New Nurse...Need advice on dealing with death

southernbelle08 · Dec 6, 2008

I think when it comes to patients dying, that is something that could never be "textbook". Everyone feels differently, and you have to find out what it all means to you. In my opinion, it is a huge personal journey. I have worked in Oncology for the past almost 7 months and, unfortunately, death is a large part of my job. I suppose in my area, at times it is somewhat expected, and even welcomed if the patient has been through a long battle with cancer and they are ready to go and finally get some relief from the horrible disease and pain. I have cried many times for those who didn't seem ready or at peace and I have also rejoiced for a few who finally got that relief from the disease and pain they were ready to be free of. No matter what the situation, death is never easy. I don't believe there will come a time when I just get used to it.

I know we come from different areas, and the patients you see are often times very different from those I see, but that is my best advice to you. You have to dig deep on this one and allow yourself time to process and see what it means to you. I've talked to nurses on my floor and they tell me even after years and years on the job, it really doesn't get any easier. But I think you get an understanding of what it means to you personally and that is when you learn to accept it as part of what you do.

Best of luck!!

tencat · Dec 6, 2008

I guess if it were me, it might help to remember that when CPR is initiated, it really is only 30% effective. That means the odds are pretty stacked against the patient once CPR becomes necessary. I have done chest compressions for real once, and it is an unnerving experience. I've been present for several codes, but only as a scribe or observer.

As to the woman who was 'gasping', it's a normal death breathing pattern. It takes the body a while to shut everything down, and agonal gasps are common (and very creepy, I know). As far as I understand it, once those appear there's no going back.

I see death all the time as I work hospice. Sometimes things seem pretty random and senseless, especially when it's a young person. It is a heavy responsibility to be present at someone's death, but it is a priviledge few experience. There is something (God, higher being) that is bigger than we are, and when it's time to check out, we are powerless to stop it unless it truly is not that person's time to die. That helps me deal with the senselessness of it.

UM Review RN, ASN, RN · Dec 6, 2008

My religion helps me cope. I believe that this life is not all there is and that death is a doorway to the next life. That said, it's still very difficult for me to accept and it's still a very tough time for me emotionally, but I can deal with it, given time.

I say prayers for all of my patients and remember that in a Code situation, the patient was already dead. Sometimes we can bring them back, sometimes not. I can't figure out why; sometimes it seems so random and so tragic. All the more reason to make our own lives count for something, all the more reason to live our own lives as though every day could be our last, because it's true -- we never know.

As I begin to accept the death of a patient, I begin to pray and to thank my God for the life of the person. I pray for comfort for the family, and I thank the Lord for the honor of taking care of this person's body. It is one of the last things that I can do for that patient and it only makes me reflect on the miracle that life is.

((((hugs, RN_1)))))

Pediatric Critical Care Columnist · Dec 6, 2008

What you're feeling is perfectly normal. We all want to take the blame when things don't go the way we want them to, despite all the odds stacked against it in the first place. As the other posters have said, there are some who will come back after a cardiac arrest and there are those who won't, no matter what is done. I work PICU and we're the one area that refuses to give up on our patients when they arrest. We have had codes go on for more than an hour and been "successful" and have even had some kids neurologically intact afterwards, but we've also had them go on forever and the child still died or was left horribly disabled. Sometimes death is not the worst outcome.

Last Monday I attended the death of a 9 month old who had a complex heart defect. He had been made DNAR that afternoon, but none of us expected him to go as soon as he did. It was almost like he decided that it was time. One minute he had a good blood pressure and reasonable sats, the next he was hypotensive, bradycardic and hypoxic. We did give him fluid, two rounds of epi and some bicarb, not to attempt resuscitation, but to try and keep his heart beating until his parents could arrive. (We weren't successful but they didn't know that.) I know his soul was gone for some time before his heart stopped.

So dealing with it... I think it will help you to learn about the physiology of death. When you understand what is happening it's easier to accept. And accepting that it will never get easier emotionally to be in the presence of death is another thing that will actually help, as counterintuitive as that sounds. As Angie O'Plasty said, God has the ultimate control over life and death; He lends us to our loved ones for a time and when He is ready, He takes us back. Why some people live to see 100 birthdays and others don't even see their first is something only known to Him. Grieve your patients who die, but don't allow your grief to consume you. All we can do is the best we can. Hugs to you.

AirforceRN, RN · Dec 6, 2008

What if I had done the compressions better. Are these normal feelings? Does it get any easier? I am looking for advice, any advice. I really appreciate it! Thank you in advance.

I've found that if you are doing compressions that aren't proper...a nurse or a doc will switch you out and do compressions properly. I've seen it happen a number of times, as many first timers are hesitant to go deep, hard and fast. So if you were allowed to continue...I doubt you were doing compressions poorly.

Are these feelings normal? Absolutely. Does it get easier? For some people...depends on who you are and how you view life and death.

What you are doing right now, debriefing, reflecting and discussing are hallmarks of a good nurse. You are going to see more of these situations as your career progresses through critical care. The moment you walk away from a code with no more thought than hanging an IV bag, I think its time to move on.

patwil73 · Dec 7, 2008

I am a new nurse and a critical care intern. I have been training for 5 months and have 1 more month before I am on my own. I am having a difficult time with death. About 5 weeks ago I did chest compressions for the first time on a real person. I do not know her history, she had only been at the hospital for about 20 minutes before the code was called and she was in a different area. She died and it was very difficult for me. When the breathing tube was removed, I swear she was gasping for air. It was all very confusing for me. I didn't understand why everyone was leaving while the patient was gasping for air. There was a de-briefing and I was told that it was natural. I read "On death and dying" by Kuebler-Ross. It didn't help much. I am looking for details on what happens to the body during and right after death.

