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New Nurse...Need advice on dealing with death

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I am a new nurse and a critical care intern. I have been training for 5 months and have 1 more month before I am on my own. I am having a difficult time with death. About 5 weeks ago I did chest compressions for the first time on a real person. I do not know her history, she had only been at the hospital for about 20 minutes before the code was called and she was in a different area. She died and it was very difficult for me. When the breathing tube was removed, I swear she was gasping for air. It was all very confusing for me. I didn't understand why everyone was leaving while the patient was gasping for air. There was a de-briefing and I was told that it was natural. I read "On death and dying" by Kuebler-Ross. It didn't help much. I am looking for details on what happens to the body during and right after death.

Now fast forward to a week ago. Another code was called on a pt that I had taken care of the week before. It was a very intense code. Again I did chest compressions. As I was doing them I saw that her lips were blue. Family was in the room and the pt was 21 years old. After the code was called and the time of death was stated there were no dry eyes. I am having a very hard time with this. I know we did everything that we could but I am feeling guilt. What if I had done the compressions better. Are these normal feelings? Does it get any easier? I am looking for advice, any advice. I really appreciate it! Thank you in advance.

southernbelle08

Specializes in Oncology, Med-Surg, Nursery. Has 8 years experience.

I think when it comes to patients dying, that is something that could never be "textbook". Everyone feels differently, and you have to find out what it all means to you. In my opinion, it is a huge personal journey. I have worked in Oncology for the past almost 7 months and, unfortunately, death is a large part of my job. I suppose in my area, at times it is somewhat expected, and even welcomed if the patient has been through a long battle with cancer and they are ready to go and finally get some relief from the horrible disease and pain. I have cried many times for those who didn't seem ready or at peace and I have also rejoiced for a few who finally got that relief from the disease and pain they were ready to be free of. No matter what the situation, death is never easy. I don't believe there will come a time when I just get used to it.

I know we come from different areas, and the patients you see are often times very different from those I see, but that is my best advice to you. You have to dig deep on this one and allow yourself time to process and see what it means to you. I've talked to nurses on my floor and they tell me even after years and years on the job, it really doesn't get any easier. But I think you get an understanding of what it means to you personally and that is when you learn to accept it as part of what you do.

Best of luck!!

I guess if it were me, it might help to remember that when CPR is initiated, it really is only 30% effective. That means the odds are pretty stacked against the patient once CPR becomes necessary. I have done chest compressions for real once, and it is an unnerving experience. I've been present for several codes, but only as a scribe or observer.

As to the woman who was 'gasping', it's a normal death breathing pattern. It takes the body a while to shut everything down, and agonal gasps are common (and very creepy, I know). As far as I understand it, once those appear there's no going back.

I see death all the time as I work hospice. Sometimes things seem pretty random and senseless, especially when it's a young person. It is a heavy responsibility to be present at someone's death, but it is a priviledge few experience. There is something (God, higher being) that is bigger than we are, and when it's time to check out, we are powerless to stop it unless it truly is not that person's time to die. That helps me deal with the senselessness of it.

UM Review RN, ASN, RN

Specializes in Utilization Management.

My religion helps me cope. I believe that this life is not all there is and that death is a doorway to the next life. That said, it's still very difficult for me to accept and it's still a very tough time for me emotionally, but I can deal with it, given time.

I say prayers for all of my patients and remember that in a Code situation, the patient was already dead. Sometimes we can bring them back, sometimes not. I can't figure out why; sometimes it seems so random and so tragic. All the more reason to make our own lives count for something, all the more reason to live our own lives as though every day could be our last, because it's true -- we never know.

As I begin to accept the death of a patient, I begin to pray and to thank my God for the life of the person. I pray for comfort for the family, and I thank the Lord for the honor of taking care of this person's body. It is one of the last things that I can do for that patient and it only makes me reflect on the miracle that life is.

((((hugs, RN_1)))))

NotReady4PrimeTime, RN

Specializes in NICU, PICU, PCVICU and peds oncology. Has 25 years experience.

What you're feeling is perfectly normal. We all want to take the blame when things don't go the way we want them to, despite all the odds stacked against it in the first place. As the other posters have said, there are some who will come back after a cardiac arrest and there are those who won't, no matter what is done. I work PICU and we're the one area that refuses to give up on our patients when they arrest. We have had codes go on for more than an hour and been "successful" and have even had some kids neurologically intact afterwards, but we've also had them go on forever and the child still died or was left horribly disabled. Sometimes death is not the worst outcome.

