Working with death may be an inevitable part of a nursing career, depending on what area your focus is. Learning how to cope and manage death seems to vary from department to department. Please feel free to add to this and help your fellow nurses understand your take on dealing with a death in your work area.
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"At the end of a rough day, I call my mom. I talk to her the whole way home. She's cheaper than a therapist. My husband is slowly learning how to just listen without trying to fix, but he just can't handle tears, so I call Mom or my older sister instead. Keeping in touch with friends is also important, and making work friends to lean on in rough work situations is just as important. No one is going to better understand what you're going through like the guys and gals who are in the trenches with you. Bubble baths, wine, all those are nice, but I find human interaction to be what keeps me grounded and sane. After talking it out, if needed, I'll go for a run. And on days off, enjoying the sun and surf, a good book, whatever makes you smile."
Sylvia Nielsen, DNP, ARNP, CPNP-AC. Nemours Children's Clinic, Jacksonville, FL. ENT/Head and Neck Surgery/Complex Airways Division.
"The way that I manage: I have been truly blessed to work with some of the most hardworking, caring, compassionate, smart, and empathetic individuals on earth, who truly give their all to save the lives of critically ill and sometimes dying children. Sometimes we're are successful, sometimes we are not... but every time we are there for each other - to lean on, talk to, cry with, learn from, etc. I would be nowhere today without the guidance, skills, knowledge, love, and compassion that I've received from my colleagues over the years, and that I have passed on to others. They have made a profound difference in my career and in my life that I will never forget. Sometimes, we do all we can, work our tails to the bone, go 12 hours without eating, etc., and even then it may not be enough to send a baby home with its parents. But, at the end of the day, we still have each other. That's what gets me by."
Jay Hunter, DNP, RN, CPNP-AC, CCRN, CPEN, CPN. Pediatric Critical Care Nurse Practitioner in PICU and PCCU at University Hospital; Instructor/Clinical Department of Pediatrics, Division of Critical Care at UTHSCSA School of Medicine.
"At the end of the day I feel it boils down to your colleagues. No one else REALLY understands unless they are also in the medical field. Losing a patient is hard and exhausting physically and emotionally. Not only have you been their nurse for weeks or months, but you have befriended a family. Me, I find peace in praying for the patient, family, my coworkers, and myself. I hold on to my faith that there is something greater after this life. The great thing about nursing is it is a very versatile field. You can go from patient care to sitting behind a desk."
Michelle Flores, RN, CPN. Perianesthesia, hematology/oncology, Driscoll Children's Hospital; Postpartum/antepartum.
"Distraction and laughter (as long as it's in an appropriate place and time...sometimes it's after I get home. It's comforting to know that my coworkers "get it" even if they don't say anything...it may be a reassuring look, a quick hug, a shoulder rub or a few pieces of chocolate....it somehow makes it easier knowing that they understand. I also tell myself that I'm still helping the situation and/or the people by being there and helping to still care for their child (whether still with us or not)...the care process never really ends...you just have to transition from trying to keep a child alive to now I'm trying to help the family say goodbye and start their grieving process with as much respect and compassion as possible. And of course, lots of exercise lol. Work it all out in the gym!!"
Jenny Collins, BS Exercise Science, RN. PICU Driscoll Children's Hospital.
"At the end of the day, I never took my work home. I always would put a loss in perspective by remembering all the lives that were saved on a daily basis. The majority of our kids would get better and go home, and it's important to remember that."
Carol S. Kaplan, BSN, RN. Cardio-thoracic surgery. Driscoll Children's Hospital.
"It's not easy, every department has it's good and bad days. They are not the same. You have to learn to take time, even if it's the 30 minutes for lunch or 5 minutes to take a breather during those heavy days. Try and find an outlet; gym time, walking, talking to fellow nurses who understand what your'e going through, or family, friends who you can just vent to. You've got to have some ME time allowed with no interruptions. I have always believed in the power and have a lot of faith in God. Especially on those emotionally trying days."
Jenny Martinez, RN. Med-Surg, Driscoll Children's Hospital
"How I handle: no matter how many bad days, how many days I feel like no matter what, it's not enough, or no matter how many shifts I leave tired, hungry, and dehydrated. The days I do make a difference, the day where you see the little child open their eyes finally,
the day the family finally takes them home, or when the family brings them back and you see progress, the time a little one squeezes your hand after being sedated for days, the day where a miracle happens make up for all the other "bad" days. The smallest smile, the smallest "success" story is more than enough to make up for the other days. In the end of the day you DID DO something and the smallest glimmer of joy in bad is all worth it. Having family and co worker support helps too. And breaks from work. Sunshine, wine, and vacations. No matter how sad or hard I'm so THANKFUL and lucky to do what I do."
Haley Troell, BSN, RN. PICU Dell Children's Hospital.
"I simply tell myself God has given this knowledge to help people. Everything else is in His hands. I do the best I can, I cry and lean on my work family when needed."
