Having trouble with a difficult situation

kakamegamama · Oct 13, 2011

Oh my....I'm so sorry you have such a struggle. I truly don't have any advice. However, I do have questions/comments. How do you handle an "ordinary" death in the OR? Does that impact you to the same level? Is there much difference there in the "dying"? Can you pinpoint what it is that is troubling you so? Can you focus on the good that will come from the death? Again, so sorry....

On a personal note....my late husband was a victim of a massive coronary and died. His corneas provided sight to 2 people, his skin helped burn victims, and his bone helped in various ways as well. There was good that came from the awfulness of that time. Will thinking about those gifts from patients you care for who die from a cardiac even help you?

I wish you the best.

canesdukegirl, BSN, RN · Oct 13, 2011

Oh my....I'm so sorry you have such a struggle. I truly don't have any advice. However, I do have questions/comments. How do you handle an "ordinary" death in the OR? Does that impact you to the same level? Is there much difference there in the "dying"? Can you pinpoint what it is that is troubling you so? Can you focus on the good that will come from the death? Again, so sorry....
On a personal note....my late husband was a victim of a massive coronary and died. His corneas provided sight to 2 people, his skin helped burn victims, and his bone helped in various ways as well. There was good that came from the awfulness of that time. Will thinking about those gifts from patients you care for who die from a cardiac even help you?
I wish you the best.

"Ordinary" deaths in the OR are also very hard, but most of these were high risk patients to begin with. For example, the 85 year old man that came in with a ruptured triple A. We took him immediately to surgery, he was unstable, we opened him, we tried to graft the aneurysm, he tanked, I took turns with the surgeon doing open cardiac massage...to no avail. Yes, this was difficult.

I am so glad that you asked me to pinpoint what is difficult for me, because now I am able to think it through. I never thought about identifying and dissecting down my thoughts regarding this specific issue, although I advise others to do just that when faced with overwhelming emotions.

"Hi Pot! Have you met Kettle?" smh

I think that with a death on the table, I am actively and physically trying to save a patient's life. With a cardiac death donor, I can do nothing. Perhaps it is the sheer feeling of helplessness that I have trouble with.

Thanks for providing this perspective. I will work on this. :redbeathe

nerdtonurse?, BSN, RN · Oct 13, 2011

Not quite like your situation, but I've performed terminal extubations of people who were not going to survive (takes a doc to put a tube in, but we can take it out with a MD's order). There's family there, saying good bye, the patient's alive, you know they are not going to be that way for long once you take out the vent. Most of these have a huge list of comorbidities, and are at a place where they would not last much longer, even on the vent, but they're still alive and often rousable if the Diprivan is decreased. You know, KNOW the person is not going to live, no matter what is done, but there's still a difference between a "cardiac" or "lung failure" patient, someone who's still "in there" and someone who's had a massive CVA, bleed, etc. and they aren't "in there" anymore.

What I do is tell myself the person "died" the minute they were put on the vent -- their life as they had known it was over. This period -- hours, days, sometimes weeks -- that they spent on the vent were the "grace period." It 's the time the family and the patient needed to have so they could come to terms with the fact that the patient will not survive. I've told families before that while this is horrible, they had the chance to say good-bye, and that's a blessing a lot of people don't get. They have the time to say what needs saying, make amends, seek and give forgiveness for real or imagined wrongs. They have the chance to tell their parent what a good mom or dad they were, or a spouse or child how much they were and are loved. I encourage families to assure the patient that the remaining family will be okay, and nobody's mad at them because they can't stay with them. I make liberal use of the hospice team, the chaplains, etc., dim the lights, play soft music, try to remove all the signs of "us" (even if it's just throwing a sheet over the vent if the person's going to pass almost immediately) and I do all I can to make the time and space all about the family for the last moments when the family is still intact.