Last Monday I attended the death of a 9 month old who had a complex heart defect. He had been made DNAR that afternoon, but none of us expected him to go as soon as he did. It was almost like he decided that it was time. One minute he had a good blood pressure and reasonable sats, the next he was hypotensive, bradycardic and hypoxic. We did give him fluid, two rounds of epi and some bicarb, not to attempt resuscitation, but to try and keep his heart beating until his parents could arrive. (We weren't successful but they didn't know that.) I know his soul was gone for some time before his heart stopped.

So dealing with it... I think it will help you to learn about the physiology of death. When you understand what is happening it's easier to accept. And accepting that it will never get easier emotionally to be in the presence of death is another thing that will actually help, as counterintuitive as that sounds. As Angie O'Plasty said, God has the ultimate control over life and death; He lends us to our loved ones for a time and when He is ready, He takes us back. Why some people live to see 100 birthdays and others don't even see their first is something only known to Him. Grieve your patients who die, but don't allow your grief to consume you. All we can do is the best we can. Hugs to you.

What if I had done the compressions better. Are these normal feelings? Does it get any easier? I am looking for advice, any advice. I really appreciate it! Thank you in advance.

I've found that if you are doing compressions that aren't proper...a nurse or a doc will switch you out and do compressions properly. I've seen it happen a number of times, as many first timers are hesitant to go deep, hard and fast. So if you were allowed to continue...I doubt you were doing compressions poorly.

Are these feelings normal? Absolutely. Does it get easier? For some people...depends on who you are and how you view life and death.

What you are doing right now, debriefing, reflecting and discussing are hallmarks of a good nurse. You are going to see more of these situations as your career progresses through critical care. The moment you walk away from a code with no more thought than hanging an IV bag, I think its time to move on.

patwil73

Specializes in ICU/CCU, Home Health/Hospice, Cath Lab,.

I am a new nurse and a critical care intern. I have been training for 5 months and have 1 more month before I am on my own. I am having a difficult time with death. About 5 weeks ago I did chest compressions for the first time on a real person. I do not know her history, she had only been at the hospital for about 20 minutes before the code was called and she was in a different area. She died and it was very difficult for me. When the breathing tube was removed, I swear she was gasping for air. It was all very confusing for me. I didn't understand why everyone was leaving while the patient was gasping for air. There was a de-briefing and I was told that it was natural. I read "On death and dying" by Kuebler-Ross. It didn't help much. I am looking for details on what happens to the body during and right after death.

Sometimes the patient will have gas built up in their abdomen - whether from compressions or misplacement of the ET tube. When the code is called and the tube is removed that gas can slowly escape. It makes the person appear to be gasping.

Also when we do compressions we are attempting to keep the heart beating oxygenated blood to the vital organs. However, the heart might be so diseased or damaged that it can not continue on its own. When we stop compressions the heart stops beating. This is cardiac death - however if our compressions were sufficient the brain may continue to live on a bit longer trying to force the body to do what is needed for life such as breathing - these efforts are almost always noted to be agonal gasps.

In both cases the patient is not really "gasping" for air. The patient is dead, the body just does not quite realize it yet. They are not hurting, or anxious the way we are when the wind is knocked out of us and we gasp for air.

Now fast forward to a week ago. Another code was called on a pt that I had taken care of the week before. It was a very intense code. Again I did chest compressions. As I was doing them I saw that her lips were blue. Family was in the room and the pt was 21 years old. After the code was called and the time of death was stated there were no dry eyes. I am having a very hard time with this. I know we did everything that we could but I am feeling guilt. What if I had done the compressions better. Are these normal feelings? Does it get any easier? I am looking for advice, any advice. I really appreciate it! Thank you in advance.

The younger a patient is the harder it is to come to grips with their death. I believe this is hardwired into us to care for the young. When we have a 90 y.o. whose life ends we can say "she lived a good life" or "it was his time". This becomes much more difficult when the patient is young - they haven't had that chance to live a good life.

How do we deal with this? Everyone is different - meaning everyone must find their own way of dealing. Mine is my family. I hug my wife, play with my kids. A lot of times I cry on the way home. I am ok with feeling bad that someone died, that someone's family is grieving. I allow those feelings and then put them aside to care for the next person.

Are your feelings normal? Yes! Does it get easier - sometimes, but then comes along that case that brings you back to square one. As you grow in your practice and learn more about disease and injury you will know what factors truly contributed to a patient's death. The guilt feelings will lessen (unless you truly do something very wrong) but the sadness will hopefully always remain.

