Approaching the topic of dying...

[Despareux]

We have not covered this topic in school yet. This is a concern of mine because of the type of patients I have cared for, as many of them would die if it were not for some of the equipment that keeps them living. Some patients are comatose and others are not.

So, my question is, do nurses tell the patients and their families that there is nothing more that can be done or is it the doctors responsibility? What if the family knows before the patient; who tells the patient? Who does the educating for DNR's, power of attorney, living wills?

I know that as a student nurse, I don't believe I will be handling these types of situations, but for future reference I would like to know.

Thanks

[Cyan8181]

Unfortunately it's so vague and, in my experience, has never gone the same way twice. Sometimes the doctor doesn't want to see it and sometimes it the patient who isn't ready to hear it. Have you read this article from the New Yorker? I thought it was amazing and it speaks to a lot of the questions you ask.

http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande

[nursel56]

In the US, it's the doctor who is responsible for telling the patient, or the patient's family that there is nothing more that can be done. From a medical standpoint, he or she would be the only person who could determine that, which is obvious in the case of some diagnoses like cancer, but not so obvious in the case of a person in a coma for an extended period of time, but vent dependent.

The area of advance directives, end-of-life discussions, DNR, and medical power of attorney (someone appointed ahead of time by the patient to make decisions if they are unable to) and how and when those subjects are brought up is much stickier, with lots of emotional issues for patients, families and caregivers as well.

You'll get the most up-to-date information on those subjects when you study death and dying in school, as it is complex, involving issues of autonomy, ethics, etc.

Nurses themselves don't always agree, either. Here is a link to a fairly recent thread with almost 70 responses to give you a more complete picture with a variety of opinions that also talks about when the family knows but the patient does not. Best wishes!

Patient Doesn't Know He's Terminal

https://allnurses.com/general-nursing-discussion/patient-doesnt-know-451394.html

[lidleanjel]

I personally think you must evaluate your own opinions on death first. then look into what you feel is ethical and unethical. i have discovered my opinions on death are SO different then many fellow friend in the local nursing program with me and even at work.

I have a more overall look at death. I believe that patients need to be honestly and bluntly be told about options about their diagnosis including talking about dying. Death is a natural process and its ok to die. People are not always aware of their options and need to be informed about them.

I have had patients (as a CNA) at the hospital that have verbal said they want to know their options or even they dont want to fight anymore. I personally feel that not only telling the RN about the request, I talk to the patient about the past, present, and future. I also put in a chaplain request in for the patient. the more at peace I can make a patient feel the better I feel about myself.

with this process for me (even as a CNA), i have had patients die on my shift or die within the next 24 hours after this discussion. Depends really on you and your views on life and death.

my opinion is when the patient is ready they will talk, but they also need to be aware of the prognosis. patients have the right to want palliative care. I also do not believe in family keeping the information from the patient.

not everyone has liked my views, but if i was in the same boat I would want to know ALL my opinions. even though I want to help people as a RN, there are times that medicine is not the best answer. the less a patient suffers the better. everything depends on the situation of the patient.

[~Mi Vida Loca~RN, ASN, RN]

My teacher just sent me a really good article on grieving today, she was sending it to me personally but it was about death and RN's. I will have to go find it and post it.

[~Mi Vida Loca~RN, ASN, RN]

she copied and pasted the article she didn't link it so i have to do the same. i have seen in my hospital that the doctors might give the news or diagnoses but it's the nurses that end up really dealing with it.

anyway, here is the article about death and the patients in general.

[color=#333333]good grief: nurses cope with patient deaths

[color=#333333]by cathryn domrose

[color=#999999]monday february 21, 2011[color=#999999]

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[color=#333333]rowena orosco, rn, bsn, had been working at johns hopkins bayview burn center in baltimore for three years when a family with seven children was brought to the hospital after a fire destroyed their home. the one survivor, a 7-year-old girl, was transferred to the burn center with burns over 70% of her body. as the medical team worked desperately to save the girl, orosco sat with her, crying and holding her hand as she died. this moment haunts the nurse 15 years later.

“i got through that day, but after that i thought about quitting,” orosco says. instead she attended a debriefing, exchanged many tearful hugs with colleagues in the halls, talked a lot with a co-worker and kept working. “you kind of put your emotions aside because there are other patients waiting for you.”

nursing students might learn how to help family members grieve, but seldom learn how to deal with their own feelings of sadness or loss. research about how nurses cope with patient death is scarce and mostly anecdotal. but what studies there are suggest nurses go through a unique grieving process when patients die, and how they manage this process is important to their well-being.

only human

“we feel that when people die, it doesn’t affect our care, which is absolutely ludicrous because we’re human, too,” says tina brunelli, rn, csn, msn, anp-c, a nurse practitioner with novant health in kentucky. brunelli, who has worked in oncology, hospice and critical care, wrote a concept analysis as a graduate student, published in nursing forum in 2005, about how nurses cope with patient death.

