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?
Oh bless you ; first for choosing Nursing. Then for choosinc oncology-that is a hard place to start. That's where I started and I admit I could not hack it there. I was 34 had no peer family or friends that had died and didn't realize what oncology was back in the 70s.
It is OK to cry. I'm 62 years old now and have been an rn since 1974. I guess I have been with dozens and dozens of people who were dying. I cried with each and every one. I also chose to offer postmortem care to other's patients when their nurse was having a hard time dealing.
Death isn't easy for some like your dear lady. Some though just smile, close their eyes and have gone before you realize it.
Morphine as Leslie said is comforting to people in respiratory distress. My dear mother in law passed away 2 years ago with sepsis not cancer but the sx were the same. Can you believe her daughter did not want her sedated because then she couldn't talk with her? MIL hadn't spoken for at least a year. I can be a biddy when I want to and I dragged the whole family to the nurses station to see the doctor. *I* insisted on MS. The doctor said "but you know what that will do?"
Of course I did, it gave her peace, comfort, eased her agony and allowed her to join her family who had gone on before.
When it is my turn I hope someone like you will be there, I hope you will give me comfort and I believe you will because you have the makings of a fine NURSE.
Will you try one thing? Please stop smoking.
----------------------------------------
Miss Ludie,
Your post really touched me. Thank you so much. I think the nurses I'm working with are so experienced, with poker faces and all, that I didn't feel like it was okay to be sad about my "dear patient." They see so much death. Really, we're as much a palliative/comfort care unit as anything. I'm new, and they've all been there forever. It is okay to cry and/or feel emotions, and I need to get comfortable with that. Obviously putting patients' and families needs first, but just feeling like it isn't a breach of duty to shed a tear. I remember so well that the CNA who sat with us when my grandmother died was crying. I'll never forget that. I didn't feel like she wasn't doing her job. I felt touched that she cried over my grandmother's death.
Specializes in Spinal Cord injuries, Emergency+EMS.
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.
some hyoscine hydrobromide may have helped to dry up some of the secretions and reduce 'death rattle' as well as providing some sedation.
Uk practice sees various concoctions given by syringe driver , usually sub-cut but generally, diamorphine, cyclizine, hyoscine feature ...
i've also seen ketamine used in a syringe driver in palliative care for the combined analgesia/ sedation that you get with intermediate doses
diamorphine has the advantage of being really really soluble so you can have very concentrated solutions for syringe drivers
I know diamorphine is very rare in the US, don't know if hyoscine hydrobromide is available ( rather than hyoscine butylbromide aka buscopan)
Specializes in Spinal Cord injuries, Emergency+EMS.
do you mean hyoscyamine hydrobromide?
aka, levsin gtts.
i have found that i need to give above the recommended dosage, in order to achieve a therapeutic effect.
but yes, it does the same thing as scopalamine.
leslie
eta: ketamine is normally given for palliative sedation: a last resort.
hyoscine hydrobromide is the Uk approved name, it;s probably very similar if not the same as hyoscyamine hydrobromide and it;s the different generic nameing conventions striking again
it's going to take a long time ot get world wide agreement on common generic names for drugs
I just thought I would jump in here from a family member point of view. I have only done OB nursing for the past 20 years and I was with my dad 4 years ago when he died of lung cancer.
He was in the hospital the last 5 days of his life (due to his wife not being able to let go, I finely got her to agree to a DNR order 2 days before he died). We kept him WELL medicated with ativan and morphine as ordered, anytime he asked for meds he got them. After he was in a coma two days before he died, anytime he looked like he was in pain, he got meds. I did NOT want him to die in pain. I do not think that by keeping him well medicated it was euthanasia, he died comfortable and not in pain. He still had the "death rattle" that most here talk about but only for a few hours. I think the ativan helped the most for that. I kept headphones on him most of the time playing his favorite music and that seemed to help also.
