Had first experience of withdrawing pt care, emotionally drained, need some advice!

[shoegalRN, RN]

Hello all,

I am a new grad in the SICU. I had my first experience of withdrawing pt care. Pt was fine a week before. Walked in to ER with complaints of HA. Smoked for 30 years, was recently trying to quit. 54 y/o male, denies past drug use or medical hx. Had CT of head which determined a mass. Was admitted to med-surg floor. Coded twice on floor. Moved to ICU. Had another CT and biospy which determined LUNG CA w/mets to brain (which explained HA). Pt never been to doctor in past. Pt vented, on 5 drips, including vasopressin and levophed. Day shift nurse calls dr to request a family meeting per the family's request. Pt was made DNR by daughter who was DPOA. Family decides to withdraw care at 19:00, right when pt was handed off to me.

There are about 20 family members in waiting room. Called all of them to be present. Paged doctor. Doctor comes and speak with family. Paged RT. Then it happens.

My preceptor told me to turn off all drips (which were keeping pt alive at this point) and give a bolus of Fentanyl. Wants me to put the monitor on silence. My hands are shaking as I turn off all drips. I am getting very emotional, but hold it together for the family. RT shows up and extubate. Pt is now breathing on his own, but very apenic. Pt's vitals are going quickly via monitor. I'm writing vitals as I'm trying to keep my hands from shaking. I give another bolus of Fentanyl. Family is losing it at bedside. Pt's BP gets to about 20/10 and then HR of 15, pt is showing flat line on monitor. Pt's daughter decides at that moment she changes her mind. Pt's daughter is SCREAMING for her father to "come back". Everyone is screaming, some family members are on the floor. I am the only nurse in the room. I call the time of death.

I get daughter off the floor. Neice is hyperventilating. I asked some of the family members to help me get neice and daughter to hall way. My preceptor steps in and takes another family member who is screaming. I am walking with neice who is still hyperventilating. She says she has asthma. I go through her purse to get her inhaler. Meanwhile, the daugther has fainted. I rush over to her. I get a cold paper towel from bathroom to put over her forehead. Another nurse happens to walk by and helps me out. By this time, there are about 40 people in waiting room (other pts family members). The whole scene is so sad and emotionally draining. Nobody expected him to go so quick. Nobody knew he had cancer. In fact, they don't even think he knew himself.

I go back in and talk to the doctor. Give my vitals and time of death. I have to call the morgue and the transplant network. Tons of paperwork to fill out. Daughter calls back and requests an autopsy. More paperwork. Then I had to do postmotrum care. Pt had so many art lines and IV's, foley, chest tube, etc. This is when I lost it. I cried my eyes out. I remove everything and clean him up as much as possible. I had to call security to have the body taken to the morgue.

The whole entire night I was an emotionally wreck. I can't get that daughter screams out of my head. I cried so hard because I felt her pain, as I had also lost my father suddenly. I go out after work with some coworkers to debrief. I've been sleeping all day, then got up to go out with a girlfriend who is also a nurse, just to clear my head. I'm still emotionally and crying. Please any advice would be greatly apperciated.

Thanks for reading.

[Coffee Nurse, BSN, RN]

I have no advice for you, just a huge hug. I am so, so sorry for your pain; working in the ICU, you know awful situations like this are going to happen sooner or later, but that knowledge doesn't make it any easier. It sounds like you did a superbly professional job of keeping it together and taking care of both the patient and his family members when they needed you most. I'm glad you have people you can talk to; keep talking to them, and make sure you take care of yourself too. Huge, huge kudos to you.

[Dalzac, LPN, LVN, RN]

Such a horrid intense shift! I have had shifts like it and it is wicked hard to do. It does feel like everything has jst been sucked right out of you. You have wonderful friends to help you debrief. That in itself is priceless. I want to tell you that you showed compassion and empathy You did a very hard task with grace and composure. Next time I have to go to the hospital I would want a nurse just like you.

[tewdles, RN]

sigh

This was a terrible experience for you and I am sorry. What you participated in was the best option for this patient. And even though the family expressed their grief in loud and physical ways, what they did was compassionate and loving.

At some point you will be able to process what happened. Keep these things in mind...that unfortunate man had a terminal diagnosis, there was nothing that was going to keep him alive,...the family made the courageous choice and then they chose to stay with him and support the daughter...giving the fentanyl was good, versed with that is also good...it is okay to just turn off the monitors and let them focus on the person not the technology...it is often to your advantage to have MSW and pastoral care on the floor when this is done.

It is wonderful that you have peers/coworkers who are walking through this with you..."debriefing" immediately after the event is so important, and the days following...your friends are doing a good job...it is particularly hard when you are also grieving for your father.

Try to remember that the screams, etc, were primarily the grief reactions of the daughter...and they are not necessarily a reflection of anything else except her grief in the moment...we are so accustomed to a quiet almost silent expression of grief in this country that I do not want you to feel haunted as if there was something horrible happening. This was probably just her honest reaction to losing her father, which is tragic but not horrible.

