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

  1. 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 close to "leaving". I kept that in the back of my mind but a part of me was hoping for at least some improvement...I was afraid she was going to let go during my shift...

    I kept an eye for her during my shift, provided suction and oral care, called RT for tx at around 0330. At approx 0615, I noted the pt was wet. The cna stated she just cleaned her up 10 min prior. Anyway, we cleaned her up again. Pt was still awake and moving, pt was on O2... afterwards I went to complete my I&Os, change another pt's iv site, then give report to oncoming shift.

    During change of shift I was looking for the nurse to give report on this pt, but 10 min prior to clock out, a nurse asked who was caring for the pt in room .... I said it was me, went over there. The RT said he couldn't get a pulse ox reading, the AM cna said he couldn't get a bp reading...the pt was cool, pale, unresponsive, not pulse felt. My heart dropped.

    This was my first pt death on my shift. Pt was a DNR, but it was my failure to notice sooner. That time when the cna and I changed her, I notce she looked a little pale, but I thought to myself, pt is awake and moving...she's ok...
    I called the UC md to pronounce her, he did, but stated she must've died some time (he said at least a couple hours) ago. It was only 0730 at that time. I called the family and that was nerve wracking and heart breaking at the same time, espeically since I just saw some of them less than 12 hours prior.

    My manager said I had to endorse everything else since it was already 0800. So I didn't do the post mortem care or see the family.

    It was my failure for not noticing sooner, my failure for not being with the patient when it happened.
    My supervisor asked me if this is my first time experiencing this, I did shed a few tears (embarrassingly) in front of her and my charge nurse and said yes. She replied, "don't worry, this is just the first of many."
    Last edit by Little_Mouse on Aug 25, '11
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    About Little_Mouse

    Joined: Feb '09; Posts: 147; Likes: 110


  3. by   nursemike
    I'm sorry for your loss, but it wasn't your failure. It would make a nicer story to be able to say you held her hand as she passed, but the reality is, other patients needed you, too. I don't think it's a bad thing to review the event a bit, in case you think of things you might do differently, next time, but you need to be fair and honest about it. Sooner or later, all of your patients will die, and so will you. Meanwhile, all we can do is our best, and you did.

  4. by   rn/writer
    That first death is difficult, but you can make it worse by taking "blame" where there isn't any. I'm not saying this to be harsh. I'm saying it so that you can keep being a nurse.

    To say that you were a failure is to imply that you had a whole lot more power than you actually did. It's tough to comes to terms with the fact that there are so many things we just can't control. This was an elderly woman with end-stage COPD, hence the DNR. She showed signs that she was getting ready to check out. Other than turning back the clock a decade or so, I don't see much you could have done about those things.

    It was my failure for not noticing sooner, my failure for not being with the patient when it happened.
    Short of standing a death watch and neglecting your other patients, I can't imagine anything you'd do differently. Can you?

    When you speak of "my failure," all I can think of is that this isn't a test that you somehow blew. It's part of your life as a nurse. These things happen. It wasn't really about you at all (except that you do need help to process this milestone first death, and that's normal). It was about a woman who was ready to go. And so she did.

    I called the UC md to pronounce her, he did, but stated she must've died some time (he said at least a couple hours) ago.
    Pure speculation on his part. You KNOW that you had last started cleaning her up around 0615. So you probably finished at 0630 or later. Do not let the inaccurate comment of someone who wasn't there talk you out of what you know to be true. She was alone, at most, for an hour.

    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.

    Have a good cry. The first death is the worst. But then dry your tears and realize that this is not a story of your failure but of your patient's good fortune to pass in a place where she was cared for until the end and found quickly instead of many more unpleasant alternatives.

    This is part of your growth as a nurse. You never want to get to the point where you don't give a flying fig about someone dying, but you have to be able to take it in stride or you won't be completely available to the living.

