My first patient death...

[guest042302019, BSN, RN]

I'm not sure how other schools arrange clinicals but we are assigned patients the night before our clinical for general preparation. This particular day, I showed up to what we call "chart study" a bit early. I arrive prior to the instructor so I walk around and have small talk with various personnel. I got wind of a hospice patient that was on the floor for respiratory failure. And, there was talk of him not making it more than a couple of days. Now, I do know we as human beings don't know exactly when one is going to die but we do know, of course, common signs of impeding death. In this case, this gentleman fit the typical description of someone close to death.

I think about this patient and I make an effort to be assigned to him for my next clinical day. I do this for a couple of reasons. My main reason was simple curiosity. I had never seen anyone die before nor be in his critical condition. Also, I believe the family should receive just as much care as the patient in times close to death. I knew, to my inner core, that I would be able to treat this family with dignity, respect, and compassion. So, my clinical instructor arrives and I fill her in on the current admits. I was assigned to the patient with respiratory failure and another patient with CHF exacerbation and worsening renal failure. I asked for a challenge for the day and I received a decent load for a 3rd level nursing student (I'm in the ADN program, so I've had almost 1.5 years of nursing school).

So, the next morning, I arrive to the unit about 20 minutes early and look at each of the patient's chart for updates. VS were worsening on the patient with respiratory failure and no significant changes for the other patient. (For reference, I'll say patient R for patient with respiratory failure and patient CHF for the patient with CHF and renal failure. Saves writing)

I am anxious to get in patient R's room and start my assessment as well as to see the situation. I have no idea what to expect aside from the brief exposure I've had from reading the fundamentals textbooks regarding death. Also, I've been briefly exposed to death, in general, throughout my life because I've only had one death in my family and I was very young at the time. Needless to say, I wasn't sure what to expect or see.

I walk up to the room and knock on the door.

Yes? (A middle aged female answers)

Hello, I'm Andrew. I'm a nursing student.

Oh, Okay.

May I come in?

Oh, sure, come in.

We begin small talk on who she is, recent changes in patient R's status, and other general topics. I learned that Patient R's wife had gone home to take care of the cats and get cleaned up but she would be back momentarily.

I ask, "May I look over your uncle?"

Yes, please.

I walk over to his right side. Patient R is very frail, sunken cheeks, open mouth, neurologically non-responsive, eyes non-reactive, not physically moving, diminished RR and short expansion breath pattern, and wounds on forehead and legs. I tell her that I'm going to listen his heart and lungs. I do so. He had bradycardia and some rubbing in the anterior lobes. I don't know how to describe the sound but it wasn't stridor or something like that. His breathes were non-labored. Then she begins to ask me some difficult questions. Relevant history with Patient R includes renal failure, respiratory failure, history of cardiac insufficiency, and recent history of basal cell carcinoma excision last week.

Keep the history in mind when you read the questions I was asked.

She asked, "what happens when the kidneys don't work anymore?"

I answered with, "The kidneys are responsible for ridding our body of the toxins and by-products of normal metabolism. When we no longer have kidney function, we see changes in electrolytes, organ function, and specifically brain function." I said something very similar to that explanation. You know we are taught in A&P and nursing, these complicated pathophysiologies. But, when a person needs a concise, straight to the point explanation, it is difficult in that context, when you are directly at bedside with a dying patient in front of you. But, I feel I answered the questions as best as I could.

Then she asked, "When do you think he will...?"

I knew what she meant. She was asking when will my uncle die? I answered her with no answer. I told her that it could be minutes, hours, days, weeks, or longer. We don't know and will never know the exact moment a person will die. And, even if a person with years and years of experience may know a possible time frame, I still feel that it isn't our place to say. What if you're wrong? What if they die 3 months from now and you projected 3 days? I believe you can teach S/S of impeding death. In this case, Patient R had visible carotid pulsations and his RR rate was noticeable. I said, "You will no longer see the pulsations on his neck and his chest will no longer move." She acknowledged what I had said.

I then left briefly to get her ice and cup that she requested. I return to find the nurse conversing with her. I go the patients bedside again and look at his eyes. I suggest to the nurse that we use some eye drops and get his mouth swabbed because his mouth was constantly open and now pretty dry. She agrees and leaves. I had brought a Pulse Ox and thermometer with me to takes VS while I was in there. I tell her that I what I'll be doing and proceed to stand on Patient R's right side.

I'm standing on his right side and I have to lift him arm to place the BP cuff because he no longer functional. This is the part where I notice a change in the patient's condition. I place the cuff and start to palpate his radial before inflating the cuff and I noticed I no longer see pulsations in his carotid arteries. I feel my heart begin to pound and pound. I blink a couple of times to determine I'm seeing "straight." I was right, his carotids were no longer pulsating. I auscultate his heart and I hear nothing. I listen for at least a minute and there was no heart sounds at all. I feel his chest and there was no expansion. I look at his neck and palpate his neck and nothing was there. He was dead (An FYI, he was DNR, otherwise I would've started compressions and code blue). I say "Ma'am" in a way that conveyed she needed to come over. I say it in a way that conveyed that he had died. I didn't know what to say to her or how to say what I needed to say. As a student, I don't have the authority to tell the family that the patient has died. I said, " I don't want to jump to conclusions so I'm going to go get the nurse for verification." And, I left.

