First patient death at change of shift...feeling like a failure - page 2

The last couple nights at work were rough, especially the first one. I had admitted the pt at approx. 2100. Frail, confused, elderly woman...came in for COPD. Pt was a DNR. She looked like she was... Read More

  1. by   cherrybreeze
    Other posters have already stated my sentiment so eloquently that I don't have much to add. As far as the doctor on the phone? He might have said "a couple of hours ago," but he wasn't were. You know you were in the room an hour prior to this, cleaning up and repositioning this patient. That can't be disputed.

    I have seen plenty of patients that *choose* to die alone, as others have said. They will hang on for hours, days, until they have that chance. Others will wait and wait until someone in particular shows up. Even if they can't express these wishes verbally, they DO express them physically. People, even when death is imminent and near, have a surprising amount of control over what happens.

    It sounds to me like you took wonderful care of this patient throughout the night....and that really is ALL that you can do. There are plenty of things that happen *right at shift change*, know what I mean? This one happens to feel much more significant, understandably. Whenever something happens at shift change, be it people calling for the bathroom, pain meds, etc etc, it makes you feel like you didn't do anything all night (or makes you fear that it LOOKS like you didn't do anything all night). We take on the responsibility for something that we don't have control over. Using the pain med can have a patient, check on them frequently to find them resting quietly, offer them meds when they are awake and they refuse, saying they are fine, etc....and then, next shift comes on, and patient calls and says their pain is an 8, they're crying, and begging for medication. Now, you know that you properly assessed and cared or them all night long, but you a) feel like you didn't do something you should have, and b) are afraid that the oncoming shift/nurse thinks that you slacked off for the last 8 or 12 hours.

    This situation is the above x 1000. You know what you did throughout your shift. You know the care you gave this woman. You know the concern you had. You know when you were in that room. Hold on to that knowledge, and don't let other factors (like the doctor's statement) cloud your recollection.

    The fact that the woman was pale when you were in there changing her that last time means nothing. People can appear to be breathing their last breath for days. A lot of the time there isn't a way to KNOW without a doubt "this is it." Obviously you can see, say, apnea progress, etc, but that isn't always present. Sometimes you think they'll see tomorrow, and they're gone 30 minutes later. Sometimes you think it's THAT time, and they hang on for at least another day. I'm not saying you NEVER can tell, but it can be deceptive. Don't beat yourself up about that. It would have been nice to have been able to call and have the family there, but....they knew her time was near, if they had been there less than 12 hours before. It didn't come as a surprise to them. They didn't opt to stay the night, so it may not have been imperative in their minds to be there at the end. There's no way to know that, of course, but it's something to think about.

    I agree with whoever said, if you DIDN'T feel a measure of sadness, THAT would be cause for concern IMO. I have felt emotion whenever I've had a patient pass away. Some cases were more sad than others, some made me sob, some I maybe didn't shed a tear but felt that grief. Do NOT be embarrassed about shedding some tears in front of your're human, you feel emotion, and death invokes heavy emotion. It's okay. In time, you will learn how to process this grief more....not efficiently, but I hope you know what I mean. A lot of times, you just need to have a good cry and get it out of your system, and then you can move on.

    Keep your head up, OP. You did nothing fact, you did a lot of things right. That lady was lucky to have you care for her in her final hours.
  2. by   rn/writer
    A part of me does feel bad because, (I hate to admit this) I'm afraid it gives the perception to other peopl that I'm not caring for my if I'm neglecting them.
    Just the opposite. We had a thread awhile back (I don't have the time to look for it right now) about the fact that cleaning up a patient who is near death after incontinence can cause enough stress to give them that final nudge toward the end. There was some discussion about whether to attend to their needs or just let them be. The consensus was that almost everyone said they would prefer to be gently cleaned and made comfortable, even if it shortened the time they had left by a few moments.

    I doubt that other people are judging you. This sounds like one of those internal battles that you can't possibly win. The only way to win is not to play. You know that you treated this woman with care and dignity. You met the only needs that were under your control. The fact that you weren't standing beside her, holding her hand when she passed is NOT the measure of whether you took good care of her or not.

    When these pesky self-accusations arise (or if someone else, like the mistaken resident makes an inaccurate remark), you have to come back with the truth in your own mind. People will read you like a book. If you believe your care was inadequate, they will agree. But if you tell yourself that you cared for her to the best of your abliity, they will agree with that instead.

    Most of this situation is not about you at all. The part you have to deal with is insisting that you tell yourself the truth and refusing to fall prey to negative emotions and searing self-doubt. That helps no one.

    Cry, determine that you will not play this destructive head game, tell yourself the truth, and move on.

    You can do this.
    Last edit by rn/writer on Aug 25, '11
  3. by   cherrybreeze
    Quote from Little_Mouse
    Thank you all for your kind and wise words.

