That nagging "Did I miss something?" feeling

That Guy, BSN, RN, EMT-B · Aug 7, 2012

Objectively, I know these things happen. Patients die. Patients can decline despite our best efforts. Even the doctors could not proceed with the care that this patient needed, so why do I think I could have done better and "saved" her?

because it is engrained in every person from the beginning that death = failure. You say it yourself that the prognosis was little if none at best. Like you said people die and frankly, it sucks.

Try talking to some of the more experienced nurses and maybe they can put your mind at ease. After my first pt died, all it took was one of the docs to say you didnt do anything wrong to make me feel better about it.

newrnltc · Aug 7, 2012

Hello I'm pretty new too. Just passed my one yr in July. I too still worry about things I could have missed. In fact many times after work I'd find myself reading up on something I just learned or wasn't sure about to reinforce the info in my memory. I also learn from my mistakes. You can bet those will really stick in ur mind!

When I transfer patients to a different level of care, I try to follow up on what happens diagnosis, labs and treatment wise so I know what to look out for. A lot of times your gut is right when you think a pt looks off!

Remember none of us are perfect but we have a duty to do our best and keep improving! Sorry that ur pt passed. It's an honor to be able to offer comfort and caring in a for someone in their last days. I bet they appreciate your thoughts and concern. Take care!

dirtyhippiegirl, BSN, RN · Aug 7, 2012

I just want to give you a big hug.

We'd had a longish-term patient on our unit who should have been on his way out and to rehab throw a PE and code. I hadn't had him as a patient for over a week and I still wonder if there was something that could have been done, should have been done, something that I should have said or done. Did I miss something on assessment? Should I have been more forceful in report about certain things? etc.

Time does heal these sorts of things. I promise. :) As someone else suggested, you might try chatting with the doctor that had your patient. At the very least, you may get a better picture of your patient's expected medical course/outcomes/etc.

whoa-now · Aug 7, 2012

I too know "that nagging feeling". Going over things in your head I think is only a natural response. As long as you know your did your best for your patient by following MD orders and facility prtocols (along with your own intuitive nature as a nurse). The good lord will take care of the rest. That mental checklist you have been rehashing in your mind is merely YOU gaining experience and learning along the way. :nurse:

RURN2O11 · Aug 7, 2012

Though your description was brief, it sounds like this pt was well on his way out of this world anyway. I doubt there was anything much that could have been done differently to change that outcome. One way to look at it is that anything "extra" you'd done would certainly have just prolonged his suffering. One thing I learned very quickly in my first few months as an RN is that when people's bodies begin shutting down, that is God/the Universe's way of saying "It's time to go." Rarely have I seen a pt fight it. Most of the time they are very ready to move on from this world. Usually the only thing that keeps them hanging on is their family which can be good & bad at times. I too have had MANY of those doubts that you mentioned after a pt has passed or ended up being transferred to ICU or another facility, etc.

Though this was a difficult experience for you I think it's one of those things that we all have to learn from as a nurse. After a few more months you will begin to trust yourself more & have less of those doubts. Just wanted to offer a different perspective that you might not have considered. Though many doctors & nurses disagree w/ me on this, I don't think death is always failure. Yes, I am going to do everything in my power to prevent it as long as the pt wishes that, but deep down I know that sometimes death is coming regardless of what we do, & the best route to take then is to make the pt as comfortable as possible. This is why I'm such an advocate for palliative care & hospice.

Liddle Noodnik · Aug 7, 2012

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How do you deal with these feelings?
Thanks everyone.

If it's abnormal then I am too HATE when that happens. All you can do is the best you can with the next person. Sometimes I will go to the autopsy if I am allowed (one time it was a pulmonary embolus so I was able to see why there was nothing I could do). I study up on what happened, a sort of case review, and see if INDEED I could have done anything different.

I hope you feel better about things too.

iluvivt, BSN, RN · Aug 7, 2012

I always remember the saying " no one gets out of here alive". We tend to live in a culture that views death as the enemy instead of the natural process it is. It can be fast too, such as in a massive PE or MI or resp arrest or an aneurysm or massive CVA and at times with little or no symptoms. At other times painfully slow and drawn out. I consider it a privilege to be able to guide another human being in transitioning from life to death. I hope some day when its time for me to go I have a kind nurse helping me b/c if you can earn that kind of thing I am way past the points needed.

As far as a sense of "missing things",I always gave my pts the once over before I left. I reviewed the chart and orders to make certain I did not miss any,checked for any new labs or report posted or an new progress notes and checked all my charting.Often with the stress of the shift almost over that review can often clarify something and help you catch something you had missed.