Try to make it the best affirmation and celebration of a life that you can. And after it's all over, I've went and sat in the bathroom and cried. Cried for me, for the day when it's going to be my mom, my dad, someone I love in the bed who's beyond any human help. I try to think, what would I want done if this was Dad? Mom? My sister or BIL? And then I do the best to make it happen.

diva rn, BSN, RN · Oct 13, 2011

Canes,

I haven't thought about this issue in a while. I was a long time PICU nurse in a busy South Florida hospital. We got so many drowings it would make you ill. The thing that was so heart wrenching was that these little kiddos would come in looking just like they were sleeping. What was worse, the medics would resus after a down time in excess of sometimes 30-45 minutes and sometimes they didn't even know how long the down time was. I know, I know..they had to, but these little kids were primarily healthly and like our intensivist used to say "if you shoot enough epinepherine into a steak-it will start beating"..anyway, they would get a heartbeat back, but of course, they'd come in with blown pupils and essentially they were dead. We would put them on a vent and do everything for them...but then the worse part would begin...the brain flow studies and trying to explain brain death to the parents who are looking at their "sleeping angel"...and could not comprehend anything you are saying to them....

Then comes the organ donation talk...then the preparation for donation...and you know the rest.

The only thing that kept us going was hearing from the University of Miami...they would let us know how many people were recipients.

Many, many tears over many years.

And the worse thing about all of this...DROWNING IS PREVENTABLE...!!!!

Canes, I know what you are going through, you just need to concentrate on those who are getting a new life. That's beautiful.

It's a noble and courageous thing the organ donors and families are doing!

(and yes, I am a dedicated organ donor)

Lucky0220 · Oct 13, 2011

canesdukegirl,

What a wonderful nurse you must be!

I have always enjoyed your posts ever since you joined AN and now to read this, while it just breaks my heart, tells me that even after many years as a nurse, you still care about your patients and their families.

Having never dealt with this type of nursing, I don't have any relevant advice and hope that you get some good responses here.

Your facility is VERY lucky to have you! I only hope that I can be one tenth the nurse that you are. :redbeathe

Zookeeper3 · Oct 13, 2011

You are absolutely right, as an ICU nurse, we were required to go to PACU, when extubation occurred and just wait. As you've experienced, not all died in the allotted time frame and were sent back to die somewhere else and all the organs for procurement died as well.

Sometimes family wishes to be present, and it's even more difficult as you silently hope for a cardiac death to harvest to save more, while watching those grieve suffer their loss.

It is an emotional turmoil to hope for death, to save another. There are no other words to say about a "cardiac death".. I've felt like a vulture, selfish at times, knowing what lies ahead for life on the other side. It challenges us morally and ethically with each patient. Going home, no one, no one, understands what we go through and what goes on in our heads, sometimes praying and wishing for death. Death to come so life can continue. It is beyond morbid what we do at times. Very, very dark.

I had to focus an those that could be saved, life brought from the dead to those that COULD live. Somehow finding peace that a person so generously gave to others in their death, so others could live. It seems shallow written in my words, and I lack the ability to justify what we really do in words, but would you consider a few thoughts....

I have worked heart transplant, on the receiving and recovery end as well. We have these people for months, almost a year at a time. To get a call at 3am, to draw blood, take vitals, get consent, call family after the surgeon harvests and we have a match.... is beautiful. To take care of these folks after, fight rejection, extubation and demand they walk to the step down for care to be able to have full access to family, takes my breath away.

I have no way to take your pain from you, but I can suggest that you work a few shifts in the actual transplant and step down and see the success, it may help put a band-aid on the hurt and difficulty of what you do. Seeing the success of a transplant coming in one year later and talking to the pre-transplant group is breathtaking. Having someone 20 years post transplant, still coming to the group, makes it a bit easier to live with.

Death and dying is the toughest to deal with, and what you do, it's 24/7. I suggest you seek out other areas of the transplant process to help make you whole.

canesdukegirl, BSN, RN · Oct 13, 2011

canesdukegirl,
What a wonderful nurse you must be!
I have always enjoyed your posts ever since you joined AN and now to read this, while it just breaks my heart, tells me that even after many years as a nurse, you still care about your patients and their families.
Having never dealt with this type of nursing, I don't have any relevant advice and hope that you get some good responses here.
Your facility is VERY lucky to have you! I only hope that I can be one tenth the nurse that you are. :redbeathe

Your post was so heartfelt and I very much appreciate your sentiments. I fear that you give me too much credit; I feel that if I was a less emotional nurse that I would not struggle as I do with this situation. I can deal with the situation professionally and respectfully during the time it takes for the cardiac death to occur. I have learned to divorce my emotions in a way that enables me to provide care for the family; my focus is on THEM and not ME. It usually takes me a few days to recognize, process and deal with the emotions that I felt during this difficult time.