Hope this helps

Pat

I agree with everyone else your feelings are normal but that doesn't make them easier. I also work in the PICU and pediatric codes are especially hard as a general rule kids are not suppose to die. I don't think you get used to them but rather learn to cope and see them differently. I used to second guess myself and wonder if I were more expierenced if the outcome would have been different but as I have seen more codes I have learned that as much as we want to control things somethings are out of our hands. Some kids recover dispite our mistakes and some sucum despite our most heroic efforts. The serenity prayer/chant helps me "...grant me the serenity to accept the things I cannot change, the courage to change the things I can and the wisdom to know the difference" Wisdome and serenity came for me later and I can tell you already have the courage part down

I know it has been six months since you wrote this post, but I have been dealing with the same thing. I just graduated nursing school and passed the NCLEX two weeks ago. I have been working as a camp nurse until I could find a hospital job. One of my campers unexpectedly had a gran mal seizure (he was an epileptic) followed by cardiac arrest. The camp has one nurse work at a time so it was on my shift, and I was the only nurse there. We initiated CPR but even as I lowered him to the floor I thought, only a small percentage of CPR attempts are successful. Thankfully the lifeguard working was formally an EMT and had more experience with doing CPR than I have. So I feel confident that we couldn't have done anything differently that woudl have saved his life. But I still have weird feelings of guilt and sadness when I think about what happened. I go over every detail in my mind, every interaction I ever had with him, and I can find things I could have done better, but nothing significant enough to save his life.

I guess my question is, how are you feeling 6 months later? Because I am so ready to not be upset about this anymore. I find myself crying at random instances, when I'm driving and something reminds me of him or someone starts talking about the incident. Its especially hard for me I think because I was solely responsible for his medical care when it happened. There was no other healthcare providers there when it happened. I guess I just feel such weight. I don't know if its something that nurses just get used to, something you learn to live with because of the nature of this profession.

I just want to know what I should do next. When will I feel better?

NurseKitten, MSN, RN

Specializes in Case Mgmt, Anesthesia, ICU, ER, Dialysis. Has 20 years experience.

Tia, please consider going and talking to a professional counselor about your experience. What you're feeling is perfectly normal, but I also worry about the effects of post-traumatic stress, as well. That's an awful thing to have happen to you in your first job out of school. God bless.

Thank you. I think you're probably right. I feel silly being so upset about what happened. Its only been 3 days but I feel like I should be more professional or something. Would it be wrong to send a card to the family or write them a short note? I feel like I need closure or something, but I don't want to cross professional boundaries. I just feel like compared to a hospital the boundaries here are so undefined.

Tia, after all of the support and feedback I received from my post I searched hours and hours on the internet. I looked up the stages of death and the grieving processes that follow. I still struggle with it and I still remember the faces of these 2 patients while I was doing chest compressions. I agree with NurseKitten about counseling. I am going to begin that soon too. Please keep in touch and know that you are not alone. Take care. *hug*

yes, counseling is a good way to cope with death and also religion. try to embrace the reality of birth and death...it is normal..and everybody will die eventually...pretty, ugly, rich, poor, educated, uneducated...nobody can escape death..one should only be spiritually ready for it when it comes...in my religion we are reminded of death every service..we sing songs of death and a new life ahead...good luck..

CrufflerJJ, RN

Specializes in ICU. Has 5 years experience.

Thank you. I think you're probably right. I feel silly being so upset about what happened. Its only been 3 days but I feel like I should be more professional or something. Would it be wrong to send a card to the family or write them a short note? I feel like I need closure or something, but I don't want to cross professional boundaries. I just feel like compared to a hospital the boundaries here are so undefined.

Please don't feel silly about your feelings. Feelings are REAL. You did your best, yet, despite that, your patient died.

I've had friends die in their early 20's, and have had patients die (as a paramedic) from ages 1 through 80-something.

Life happens...death happens.

Yes, maybe in a perfect world, you should be able to totally shut out feelings about your patients. If that happens, though, I think you'd be LESS of a nurse. It's a touchy balancing act, between feeling too much & not feeling enough.

If you continue feelings of "could have, should have, I'm useless & incompetent", PLEASE talk with a trusted coworker or CISD (critical incident stress debriefing) counselor. Having these feelings is not a sign of weakness. It's a sign of humanity.

Caring hurts.