    I felt bad I couldn't be there during her last breath. I should have trusted my gut after changing her...she did look different...but all I can do now is learn from this.

    What struck me about this case was that just about a month or so ago, I took care of a patient (also DNR), came in for meningitis, on isolation. Pretty young pt, in his 30s I think. He had been on the unit for about a week already, the first time (and last) I took care of him, he looked and sounded he would go soon. CNA and I changed him before shift change, I even went in one last time to check on him and clean things up in the room. I gave report then went home. I came back that night and was told by the AM nurse pt had died after report...she was called in by the RT and the nurse went in and found him unrepsonsive, this was almost 0800 when it happened, I was told. I still think about it to this day, every now and then, about that patient, and so after this incident it made me feel particularly bad. 2 pts died after my care during change of shift. A part of me does feel bad because, (I hate to admit this) I'm afraid it gives the perception to other peopl that I'm not caring for my if I'm neglecting them.
    Guess we're on the same wavelength...I typed my post before I saw that you wrote this, and addressed it. Hope my thoughts on it help!
  4. by   Liz, RN
    You did everything right, it was her time to go...
  5. by   MrChicagoRN
    Quote from wooh
    I'm kind of an angel of death. It's not that I make patients die, but I don't mind if patients die on my watch, so I tend to get assigned to ones that are going to die. (After all, if wooh doesn't mind, why give the patient to someone that will spend the whole shift saying, "Hold on until shift change!")
    I've noticed, you can be with someone nonstop, then they go the second they're alone. My spiritual side kind of feels like it's a moment for just them and their maker.
    I went to a death & dying conference many years ago, and one speaker mentioned that sometimes a dying person will wait till the family steps out and they can slip away in peace. It'd be interesting if that could be somehow researched.

    To the OP:

    Yes, things like this are emotionally rough, but there was probably nothing else you could do.

    I'd sit down and talk to you manager, social worker, or chaplain and do your own post-mortem: "This is what I did, this is how I feel. Is there anything I can differently the next time.
  6. by   eagle78
    Quote from rn/writer
    I've heard of many cases where a last clean-up is a stressor that brings about the end. Should nurses then let patients lie in their own incontinence? If I were the patient, I'd rather pass twenty minutes sooner clean, dry and with a measure of dignity. If someone is that close to death's door, we really are just talking a matter of minutes. You didn't fail her. You let her know that even in her final moments, she was cared for. I call that a success.

    Would it be nice if you had been holding her hand as she breathed her last? Certainly. But real life has a way of intruding and rewriting the Hallmark Channel scripts.

    It sounds like you did everything you could for her. I'm thankful on her behalf that she had a nurse who cleaned her up one last time and cared about her passing.
    My sentiments exactly, I could not have said it better. Please hear what was said here, you did the best that you could do and I would want my loved one to have that type of care in their last moments. Thanks for being a good nurse... You can cry, just remember "weeping may endure for a night but joy comes in the morning"...
  7. by   Horseshoe
    Quote from wooh
    I've noticed, you can be with someone nonstop, then they go the second they're alone. My spiritual side kind of feels like it's a moment for just them and their maker. Families will stay, the step out for coffee, for just a moment, that's when they go.
    Yep. I've seen that happen numerous times.
  8. by   leslie :-D
    wooh and cherrybreeze's posts were spot on...
    specifically noting that often enough, pts want to die alone.
    so littlemouse, if you were feeling guilty because of that, i can confidently say that as you see more deaths, your view of death will likely change.
    i've been doing hospice for yrs.
    the 1st year i had realized that my feelings about death, had shifted from me feeling sadness, to feeling warmth and's bittersweet.
    if anything, being around death a lot, almost forces you to examine your own feelings about death.

    the way your pt, sounds as it should have been.
    i would say at 85, her death was result of resp arrest...what we don't know is if it was from natural causes or copd.
    but it's because of my beliefs, that i can often feel comfortable when someone dies.
    that doesn't mean i don't feel sadness...
    i do...but it's a selfish kind of sad, which when acknowledged, makes the grieving much less so.

    in summary, try not to feel overcome w/sadness...
    you don't even know if she wanted you or anyone to be holding her hand.
    (i plan on dying alone myself...but if i wanted someone around, it'd be loved ones, and not strangers)
    as others have noted, what you can feel good about, is the care you provided for this woman...
    she wasn't neglected, treated respectfully and w/dignity, and obviously treated with sensitivity.
    what more could a dying person ask for?

  9. by   Little_Mouse
    Thank you, all of you.
    I really appreciate your words of wisdom and for taking the time to respond.
    I'm going to take each of your replies to heart. :heartbeat

    P.S. I think I'll put the stick down now
  10. by   rn/writer
    Have some cheese, Little Mouse. Sleep well, and avoid traps.