Two days in as a newly minted RN, and I am struggling. Everything is new. I’ve never worked at this hospital before, I don’t know anybody and to make matters worse I’ve thrown myself into the deep end taking a job as a critical care nurse resident on an IMCU/PCU/Telemetry unit. Our patients are sick or they are ok but ready to crump and decompensate on us in a split second. I’m that new nurse doubling back to the med room multiple times for supplies each time I get to a patient’s room only to realize I’ve forgotten something I need for the third or fourth time. Luckily I have a preceptor who is kind and patient and supportive. She wants me to succeed.
My patient I’ve taken for the day is sick; in fact she is dying. My preceptor and I cared for her yesterday as well. She is not responsive and on high-flow oxygen. She is puffy, at first I think she is just obese. I’m too green as a nurse to recognize this as a sign of third-spacing of fluid, which is when the body can’t keep fluids inside the cells or in the blood vessels and that fluid seeps into all the tiny microscopic spaces between cells. I’m too new to tell just how close to death she is, but I am about to learn. I do know that she has a history of COPD and is septic from its complications. We told her at the end of my first shift on the unit yesterday that her family is coming to see her in the morning. I hope she heard. Her family has arrived and discusses options with the doctor. They have agreed to transition her to “comfort care”, which means we will no longer be attempting to treat her illnesses, but will rather shift the focus of care to helping her be comfortable in the dying process while making that transition to the other side in the most peaceful manner western medicine knows how. In the comfort care order set is western medicine’s death-and-dying gold standard: a continuous morphine drip, backed up with Ativan, a sedative medication to control restlessness, agitation, confusion and anxiety and a handful of other medications like liquid tears, medications to dry up respiratory secretions and anti-nausea medications. I’ve run off to get the supplies needed to set up the morphine drip. I’m not going to forget anything. The last thing this family needs right now is a bumbling nurse who barely knows where the bathroom is, much less one demonstrating incompetence while their loved one passes on. I work slowly and methodically to make sure I set up everything correctly and start the drip. My patient’s granddaughter mentions that she is studying to enter nursing school and works as a nurse assistant. She tells here family about the Cheyne-Stokes breathing pattern she has just noticed in her grandmother. This is an abnormal breathing pattern in which a person alternates between breathing progressively deeper, and sometimes faster, followed by a gradual decrease in breathing and a temporary stop in breath called apnea. It is often an impending sign of death and she has picked up on it before me. The granddaughter has the advantage though; she is able to focus solely on her grandmother, while my vision is narrow and being squeezed tighter by stress and anxiety from everything that is new tome in this exact moment, which happens to basically be everything going on in my life currently. I’m barely capable of priming my patient’s morphine drip and getting her vitals, much less being able to see the big picture of my patient and the even bigger picture which involves caring for her family’s needs. My nursing vision is small and I don’t have the defenses yet that are needed to push back on the forces constantly seeking to make that vision smaller. I step out of the room to update the patient’s chart with the cares I’ve just provided. Not even five minutes pass and the granddaughter comes to grab me. She is flustered and thinks her grandma has passed. I return to the room. I brutishly feel for a carotid pulse, which is absent. The granddaughter states that her grandma has stopped breathing. I’m not exactly sure what to do. They didn’t teach us this part in nursing school. I look back to see my preceptor watching over me from the door. She quietly prods me to use my stethoscope to listen for any heart or lung sounds. I sheepishly turn back to my preceptor and state that I don’t hear anything and I believe she has passed. I don’t yet have the confidence to look up into this family’s eyes and deliver to them poignant but expected news that their loved one has passed. I will unfairly beat myself up about this for the next foreseeable future. My preceptor steps in and offers consolation and comfort to the family. We step out to give them some time and space to grieve with the body. It won’t be until a month or two later, after I’ve placed a few more patients on comfort care, that I better understand and more importantly come to terms with my roll as a nurse in the death and dying process. For some patients, our unit is the last stop on a progressively rickety train of life all too commonly plagued by years of physiological neglect or decades of chronic systemic physical deterioration. Patients either get better here or they don’t. And when they don’t, some families are ok with that and are ready to let their loved ones go. Other families struggle to let go or at least are caught off guard by the emotional assault related to impending acute loss or weighty decisions like doubling down on invasive care leading to intubation, ventilation, and transfer to the ICU. I’ve quickly learned as a new nurse the stark truth that in these moments of crisis, I am the one these families turn to for guidance, direction and support. Whether I have 2 days, 10 weeks or a year on the job, I am somehow, an expected (and trusted) expert