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

smileyperson · Oct 25, 2009

What an intense story. It sounds like you did a great job and kept your professional cool on the outside. All I can say it's important that you talk this out with someone, as it seems like you did with your coworker and girlfriend.

I think you're a great example to all new grads who will have to handle a situation like the one you described. I hope I can do as well as you when I have to deal with it. Hang in there!

AlabamaBelle · Oct 25, 2009

After re-reading the OP, I am also questioning the lack of support that was there for you in caring for this family.

Our practice is to have extra hands available - MSWs, chaplains, the family's spiritual support, along with our charge (we usually have a "free" charge). The Nursing Supervisor is also available. If possible, those with a "lighter" assignment will pitch and help with crowd control. Usually, other families are very respectful - they sense and/or know (because families bond in the waiting area) what's taking place. Our attending is there at all times. If it's one of our chronic children or a child that's been with us a while, some of us will come in to support the family as well as attendings who are not on but have also bonded with the family.

After, we have debriefing and the chaplains are available to us. Then, home to our families for hug therapy.

Don't ever get used to dying. If I get to the place I cannot cry and just shrug death off, I'm quitting.

CASTLEGATES · Oct 25, 2009

I won't pretty up my post so it may look rough;

I hate killing people and no one understands unless they've done it! My first times were in a more conservative state where it would take a whole day or days, then I moved to a state where they were very forward and you basically disconnected the vent (extubated or put on blow by), cranked up versed and morphine (very very liberally to stop agonal breathing), shut off the monitor and did so while family was sitting and milling around (we had unlimited, open visiting hours). My brain would tell me "you just murdered someone by your own hand." I can pretty it up by saying "I had a doctor's order, etc..." but my brain and my morals were telling me I was a muderer. I was really good at what I did and would equally get really good and wasted when I got home to try to forget about it. It seemed that for about 14 weeks in a row I was killing someone every week. It put my brain on frappe! Multiply one every week or two by a decade or so and that's a few.

I can't tell you the toll it took on me but I'd typically be stuck because I'd choose the highest acuity patients to keep my skills exercised and fresh. I joined the code blue team and that seemed to help because the deaths weren't my fault (in my mind, remember). I had this desire to be the best of the best on my unit and wanted to do it all but seemed to have gotten stuck by this reality monster.

It's difficult and you never ever get used to it but you CAN change your thinking and make sense of it. What helped me is I started to find a part of my heart; my brain that said "It was his time and I'm just the man with the sickle." We ALL will die and many of us will die like dogs. I think the difficult part is our society that avoids death and talk of death and wants death to look all pretty. When was the last time your family sat around and talked about who's going to die next openly and talk about what you'd all do? THAT is healthy.

Death is a part of life and I can honestly say now that I'm ready to die and will be fine on my way out. It took lots and lots of understanding and figuring to get to this point. I also discuss with my family and extended family and kids what we'd do if one of us died just like what we'd do if we got the flu. It somehow reduces the terror and fear of death (for me) because it's a part of life!

Just because someone else isn't ready doesn't mean we can't be. You definitely need to make some spiritual sense of it all and set it in your mind that it's not up to you and even the doctor's order was "meant to be" and there's a bigger plan. If your Buddhist, I'm jealous because they get to come back so it's not nearly as big of a deal. That culture rubbed off on me a bit and I learned to not value life at all costs because people will die and there's nothing we can do about it. It's their destiny, it's meant to be and not my problem...I'm just going through the motions I'm supposed to...

Hey! Notice how the docs write the order then are never to be seen again? They're chicken! I have yet to see a doc hang around during a plug pulling. Sometimes I call em on it and tell them they need to work on their death and dying skills.

After a while, you'll do it so much that you'll have your own set thing you do. I'd always clue the family in on what I was going to do and how it would look before they came in. If they needed a hug, I'd hug em and cry with em (I'm human for God/Buddha/Allah's sake). I always felt like their family killer but they'd always thank me for handling it so well and many would bring goodies later as a thanks; it's difficult until you take initiative and take control of your mind, heart and the situation.

At my hospital, we handled the vents, extubated and did a lot more than some places allow. My support was nill since everyone else was busy. It's just how it is sometimes. The resident would be running the other way after writing the order so I'd usually call the family in and let them know, page the doc if he'd come in to back me up. They'd all know it was coming and I'd tell em this was the best way to go cause they'd sleep right through it.