Thank yall for your posts. I am a recent grad (May), I have been off orientation 4 days and I am working at a level one trauma center in the Surgery Trauma Intensive Care Unit. I have actively participated in 2 codes. One during my practicum as a student and this one last night. I was the primary nurse and I have to admit that I was terrified...

Since I am a new grad the charge nurse assigned me one of the lower acuity patients... He had a C5-C6 fracture and had been in our unit less than 2 weeks. He was having problems with autonomic dysreflexia (as he was a quad) He had a trach placed Thursday am *so roughly 72 hours prior*

I am the new kid on the block but I can smell a GI bleed from a mile away. His coags and H/H were slightly abnormal. He had dark brown thin residuals from his PEG and the insertion site was weeping serosanginous fluid (a substantial amount) His a-line and TLC were also seeping serosanginous fluid. I made the comment that I thought he may be going into DIC during shift report. His O2 sats were hanging on the low side 91% so I notified respiratory and I suctioned my patient. What I got back was frank blood.

Doc bronched him for a while and his sats steadily dropped. We ordered a stat CXR and it revealed a small pneumo and the doc elected not to place a chest tube right then. Well over the next 30 minutes He was on a peep 22 and 100% FiO2 and his sats were in the 70s. Called the doctor back and he put a chest tube in. Immediately his sats came back up to 100% he was pink, following commands, and just totally with it.

He was a night bath and he was filthy. I spoke to the charge nurse and we felt that he was stable enough to turn. There were NO do not turn orders on the patient.

His T&L were clear but just to be safe I had two other nurses at the bedside to log roll. Sats were BEAUTIFUL when he was on his right side (toward the vent) but when we rocked him slightly to the left to pull the sheets out from underneath him his sats fell from 100% to 88... then to 70.

Doc back at the bedside, rebronched. He saw a massive clot that was blocking the right mainstem. He continued to manipulate the clot without much success. Sats down to 27. Then 18 then pulseless.

Code 1. Chest compressions, bag, Responded to Epi-Atropine-Epi. Epi gtt started Dopamine stared. SVT 160s

Sats 50s Rebronched sats 70s... then fell. Then SBP the HR.

Code 1*2 Epi push, Atropine, Amio- responded. Family called. On there way (staying 2 hours from the hospital)

Rebronch with the attending at bedside. The attending said that the clot was well organized and looked like it had taken days to develop... he assumed that it was a result of of the trach site blood slowly trickling down... (terrible)

Code 1*3 Started at 0617 same as before... ribs cracked during compressions ended at 0645 when the patients family arrived and opted to withdraw care. Gtts and vent off. Asystole in 5 minutes

Now... I feel guilty. I feel confused. Angry at myself. Incompetent. During the codes I was shaking, the charge nurse pushed the drugs. I monitored the vitals and gtts. Could I have done more? Is this my fault? When I saw the family a couple tears slipped down my cheek.

The first thing that his wife said to me was "I am so thankful that you were his nurse. I know that he was well taken care of. He always looked so clean when you had him" (This was only my second night with the patient) She said that she knew that we had done everything that we could. And that she woke up around 0300 to him (my patient) approaching her in a dream to tell her that he was "going home." She also told me that she felt he had waited to pass until his daughter that lived out of town could get there. (She came for the weekend).

I believe in God and Heaven and a life that is better beyond this earth. But I also believe in medicene and the science behind health care. I am just sad and bummed that my patient died.. =(

NotReady4PrimeTime, RN

Specializes in NICU, PICU, PCVICU and peds oncology. Has 25 years experience.

A couple of things jump out at me right off the bat...

Since I am a new grad the charge nurse assigned me one of the lower acuity patients... He had a C5-C6 fracture and had been in our unit less than 2 weeks. He was having problems with autonomic dysreflexia (as he was a quad)

Patients with autonomic dysreflexia are not "lower acuity". Autonomic dysreflexia is life-threatening and requires an astute nurse with excellent assessment skills. Not saying that isn't you, but just saying.

He had a trach placed Thursday am *so roughly 72 hours prior* His O2 sats were hanging on the low side 91% so I notified respiratory and I suctioned my patient. What I got back was frank blood. Doc bronched him for a while and his sats steadily dropped. We ordered a stat CXR and it revealed a small pneumo and the doc elected not to place a chest tube right then. Well over the next 30 minutes He was on a peep 22 and 100% FiO2 and his sats were in the 70s. Called the doctor back and he put a chest tube in. Immediately his sats came back up to 100% he was pink, following commands, and just totally with it. He was a night bath... Sats were BEAUTIFUL when he was on his right side (toward the vent) but when we rocked him slightly to the left his sats fell from 100% to 88... then to 70. Doc back at the bedside, rebronched. He saw a massive clot that was blocking the right mainstem. He continued to manipulate the clot without much success.