Karen Martinez, BSN, RN. Emergency Department, Driscoll Children's Hospital.
"Never look for a reason."
Teresa Ercan, MSN, RN, CEN, CPEN. Emergency Department, Driscoll Children's Hospital.
"Nursing is a double-edged sword that pierces through our compassionate hearts. We love our patients with our entire being. We advocate for them, we comfort them, we heal them, we hold them. When you know your patient's favorite cartoon character, color, snack, siblings' names, their stuffed dog's name, and what they call their grandparents--you become part of their extended family while they are in the hospital. A majority of these kids improve and get to go home. Your heart pangs with joy when you transfer them to the floor, knowing that everything will be okay. You hug their mom and tell her to stay strong because their journey to home isn't quite over yet, but you know it will have a happy ending.
Then there are those that don't ever make it home. Your heart hurts when you hear the physician tell the parents there is nothing left to do. As you see the child on life support undergo a brain death test without any response, your heart sinks but you blink back the tears before their family sees. When you bathe the patient you've cared for over several months with his mom for the last time and she asks to put his toe tag on, your heart shatters into a million pieces. You feel as if you are losing a family member of your own, but you have no time to grieve because you have to be strong for their families. You will probably get a new patient before your shift is over and you don't want them to see your tear stained face and wonder if their own fate is grim.
How do you cope? How do you not burn out from the surge of emotions that bombard you each and every shift? It's simple. You remember that you made a positive impact on that child and family. You remember the mom who thanked you for always trying to soothe her baby by singing to her and patting her instead of giving her medication to put her into a drug induced sleep. You remember the scared teenager that asked you to pray with them because they didn't want to burden their sleeping mother in the middle of the night. You remember the toddler in DHS custody that you held tight to your chest and rocked, who calmed down and smiled at you as they finally felt safe and peacefully drifted off to sleep. You remember the difference you have made in every patient's life. Even if the outcome wasn't what you had hoped and prayed for, know that you had a positive impact on that patient and their family through your care and compassion. Let that give you peace for today and encouragement to wake up and do it all over again tomorrow."
Candace Mayle, DNP, APRN, CPNP-AC. University of Arkansas for Medical Sciences in the Department of Pediatrics.
"This may sound callous, but as an ER nurse, I felt it was selfish to get too emotional about the horrid things we see. In most cases, the families are strangers to us and there is a difference between being caring and compassionate towards them and making it all about yourself by breaking down. It serves no purpose to the grieving family. That doesn't mean there weren't times I would get home from work and just want to drink a glass of wine in quiet, but I had to build an emotional wall for my sake and that of my patients and coworkers."
Elissa C. Norris, RN, CPEN. Pediatric Emergency Department and School Nurse.
"I keep a scrapbook of all the "kudos" that I get from patients as well as from supervisors. I have also taken pictures of flowers that patients have given me. I put those in the scrapbook as well. And on bad days, when I wonder why I do what I do, I pull that out and read all the notes. On my floor we don't deal with such high acuity. So I never actually come in contact with dealing with death. I really don't know how I would handle that."
Dawn N. Tollett, BSN, RN
"I agree with Elissa Norris. You are the tool that the family uses to get through the crisis, but it is not your crisis. It is theirs. It is sometimes selfish to internalize it and make it yours. I think you see the grieving and cannot help but be sad for the hurt a human suffers, but it is important to know this is not your burden."
Julie Browning, BSN, RN, CPEN. Pediatric Emergency Department, Driscoll Children's Hospital.
"To show emotion is compassion. By definition, compassion is the emotion that one feels in response to the suffering of others that motivates a desire to help. It does not mean that you are unprofessional, or weak, or selfish."
Jenny Collins, BS Exercise Science, RN. PICU Driscoll Children's Hospital.
"To blubber on with a patient's family and then to internalize it and take it home with you is the fast train to burn out, which is what we are talking about. To shed a tear knowing that sadness has happened to another human, is to keep in touch with our humanity. You can show compassion without joining the family in the grieving process. I think the nursing scenario is different. If you have time to step back and properly grieve with a family, then wow, what a lovely time schedule you have, but it makes it difficult to go to room 8 with a mvc if you are shook up about what happened in room 1."
Julie Browning, BSN, RN, CPEN. Pediatric Emergency Department, Driscoll Children's Hospital.
"I really love this discussion! I think that is what makes nursing such a great field, no one situation is able to be handled by every nurse, and there is a nurse who has the personality for every situation."
Julie D. Reyes, DNP, RN, CPNP-AC.
"As a nurse, it's important to find a way or ways to cope through emotions. We have the opportunity for all types of growth in our field and that's what makes it awesome! Death is guaranteed to be part of the package and it's great that our experienced nurses step up to show our new nurses how adaptation is possible through their examples. This is how new nurses will find their own path and be successful and to hopefully avoid burn out while standing by our families, patients, and fellow staff during the best and worst of times. It's a rollercoaster of emotions some shifts, but strong nurses are built and molded each day!" Monica Cantu Martinez, BSN, RN. SWAT (Special Work Assignment Team [i.e., POOL]), Driscoll Children's Hospital.
