I can’t stop crying over a bad death

[rmacns]

I work on a very busy neurosurgical floor. I haven’t dealt with death a lot - only a girl with cerebral palsy but this was expected, she had comfort care, and she was surrounded by her whole family. This is what I considered a “good death”.

Another patient I had was an off-service medical patient who came in for hyponatremia, CHF, and failure to thrive. She was an elderly woman in her late 80s with no close family and was living by herself up until now. She was found by her landlord covered in feces on the floor after a fall, she was there for a couple of days and covered in pressure sores. On the the floor she would constantly ring every 15-20 minutes in the 12 hour shift for non-emergent things and she became quite well known as the call bell happy person. After 2 weeks, people were getting short with her (including myself) trying to get her to do things as best she could herself, but this didn’t really work out.

Fast forward to my night shift last night, one of my colleagues had her as a patient. She was audibly wet and had terrible SOB and her sats went down to the 80s. The doc came and started her on nebs, antibiotics and lasix. Respiratory came and got her 02 back up at 94 on 2LNP.

I went to help and insert and IV and she was shaking. I asked why and she said that she was scared and nervous. I reassured her that she is going to be okay and just for a moment to try and keep her hand still. After a couple of minutes her arms were still shaking and I said in the really direct tone please stay still and she did. At that point I felt rushed to get onto the next task and I could actively feel the compassion in my voice slowly go away. I needed to be better.

I got the IV in and she held into a rosary the entire time and and I said you have nothing to be afraid of we are going to take really great care of you, don’t be scared. God is with you. I was leaving the room and a CTA was with me. Her nurse was coming back for meds in a little bit. I said I was leaving but we would check in her.

The look in her eyes was pure fright. She said she did not want to be alone, she begged us to stay. We explained we have a whole floor to attend to also but we will check in routinely. We didn’t have the resources to stay 1:1 and her vitals were back to normal. Well her nurse went in for her meds not 10 minutes later and she was found dead. Nobody expected this at all.

She died alone, scared, and frightened. She had her rosary in her sweet hands and she held onto it until her final minutes. Wouldn’t even let go to wash her hands.

I feel an unbelievable amount of guilt. I let her die alone, I had no idea she was so scared because she probably knew she was going to die. She probably had an impending sense of doom and we left her. She had a PE. And if I was more compassionate and stayed with her and wasn’t short with her, her final moments would have been better.

I can’t do nursing anymore. I honestly don’t deserve to be one.

[Horseshoe, BSN, RN]

On 1/30/2020 at 2:11 PM, rmacns said:

Fast forward to my night shift last night, one of my colleagues had her as a patient. She was audibly wet and had terrible SOB and her sats went down to the 80s. The doc came and started her on nebs, antibiotics and lasix. Respiratory came and got her 02 back up at 94 on 2LNP.

I went to help and insert and IV and she was shaking. I asked why and she said that she was scared and nervous. I reassured her that she is going to be okay and just for a moment to try and keep her hand still. After a couple of minutes her arms were still shaking and I said in the really direct tone please stay still and she did. At that point I felt rushed to get onto the next task and I could actively feel the compassion in my voice slowly go away. I needed to be better.

I got the IV in and she held into a rosary the entire time and and I said you have nothing to be afraid of we are going to take really great care of you, don’t be scared. God is with you. I was leaving the room and a CTA was with me. Her nurse was coming back for meds in a little bit. I said I was leaving but we would check in her.

The look in her eyes was pure fright. She said she did not want to be alone, she begged us to stay. We explained we have a whole floor to attend to also but we will check in routinely. We didn’t have the resources to stay 1:1 and her vitals were back to normal. Well her nurse went in for her meds not 10 minutes later and she was found dead. Nobody expected this at all.

She died alone, scared, and frightened. She had her rosary in her sweet hands and she held onto it until her final minutes. Wouldn’t even let go to wash her hands.

I feel an unbelievable amount of guilt. I let her die alone, I had no idea she was so scared because she probably knew she was going to die. She probably had an impending sense of doom and we left her. She had a PE. And if I was more compassionate and stayed with her and wasn’t short with her, her final moments would have been better.

I can’t do nursing anymore. I honestly don’t deserve to be one.

You had nothing to do with her dying. You did not have the ability to stay with her. Try not to fill guilty.

Lessons to take forward:

You can never promise any patient that they "are going to be okay." This just isn't something we can take to the bank.