The nurses were great there as I was from out of town and stayed in his room with him the whole time. They let me care for him as much as I could and helped me deal with his death when the time came.
My hats off to all of you nurses that work with cancer pts. Watching my dad die was one of the hardest things I have ever done.
I think you've gotten terrific advice so far from everyone. I'll just add a few things, definitely talk to your coworkers when things like this happen, especially if its a long-term patient or a "frequent flyer", its helpful to talk about what happened and helps you cope. And when you feel its okay, its fine to grieve with families. We had a patient on our unit for a very long time (this is acute care mind you) who couldn't get well enough to go to LTC or rehab or hospice...the family just wouldn't give up on her (nor would the patient till near the end), anyway, she was on our unit for months. Everyone knew this family...when the patient died, many of us grieved with the family, I remember hugging them even, and I'm not a "hugger". I think it was good for the family to have support like that from staff. Also, you may see in the future morphine drips on patients (PCAs with basal rates) which is very beneficial, and don't forget to ask for a scopolamine patch for your patients when they get heavy secretions, it is so helpful, and I think many times the MDs forget, because they don't spend the time in the room that we do.
Specializes in Acute rehab/geriatrics/cardiac rehab.
First of all. Thanks for choosing oncology. I have great respect for folks who go into that field. I speak as a family member who has had father, grandmother, great grandmother, etc. die from one cancer or another.
Not sure if you mentioned this. I know that the oncology floor at a local hospital where a friend works actually has a support group for the oncology nurses. Perhaps your hospital has something similar. I know someone else mentioned talking to a chaplain. That may help.
As a relatively new nurse (2004), I feel your pain. The first time I witnessed a "hard" death, it haunted me for days. I had come from a background in manufacturing & at age 32 had only witnessed deaths as a family member. What you see as a family member is controlled by the nurses...especially the good nurses. They'll ask you to just "step out and get some air for a minute" as they perform the nasty procedures, (i.e, deep suctioning, diaper changes, dressing changes). They'll keep your loved one comfortable, not only for the benefit of the patient, but also for the family. They'll ask you to step out of the room and give them a few minutes after the death, so you never have to know about the evacuation that often happens. Nothing I learned in school prepared me for what I saw with that first death. And the difference was that now, I was the nurse trying to help both the patient and the family deal with what was happening and I wasn't prepared for it myself. I believe in many ways, the deaths can be harder to witness when you "know too much".
As a nurse, your perspective on the death is totally different than that of a layperson. You now are able to identify the signs that indicate pain and suffering. Have you ever had a family member ask you if you "think he is hurting"? (If you haven't, you will. And sometimes you will probably give the answer the family wants even though you know it isn't true). As a layperson, some things aren't as obvious as to us nurses. You KNOW he's hurting because you are able to recognize signs the family doesn't. You also know the end is near before they do. You know that morphine is going to shut down his respiratory drive. You know that giving that injection of morphine will probably hasten the end. But, you also know, that without that morphine, he will suffer and suffer greatly. And the family will suffer as well. Imagine the memories the family would have been left with, had you not given the morphine to their loved one? Not giving the pain medication would not have prevented death. It would only have made it a much more miserable way to die.
I work in a small rural ER. There are only two nurses on at a time. Myself and an RN. Most of our pts are older pts that come in repeatedly. We grow to know these pts and their families. And we become attached. I have witnessed and been a part of many deaths of pts that I cared about in the 2 years I have been in the ER with the most recent just being this past Sunday. Many of these families are people that I have known all of my life, having grown up in this area. My job during this time is to make the families and pt as comfortable as possible. I make coffee. I offer soft drinks. I pass out Kleenex. I hold hands. I give hugs. I make phone calls. I give pain medications as ordered and ask permission when I see a need for more. I have the family witness as little of the "nasty" stuff as possible. I cover the suction canister with a towel so they don't have to look at that. They know its there...no need to have to see it. I waive visitation guidelines as needed. I move extra chairs into the room. I give out blankets and put extra ones on the pt. I nurse both the patient and the family.