Rebronch with the attending at bedside. The attending said that the clot was well organized and looked like it had taken days to develop... he assumed that it was a result of of the trach site blood slowly trickling down... (terrible)

So this guy was bronched how many times before the attending came and saw a HUGE, ORGANIZED CLOT in the right mainstem? Whose fault is that?! Of course his sats tanked when you rolled him off his right side. His left lung was doing all the work and then was compressed by him lying on it. How were you to know that, since the doc who did the bronch didn't know that?

Now... I feel guilty. I feel confused. Angry at myself. Incompetent. During the codes I was shaking, the charge nurse pushed the drugs. I monitored the vitals and gtts. Could I have done more? Is this my fault? When I saw the family a couple tears slipped down my cheek.

Everybody shakes in a code situation. You just might not be able to see them doing it. Most times on our unit, the bedside nurse is responsible for monitoring the patient, as you did, providing information to the code team and working with the family. I doubt anyone expected anything more from you. Except maybe you.

The first thing that his wife said to me was "I am so thankful that you were his nurse. I know that he was well taken care of. He always looked so clean when you had him" (This was only my second night with the patient) She said that she knew that we had done everything that we could. And that she woke up around 0300 to him (my patient) approaching her in a dream to tell her that he was "going home." She also told me that she felt he had waited to pass until his daughter that lived out of town could get there. (She came for the weekend).

This is what your patient's wife will remember about you and your care for her husband. She has given you a wonderful gift.

I believe in God and Heaven and a life that is better beyond this earth. But I also believe in medicene and the science behind health care. I am just sad and bummed that my patient died.. =(

We can't save everyone. People die. It's how we're made. This man had everything possible done for him but he knew he was dying and he was ready. Why else would he have visited his wife? It's natural for you to grieve for him and for all the patients who come after him who die. You will go on and you will be a good nurse with a huge well of compassion for those you touch. If you ever lose that you'll lose the essence of why we all do what we do. Hugs.

TemperStripe

Specializes in ICU. Has 5 years experience.

I'm also a new grad (Dec, '08) in a critical care unit. I was the primary nurse when my patient died about two weeks ago. I was very close to his family, and it was a very, very difficult situation. Here's what our palliative care nurse said to me:

Never allow yourself to stop feeling.

I think it's some of the best advice I've received thus far, seriously. If you're not feeling something during these types of situations, maybe you need to reassess your career choice.

That being said, a few things that helped me:

1. Talking to people about it. My mom. My husband. My non-nursing friends. My co-workers. My nurse friends at other hospitals. I realized I needed a lot of validation from a lot of different sources. After I talked about it a lot, I felt much better, like, to the point of being able to sleep again.

2. Crying, really hard, for awhile. I don't get emotional about it now, but I spent a good deal of time crying. I'm not a cryer. I practically had to pull of the road when I drove home that first night.

3. Remembering that the guy is in a better place now. Regardless of your beliefs about what happens after you die, it certainly can't involve anything worse than being in an ICU, right?

The most important thing is to take care of yourself. Be selfish and give yourself whatever you need, if it means talking to what seems like an ungodly number of people, posting on this website for some support, getting a massage, eating a cheeseburger. Whatever. Do it. (In moderation, regarding the cheeseburger. Ha!) You're not good to anyone if you're no good to yourself.

I support you!

NotReady4PrimeTime, RN

Specializes in NICU, PICU, PCVICU and peds oncology. Has 25 years experience.

The last of my patients to die on my shift was an infant who had been found not breathing in his bed. He'd been resuscitated and came to our unit where I admitted him. I knew when he arrived that he was already with the angels, but did my job and offered support to the family. We opted for 24 hours of neuroprotective hypothermia after which we'd let him warm passively and see where we were. By early afternoon on day 2 we knew for sure that he wasn't there and we withdrew life-sustaining treatment. For all of that, and allof my many years of experience, I was still very shaken up. I second-guessed every single thing I had said to the parents and other family members and was convinced that I could have done a better job of supporting them. As Caroline said, I talked about it a lot. I took comfort in the belief in me that my friends showered me with and finally began to believe in myself again. Caroline gave good advice.

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