"You have nothing to be afraid of." "Don't be scared." Clearly she had something to be afraid of-you know that in retrospect. We can't judge what occasions are worthy of fear. Many times when patients are needy or grumpy or downright hostile, it's because they are AFRAID-afraid of dying, afraid of losing their autonomy, afraid of their lack of ability to control their destiny, afraid of pain. Or they have figured out that they are very close to dying- i.e., that "sense of impending doom." I've seen this before in patients that knew that were about to die. A colleague told me that their patient said "Coleen!" She said "yes?" "I'm going down!" And proceeded to go into cardiac arrest, which they were not able to reverse.

I think telling her "we're going to take very good care of you" is absolutely appropriate if you can make good on that promise. "We're here for you." When I've been 1-on-1, I have said "Hey, I'm going to watch you like a hawk. " These kinds of statements tell them that we aren't going to neglect them, forget about them, ignore them, etc. But we don't promise them that there could be no negative outcome, because we honestly don't know that to be the case.

In your patient's case, she was holding a rosary, so it was a reasonable assumption that she believes in God. Absent any direct knowledge of a patient's religious beliefs, I would not tell any patient that God is with them. This could actually not be comforting if they do not believe in a deity.

I don't think anything you did warrants believing you are a bad nurse! The fact that you feel the way you do is evidence that you have not in fact lost your compassion.

[LibraNurse27, BSN, RN]

You sound very compassionate to me! You can be caring toward a patient and still feel annoyance about them falling every 15 mins when you have other patients to help. And you were there with her in her final moments, reassuring her the best you could.

At her age and with her comorbidities I don’t think she would have survived a code, so if she was a full code I think she had a more peaceful death talking to you a few mins before she passed and praying her rosary than receiving painful treatments that most likely would only prolong the inevitable. It was nice of you to be helping your coworker and letting the patient know you would all take good care of her. Also many patients who do have family surrounding them often wait for their family to leave and pass away alone. Even though I’m not super religious trying to believe in some type of after life helps me not find traumatic deaths so final. Hugs to you!

[HappyCCRN1, BSN]

On 1/30/2020 at 2:11 PM, rmacns said:

I work on a very busy neurosurgical floor. I haven’t dealt with death a lot - only a girl with cerebral palsy but this was expected, she had comfort care, and she was surrounded by her whole family. This is what I considered a “good death”.

Another patient I had was an off-service medical patient who came in for hyponatremia, CHF, and failure to thrive. She was an elderly woman in her late 80s with no close family and was living by herself up until now. She was found by her landlord covered in feces on the floor after a fall, she was there for a couple of days and covered in pressure sores. On the the floor she would constantly ring every 15-20 minutes in the 12 hour shift for non-emergent things and she became quite well known as the call bell happy person. After 2 weeks, people were getting short with her (including myself) trying to get her to do things as best she could herself, but this didn’t really work out.

Fast forward to my night shift last night, one of my colleagues had her as a patient. She was audibly wet and had terrible SOB and her sats went down to the 80s. The doc came and started her on nebs, antibiotics and lasix. Respiratory came and got her 02 back up at 94 on 2LNP.

I went to help and insert and IV and she was shaking. I asked why and she said that she was scared and nervous. I reassured her that she is going to be okay and just for a moment to try and keep her hand still. After a couple of minutes her arms were still shaking and I said in the really direct tone please stay still and she did. At that point I felt rushed to get onto the next task and I could actively feel the compassion in my voice slowly go away. I needed to be better.

I got the IV in and she held into a rosary the entire time and and I said you have nothing to be afraid of we are going to take really great care of you, don’t be scared. God is with you. I was leaving the room and a CTA was with me. Her nurse was coming back for meds in a little bit. I said I was leaving but we would check in her.

The look in her eyes was pure fright. She said she did not want to be alone, she begged us to stay. We explained we have a whole floor to attend to also but we will check in routinely. We didn’t have the resources to stay 1:1 and her vitals were back to normal. Well her nurse went in for her meds not 10 minutes later and she was found dead. Nobody expected this at all.

She died alone, scared, and frightened. She had her rosary in her sweet hands and she held onto it until her final minutes. Wouldn’t even let go to wash her hands.

I feel an unbelievable amount of guilt. I let her die alone, I had no idea she was so scared because she probably knew she was going to die. She probably had an impending sense of doom and we left her. She had a PE. And if I was more compassionate and stayed with her and wasn’t short with her, her final moments would have been better.

I can’t do nursing anymore. I honestly don’t deserve to be one.

First, I’m very sorry for your experience and feelings of inadequacy. We have all been there. Through this, you will be a better provider and a better person.