TonyaM73, ASN, RN · Aug 7, 2012

I had this recently myself. A pt I took care of off and on for over 3 weeks. Last shift I had with this pt, they didn't look good, but there was not much that could have been done since they were a DNR and the family did not want anything invasive done. Some areas looked better, but some looked much worse. Came in the next day and found out they passed about midway through night shift. I spent the next week going over what I could have done differently. I think that this is part of being a good and caring nurse. It just drives me crazy until I can let go of it. My only advice is to go over it piece by piece and see if you could have done anything differently. (You have to do this objectively and realisticly) Once you have gone over the whole senario, decide if there was something that could have been done and do it next time, or let it go and decide that you did ALL that you could have with the information that you had at the time. Good luck in your career and don't EVER stop learning!!

uRNmyway, ASN, RN · Aug 7, 2012

Believe me, it will keep bothering you. As well it should. If it didn't, I would question THAT! Learn from it, that is all you can do.

Ive had patients who were actually pretty much hospice. Had regular s/c morphine, ativan, and scopolamine to ease their suffering. When the patient died that shift, I beat myself up, even if that had been completely expected, had the family at bedside for final hours and all.

Like someone mentioned, we have come to associate death with failure when it comes to caring for our patients. But sometimes, 'winning' is just doing our best, making them feel respected and loved, and easing their pain in their final hours.

RNperdiem, RN · Aug 7, 2012

I had a similar experience when I found my patient in the obituaries section of my newspaper. I had only taken care of the lady 2 days ago and she seemed fine.

I never knew what happened.

Hope you feel better soon.

Ruby Vee, BSN · Aug 7, 2012

hello allnurses folks,
a patient of mine died soon after i ended my shift. i have this strong feeling of guilt and i keep asking myself if i missed something. was there something crucial that i should have picked up on? could/should i have called a code? should i have advocated for a transfer to critical care? on and on that crazy train goes.
obviously i cannot provide a lot of specifics. generally speaking, this pt was not well. patient needed several major surgeries badly but was a poor candidate. pt declined slowly and i had her for several shifts in a row, so it does not help that i was familiar with this patient and family.
objectively, i know these things happen. patients die. patients can decline despite our best efforts. even the doctors could not proceed with the care that this patient needed, so why do i think i could have done better and "saved" her?
i also worry what the next shift who relieved me thinks of my assessment skills. i am a relatively new rn. all reports of my job performance have been good, but there is always newbie jitters in the back of my head.
i guess i just needed to vent and get support. you guys get it.
how do you deal with these feelings?
thanks everyone.

patients -- especially those who aren't doing well -- do die. we aren't able to "save" everyone, nor should we. if you cared for her for several shifts in a row and knew her and her family, they were probably very happy to have you there with them in her final hours. sometimes all we can do is make a patient as comfortable as possible and reassure the family that everything that can be done is being done. that's the "art" part of the art and science of nursing. you're perseverating on the "science" part, wondering what you've missed and if someone else might have been able to save her. probably, the answer is no. she was declining for several shifts.

it's normal to have all sorts of feelings when our patients die, especially if we're new. if the patient declined suddenly, we might wonder if we've missed something that could have altered the outcome if caught. many new nurses have never been exposed to death before, so there are all those feelings of confronting death for the first time. your religious beliefs (if you have some) may provide questions or yield answers or comfort here. we may be sad that our patient is dead or we may be relieved that he is no longer in pain. if you've taken care of the same patient or group of patients frequently, it's normal to "miss" them when you go in to work and they're not there.

as for how to deal with these feelings . . . there are as many ways to deal with the feelings as there are those of us to deal with them. i personally have found comfort and clarity in writing. when i'm overwhelmed with feelings and cannot sleep, i'll sometimes set a timer and write for 20 minutes -- anything that pops into my head. usually, i'm able to see what exactly i'm feeling, and resolve some of those feelings. not always. exercise helps. the night one of my favorite patients died, i set out from the hospital to "walk a few blocks" to the next bus stop and ended up walking the whole 7 miles home. by the time i got there, i had worked through a lot of those feelings. sometimes it helps to talk to the nurse who was caring for the patient after you and come right out and ask "did i miss something?" if the answer was no, you'll feel better, and if you did miss something, you probably never will again.

i'm fortunate in that my husband is also a nurse, works in the same hospital as me, and knows most of my colleagues and many of my patients. a bottle of wine and a nice long chat with him restores perspective. so does throwing the ball for the labradoodle, attempting to wear him out. (usually my arm goes first.)

sorry this got so long. i hope it helps.