attempting to guide families through the turbulence and stress of events that are just barely something more than foreign to me. It’s a part of the job I knew I was signing up for but in no way could have ever understood the burden of until I walked through the gates of nursing on the IMCU. Nursing school prepared me for the NCLEX and gave me the bare bones knowledge required to begin to think critically about my patients, but it in no way could have prepared me for the weightiness of staring death in the face on a semi-regular basis. It didn’t prepare me for having to note the time of death of a patient and deliver that news to a family, as far as I knew that was the doctor’s job. In my pre-RN life, my experience with death was minimal. I’d attended a funeral here and there and watched my extended family grieve for a cousin taken from us suddenly and perhaps unexpectedly. All of my grandparents passed on, but I was miles from their bedside. I’d never seen anyone die. I’d never felt the salience of that moment when someone takes his or her last breath. After a while the family was ready to leave. I couldn’t find the words to say beyond telling them I was sorry for their loss. My preceptor offered that she was a great patient and a sweet lady, but I didn’t know those things. It was my second day and I barely knew this patient. But perhaps my preceptor didn’t either, maybe she just knew the right time to offer some thoughtful words and provide a hug. And compassionate touch. I reflected later what a cold, sterile experience death in the hospital can be; and worse, I worried that I’d somehow unwittingly contributed to that type of experience for this family. That first patient death was a right-of-passage for me. It took me a while to process what it all meant. What I took away was that I did the best that I could in that moment, and looking back like many things in life, hindsight is 20/20. That first experience is now my litmus for how I will approach future encounters with death. We start out as nurses with minimal confidence and tunnel vision, but it is a beautiful thing to see ourselves grow and be able to take on more stressful situations and see more clearly the needs of our patients and their family. While doing post-mortem care for my patient, I offered a silent prayer for her. I didn’t know her well or for very long, but it felt like the right thing to do. When we were ready to transport her to the morgue my manager decided to accompany me. She showed me our hospital’s ‘books of the dead’, which are two very large ledgers documenting the names of all those who’ve died at our hospital. It is a record stretching back more than 50 years. I added my name next to my patient’s name and added some of the details surrounding her death. We flipped back through the pages, remarking on the weight and power of this record. It was impossible not to feel a part of something so much larger than myself in that moment. Here in this basement room of our hospital I inked my name into a chain of events that started long before I was born and that will continue on long after my name is perhaps been added to another book of the dead somewhere else. In some ways, as nurses, we stand as gatekeepers of death. We hold the keys to the medications and interventions doctors order. In most cases if we used those tools to hasten death we would be called murderers. However under the special circumstances of comfort care, this action is encouraged and sanctioned. Its taken me transitioning several patients to comfort care for me to become comfortable with this roll of nursing, but it is still something I struggle with at times. In essence the medications we provide for comfort at the end-of-life can potentially hasten death. However guided by the principal of beneficence we as nurses act to minimize suffering, through charity, mercy and kindness. No one is immortal and we cannot ultimately push off the bounds of death. We can however make that experience more tolerable and calm for our patients and their families, which hopefully, ultimately outweighs any commitment to nonmaleficence we may feel. As a nurse with strong religious inclinations, this has been something I’ve had to work to come to terms with. Those decisions are particularly difficult in cases where a patient and family are refusing care and intervention in spite of a provider’s belief and perhaps a personal belief that something more can be done. Later when we got back up to the unit from the morgue, my manager told me that it would be important for me to find a way to process death in this line of work. She shared that her method was to keep a list of the patients she cared for that died, and when that list gets full she goes to the ocean and lets that list go in some form of cathartic release. I reflected back to the prayer I offered in the room that day for my patient and decided that would be something I would take forward to bring closure for myself and to give to each of my patients I cross paths with who ultimately pass away. Looking back, she was certainly right. Here I am seven months later still processing those events. These are real people, with real lives we care for and their imprints will be left on us from time to time, sometimes when we least expect it. While I didn’t start keeping my own list that day, I do remember that patient’s name. And perhaps when my list gets too large to keep track of in my head, I’ll jot those names down, hike them to a beautiful mountaintop and devise my own catharsis to let them finally go.
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Alexander McNaChronicles of my journey into the nursing profession. Archives
September 2018
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