Challenging Your Own Beliefs

Giving care to a palliative patient when you're not yet a nurse allows for reflection. Do you really practice what you preach, or are you just giving lip service? This is my account of a night that changed my perspective on what it truly means to support autonomy. Nurses Announcements Archive Article

Challenging Your Own Beliefs

My philosophy of nursing is being written tonight in the room of a dying ALS client. My job tonight: sit, watch and wait. She sleeps nearly constantly. Moments of terrifying choking while refusing suctioning and interventions. The nursing student inside me is crying out. "I can help!" I want to demand. Clearing an airway relieves distress, I'm nearly a nurse and I can help! I find myself changing.

My perceptions being challenged. Do I truly support autonomy, or do I merely give it lip service?

Her rhythmic rattling breathing now has moments of apnea. One particularly long episode has me at her side, touching her shoulder. My touch stimulates inhalation, causing both our bodies to jolt in unison. I return to my chair, settling in to sit, watch, and wait. Her breathing enters into a normal pattern. My ears stand guard to the gurgling breaths, permitting my mind to wander.

I have been taught the theory and nursing practices during the end of life care. I know the nursing standard that applies. I have provided palliative care to several families within my clinical placement. But this is different. Nowhere in my training have I been prepared for this. I'm not here in my nursing capacity. I'm here as a caregiver, in a home. Listening for that moment of death.

I don't like this.

It isn't comfortable.

Of course, I will give all the supportive measures I can within my scope. Use a gloved hand to remove mucous to clear her airway, I can moisten swabs for oral care and to provide moisture to prevent uncomfortable cracking. Frequent turning and applying creams to prevent skin breakdown. These are the most basic of skills that are the cornerstone of what it means to be a nurse providing care.

An exceptionally long apneic episode causes a tightening in my chest. Yes, this is fear, and I don't like it. This is uncomfortable, stomach churning. That "run away as fast as you can" kind of fear from childhood, wrapping its tentacles around my waist and squeezing. When I'm in the hospital I'm there as a student. I am surrounded by brilliant people who know so much more than me. Who have experienced so much more than me. They don't expect me to have all the answers, and to ask (what I am positive, to them are) stupid questions. They are there to jump in and save the day, I, however, am there to learn, observe and practice. They're the pros, they can rescue inexperienced me. Here, I'm alone. My only supports are myself and all my schooling, my instructors' experiences so generously shared, my ethics of nursing: promoting client choice, ensuring client well-being and respecting life ringing in my idealistic, soon to be graduate nurse ears.

Ya, I'm alone.

It's uncomfortable.

And I don't like it.

There are changes to the rhythms of her breathing. I feel that nagging fear again. Do I call her daughter? Is death knocking, or is it days away? Ouch! Fear's grip tightens. "You're all alone! What do you do? What is comfort care? What is 'no heroic efforts'? Where is the line?" Fear hisses in my ear. Breathing sounds regulate and return to their previous 8resp/min

I struggle with the similarities between birth and death. Being a doula, I have the philosophy that when an expectant mother is well informed, at peace with her decisions and well supported, she is able to relax, trust her body and give birth. Why then, do I struggle with the concept that death is no different? As I examine the ethical principles of nursing that I have learned, the struggle eases. It hits me like a ton of bricks. I'm not here to save her. I'm not here to provide care as what "I" consider a comfortable death, based on whatever evidenced-based practice I have bouncing around in my student nurse brain. I am here, to do in all my capacity, the wishes of my client. Using sound judgment, and fundamental nursing care, I will be there with my client till the end.

So here I sit.

Listening,

Watching,

Waiting......

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3aremyjoy

About 3aremyjoy

Nursing Student

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Specializes in Family Nurse Practitioner.

That was such a thoughtful and meaningful article! Sometimes stepping back and NOT doing anything is the way to provide care. Holistic nursing means taking the patient's preferences to mind and sometimes it means stepping back and letting time do its job.

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Specializes in Med/Surg, Ortho, ASC.

Never mind. Obnoxious post was removed

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Thank you Lev, I was very surprised at my own fears and insecurities that I felt with my first palliative client. My own insecurities regarding my abilities and my own personal beliefs surprised me. I had inner conflict with having nursing knowledge and fledgling skills but not being permitted to provide that care due to my job description. All the while knowing this client could have relief from some of these symptoms. I had given her care weekly for 5 months and gotten to know her and her daughter. She was a stubborn and courageous woman and we all came to care about her. They were consistent with all the caregivers and she had around the clock care given to her in the way she requested. Her rituals and routines were important to her, and we assisted her with carrying them out. We all came to know and were invested in following her wishes of dying at home with dignity.