    Here's a hug.
    Last edit by rn/writer on Aug 25, '11
  5. by   KalipsoRed
    First, quit beating yourself up. You are doubting yourself and I don't really see any reason you should be after reading your story. This is your first experience and fortunatly it will become more organized for you as you continue with your care. I won't say it get's easier. I'm a nurse of 3 years, have had several patients pass on, and I cry still.
    Death is a hard thing to judge and no one knows when it's comming, we just know when it is near. Most patients have a 'death rattle' in their breathing, but I haven't found this to be all that accurate of a sign of immienent death.
    I remember calling a family in during the middle of the night because I had a DNR pt's breathing pattern changed to Cheyne-Stokes. The patient ended up living for another day and a half.
    At first I felt foolish for waking the family up when the pt lived for another day and a half, but I've just had to realize that death comes when it does.
    My only suggestion to you is that the next time you get that feeling the one that make you think she was close to leaving, then you need to call the family then. What you say is " I'm sorry to wake you but your family member is looking very weak (or has had a change in respirations or whatever makes you think the pt's condition is close to death...and if you can't point out the excat thing just say to the family that you are just concerned that the pt is close to can't put your finger on it but it is how you feel) and I thought you would like to know.
    It is always OK for you to be wrong about this and the patient be alive for another day or two. It is better to mess up like this than for the family to not be at the bedside. Don't feel bad about this, it is a new experience for you and this is how you learn what to do.
  6. by   xtxrn
    I'm so sorry It's not your fault she passed when you weren't there- it's hard when patients are alone, but it happens, and you can't know when it's going to happen.

    It's not bad to cry sometimes- no need to be embarrassed.

    We've all had times when it felt like we could have done more- but there's only so much you can do- you learn anything you need to for the next time, and go on...:heartbeat
  7. by   Hospice Nurse LPN
    Big hugs to you, Little Mouse. The others posters have given you some great words of wisdom. The first death we experience as a nurse is hard. It sounds to me like you gave this pt the best of care. Please, put the stick down and quit beating youself up.
  8. by   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. Families will stay, the step out for coffee, for just a moment, that's when they go. Actually saw a patient, overnight the nurse just didn't want her to die on her watch, and she did, for about 5 minutes, was even pronounced, then big old breath, came back until I kid you not, that nurse had given report, clocked out and walked out the door. Died AT that moment. If they need someone with them, someone will be with them. It will happen the way it's meant to happen.
    Here's why I think I can handle being the one that handles a lot of "expiration" paperwork better than a lot of my fellow nurses. I know one thing well. Death is not a failure. It's hard for those of us that do a lot of "healing" to keep that in mind. We take our CPR classes and we watch our monitors and we do all the things needed to keep people alive. It's what we do. And even if you know that there are worse fates than death, even if you know that people are going to die, I think that it takes some real pondering on that to KNOW it so deep down that you can counter all that training that tells you, "Gotta save them!!"
    I think it helped that I started my healthcare career in a nursing home, where death happens a bit more frequently than elsewhere. There's really something very special about knowing that you kept someone comfortable in their final moments. You don't have to be there with them at the moment. Just knowing that someone's last moments on this planet were warm, dry, as comfortable and painfree as possible... And knowing that you were a part of making that happen for them... It's a privilege. It's as far from "failure" as you can possibly be as a nurse.
    You did good. You made her last moments more comfortable. In my opinion, THAT is what being a nurse is about.
    Have yourself a good cry, there's nothing wrong with that. And feel good about your work, you were far from a failure. You were a nurse.
  9. by   xtxrn
    What wooh said heartbeat
  10. by   classicdame
    I do not want to sound crass, but you do not have control over life and death. Your job is to provide quality care to the best of your ability and I believe you did that. If your employer has an employee assistance program please take advantage because many of us do grieve over losses. You sound like a caring nurse.
  11. by   Minnie2006
    I would be concerned if you didn't feel a measure of sadness. It is difficult to lose a pt. no matter what. You always feel like you could have done more. That's what makes you a good nurse, you are not content to do the minimum. As a previous poster said other pts needed you too. Learn from each experience but realize you can only do what you can do. Don't be too hard on yourself, we have no way to predict what can happen and in nursing things change from minute to minute.
  12. by   Sparrowhawk
    I don't usually feel badly when my residents die...I did all I could do. I will say, the last resident that died on my shift, died while I was on lunch. THat did make me feel bad...I just left the building for a little bit and said to myself, I bet she'll go while I'm gone, and she did...not ten minutes before I came back. I felt like a bad nurse, but then the family was there and they were with her and everything was ok...things like this happen, you can't pyschically know when it will happen, only God and the Spirits know..You took *good* care of her through the night, better care then some nurses give to dying patients. Don't feel bad. Your manager's right, it's the first of many love...8 times out of 10, you're *not* going to be with the patient when they go.

    Yes, feeling badly is normal...but in reality, it's not anything to worry made no mistakes. You are not a failure. If you had left her all night and she died at say..oh...12 am...and she was rigor by the time they found her..THEN I would feel bad. K? You're all right. *hugs*
  13. by   lrobinson5
    Gut instincts can be very accurate. I think you and maybe more people kind of knew what was in store for her. From what you said you sound like a very caring nurse, and I hope you can see that and get past the blame game that your brain always plays after these events happen.
  14. by   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.