The term "actively dying" has always struck me as amusing, because in the end, we're all going to die. So in a sense, no matter how healthy, we're all actively dying. Of course, when we say it at work, we mean that the patient is probably going to die within the next 1-12 hours. In other words, your patient will probably be dying on your shift.
I use the 1-12 hour timeline very loosely, because humans and our will to live can be amazing. Accurately predicting when somebody will die can be very difficult, and is extremely individual, no matter what the circumstances. I've seen people taken off ventilators where it was predicted that they would have no chance of breathing on their own. Surprisingly, they get off the ventilator and they started breathing on their own, living for weeks. I'll relate a story about a person who had a hemorrhagic stroke and was given a slim chance of meaningful recovery. After their family had traveled for hundreds of miles to say goodbye, the ventilator was turned off. The person lived for several weeks afterward. They were unconscious the entire time and the situation was really sad. Sometimes, although I've never seen it personally, I'm sure that people are even able to make a full recovery against the odds. Medicine and nursing are sciences and art forms. However, the outcomes are not predictable like in a math equation. The course of events in the hospital can be unpredictable. However, we can influence the outcomes in a positive way by applying our knowledge and abilities.
At one time in my career, I was a new nurse with very limited experiences. I was learning as I went. Coming into work one evening, about three months after passing NCLEX and being able to practice on my own, I was assigned a patient who was active in the death process. The patient was exhibiting the classic signs of impending death. To me, a person who is dying literally looks like a fish out of the water. Once you see that type of breathing its easy to identify. You know all those death scenes you see in movies? Nice easy breathing and then their eyes closed and they pass away? Death doesn't tend to happen like that. Ever caught a fish before? Ever see them gasp for breath as they suffocate on dry land? It's basically the same thing for people. It is hard to watch. And that breathing pattern goes on and on and on. Fortunately, by the time people get to that point, they're usually unconscious.
My patient's breathing pattern was basically like the fish out of water, and she had the death rattle. The death rattle is a sound they make when they are breathing. It is hard to describe, but death rattle is definitely a good term for the sound. The death rattle occurs as the lungs fill with fluid. Its sort of like drowning in your own body fluids as your heart fails. Again, in my experience, 99% of people are unconscious through this process. It still sounds awful.
My patient had cancer, sadly. Breast cancer that went undiagnosed until it spread through her whole body. I won't go into details. However, I will say that when I came onto duty that night she was my patient, treatment options had run out, and she was "actively dying."
The patient had about 10 family members present. They were aware of the fact that she probably wouldn't make it through the night. The patient had been sick for years, had a recent downturn during the last weeks, and had slipped into a coma several days previous. At some point prior to that night, while still able to make decisions, she made it clear that she wanted to go peacefully. Accepting the inevitable, she didn't want any heroic measures taken to keep her alive. Her family had gathered there that night because they loved her, knew the end would be soon, and wanted to spend a little bit more time with her before she went.
I started off my shift by giving her a shot of morphine to ease her breathing a little bit. She was unconscious, but she looked really uncomfortable. I also focused on her family. I broke the hospital rules and squeezed a few extra chairs into the room so they could all be comfortable. I wanted them to be able to chit chat in earshot of the patient. I was taught that when someone is dying, the sense of hearing is the last thing to go. The random facts you remember from school during situations like this are interesting. Although the patient was unconscious, unresponsive, and lying there with her eyes closed, I knew she could still hear her family around her. Ever hear stories about people in comas, and they wake up and remember all kinds of stuff that people were talking about around them? I explained to the family how comforting it probably was to her to hear their voices. Then I made sure to help lubricate their conversation with a big jug of ice water, a carafe of coffee I had finagled from the kitchen, and a mountain of cups. It wasn't a customer service move. I did this more for the patient than for the family. I knew she could hear them. I wanted her to be able to hear them. To use her one last sense to unconsciously know that her loved ones were there with her.
I made sure the patient was as comfortable as I could get her. I noticed the tiny dose of morphine was starting to make her breathing appear a little easier. I put extra pillows under her pressure points, put a cool pillow under her head, and demonstrated to the family how to moisten her mouth the glycerin swabs which I had left sitting at the bedside. Then I left the room, to the next patient.
Even though there were no vital signs to obtain or medications to administer, I peeked into the room from time to time. The atmosphere was the kind that only close brothers and sisters that hadn't seen each other in a long time can create. There were peals of laughter echoing down the halls from that room from time to time. I made sure to tell the family that they weren't being too loud despite their concerns.
A few hours later one of the family members came out and approached me at the nurse station. A young woman that appeared around my age. I think it was one of the patient's granddaughters. She said, "Can you come to check? I think she stopped breathing."
Great. I had other patients to think about right at that moment. I was sitting there waiting on a physician to call me back about some minor issue some other patient was having. What was I supposed to pick? The dead that has no needs? Or the living? I decided that the living could wait a little while longer for their 3 am the decongestant request, this was about respect.
I walked into the room with my stethoscope. I noticed the 10 family members were staring at me. They were looking at me because they didn't want to focus on their mother/aunt/grandmother. Anything else to look at besides my patient, their family member, who was lying there peacefully. Like the family member said, the patient was not breathing. I tried to stand up tall and look really official.
I smoothed my scrub top out, made sure my badge was facing the right way, and put my stethoscope to her chest. I listened. I heard nothing...no heartbeat. I moved the stethoscope a little on her chest. Nothing. 5 seconds...family staring at me...10 seconds...
I thought back to my schooling. I tried to remember what I was supposed to do. I had a lecture to help get me ready for this. I drew a blank. My badge swung out and twisted around, facing the wrong way. 15 seconds...I pretended to listen while I tried to remember...20 seconds...
Finally, after a minute of listening for a heartbeat and hearing nothing, I withdrew my stethoscope. I looked at the family, I looked at her daughter, their eyes were on me. I didn't know what to say. What came out of my lips was, "I'm so sorry..." It wasn't my brain speaking, though, it was my heart.
They knew what I meant by my apology. They hugged one another, softly crying, tears falling. I quietly excused myself from the room and paged the patient's physician.
While I waited for the physician to call me, and ever since, I've tried to think of better ways to say than what I did. I'm no superhero, I can't bring people back from the dead. I can't cure terminal cancer, and neither could the patient's physician. All I could do was be there.
While the patient's daughter was leaving, after spending an hour saying goodbye to her mother, she gave me the biggest hug I've ever received from a more or less perfect stranger. Through tears, she thanked me for the care I gave to her dying mother that night. A few weeks later, I found a thank you card taped to my locker from that same woman.
Years later, the lessons I learned that night have stuck with me. One of the important ones to remember is that, as a nurse, sometimes your heart can explain and do things better than your brain can.