stifling personal emotions about patient death has been equated with professionalism for nurses and physicians. “these fields evolved from the military and there are still feelings of, ‘suck it up and move on,’” says robert s. mckelvey, md, a professor of psychiatry at oregon health and science university, portland, who wrote a book titled, “when a child dies: how pediatric physicians and nurses cope.”

but in interviews with nurses and physicians about the subject, mckelvey found “nurses, on the whole, did a better job [of coping]. they were more open to talking about these things than their physician colleagues.” those who allow themselves to go through a grieving process seem to be healthier, mckelvey says. those who hold it in, he says, “pay a price by not being able to deal with their feelings at the time and place.” they may feel reluctant to get close to other patients, have difficulty with personal relationships or have trouble sleeping or eating properly.

how a nurse responds to a first death — and whether he or she is supported by colleagues and supervisors — seems to affect how that nurse reacts to future losses, says lisa gerow, rn, msn, a doctoral candidate at the university of kansas, kansas city, and associate professor of nursing at tulsa (okla.) community college. she is the lead author on a report, published in the february 2010 journal of nursing scholarship, which uses interviews with 11 nurses to describe the grieving process after a patient dies.

nurses may be especially at risk for problems in coping with patient death if they believe they had some responsibility for it or didn’t do enough to save the patient, gerow says. many icu and ed nurses become angry and upset after seeing very sick or elderly patients die in pain after extreme and futile treatments to prolong their lives, says catherine miller, rn, msn, ccrn, clinical education program manager for the icu and special care units at howard county general hospital in columbia, md. they might feel they didn’t advocate enough for the patient to experience a “good death,” she says.

self care

some coping strategies, developed over time, nurses say, include: rituals to help the patient and family feel better, such as bringing the family food; attending funerals or posting obituaries; and praying or drawing strength from spiritual beliefs. some nurses use exercise and relaxation therapies, such as a hot bath, to help ease stress caused by patient death. “the nurses that care for themselves will grieve better,” miller says, especially if they recognize their limits and turn down extra shifts or working with insufficient sleep. if they don’t care for themselves after a traumatic event, she says, they put themselves at risk for eventual burnout, compassion fatigue or moral distress.

nurses often use humor to deal with death, though they must take care not to use it inappropriately, especially in the presence of family members, says terry foster, rn, msn, ccrn, cen, a clinical nurse specialist in the ed at st. elizabeth medical center in edgewood, ky. “ask any nurse, the most pressured laughter they have ever heard is in the presence of a dead body. because it’s so awful, but there’s something funny that goes along with it.”

an ed nurse for 35 years, foster has given many clinical lectures, but the most requested, he says, are those dealing with nurse humor, including humor about death. “sometimes it’s just the way you maintain your sanity,” he says. “this is just one way that someone can channel the anxiety and stress.”

talking with co-workers is probably the most helpful coping strategy in getting through a difficult death, nurses say. spouses and family try to be supportive, but they can’t know what a nurse goes through, brunelli says. “the people who don’t talk about it with their co-workers probably don’t survive in the long term. it’s unbelievable how much people can suffer before they die. if you’ve never seen it, you can’t understand it.” hospitals and supervisors can be supportive just by acknowledging that patient deaths affect nurses, she says. just giving nurses time to talk to one another would be helpful, she says.

some hospitals hold voluntary debriefings after difficult deaths. mckelvey says people who have gone through traumatic experiences may be better able to express themselves in private counseling sessions or meetings without administrators present. “they really have to feel safe to grieve and talk about what is on their minds,” he says. he thinks hospitals should make one-on-one support available to those who want or need it as soon as possible after a traumatic death.

some nurses in gerow’s study said they wished their hospitals had supported them more during difficult deaths, or they had learned more about the grieving process in nursing school. but they also talked about how patient deaths, though upsetting, changed them and helped them to grow.

foster vividly remembers an ed patient who begged to see his daughter. foster brought her in and watched the patient tell her he loved her, minutes before the man unexpectedly died. “i am so glad i brought that daughter in,” he says. “i think, ‘who am i to keep people out of the room.’”

miller has a letter on her wall from an angry, difficult patient who came to her unit with advanced pulmonary disease. two days before he died, he wrote to his caregivers, praising those who showed passion and compassion in caring for him and helping him overcome his fears. thanks to them, he wrote, “i have become ready to march on.”

for orosco, a turning point in her career — which made her decide not to quit her job — was a thank-you letter from a relative of the girl who died holding her hand in the burn center. “even though we didn’t make any difference [by saving her life], that moment was a big thing, that she didn’t die by herself,” orosco says. “since then, i have never let a patient die alone.”