Sometimes the patient will have gas built up in their abdomen - whether from compressions or misplacement of the ET tube. When the code is called and the tube is removed that gas can slowly escape. It makes the person appear to be gasping.

Also when we do compressions we are attempting to keep the heart beating oxygenated blood to the vital organs. However, the heart might be so diseased or damaged that it can not continue on its own. When we stop compressions the heart stops beating. This is cardiac death - however if our compressions were sufficient the brain may continue to live on a bit longer trying to force the body to do what is needed for life such as breathing - these efforts are almost always noted to be agonal gasps.

In both cases the patient is not really "gasping" for air. The patient is dead, the body just does not quite realize it yet. They are not hurting, or anxious the way we are when the wind is knocked out of us and we gasp for air.

Now fast forward to a week ago. Another code was called on a pt that I had taken care of the week before. It was a very intense code. Again I did chest compressions. As I was doing them I saw that her lips were blue. Family was in the room and the pt was 21 years old. After the code was called and the time of death was stated there were no dry eyes. I am having a very hard time with this. I know we did everything that we could but I am feeling guilt. What if I had done the compressions better. Are these normal feelings? Does it get any easier? I am looking for advice, any advice. I really appreciate it! Thank you in advance.

The younger a patient is the harder it is to come to grips with their death. I believe this is hardwired into us to care for the young. When we have a 90 y.o. whose life ends we can say "she lived a good life" or "it was his time". This becomes much more difficult when the patient is young - they haven't had that chance to live a good life.

How do we deal with this? Everyone is different - meaning everyone must find their own way of dealing. Mine is my family. I hug my wife, play with my kids. A lot of times I cry on the way home. I am ok with feeling bad that someone died, that someone's family is grieving. I allow those feelings and then put them aside to care for the next person.

Are your feelings normal? Yes! Does it get easier - sometimes, but then comes along that case that brings you back to square one. As you grow in your practice and learn more about disease and injury you will know what factors truly contributed to a patient's death. The guilt feelings will lessen (unless you truly do something very wrong) but the sadness will hopefully always remain.

Hope this helps

Pat

PICURN74, ASN, RN · Dec 15, 2008

I agree with everyone else your feelings are normal but that doesn't make them easier. I also work in the PICU and pediatric codes are especially hard as a general rule kids are not suppose to die. I don't think you get used to them but rather learn to cope and see them differently. I used to second guess myself and wonder if I were more expierenced if the outcome would have been different but as I have seen more codes I have learned that as much as we want to control things somethings are out of our hands. Some kids recover dispite our mistakes and some sucum despite our most heroic efforts. The serenity prayer/chant helps me "...grant me the serenity to accept the things I cannot change, the courage to change the things I can and the wisdom to know the difference" Wisdome and serenity came for me later and I can tell you already have the courage part down

Tiaj72187RN · Jun 29, 2009

I know it has been six months since you wrote this post, but I have been dealing with the same thing. I just graduated nursing school and passed the NCLEX two weeks ago. I have been working as a camp nurse until I could find a hospital job. One of my campers unexpectedly had a gran mal seizure (he was an epileptic) followed by cardiac arrest. The camp has one nurse work at a time so it was on my shift, and I was the only nurse there. We initiated CPR but even as I lowered him to the floor I thought, only a small percentage of CPR attempts are successful. Thankfully the lifeguard working was formally an EMT and had more experience with doing CPR than I have. So I feel confident that we couldn't have done anything differently that woudl have saved his life. But I still have weird feelings of guilt and sadness when I think about what happened. I go over every detail in my mind, every interaction I ever had with him, and I can find things I could have done better, but nothing significant enough to save his life.

I guess my question is, how are you feeling 6 months later? Because I am so ready to not be upset about this anymore. I find myself crying at random instances, when I'm driving and something reminds me of him or someone starts talking about the incident. Its especially hard for me I think because I was solely responsible for his medical care when it happened. There was no other healthcare providers there when it happened. I guess I just feel such weight. I don't know if its something that nurses just get used to, something you learn to live with because of the nature of this profession.

I just want to know what I should do next. When will I feel better?

NurseKitten, MSN, RN · Jun 29, 2009

Tia, please consider going and talking to a professional counselor about your experience. What you're feeling is perfectly normal, but I also worry about the effects of post-traumatic stress, as well. That's an awful thing to have happen to you in your first job out of school. God bless.

Tiaj72187RN · Jun 29, 2009

Thank you. I think you're probably right. I feel silly being so upset about what happened. Its only been 3 days but I feel like I should be more professional or something. Would it be wrong to send a card to the family or write them a short note? I feel like I need closure or something, but I don't want to cross professional boundaries. I just feel like compared to a hospital the boundaries here are so undefined.

pcurn2008 · Jun 29, 2009

Tia, after all of the support and feedback I received from my post I searched hours and hours on the internet. I looked up the stages of death and the grieving processes that follow. I still struggle with it and I still remember the faces of these 2 patients while I was doing chest compressions. I agree with NurseKitten about counseling. I am going to begin that soon too. Please keep in touch and know that you are not alone. Take care. *hug*