Let's talk about death

cuddlebug · Nov 17, 2007

I am a new nurse. I have participated in 2 codes. Just passed my ACLS. The first code was a dead person, found on the floor and was there for who knows how long. I will never forget the patient's face. The second code was 1 week ago, 2 days after my ACLS certification. Can u believe it was the same scenario I had during my ACLS mega code? I was working on another unit down the hall and saw the stretcher in front of the code room. There was already enough people so I primed the saline and watched. One of the other nurses actually ended up shocking the patient who was in VTach because the doc hadn't made it up to the code room yet. Good thing, the patient is alive now. The first patient who was already dead was an icebreaker. I learned alot about myself. I just think to myself. Remain calm. Remain calm. It seemed to work this last time.

As for my first dying patient well that was a week ago also. The Family member knew that the patient was going to die as this went on for a number of days. When the patient died, I was standing there along with the family member. The family member started yelling and grabing their head walking around the patient's bed yelling for the person who just died. I was shocked too. I called my supervisor for help since I was the only nurse on the floor. I did what I could for the patient. Kept them comfortable, medicated them, mouth care, eye care ect. Also took care of the family member but wonder if there was something that I could've done more. Does anyone know of a good book for a new nurse to read about dealing with death and how to treat the patient and the family? I feel good about helping people die. I work in Geriatrics and they have lived long lives. But if I had to deal with a kid or baby.........that would be hard for me I think. That is very different.

vamedic4, EMT-P · Nov 17, 2007

Okie,

I hear you. But I guarantee that the "calm" you witness was solely on the face of it...and not deep down in places we don't talk about at parties. Down there, we're scared sh*tless...that the patient will die, that we'll do something wrong, that the parents will think we're not doing everything we can.

Pediatric codes are different, because these kids are being robbed of a future, of a life. There's nothing normal or mundane about it. It's tragic, heartbreaking.... But to know that you made a difference in their lives? That's a feeling that stays with you for a long time.

vamedic4

Pediatric Critical Care Columnist · Nov 18, 2007

vamedic, you're speaking the gospel there. That calm exterior hides a writhing, seething panic... if you look closely you might catch a glimpse in the minutest of tremor as I draw up that epi, the faintest hint of fear in my eyes as I rifle through the cart looking for a stopcock, the slightest sheen of sweat on my upper lip when I ask where the mom is... and does she know? I fare much better when I'm recording events, or observing them from the other side of the unit where my own unstable patient won't allow me to do much more than pull meds from Pyxis, but I won't back away from the chaos and terror.

I've held an infant in my arms as he died... because his mom just couldn't do it, couldn't witness it. December 11, 2003. I'll never forget. I feel so fortunate to have been the one to be there for him that night, a privilege and an honor I never expected. In some ways, every day that I work is an honor and a privilege, because what I do does make a difference, even if it's only for a moment.

danissa, LPN, LVN · Nov 18, 2007

[quote=Okiecruffler;2500328

But we talk. And I know what you do when the day is done and you get home. I know how we keep the demons at bay, too often with the help of other demons. And yet we go on. For what we have done we deserve nothing more than hell, for what we do we deserve nothing less than heaven.[/size]

Okie,you got it EXACTLY! Its 4 am here in Scotland, & after two nights on in the NICU..(last night particularly bad), tonite I'm still up, on here way after my family are in the sandmans tender hold..just cause I CANT sleep...just cause i'm in that questioningly hellish place. Demons...I know them well tonite!

elizabells, BSN, RN · Nov 25, 2007

My NNP/mentor at work and I finally decided: Dante wrote about nine circles of hell only because neonatology hadn't been invented yet. If it had there'd be a tenth, one with oscillators, epi pushes, defibrillators, and never, ever any pain meds or sedation.

Okiecruffler · Nov 26, 2007

This is what I was hoping to see, an open discussion that boils down to "damn right, this is hard" I remember my first tour of the PICU. I asked the nurse supervisor how she coped with losing children. She answered, "you get used to it." So I asked her how long it would take. Her reply, "I'm still waiting."

Other than each other, there was no support net for the physical, emotional and perhaps the worst, the spiritual exhaustion we all felt. The last one I lost was the worst. I had literally known her since birth. I was floating in the NICU and admitted her the night she was born. Born early and a twin, things don't always go as planned. CP, hydrocephalic, DM to boot. For 6 years she made continual visits to the PICU. We pulled her thru non ending seizures, a really nasty spell when her shunt malfunctioned. Each time we thought it could very well be the last. But the little bugger would pull thru and be back to her loving charming self. A nicer family I've never met. And after all that time, all those threats, she dies because someone in the field couldn't tell the difference between intubating a trachea and pumping a stomach full of air. I spent my day off sitting with her and the family while the organ procurement team called all over the US to find matches. And so I keep her close with the rest. Each and everyone taught me something. I love them for allowing me to share in their bright, too short lives.