I try to do EVERYTHING I can think of to help the family and patient be comfortable as they move from this one phase of life into what I believe is the next. And KNOWING that no matter how horrible the circumstances of the death, I did EVERYTHING in my power to help this person through the transition as easily as possible has given me more peace than anything else I can do. I carry this attitude into the post-mortem care. I am as gentle and as respectful to the "body" as I am to any living human, because I want to know that as the last nurse to take care of Mrs. Smith, I did the best job for her that I possibly could until even after the end.
Sometimes I go through my job with tears in my eyes. Sometimes I am doing these things with a stony face. I depends on the situation and what I believe the family needs from ME. If I feel a need to be their rock, then I will not cry with them. I will have my poker face on while I am secretly biting the inside of my jaw to keep myself from tearing up. If I can feel that Susie needs to know how much we loved her dad, then I will allow her to see my emotions. It all depends.
And sometimes, like after the death of a 15 year old MVA victim, I will go outside after it is all over and collapse in a pitiful heap on the concrete for a few minutes. Then I will pick myself up, shake it off, and go back in to take care of the rest of my patients. Because I am a nurse.
And sometimes, I will not grieve the loss of a patient. If your brother was the drunk driver that hit the 15 year old, I will not feel sorry for HIM. I will however, grieve for you. I will empathize and sympathize with you. You will know that I am sorry for your loss. You will know that I am so very sorry for what you must be feeling. But I probably won't cry for your brother. I probably won't even feel bad that he is gone. You, however, will never know this. Because I am a nurse. But I am also human.
I would tell you it gets easier with each death, Grad, but it doesn't. Some will be easier and you will think you're becoming jaded. Then someone will come along and completely knock you off your feet. Like the 38 year old single mother of 2 that is dying and isn't ready to leave her children. The patients that completely break my heart are the same patients that remind me why I became a nurse in the first place. Because I care. Because I know I can provide a loving touch, a friendly smile, and comforting words to the patients that need it most. And that's why, even though sometimes this job is the hardest thing I've ever done in my life, I'll continue doing it. Because at the end of the day, I know, I made a difference in someone's life. And you did for both your patient and their family, because you cared. You hurt, you grieved with them. And they will remember you. Because that's what makes a great nurse.
I've also grappled with similar issues after pt deaths. It's sad, but somehow life-affirming, to see someone slip away easily, in the company of loved ones, free of obvious pain. Much worse to watch them struggle for air, body fighting to hang on long after the mind has gone. So far I haven't had to watch anyone die knowing what was happening--we're pretty generous with pain meds, near the end.
I see a parallel between an easy death and a recovery. We do our best to help a patient recover, or if they can't recover, to die comfortably. But we can't really guarantee a patient will recover, nor can we promise with certainty an easy death. We do all in our power, but our power is limited. In some cases, the dying patient's body fights on long after the mind and soul have given up. No way to know whether the mind and soul are suffering, but the body appears to be in agony, even as it fights against all we do to relieve it.
I hope the mind and soul are at peace, but the only sure comfort I can think of is that the struggle does eventually end.
Specializes in critical care; community health; psych.
I do hope you can find peace in the knowledge that you did what you could. That you used all of your knowledge and skill available to you and really put your heart into making your patient as comfortable as you knew how. Sometimes even our advanced technology and modern medicinal orificenal can't hold back the symptoms of a traumatic death. You will not forget this one but it will eventualy find a neutral territory in your memory where it won't hurt so much to think on it. You may even learn from it in time what you can do and what you can't to help a similar situation and be at peace with it.
I don't know if you believe in God, but I think the concept, if not the prayer itself is appropriate. God, 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.