I go up to the nurse and say, "I believe the patient has died."

"The patient is dying?" she says.

"No, I believe the patient has died." I return

"Ohh, I see."

My heart still pounding pretty rapid, I say, "This has never happened to me before, I'd like verification."

"Okay," and she joins me shortly in the room.

Needless to say, today was a enlightening experience to say the least. I wanted to be there when he died and I was right there, unexpectedly. It was a nerve-wracking and heart-breaking experience. To tell someone that the patient has died even if I didn't say it directly, I conveyed it with the way I looked at her and said, "Ma'am." She knew what had happened. I eventually told my clinical instructor what I had happened. She knew that it initially emotionally bothered me and we hugged. That was comforting. I did learn a great deal today that I didn't expect to learn. I learned that a nurse, to truly care for a patient, needs to open up somewhat to a vulnerable state to care. You need to feel the patient's and family's struggle to a certain extent to be able to care. They say a medical professional should be objective and impersonal. I completely disagree. To provide care to a person, patient, or family member, one is inevitably vulnerable. I thought I was "strong" and "tough" and then I let the situation sink in a bit. I felt the pain of the niece. I felt the pain of the patient yearning for good health. And, I teared up a bit as I headed back to a solitary room, non-occupied room to debrief and come down from the situation. Also, my instructor if I noticed common post-death changes in the body. I thought that would be interesting to see but as I walked towards that room, I thought about what I was about to do. I came to the conclusion that my curiosity about color changes and such, isn't as important as providing respect for the family and leaving them in a private setting. This is a difficult time and I didn't need to be in there to be inspecting their dead family member. This won't be the last dead person I see so I'm sure I'll get more opportunities. This time, I went in the room after the death as little as possible to provide privacy and respect to the family. Also, I noticed the difference between some of the staff that respects death and doesn't as well as among nursing students. I understand if one is around death so often one should be somewhat lighthearted about it because it does take a psychological toll on someone. But, don't say inappropriate comments such as what was said to me. For instance, "You killed your patient didn't you, or you scared them to death huh?" I gave a smirk but that was the extent of my recognition of these comments. I feel that these comments dishonor medical professionals and nurses. This is extremely disrespectful to me and to the patient and to the family. Keep those types of comments to yourself in my opinion. Once word got out that my patient died, there were around five comments that I found very disrespectful towards me but more importantly, towards the patient. Be mindful of what you say and where you say it. There's eyes in the sky and ears everywhere. But, on moral grounds, respect death and leave the comments out.

So, I satisfied my curiosity. Was it worth it to be next to someone that dies? Yes and no. Yes, because I got the experience. Yes, because I could provide support for the niece while she was there by herself. Yes, because I know there is evidence that patients can hear us even if it doesn't appear that way when he or she is close to death. So, I was able to give care to a degree at least with my presence. But, no mainly because it is a very sad time for the family and to see people cry and grieve is very difficult emotionally.

I felt the need to share my experience. Maybe a student out there will learn from it in some way. Moral of the story, treat death with respect and support the patient's family and friends when death takes their loved ones.

What do you think? Do you think I handled the situation appropriately? What would've have you done differently? Do you have a similar story?

[JennyNurse2B]

Wow. I am still pre-nursing, so this is a strictly personal opinion, but it sounds like you handled things extremely well. That is just how I would like to be treated if one of my family members were in such a situation.

God bless you. It sounds like you will be a fantastic nurse.

[guest042302019, BSN, RN]

Wow. I am still pre-nursing, so this is a strictly personal opinion, but it sounds like you handled things extremely well. That is just how I would like to be treated if one of my family members were in such a situation.

God bless you. It sounds like you will be a fantastic nurse.

Thank you for your thoughts. :)

[IMOKAY, BSN]

I am level one nursing and I don't know how I would have handled that. You sound like you are in your element for sure...confident while comforting to those around you. Nice job.

[Lifeofanurse]

My first clinical day my first patient. We were shadowing the CNA's and assisting them in their duties. I was asked to retrieve a breakfast tray. Entered a room to find the patient had passed away. Thankfully I was paired w/ a classmate who had been a CNA for a long time and it was not her first experience with death. But it was shocking for me.

[guest042302019, BSN, RN]

My first clinical day my first patient. We were shadowing the CNA's and assisting them in their duties. I was asked to retrieve a breakfast tray. Entered a room to find the patient had passed away. Thankfully I was paired w/ a classmate who had been a CNA for a long time and it was not her first experience with death. But it was shocking for me.

I have heard of this. First level and first few clinicals, a student witnesses a death. As odd as it may sound, you are fortunate that it was early on for you. You can see how you are able handle the situation and realize, you will see and experience death more and more. At least you aren't out of school with time and energy invested into nursing and come to conclusion that you aren't able to deal with death. Although, I don't know how any person can be 100% comfortable with death no matter how much exposure one gets.

