Death & Dying

Before I started nursing school, I was very nervous about the thought of being around someone after they had died.  I have realized that there is a common uneasiness about this issue shared by most new nurses.  

While working as a nurse in the ICU, I have encountered numerous situations in which patients have passed away.  I remember one night in particular where I helped to put five different patients into body bags.  Not the normal night, but a pretty terrible one nonetheless.

My first experience with death as a full-blown nurse was rather traumatic and sad for me.  The patient was in liver failure and had a new diagnosis of a perforated bowel.  There was nothing that the surgeons were willing to do because of his advanced liver failure, so he was essentially left to hospice care.  We oftentimes provide short-term hospice care in the ICU when the family has decided to withdraw care on a patient or the patient has received an imminent terminal diagnosis.  

At the beginning of the shift, I was talking with the patient about his family and occupation.  As the night progressed, the patient continued to deteriorate and lose consciousness.  As the patient worsened, I started to have an internal panic attack.  I saw that his oxygen saturation was now in the 80s.  Should I go talk to the family?  Have they noticed that this is happening?  Is he going to die soon?  These were all questions that came into my mind.  How do I comfort his family?  What do I say?

In my mild panic attack, I decided to ask the charge nurse how she helps families when their loved ones are dying.  She said that it varies, but for my particular family, it is important to give some gentle education about the process of dying.  I went in and talked with the patient's brother and told him that the patient's oxygen was dropping.  He said that he had noticed already and was mentally preparing himself.  Every hour I consulted with the charge nurse (thank goodness she was there) and she coached me through the night as the patient got nearer and nearer to passing away.

The patient died at 6:30 AM, just before my shift was over.  I went into the room and gave my condolences to the family and mentioned a little of what to expect over the next couple of hours.  I left the room and distinctly remember as his young daughter wailed over losing her father.  I could hardly handle the grief that had not only overcome the family, but myself as well.  

What Can We, As Nurses, Do To Help A Grieving Family?

The first words of advice in this area is that every family is different.  Everyone grieves differently so recognize this as you are discussing death and dying.  Some families are quiet and want space.  Other families are screaming and crying at the top of their lungs for you to do something.  Each experience with a patient dying will be different from the next.  Here are some general tips for how to handle death and dying in a hospital setting:

  • Help the family to understand what the provider is saying to them about their loved one.  In most situations, the news of a loved one nearing death is a shock to the family.  A few minutes after the provider leaves, ask the family if they have any questions.  Some families may ask questions while others may be somber and need time to digest what they have just heard.  I've found that it is in those quiet moments that you are really able to get through to the family. 
  • Help families to make important decisions.  If the family is struggling with end-of-life decisions, prompt questions that might help them to gain clarity.  One of the most common questions that I ask is, "Had you talked with (the patient) about what they would want in this type of situation?"  Sometimes the response is that they would want everything done, while other times they recognize that the patient would not want to live like this.  This may prompt the family to ask questions about what would happen if they did withdraw life support.  
  • Give clear expectations of death and the dying process.  It is important to let the families know what to expect when withdrawing life support.  One of the biggest issues I have seen with this situation is when families expect the patient to immediately pass away.  It can happen that way, but most of the time it takes longer than that.  Younger patients with strong hearts or patients with catastrophic neurological issues (strokes, for example) can take hours or days to pass away, whereas the chronically ill may pass away within minutes. 
  • Provide support.  Call loved ones for the family members if there is additional support that they need.  Chaplains are also a great resource to utilize during these traumatic times.  They are available to provide emotional and spiritual support for the families, as well as give the patient certain religious blessings.
  • Provide the patient with whatever the family requests.  I have noticed that families commonly get fixated on certain aspects of dying whether it be oral care, pain medication, positioning, etc.  Provide excellent care for your patient (not just because that is what we should do), but also to put the family at ease that their loved one is dying with respect and dignity. The families also become a strong focus during the dying process.
  • Continue to provide nursing care for the patient even though they are dying.  Provide frequent oral care, reposition the patient as needed, and give as much medication as the patient needs to be relaxed.  I know it sounds excessive, but I usually give a large dose of Ativan and Morphine prior to extubation. Many providers are very liberal with the amount of prn medications they order which allows the patients to receive whatever amount of medications they need. If they have a large amount of oral secretions, see if the provider would be willing to prescribe a Scopalamine patch to dry up secretions.

Death and dying can be a very scary aspect of nursing care.  Our doctors talk with the families and commonly speak about what a sacred and special time this is to be with a family member as they pass away.  Provide the families with as much emotional support as they need.  There are times when you also need that emotional support.  Take a minute for yourself if you need it.  Step into the break room and let it out for a minute.  If you need to, ask your charge nurse to step in and visit with the family while you refocus yourself.  Care for the patient, their family, and yourself through the whole process.

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