As for the skills, they will come. You will watch this nurse and that nurse active in their art of giving comfort and you will find something that works for you and your patient. Remember, relieve the pain first. Aid the breathing by keeping the airway clear as possible from secretions and keep the patient calm. Think of all you have at your disposal from medicines to repositioning. And when you have done all you can, try to find peace.
Others have made some fine comments and suggestions. My thoughts:
1. Time is a good healer. You will (and should) grieve over someone's death, but the raw edge will ease in the days and weeks ahead.
2. Be glad, too: you did your job. You cared this woman while she was still alive, you helped her manage her pain, you helped the family, and provided post-mortem care. Your job is to provide that care, and you did it. Nurses who break down or find themselves unable to perform under such circumstances are ultimately not doing their job.
3. There will be other deaths that -- for whatever reason -- you won't feel what you felt with this one. That's OK. As I've said many times, a nurses job is to provide professional services, not to have heart-felt sympathy with your patients. If you provide the best level of professional care, you can hold your head high, and be proud of your competence. Such professional care might well include talking with a patient, listening to family members, or any number of things. But we are not there to be counselors, ministers, or whatever. Be very proud of what you did as a nurse in the end of this woman's life.
4. Most nurses -- after such an experience -- find themselves asking if there was something they could have done better. Maybe there is, and if you think of something, remind yourself, and resolve to do it better next time. Some nurses are wracked with guilt over some slight mistake or oversight, and guilt like that is wasted energy. Your patient is now gone. You probably did the very best you could do under the circumstances.
5. Finally, be gentle with yourself. You graduated 2 months ago. You are learning (that's the big shock of graduation -- you probably thought you'd learned it all : ) and growing. As I said, be proud of what you did. This woman's family will never forget your professional care.
Specializes in SICU, EMS, Home Health, School Nursing.
Everyone here has made great comments! I also really struggled with death when I first began my career in nursing. Death is never a fun thing, but sometimes it is a blessing. I still have a hard time when patients die and I have learned that sometimes the best thing you can do is just be there with the family, hold them, cry with them, pray with them, whatever is needed in that situation.
The first traumatic death I experienced was a teenager! This teenager was intubated, but was in severe pulmonary edema...it was just bubbling out of the ETT!! We had to code this teen several times before the family was ready to let him go. We had the family at the bedside watching everything we were doing for him. A few days after that, my ANM pulled me into her office and asked me how I was handling it, I had to use everything I had not to cry in front of her!! She talked to me about how all nurses have to find something to help them and I had to find a way to cope... I figured out for me I read, pray, listen to music, talk to people, etc and that really helps me.
When I have a comfort care patient that is knocking on deaths door, I give them morphine and ativan whenever it is needed to ease their suffering. Just like others have said, it is comfort care measures and that is the point of the meds. The point of the meds is not to make death come more quickly, but for them to die in as little pain as possible. Sometimes just getting the patient out of pain tends to make them die faster. You had better believe that if I was dying, I would want to be as comfortable as possible.
Like I said, death is never easy, but we are nurses and we need to be there for our patients and their families when death comes knocking on the door. Our job is usually to prevent death, but sometimes it is to help our patient die with as much dignity as possible and in as little pain as possible. I will definitely say a prayer for you! If you need anything, please feel free to contact me!
Annebug
51 Posts
----------------------------------------
Miss Ludie,
Your post really touched me. Thank you so much. I think the nurses I'm working with are so experienced, with poker faces and all, that I didn't feel like it was okay to be sad about my "dear patient." They see so much death. Really, we're as much a palliative/comfort care unit as anything. I'm new, and they've all been there forever. It is okay to cry and/or feel emotions, and I need to get comfortable with that. Obviously putting patients' and families needs first, but just feeling like it isn't a breach of duty to shed a tear. I remember so well that the CNA who sat with us when my grandmother died was crying. I'll never forget that. I didn't feel like she wasn't doing her job. I felt touched that she cried over my grandmother's death.
Thank you so much for your wonderful post.