"This discussion of your article started me thinking. I was an oncology nurse for 6 years and suffered horrible burnout to the point where I no longer wanted to be a nurse. There are plenty of studies about oncology nurses. Changing into management and then into ER has been a fascinating road and I was reading about burnout in nursing and the impact on the nurses home life, job satisfaction and etc.
I know the ER nurses handle everything different, every minute is someone coming into the ER with a family crisis, a forced injury, abuse, assaults, a death, a near death. PICU environment is so far away from the ER spectrum. Two patients instead of 4 or 5, time to prepare for patients and know what is coming in, not a shocking surprise of a blue baby being handed to them. Does the PICU nurse have a grieving pattern that the ER nurse does not? Do they have time to collect themselves, etc? Perhaps that is the difference.
The ER environment may not allow time to be attached or even be involved for long periods. We have seen some horrible things that never arrive to PICU, and we have arrived some things that we never know the ending of because they go to PICU. Does the environment matter? There is no time for grieving three or four times for the things we see in a single shift. In fact, if a nurse did get sad of all the things she saw in the ER, I would think she would have a short career in ER medicine. PICU nurse holds the hand of a patient for 3 days or longer. A bond is there.
I don't want you to think that the ER nurses are a group of unfeeling robot nurses who are uncaring. We will not sit and grieve with a patient's family. We will show compassion. I probably see about 4 hard sad things in a shift. The child abuse rate alone is so high, how can we not? But my professional side is to stabilize them and get them to the place where they can heal, not to solve them, cure them and place a bow on their head. We see 60+ patients in a shift most days. If I am caught up in a grieving process, how can I continue my shift and the next two shifts?
I think the type of nursing is the key, the environment and the expectations. Can compassion be shown, yes. Does it have to be my emotional breakdown? No. Can I go to work knowing that this crisis is not my crisis. Yes. That keeps us healthy. You asked the question about "losing a patient" as if you had the power to keep that patient or it was a quest you "lost", that statement alone shows ownership and therefore you own the grief with that, but I believe that to be unhealthy. At least in my environment."
Julie Browning, BSN, RN, CPEN. Pediatric Emergency Department, Driscoll Children's Hospital.
"Thank you for elaborating on this. Like I said in my original post, this was from an ER [nurse] perspective and not meant to be a criticism of how other nurses handle themselves. I will say that in the ER it is not fair to your coworkers if they have to take on your 4-5 rooms as well as their own if you are having a breakdown. Nor is it fair to the other patient for you to be crying in their room because of something happening in another room. One can lose their sanity and respect of their peers (in the ER) if unable to control your emotions in a professional manner."
Elissa Norris, RN, CPEN. Pediatric Emergency Department and School Nurse.
"I can completely agree with y'all. It definitely depends on the environment and where you are working. ER nurses take a very special nurse. Some of the toughest. There is not time to bond like there is in PICU and / or other areas. That doesn't mean you lack compassion or are cold; it's what you are dealt. You could have two codes back to back; you can't be thinking of the previous one in the middle of the 2nd. I used to love that about going to the ER. Less attachment, more nursing. But now that I have worked in PICU for over a year, it's different. One's not better over the other, just different environments like you said. We have had patients in house for months. Not getting attached to them is impossible. Or the ones that come back time and time again. You begin to know the families, they begin to request you. Just different.
You sometimes do have the time to sit with families and be with them if your 1:1 patient just died...everyone has their own way of dealing and this new nurse will find theirs. ER isn't for everyone and either is PICU. I find it hard to not get attached but I can also realize it's not always the best decision to get attached. As long as you know you did everything that you could from a nursing perspective. It's important to be thankful that you have the ability and knowledge to help at all.
PICU can end up being long term care and ER is not. That's the beauty of an ER and why it takes such bad *** nurse.
There is no right or wrong answer here, but after 3.5 years as a SWAT nurse, you see how every department has a common trait in their nurses. Everyone copes differently, everyone see trauma differently. We may get some crazy unstable awful abuse admission in the PICU but we can't forget where they started. Thanks ER nurses!"
Haley Troell, BSN, RN. PICU Dell Children's Hospital.
In summary, I have also noticed that every unit nurse has a very different personality. ED nurses compared to ICU nurses, compared to oncology nurses, compared to med/surg nurses, etc. Each department seems to have a very unique personality and coping mechanism. Which leads me to truly believe that is one of the awesome characteristics of the nursing profession - if there is an area that is not for one nurse, that nurse has so many other options to explore where they can fit right in and feel comfortable.
I would like to know how other nurses across the world and in different areas of practice cope with death and care for their own needs. New nurses out there will find great benefits from our experiences and may save them many hours of sleepless nights. There are no right or wrong answers - just personal experiences that share insight and wisdom from battles and lessons hard fought and won.
