We explored our nursing responsibilities and the students were much relieved and satisfied when we came to the following convictions:
1. The nurse's responsibility is to support the dying patient physically, psychologically, and spiritually. She is to be kept comfortable, dry, wrinkle free, in good alignment, and in a comfortable position.
2. She is to be hydrated by being offered fluids as long as she is able to swallow and then by use of a moist cloth or swab when no longer able to swallow.
3. She is to have patent airway for as long as possible through suctioning the nasopharynx.
In the obituary column the following day was the announcement that Mrs. A had died at 4:50 the previous day.
Did she die with dignity?
Helen P. Long is Associate Professor in Nursing at Lima Technical College in Lima, Ohio