My son is born, perfectly healthy, but even after a year of being away from it, I still look at him and wonder when the cancer will show itself, or will he choke on a cracker, or be hit by a car. Whatever it is, it will be something, it always is.

And so now I'm out of the game, never again to wrap a kid in plastic or to walk into the next room and pretend nothing has happened. And those of you who still play the game, I watch you with that same sense of awe that I used to enjoy being in so much.

I used to tell my trainees, "If you can do this, you should do this. Not enough can." Never thought I'd be on the other side of that glass. God keep you all, for if this isn't his work, what is?

Pediatric Critical Care Columnist · Nov 26, 2007

We must do what we must do to protect our spirits. I often look at my young coworkers with their pregnant bellies and wonder how they can come to work and not be terrified for the new life inside of them. The same winter that I held my special angel, one of the girls went off on mat leave really early. No one said anything about her or made a grand announcement about the birth, as is usual in our unit. As I later learned, her baby had hypoplastic left heart. She and her husband opted for palliative care and the baby died shortly after his birth. She was unable to face working with other hypoplasts (we see about 60 a year for one stage or another) and their families. I think she walked away from nursing altogether. I often think of her and hope she's doing alright.

The sudden and dramatic deaths are not the ones I have the greatest trouble with. That emotion goes to the children whose deaths are prolonged and agonizing for everyone who obeserves. We have six attendings in our PICU and one of them is the eternal optimist. Even with parents who are well-educated, sophisticated and reasonable, he will dangle that carrot... "But we still haven't tried this, or that, or the other." And so they tune out the voices of the more realistic and push for continued futile treatment until one day the child decides (s)he's had enough and just dies. We kept a child breathing for 199 days, not one of which had any redeeming quality about it. The child asked to die several times before the end, and the staff are still distressed about it.

Recently we had a beautiful teenager who had a 6th cardiac surgery on a Friday. The surgery was expected to be fairly simple and straight-forward, but wasn't at all. They were in the OR for 14 hours, including the intraop catheterization they did... Kid arrested suddenly without any warning in the middle of the night. Because of an internal pacemaker, the monitor showed a rhythm even though the heart, visible through the open sternum, was not moving. The physician first on the scene ignored the nurse at the bedside and several minutes of PEA ensued before they got on the ball. By then the damage was done. Two days later I took this child to CT on ECMO and the news was dire. But this family had the courage to say "enough" and a couple of hours after I left, they withdrew life-sustaining treatment and allowed God to take their precious child. I think that takes far more courage than to press for every possible intervention. But that's me...

elizabells, BSN, RN · Nov 26, 2007

The sudden and dramatic deaths are not the ones I have the greatest trouble with. That emotion goes to the children whose deaths are prolonged and agonizing for everyone who obeserves. We have six attendings in our PICU and one of them is the eternal optimist. Even with parents who are well-educated, sophisticated and reasonable, he will dangle that carrot... "But we still haven't tried this, or that, or the other." And so they tune out the voices of the more realistic and push for continued futile treatment until one day the child decides (s)he's had enough and just dies. We kept a child breathing for 199 days, not one of which had any redeeming quality about it. The child asked to die several times before the end, and the staff are still distressed about it.

We had a child in our PICU for several months - 3yo, ex 28wk preemie. The whole family caught a cold, and everyone recovered except the baby - turned out it was adenovirus. She was on ECMO for over a month, and they couldn't even get her off the oscillator while she was on ECMO. She ended up with 8 chest tubes. She lost both of her ears to tissue breakdown. The entire back of her head was covered with duoderm by the end. Her CXRs were described to me as "cement lungs." We had a bunch of ECMOs in a row in our NICU while this little girl was upstairs, and the perfusionists started showing up earlier and earlier for their shifts so they wouldn't have to go to the PICU, and they'd tell us about it. I found it horribly affecting, partly because we shared the same first name. She passed away while I was on vacation, so I don't know how it ended - if she coded or they let her go.

