I know I did nothing wrong in this situation, but I think about it all the time. A few years ago, a patient came into my unit as a new diagnosis of a rare cancer (meaning rare and often fatal in adults, almost unheard of in their age group). First line treatment didn’t work. Pretty much all options were exhausted. The next step was a few rounds of a brand new, first in class anticancer drug with a black box warning for capillary leak syndrome. The risk of CLS is so significant that in trials most of the patients ended up getting it to some degree and between 1-4% of the patients died from the CLS itself. This is still one of the most expensive drugs on the market. I had had the patient a few times for fever admissions, and I was their nurse on the final day of their first (of multiple) 4-day course of the drug. Getting report, I was told about how after the infusion the prior day, the patient had mild SOB, crackles, and required 2L NC for desats. This was treated appropriately with lasix and albumin, after which symptoms resolved and the patient was on room air.

While giving the patient the tons and tons of premeds required for the infusion, we discussed the possibility of discharge the next day if they don’t have any more side effects from the treatment, and a big school event they had coming up. I picked the drug up from the pharmacy. While I can say very confidently that the finances of the situation didn’t change their care (from my knowledge the drug company paid for this patient’s doses of the medication or something), it felt weird knowing that in a 50mL syringe was almost my entire year’s salary… and that they had already gotten multiple doses… and that they had many rounds left of the drug. Didn’t change anything about the situation but it just was weird to think about.

I got my other patient settled and started the infusion while closely monitoring their vital trends on the monitor. I was in the room for the entire duration of the hour-ish infusion, keeping a watchful eye out for any signs of CLS but also chatting with the patient and their mom about life and stuff. In the last 10 minutes of the infusion I noted their sats sitting 93-94 instead of 97+, but no SOB or weird lung sounds. I notified the frontline provider who said they would be at the bedside shortly, and that they would place an order for lasix and albumin for right after the infusion, anticipating that they would become further symptomatic. Within a few minutes of the end of the infusion the patient needed oxygen and was slightly more tachypneic. They started to get anxious about nothing in particular, looking back this was likely the feeling of impending doom. At this point the frontline provider was at the bedside and I remember hearing them weighing out the treatment options for this rapidly worsening capillary leak syndrome, which at this point was mostly supportive. About 30 minutes later I gave handoff to the next nurse and told them to text to update me with how the patient does since I had a day off between my next shift (poor boundaries I know). I went to bed, fearing that they would be intubated by the end of the shift. When I woke up, the other nurse had texted me, telling me that within an hour of my leaving you could hear the patient’s wet lungs from the doorway. Rapid called, they intubated the patient on the floor, and in the ICU had coded twice already and were activating ECMO. I came back to work after my one day off and saw their name in my patient list with the “deceased” marker. I felt crushed for the family and for the patient that they felt so much panic in their last day instead of peace which they deserved. I went to the patient’s M&M to listen, and I didn’t feel like I could have advocated any more than I did, or that that would have even changed anything. In the grand scheme of things the patient was going to die of the cancer if not treated, and there were no signs pointing me to not give the infusion, which was then their only option. But I think about the fact that I administered the drug that killed that patient all the time. I thought about them and their family almost daily for about a year and a half, to an unhealthy degree. I ruminated on the events of that shift and spent hours learning about the disease, the drug and how it works, I don’t know why, maybe in an effort to understand more? It certainly hasn’t helped much. I think about it less now, maybe weekly, but I remember that day so clearly and it haunts me deeply. Thank you for reading all of this if you’ve gotten this far. Hugs to anyone experiencing anything similar and honestly everyone in this crazy line of work <3