On the one hand, I know that these donors provide organs to those who would otherwise not live. On the other hand, the circumstances surrounding the cause of death for these donors is what I am finding to be the most difficult and the most challenging issue that I face as a nurse. It is extremely hard for me to stand there and WATCH the patient die.

Furthermore, I must ask myself an honest question: WHY do I feel such strong emotions regarding cardiac death donors, and WHY do they stay on my mind for so long? These donors and their families, the care providers, docs, surgeons, and donor services staff ALL feel an incredible impact on such a visceral level. I am toying with the thought that there should be a "debriefing" after a donor harvest so that everyone can discuss their feelings. Is that Polly Anna?

I am not suggesting a Kumbaya session, but I am suggesting that an invitation to those that cared for the donor be extended for a short meeting to talk out feelings and thoughts. I think that would be healthy, and would also spark some interest and thoughts regarding morbidity and mortality.

Our surgeons go to an M&M conference when a death occurs. The nurses are not invited. Do you guys think that I should request that nurses be involved with these conferences?

AndiSN · Oct 13, 2011

Talk about a cryfest there. I pretty much can hardly see now. I am still a student and I haven't been through all of these things so I can't give any words of wisdom. I can say that your posts and posts of others like you help to keep me inspired and let me know that it's ok and normal to have emotions as a nurse. I know it's important to be there for the family and save my emotion until I have already done that but it helps to know that I won't be some oddball to feel that way.

carolmaccas66, BSN, RN · Oct 13, 2011

I don't deal with this, but I'm sorry ur going thru this. Peads deaths must be the most awful part of nursing to deal with.

I have sat with a mother who had tried for years for a baby, and got pg. Then the baby died somehow (can't remember the cause). This mother was a bit older (back in the late 80s), but she was absolutely devastated. I spent half the shift comforting her - I was a nurse assistant then, and the RNs didn't have time 2 be with her. That really affected me, I won't forget that woman. She was sitting cradling her poor baby daughter, the tears dripping onto the babies face. I remember this so clearly because the baby looked like it was made from hardened wax. And the cleaner was absolutely horrified that the mum was cradling this dead baby - I tried to explain re bonding with the baby in death but this cleaner was appalled. I remember talking a long time with her as well.

We put our heart & soul into our job. We are not appreciated much I don't think - we are there at the beginning & end of life.

One consolation is that the time on earth these people spent - even little babies - they would have touched someone, whether it was a partner, or a mum and dad etc. They brought some happiness to others.

It is the cycle of life and death, and we are there to make the transition easier for those who can't handle it.

Can u take a holiday at all? Also I write a journal and do pilates, and burn lavender oil (good for stress & anxiety etc) when I get home after stressful shifts. My journal is my life saver, as I get it all out in one hit & then don't dwell on the upsetting stuff so much.

Hope you feel better soon :)

carolmaccas66, BSN, RN · Oct 13, 2011

Just read ur last post, we used to have a memorial service for our hospice patients, all the patient's families & nurses etc used to attend. Maybe u could do something like that?

AOx1 · Oct 13, 2011

I try to remind myself that nursing is not just intervention, it is also presence. I too, prefer to "do" something. It feels more proactive to run a code. But sometimes I also have to remind myself that we are also allowed to be present & bear witness to a quieter death. I think in my head as they pass "Thank you for the honor of letting me be here as you exit this world. Although it is painful, I will comfort you, even if it is only by ensuring you are not alone." I still cry later, even after all these years. Like many things in nursing, there can be so many feelings:anger, disbelief, powerlessness, numbness, sorrow. For me, I reflect on my own past losses of family and friends; it helps to remember that at a time that is equal parts sacred and terrible, what stood out was the kindness of those who were simply willing to be present.

Many of us come to nursing because we want to heal others. When this isn't physically possible, it's easy to feel loss. A few years ago a friend died. It wasn't the code team I will remember; couldn't id them in a lineup if I tried. It was the nurse who stood, quietly present, in the worst moments at the end as we felt our hearts break. Your presence itself is a priceless gift.