The hard part is that is was so early on for you. That would be difficult to see-emotionally I think. I hope you are handling the experience well.

But, as I walked in the halls after all this experience. I saw that the hospital went on. We are still helping people, nurturing health and happiness, and saving lives. So while one man did die, others are being saved and helped every minute of every day. That was a comforting realization.

[LeighaChristineSN]

I too think you handeled the situation really well. I have never experienced death of a patient at clinicals but, I have at my CNA jobs (both past and present). I have only been present for one (as she took her last breath) and I remeber it as if it were yesterday; I truely believe you never forget your first.

Mine [first death] was a resident that I had cared for for almost a year. She made a rapid decline; went from walking and talking to dieing in a matter of months. For weeks she was bed ridden, she eventually quite eating, then voiding and in her last week had a rattle in her chest that was almost unbareable. On the day she passed we were giving her morphine every hour to hopefully help with the rattle and to keep her comfortable. It was a small group home (4 residents, 2 staff) so we had plenty of time to spend with her and she also had family spend ample amounts of time with her.

At about 1845 we went in to check her brief, do some more mouth care, clean her up, and put her in a fresh nightgown. Her rattle had gotten worse and her eyes no longer looked like there was life left behind them, they were all glazed over. No more than an hour later after I checked on another resident I popped into her room to sing a little to her, I went to hold her hand and it was puple like an eggplant. I called in my coworker who also called in our boss and as we stood around the bed she took a large breath and let it out and then her chest was still. A still chest is so bizarre I kept looking at it expecting the rise and fall but, it never happened.

What death does to a body is crazy. No more than a half hour after her last breath her skin turned an ashen gray and as I kissed her forhead goodbye it felt like sand paper on my lips.

I'll never forget her. I'll never forget that night. I'll never forget her death rattle and I'll never forget the craziness of a chest not rising and falling. It never gets easier and it shouldn't.

"Sometimes I help people live.

Sometimes I help people die.

Always, I help them.

I'm a nurse."

-quoted on the back of Nurse: the true story of May Benjamin. R.N

[thenameismac]

This post is so intense. I just finished my PCT courses and I've only cared for a patient who dying but they transferred him to a hospice before he passed. I helped with chest compressions when there was code. She didn't make it but I believe she was gone before I got in the room. The first time I came close to a dead person was one of my first clinical rotations and they wheeled out a body in a bag. It was literally close enough for me to touch. That's when it hit me. People die everyday. Then a few weeks later I lost a cousin to cancer. I am getting better at it but I couldn't sleep well for weeks. I just know now that death is a part of life. I don't think I'll ever get used to it and I'm darn sure I won't make comments like the ones mentioned in this post. That is beyond heartless. Just don't say anything at all.

[lindsayrenee]

I'm currently working as a CNA at a nursing home and I completely agree that death never gets easier. I've never actually been present for a death, but in my three years of working there I've lost so many people that I held close to me. It's so difficult caring for someone every day for years and then having them have a sudden decline and then be gone in a couple weeks. This post touched me and I wanted to say thanks.

[sandyfeet]

I think you handled it very professionally. The niece will always remember how you acted and what you said, so it is better that you were brief, that you acknowledged that you weren't making a final diagnosis, etc. I had a patient die last semester, but I wasn't at the bedside when he died. I noticed that he was satting in the low 80s and told my nurse, who called Rapid Response Team, and he was transferred. Later in the day when I was gathering information for my care plan, I saw a note from the new floor saying he had died. So for me, it was important to go back over the day and review what care I had given, because that was his last day on earth. I was so relieved to find that I had not missed anything or skipped anything. He was in a lot of pain, so I was attempting pharmacological and non-pharmacological pain relief. His lungs were full of fluid so I was calling RT for suctioning. For someone's last day, I gave him everything I could, and knowing that made a big difference to me. I think it will make a difference for you too.

You mentioned that some people made crass remarks. I have heard from firefighters and paramedics that this is a way to deal with the stress of death, especially when you see it all the time. It may not be the way that you deal with it (and it's not my way either) but it is a way to process for some people. It doesn't excuse any remarks said to the patient, but the ones to you were said as "professional to professional".

Lastly, I'm not sure how your classmates are reacting, but mine were pretty much mystified and couldn't really understand how I felt. This includes friends and family too. We go into nursing knowing that we can't save everyone and that everyone must die. But that doesn't mean we are emotionless and unreactive. I was really surprised by classmates that didn't get it, but I think it's something you have to experience for yourself. One of my friends had a patient die a month later, and she called me to say "Now I understand how you feel, and I'm sorry that I didn't get it when you were going through this with your patient." So keep your expectations kind of low for that sort of thing.

[guest042302019, BSN, RN]

Everyone's comment have been very helpful. Thank you. I still mull over the situation. It's been a couple weeks now so I'm not constantly thinking about it. Thanks again.