Witnessed a terrible death last night--pls help me...

[Annebug]

I think I just need to write. I am freaking out. As a new nurse, I expected to have to deal with death. And especially with the population I'm working with, who are mostly cancer patients in crisis. I chose this job because my grandmother, my angel, was once one of those patients--and on the very same unit where I decided to begin my nursing career.

I've been there 3 weeks and witnessed or heard about like 6 deaths already, which is to be expected. The first one I witnessed. She was my patient but I had just come on shift when she died. A caregiver was in the room with her. She had no family. I almost cried that night, but I didn't. I didn't linger on the subject too much after that either. Then I admitted a man with brain mets who was really anxious and in so much pain. I met his wife and daughter, who were grieving, and again I almost cried. I did cry when I left him that morning, and he had just died when I arrived the next night. I though a lot about him that night and the following day. I had trouble sleeping that day. I kept thinking about his family, and about the interactions between us after his family left the hospital the night he was admitted. I can remember word for word most of the things he said to me that night. I still feel sad for them, but I'm not thinking as much about it now. There have been other deaths that didn't really affect me so deeply.

But this morning I witnessed a terrible death. A really bad death. Woman dying of lung CA, unable to breathe, gurgling with each inhalation and exhalation for hours--anxious and trying to sob, but not really having the energy to do so. Her room was full of family, and they were all grieving. I was there when she died, and it was not a peaceful death. I was relieved when the end came, and then spooked to provide post-mortem care, but I did it. I didn't cry or anything like that, even after I left this morning, but I just keep thinking of her. I can see and hear and even smell the experience. I can't sleep. I just keep seeing her face in the horrific grimace and the anxiety just under the surface that she didn't have energy to properly display. The morphine we were giving her every 15 minutes didn't really work, but I think in the end she died more quickly because of it. It almost felt like euthanasia, to be honest, but we were following the orders. What could we have done differently? The sound was incredible, and I'll never forget it. It never seemed to phase the other nurses, but I guess to them it didn't seem to phase me either.

How in the world do nurses get over seeing such awful deaths? I'm freaking out. I've had a panic attack this morning. I just wish I could wash it out of my memory. Does anyone have any advice for me?

[Tweety, BSN, RN]

Those kinds of deaths from respiratory issues can be pretty rough to witness. I think you did the best you could. MS every 15 minutes is generous and hopefully kept her comfortable. Maybe some Ativan might have helped as well.

Don't try to read things under the surface that you really don't know where there. She was surrounded by loved ones and hopefully pain free because of the morphine.

Hugs.

[Annebug]

Tweety, I hear you, and thanks for your message.

Maybe the horrific grimace on her face was O2 deprivation and not anxiety, but she was grasping weakly at her daughter's hand, and I could almost make out "oh god" at times along with all that terrible gurgling.

ATIVAN--yes indeed. I wasn't her primary nurse and I don't know if there was an order for ativan, but that would have worked I think.

How do you resolve the euthanasia issue though, when giving morphine and ativan to someone whose sats are like 40%?

[Sunflowerinsc, ADN, RN]

It is alright to cry.

[miko014]

it's always hard to witness a death, especially when you feel the pt is not comfortable. We use ativan a lot for people with resp. issues, and also robinul IV or SQ or atropine gtts (SL, not in the eyes). They do seem to help. We never suction those pts (unless it's per family request) because we feel that is more traumatic and just makes things worse. Obviously if they have a trach and can't breathe unless we suction them, that's one thing, but if they're doing okay and just sound bad, we don't.

I'm sorry that you had to deal with this so early in your career. It's wonderful that you care so much, and hopefully it will get better with time. But please, don't stress yourself out or make yourself sick over it! If it's that much of a problem for you, maybe you should consider moving to a different unit until you have more nursing experience and feel more prepared to handle it. That or perhaps you could talk to someone...an oncology counselor or a chaplain. Where I work, we have occasional inservices or groups to just talk about what we see every day, and ways that we relieve stress or try to cope with it. Good Luck to you!!!

[miko014]

Ah you just posted another great question! The euthanasia thing...as long as the intent is to relieve pain/suffering and NOT to end life, it is okay to give the drugs. You are trying to help the pt, not trying to kill them...that's what comfort care is about, really. To make their death as comfortable as possible. It's the whole beneficence/non-maleficence thing...

[Dixielee, BSN, RN]

I am so sorry you are having such a bad time, but I would be more concerned if you were not responding the way you are. You never get used to seeing people die. You never get used to watching loved ones grieve for their loss. Don't expect it to get easy, but it will get easier.

You have put yourself in a position to see more death than the average new grad by being on a cancer floor. You will probably see more in a year than most see in an entire career.

I have seen many people die, including my own mother. It is never something that becomes routine. You will identify with the family and recognize their loss. I think the older I get the harder it is or maybe it is because I have seen so many.

I work ER, a place where people come and go quickly, so I don't have time to get close to the family when dealing with a death. It still is not easy, and I am thankful we have chaplains 24/7 to take care of the family while I take care of the patient.

If you have come to terms with your own death, I think it might make dealing with others a little more palatable. I, personally am comfortable with the surety of a heaven and eternal life beyond the pain here. It helps me cope. For those who believe life ends with the last breath, I think it would be more difficult.