I am curious, though, if there was any diagnostic imaging ordered? And if her other vitals beside spO2 were stable and within her baseline? SOB, desat to 80’s, anxiety (above baseline of being needy), and I immediately want a CXR (which would not show a PE, but other things could then be ruled out), and an ABG. Nothing on CXR? Start heparin and get a stat CT chest. No one ever expects a patient to get a PE, but there are more things that can be done to catch it and prevent it from being fatal. Yes, her sats came back up, but with supplemental oxygen now. She sounded wet, so lasix seems appropriate given her CHF, but still with her symptoms, more should have been ordered and done to figure out the exact cause of these things.

This is not your fault. But you can use this tragedy to learn and be better. You are truly compassionate and that will take you far. Don’t lose that.

[DallasRN]

On 1/30/2020 at 1:11 PM, rmacns said:

I can’t do nursing anymore. I honestly don’t deserve to be one.

I'm sorry this happened to you. Many years back I had an experience that never left me but in the end, it made me a far better nurse for that exact reason...it never left me.

You can't see it right now, but I do. You are the exact type of person that DOES deserve to be a nurse. You are the nurse that many of us would want at our bedside because of what your recent experience taught you.

One thing I would suggest...don't let your feelings of guilt get ahead of you. You may find you need a bit of counseling to deal with all that happened and how you've internalized things. I did. You may want to check into your employer's EAP. Cut yourself some well deserved slack.

[UTAandGray, ASN, BSN, RN]

I had a patient return to the ED from x-ray and when the tech placed her back on the monitor, she was in idioventricular rhythm. She was a DNR, so all I could do was hold her hand for a moment and wait for the doctor to come pronounce her. I felt bad that I had missed her final moments on earth, so I softly spoke to her as I prepared her for the morgue and wished her a safe journey to her next destination.

People die alone all over the world every single day; there's no guarantee loved ones will be there when it happens. Don't beat yourself up over this; you can't be everything to everyone.

[NutmeggeRN, BSN]

She had her rosary in her hand...Im sure that brought her some measure of comfort. Don't beat yourself up over this.

[Lynne]

Aw that's unfortunate, but you *did* help her. You ARE a good nurse because you aren't running from these feelings of what you could have done differently. If you were faced with this situation again, you'll have this experience to draw on. And because you actually, truly care (otherwise you wouldn't feel badly), you'll tap into this and be even better for it.

And nothing would have changed the fact that you had a bunch of other patients to see and that it wasn't a 1:1 setting. I don't think you did much wrong here. Maybe you were impatient at times, but the constant call bell, long term needy patient, your work load etc all contributed to that feeling.

Her circumstances are undesirable (being alone at the end), but it's no one's fault..not yours and probably not hers. Some people don't have kids or get married. It isn't a "fault", it's just the circumstance. Even people *with* family die alone a lot of times..and she was in a hospital, not Assisted Living with an option to bump up to skilled nursing, where someone may have been able to literally sit by her side. Again, not your choice.

No sailor ever learned much from sailing in calm waters. And when good people make mistakes they acknowledge what they could do differently and accept that. That's why you *are* a good nurse. I'd be way more concerned about someone who didn't care about what happened and never gave it a second thought. Feel better and keep your head up. It's all over now, she is at peace.

[llamajules]

I agree wholeheartedly with what the others have said. Our community has such compassion.
I write this from my hospital bed on CIRU, PT and OT for a week after back surgery. My nurses and CNAs give superb care. They know I retired from dementia nursing several years ago.
There was a code 2 doors down in the early hours today. The little lady had been fretful, but no more than usual. She just went out during rounds with no ADs. I feel so bad for everyone BUT they continued to give their care with compassion and dignity. A couple stopped into my room to regroup. I felt privileged to be included.
You’re not alone, and you gave what you could. We’re all thinking and praying for you!

[jeastridge, BSN, RN]

Thank you for sharing so vulnerably. I am glad that you wrote this because this was a really hard experience. Maybe another nurse will get some encouragement from your willingness to share. Bless you.

[NewGurl, ADN]

I am an oncology nurse and deal daily with death and the way my patients passing makes me feel. The thing that helps me most is, death is inevitable. We will all be there. As long as you have given the most compassionate care you were able to, there is no reason to feel guilty or sad for the person. Their suffering is at an end. Instead you should take it as a learning experience and maybe give a little more care to the next patient. Although it sounds like you did what you could at the time. Good luck to you and don't be so hard on yourself!!!