My heart goes out to you. It's difficult no matter how we look at it, we're a part of this culture that does not deal with death very well at all.

shoegalRN, RN · Oct 25, 2009

I would like to add spiritual care did FINALLY show up, after the fact, due to a trauma going on in ER. The other spiritual care advisor was at the bedside of another dying pt over in MICU.

Social work was also tied up in the trauma. Charge nurse in the trauma also. So, that left me, my preceptor, and my co workers, but they had their own pt load. Doctor didnt stay for care withdrawal, however, did return after pt passed away.

So, basically, I was on my own. Only been in the SICU for 4 weeks now (I am part of a new grad residency program). All my co-workers and preceptor told me I did a good job handling this situation. The charge nurse heard about it and told me I did a good job as well. Needlessly to say, none of that made me feel good at that moment.

CASTLEGATES · Oct 25, 2009

I would like to add spiritual care did FINALLY show up, after the fact, due to a trauma going on in ER. The other spiritual care advisor was at the bedside of another dying pt over in MICU.
Social work was also tied up in the trauma. Charge nurse in the trauma also. So, that left me, my preceptor, and my co workers, but they had their own pt load. Doctor didnt stay for care withdrawal, however, did return after pt passed away.
So, basically, I was on my own. Only been in the SICU for 4 weeks now (I am part of a new grad residency program). All my co-workers and preceptor told me I did a good job handling this situation. The charge nurse heard about it and told me I did a good job as well. Needlessly to say, none of that made me feel good at that moment.

4 weeks...unacceptable for you to be alone. Must be a for profit system you're in; sad.

iwanna · Oct 25, 2009

((((big hug)))) to you! I am so sorry that you experienced this, only a mere 4 weeks at this job. And, a short time after losing your own father must have been really painful. Death is a part of life. And, I agree with OP that it is healthy to talk about it. I try to with my family, but they all get freaked out and think that I am being morbid. However, the fact is that I will die, and so will each of them. But,we never know when it will happen. My pastor says that he is ready to when his time comes. He says that it only gets better after this life.

You did a great job. That family was very fortunate to have you there for them. Although, I am sorry that you had to experience this pain. You were very empathetic to them. And, they did a very loving, unselfish thing in letting him go.

:redbeatheiwanna

SunnyAndrsn · Oct 25, 2009

What a horrible night. I think you did everything possible to debrief, it's simply going to take some time. Add into that your own memories/triggers of your father's loss...well, it's no wonder this has been so hard on you.

Sending a hug...

My experiences with withdrawing medical care and doing supportive care only are quite different, but we've also had family members who suddenly want medications restarted, especially things like vitamins. As if vitamins will suddenly cure their loved one...it's always sad.

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.

llg, PhD, RN · Oct 26, 2009

I would like to add spiritual care did FINALLY show up, after the fact, due to a trauma going on in ER. The other spiritual care advisor was at the bedside of another dying pt over in MICU.
Social work was also tied up in the trauma. Charge nurse in the trauma also. So, that left me, my preceptor, and my co workers, but they had their own pt load. Doctor didnt stay for care withdrawal, however, did return after pt passed away.
So, basically, I was on my own. Only been in the SICU for 4 weeks now (I am part of a new grad residency program). All my co-workers and preceptor told me I did a good job handling this situation. The charge nurse heard about it and told me I did a good job as well. Needlessly to say, none of that made me feel good at that moment.

In this situation, your preceptor and colleagues should have stepped up to the plate and said, "Wait!" There was no reason that man had to die at that minute. The death could have been postponed a little while until the proper support personnel were on the scene.

I am sorry that you, as a new nurse, were put in that situation. As a nurse with a lot of experience in the discontinuation of treatment and death (in NICU's), I would have insisted that the appropriate support be present before I would allow the death to ocurr. That's a thought you should include in your future discussions of this incident with your preceptor/management. I would insist on that support to protect myself, the patient, the family, other family and patients in the unit, the hospital, etc. Someone who fainted could have hurt themselves and sued the hospital. Other families could complain about the lack of crowd control. etc.

MSPRN01 · Oct 26, 2009

You did a great job and a big, big hug goes out to you. I work in a Level III NICU and I can relate to how you feel. A 36 week infant died last night and I promise you that baby waited to die until his mommy held him (she had a c-secion so she didn't get up to the floor until 10 hours post-delivery). I have been doing this for over 8 years now and you never get use to it, you just find ways to cope via spirituality, physical activity, etc. You learn to be in the moment, take care of the patient/family needs, and remain professional until you can decompress, which you did!!!