If you are having this many deaths on your floor, do you have a chaplain or grief counselor for the staff? If you do, I suggest you speak to them or attend sessions they may offer. It may help.

Even after the hundreds of deaths I have seen, some still have a more profound affect on me, as they will you. Some you are grateful for their swift passing, some you agonize with them over every breath, and some you will be sorry they are gone. It makes you human. It makes you compassionate. It makes you a better nurse and a better person.

Be assured that it will get somewhat easier to cope, but it will never be something that you see as routine. Thank you for caring.

[leslie :-D]

Tweety, I hear you, and thanks for your message.

Maybe the horrific grimace on her face was O2 deprivation and not anxiety, but she was grasping weakly at her daughter's hand, and I could almost make out "oh god" at times along with all that terrible gurgling.

ATIVAN--yes indeed. I wasn't her primary nurse and I don't know if there was an order for ativan, but that would have worked I think.

How do you resolve the euthanasia issue though, when giving morphine and ativan to someone whose sats are like 40%?

i work in hospice and see this all the time.

anxiolytics are always given w/ms04.

scopalamine helps alot in drying secretions.

it is not euthanasia if your intent is to relieve suffering.

giving ms04 continuously is very common.

i can't tell you how often i've continued in giving the mso4, even with long periods of apnea.

as long as i continue to see a grimace, fretted brows, soft groans, tense muscles, grabbing hands, etc., then i know they are not completely comfortable.

i'm sorry you feel so helpless.

there will always be some who struggle til the end.

your pt is finally at peace.

may you find the same.

leslie

[Annebug]

Okay, now I am crying, and I probably needed to.

No, I haven't come to grips with my own death, and I have no religious beliefs that help me to cope. Also, I'm a smoker, and so was the patient last night. Also, lung CA was what my grandmother died of. The difference in her case is that she was zonked out (I think on ativan and morphine) when she died, and there were never any secretions, just obvious air hunger.

The woman this morning did not just have secretions though. She had been coughing up blood, and she was drowning in it. It was a continuous coorifice gurgle, like a pot of boiling water. Her anxiety was obvious to me. I only wish that we could have made her comfortable. I think that's what bothers me the most.

I became a nurse (because of my grandmother's experience) to ease suffering. To ensure that folks died peacefully at least. This woman did not. That's what's getting to me. When we zipped up the body bag, she still had that horrible grimace on her face. I'm having such a hard time with this. Almost as bad for me is the way it didn't seem to bother anyone else. Am I going to become as seemingly cold?

[EmmaG, RN]

Does your unit have a oncology nurse specialist as a resource? If not, speak to your manager. As a new nurse, what you're experiencing is normal.

What concerns me is that you might be identifying too much with what your patients and families are going through. In oncology, you get very close to your patients and their families; because of the nature of the disease and dying process and also because of repeated admissions. There's a fine line to walk between caring for and empathizing with your patients, and becoming so involved that you suffer as well.

Speak to your specialist or manager, some of the "old" nurses on your unit, and the chaplain who works with your unit for their perspectives in maintaining therapeutic boundaries while caring for dying patients.

Don't beat yourself up over this. You're new but anyone who has worked oncology for any length of time crosses that line at some point; it's inevitable.

If you continue to have difficulty sleeping because of these issues, perhaps go to your EAP to talk things out.

[tnbutterfly - Mary, BSN]

I'm so sorry you had to witness such a painful death so early in your career. It is always hard when a patient dies, but even harder when they struggle and suffer. You may need to get some in-house pastoral counseling to help you deal with this death. While you were quite disturbed by this event, I'm sure the family appreciated you being there. Try to draw comfort from that.

I was present when my father-in-law died at home with lung CA. It was hard to see him struggle and it was also hard watching his son give him Morphine drops since I knew it would further supress his respirations. I never did say anything about that because he did get relief and the family seemed more at ease.

While it will always be hard when patients die, you will eventually learn to deal with it. I've been in nursing more years than I care to admit, and I still get teary when patients die....sometimes even in front of the family. But it is good for them to see how much their loved-one's death affects others....that you cared so much.

Compassion and empathy are characterisics of a good nurse.

[leslie :-D]

I became a nurse (because of my grandmother's experience) to ease suffering. To ensure that folks died peacefully at least. This woman did not. That's what's getting to me. When we zipped up the body bag, she still had that horrible grimace on her face. I'm having such a hard time with this. Almost as bad for me is the way it didn't seem to bother anyone else. Am I going to become as seemingly cold?

i'm sorry you're hurting so much.

i promise you, it does affect the other nurses.

but in order to bolster one's coping mechanisms, the mind switches off.

it's really a form of dissociation.

that doesn't mean that one's stomach isn't in knots.

but if we allowed ourselves to truly feel the pain of those who suffer, we would never last in our specialties.

it is not insensitivity at all.

it's survival.

you will find your own unique way of dealing with these daily stressors.

many exercise after work; or meditate; take a class...whatever it takes to constructively vent.

i've dealt w/sev'l onc units who are familiar with pain mgmt in the dying.

they've studied concepts in hospice and palliative care.

it really is so helpful to these pts, to be able to anticipate and treat their symptoms.

but for now, you can educate yourself and advocate for your pts.

most times your knowledge will be invaluable.

but there will always be those times that nothing helps.

continue in your vision to bring peace to your pts and those around you.

it will bring you far,

and your pts., even further.

leslie