Writing about this experience was cathartic for me, and forced me during this long night shift to practice self reflection in real time. I believe that night will be one of those pivotal moments in my career.

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Specializes in Ortho, CMSRN.

Beautifully written! I loved the contrast between aiding a patient between transition in their lives as a doula in birth, and then in palliative care. It takes a very mature individual to work in palliative care without it rattling them. You either have to be calloused, good at not bringing work home, or know yourself... VERY well. I admire those in the latter category, which... I think most are. It is hard. As a nursing student working as a PCT, I got asked to sit on various floors occasionally at nights. I remember one patient who was dying who I really wished I could have done more for... He kept saying "it hurts, it hurts, help... please help". I asked about his pain control and was told that his respiratory condition was such that they were worried that he would quit breathing. He was in and out of coherency, but I think, looking back, that THAT was the time for someone to talk with him about a living will and palliative care, he had refused it prior. I'm sure that was in the works and I just didn't know about it. Sitting with him though I remember the helplessness that I felt. All I could really provide was human presence and sympathy. But the pain and despair in his voice was just so sad. Many nurses that I know, especially older ones have living wills and DNR's. I haven't drafted one yet, but it is on my to do list. Seeing what we DON'T want in death is fairly common in our profession I think. Meanwhile, we must respect our patient's wishes on death.

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These moments are very tough and working in an ICU, I can tell you I work around death almost on a daily basis and it does take a toll on you mentally, physically, emotionally and intellectually. Anyone who says the can leave work at home, are liars. Some of us just have an easier time putting those memories and moments way back, in the farthest corners of our consciousness. It is very hard to have to sit back and watch the patient practice their own autonomy, but at the same time you have to realize if you were sick, wouldn't you want to make your own decisions. This goes to show you to that the opposite can happen. For example, when a patient shows no signs of coming out (i.e. brain death) but family wants every measure in place possible. One time we coded one person 5 times throughout the day before family decided to stop and the only reason was blood was shooting our of her ET tube when we were doing chest compression's otherwise we probably would have kept going. This job will challenge you in every sense of the word, day in and day out, but know other RN's around you are feeling the same and just talking about the process helps, or just stepping out for a few minutes to collect yourself and then come back.

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Good article and interesting read. Thanks for sharing your thoughts.

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Great Article…It takes a special nurse to perform palliative care,with that being said, You may just be one of those little angels.I like hospice because you don't have to be a hero and try to save a life.You sit at the bedside keep them comfortable,administer what you're ordered,and DOCUMENT!All while being apart of that person's last journey in life and the family's last journey with that person.You sometimes will be the person to help that individual let go and feel it's ok to leave.That's compassion.God bless you

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Specializes in Oncology; medical specialty website.
Thank you Lev, I was very surprised at my own fears and insecurities that I felt with my first palliative client. My own insecurities regarding my abilities and my own personal beliefs surprised me. I had inner conflict with having nursing knowledge and fledgling skills but not being permitted to provide that care due to my job description. All the while knowing this client could have relief from some of these symptoms. I had given her care weekly for 5 months and gotten to know her and her daughter. She was a stubborn and courageous woman and we all came to care about her. They were consistent with all the caregivers and she had around the clock care given to her in the way she requested. Her rituals and routines were important to her, and we assisted her with carrying them out. We all came to know and were invested in following her wishes of dying at home with dignity.

Writing about this experience was cathartic for me, and forced me during this long night shift to practice self reflection in real time. I believe that night will be one of those pivotal moments in my career.

What a thoughtful, well written article. When I worked in hospice, that first time I had to go to a pt's home to "pronounce" him was scary. I remember speeding my way to his home, hyperventilating, barely stopping at traffic lights. Then it hit me: He's dead. I can't do anything more for him other than verify lack of VS, fill out the death cert., and do post-mortem care. My biggest job was going to be supporting the family. After I figured that out, I calmed down.

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Specializes in Critical Care; Cardiac; Professional Development.

Very well written and well thought out. I am glad it was cathartic for you. Many can't do what you did.

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Specializes in orthopedic/trauma, Informatics, diabetes.

Interestingly, I am co-writing a paper in one of my RN-BSN classes and the topic is how nursing students are not prepared enough for end-of-life issues. I am not sure how it could be better, but it is very difficult,dealing with death.

Great article.

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