I hope that in time you can find peace in your participation in this act. What was done for this man was compassionate and appropriate. Thank you.

[shoegalRN, RN]

sigh

This was a terrible experience for you and I am sorry. What you participated in was the best option for this patient. And even though the family expressed their grief in loud and physical ways, what they did was compassionate and loving.

At some point you will be able to process what happened. Keep these things in mind...that unfortunate man had a terminal diagnosis, there was nothing that was going to keep him alive,...the family made the courageous choice and then they chose to stay with him and support the daughter...giving the fentanyl was good, versed with that is also good...it is okay to just turn off the monitors and let them focus on the person not the technology...it is often to your advantage to have MSW and pastoral care on the floor when this is done.

It is wonderful that you have peers/coworkers who are walking through this with you..."debriefing" immediately after the event is so important, and the days following...your friends are doing a good job...it is particularly hard when you are also grieving for your father.

Try to remember that the screams, etc, were primarily the grief reactions of the daughter...and they are not necessarily a reflection of anything else except her grief in the moment...we are so accustomed to a quiet almost silent expression of grief in this country that I do not want you to feel haunted as if there was something horrible happening. This was probably just her honest reaction to losing her father, which is tragic but not horrible.

I hope that in time you can find peace in your participation in this act. What was done for this man was compassionate and appropriate. Thank you.

Thank you for your post. I would like to address the bold part. I will say that I am used to this type of reaction to grief and pain as I am African American, and so were my pt and the family members. This is an outward reaction to grief in our culture and I am aware of it. It was just it doesnt make it any easier, although I do understand it.

I understand all too well how she felt, because I reacted the exact same way when I lost my own father. But I kept my composure, although I wanted to hold that woman in my arms and tell her it will be alright in due time. It was just this whole experience was a first for me (as in withdrawing care) and I am struggling with that part the most. I know it was the best option for the pt, but it is something I am still struggling with and is trying to come to terms with it.

The family dynamics is something I've experienced time and time again, only in my personal life, not my professional life. So, I wanted to just "be there" for them in their time of need.

[PostOpPrincess, BSN, RN]

You will get used to it.

[shoegalRN, RN]

I would like to thank everyone for their kind words. I am on my way to church, and I will pray for this family for their loss. I am off tonight and I return back to work tomorrow night. When I get out of church, I am gonna go get my son from my mother's and spend some quality time with my family and siblings. Life is just so short, you never know when it's your time to go.

I do understand it was the best thing for the pt to withdraw care, considering he had multiple organ failure and I believe he was just in so much pain. I am struggling with knowing I did the best I could have done for him and the fact that I cut off his "life support", although I know it was the cancer that killed him. Emotionally, I'm just drained.

It was something about hearing the daughter screams and knowing EXACTLY how she felt that is haunting me.

[silas2642]

I'm sorry to hear about your night, but it sounds like you helped get the family through what was probably the worst night of their life and you did it with professionalism and a great sense of compassion, which helped them immensely even though they might not even realize it at this point.

[traumaRUs, MSN, APRN]

You are going to be such a good ICU nurse! I am so sorry for your awful night. Sometimes what makes a person such a good nurse is the ability to separate the patients from you. It means focusing to some extent on their grief while not allowing it to impact the care you provide.

I've had this when I've taken care of families who's lost their child in a horrific way, or taken care of a convicted child murderer. It is very hard but it does get easier.

It is so easy to personalize the care we give and because we are all human, its how we show compassion also. Please take some time (as you plan to do) to de-stress and relax.

You are so right, we never know what is around the corner.

[AlabamaBelle]

{{{{{Hugs}}}}}}. You'll never forget your first. You gave superb care.

Take care of yourself as you are doing.

[llg, PhD, RN]

As everyone has said (and you realize), this was actually a "good death" for this patient and the family's expressions of grief were understandable.

The one question/concern I have about the situation is that YOU seem to have had so little support from the rest of your team there at the scene with you. Why is that? Does your hospital not provide have other people (e.g. Chaplains, Social Work? preceptor, charge nurse? etc.) to give you some help in managing the "crowd"? This is something you might want to discuss with your preceptor and/or unit leadership at some point in the future. You could have really used some help with so many people there, many with intense needs.

Also, some hospitals limit the number of people at the bedside in ICU's -- bringing family members in a couple at a time to say their "goodbye's" and only have a few of the closest members there at the actual time of death -- and then letting them to come back in an view the body afterwards. That can decrease some of the "spectacle" of it all and help prevent some of the stress you were under to meet everybody's needs at once right there in the middle of the unit.

Take care,

llg

[nurse_mo1986]

If you ever get to the point that death doesn't bother you, then it might be time for a change. I work in an ICU also, and see death freq, it still bothers me. The only thing I can know for sure is that I do my best each and every time I go to work. God alone has to handle the rest, cause it's not my burden to bear. Good luck to the OP. May it get easier with time.