One of the worst things I've ever observed, and thank god I didn't have to participate in, was the final code of a baby who had been trying her damndest to die for six months. She was coded multiple times a day for what seemed like forever. It took three people to suction her, because each time you did her HR would go to 50, she'd need bagging and CC, and you had to suction her q15min or she'd drown. All of her ribs were broken from the compressions. On the last night, they coded her just long enough for her mom to make it into the hospital. Her heart was beating about once every two minutes. I could see the monitor, but not the baby or the doctors. Every time there was a QRS complex on the screen I heard a soft curse from behind the curtain. The minute mom walked in the door they stopped. Her grandmother used to say "it's up to God now, whatever God wants to happen will happen" so often I wanted to scream that God had made his opinion pretty &^%%$^ clear at that point. But that wouldn't have been therapeutic, so I didn't.

I don't know how many of you have read my post over in the NICU thread about my primary, but I'm pretty sure the devil is keeping a seat warm for me.

Okiecruffler · Nov 26, 2007

I sometimes think that doctors are our worst enemy. Working for so long with residents I've seen all the false hope I ever want to see. Had a 14 y/o come in one night, ATV accident, C2 internal decap. I took him down to radiology with the bright new resident at my heels. Even the housekeeper could have spotted the herniation. We get upstairs and I start a round of manitol. Mom ask the resident if this med will make everything alright. He looks her straight in the face and says, "Yeah, once this kicks in we'll be in good shape." I had the charge run him back to his den while I sat down with the family and explained what was really going to happen.

I used to have a picture of a room in our PICU. Somewhere in there was a bidirectional glen pt who hadn't come out well, but you couldn't see him. All you could see was the ECMO, the PRISMA and 3 full IV trees. I used to show it to people who said how nice it must be having a job where you just played with kids all day.

Pediatric Critical Care Columnist · Nov 27, 2007

I really hate it when the docs make it sound like we're going to magically return the kids to the parents unchanged by their critical illness or injury. I find I'm constantly contradicting them after they've left the bedside. It's a crime to make these lovely, wounded people think that eveything will be the same as it was before, that little Billy will ride his bike again and laugh at his little sister's antics... when little Billy's brain has been banged around, smooshed and squished, and his muscles have begun to atrophy. Are we even sure he can still see? But oh, Mrs. Jones, we can do this procedure and use that drug and soon Billy will be ready to go home.

Last April we had two horrible situations back to back. The first was a 13 year old who had hanged himself over his inability to get along with his mom's BF. He was only unobserved "for a few minutes" and was given ACLS within minutes of being cut down, but when I took over his care on the Sunday, it was obvious that he had a profoundly damaged brain. No pupil response, no protective reflexes, no response to painful stimulus, no thermoregulation... When we met with the family, this mom said fairly early int he meeting that he wouldn't want to live like that and she didn't want him to either, but our attending talked her into waiting another 48 hours, and the window slammed shut. Now the kid is in a long-term care facility with a trach, gastrostomy and no awareness.

Second kid was ejected from a car at highway speed and was thought to be DOA. But no, he still had a pulse. So he came to us and we flogged him for more than a week. He would have met brain death criteria on the first night if we could have tested cold calorics, but since he had gray matter oozing from his ear, we couldn't. He was maxed out on epi and norepi for most of his stay with us... was on Kayexalate q4H and D25W and insulin to pull his K+ down, it had gone as high as 8.6 without stopping his heart... No one was willing to do an apnea test and the family refused a flow study because they believed the trip to angio would kill him. I nursed this kid for three shifts and almost quit nursing over him.

More recently we had a series of previously healthy infants who presented with vomiting and progressive neuro deterioration progressing to coma and cardiac arrest. No obvious cause. One family insisted that we continue to provide care for the baby even after brain death had been amply proven. We nursed that child until her heart finally stopped a week later. It was brutal.

Some of my coworkers have likened our unit to Dr Frankenstein's lab. Just because we can do something doesn't mean that we should. I wish the docs would recognise that!

danissa, LPN, LVN · Nov 27, 2007

ILast April we had two horrible situations back to back. The first was a 13 year old who had hanged himself over his inability to get along with his mom's BF. He was only unobserved "for a few minutes" and was given ACLS within minutes of being cut down, but when I took over his care on the Sunday, it was obvious that he had a profoundly damaged brain. No pupil response, no protective reflexes, no response to painful stimulus, no thermoregulation... When we met with the family, this mom said fairly early int he meeting that he wouldn't want to live like that and she didn't want him to either, but our attending talked her into waiting another 48 hours, and the window slammed shut. Now the kid is in a long-term care facility with a trach, gastrostomy and no awareness.
jan...that is one of the sadest things I have ever read. Shame on that doctor!