Dead Zone
Melissa Gaskill

Student nurses must learn to be able to care for dying patients, and need to talk about the experience and their emotions.

Nurses need to think about death — their own, that is. Otherwise, says Karin Kirchhoff, RN, PhD, professor and Rodefer Chair at the University of Wisconsin-Madison School of Nursing, they won’t be prepared to deal with the death of a patient.

Kirchhoff has students write their own obituaries. So does Marianne Matzo, APRN, PhD, BC-GNP, FAAN, a hospice nurse and associate professor at the University of Massachusetts-Worcester Graduate School of Nursing. She also asks students to write about what they would do if they had one year to live. These exercises in thinking about death are the first step toward being able to care for dying patients.

Seeing a body, perhaps in a mortuary or an emergency room, also helps students deal with patient death, says Kathy McGregor, RN, executive director of a Washington D.C. parish nurse program and a hospice nurse for 20 years. “There is a big difference between someone who is dead and someone who is dying. As a nursing student, the first time I saw a dead body it wasn’t as part of the death process. I was free to explore what death actually looked like, up close. There was no one else in the room. It was very freeing.”

After seeing a dead body, students should experience the death of someone else’s patient.

“If you know there is someone on the unit who is dying, ask to attend with the nurse so you can see what the dying process looks like,” says Judy Davidson, RN, MS, CCRN, FCCM, clinical nurse specialist at Pomerado Hospital in Poway, Calif.

“See what happens to the person’s body, and how the nurse handles it. Watching other nurses will give you a feel for how it is done and what is acceptable and expected.”

Matzo even suggests that students ask to be assigned to dying patients. “In the past, we thought there was nothing to be learned because this person was dying, but there is. We need to let students experience the process of a patient dying with their faculty member.” This helps nurses learn symptom management, how to help family members, and the nursing care that is needed surrounding time of death and post-death.
“A person trying to leave their body is often accompanied by so much suffering, and we have a hard time dealing with that as caregivers,” McGregor says. “But you can prepare for this. Recognize and learn to sit with your own humanness and suffering. That makes it easier to sit with someone else’s.”

Watching movies that deal with the end of life can help nurses think about issues and emotions connected with death. There are also popular books on the subject such as Tuesdays with Morrie. Kirchhoff has a dying person come and talk to her classes. “There is a wide spectrum of what is an OK death for people,” she says. “We tend to have our own narrow definition and impose it on others, so it is important to ask people how they feel.”

Saying Goodbye

When a patient is dying, the skill of assessment that all nurses learn can be brought to bear. “Ask the family if there are things they want to say, or someone they want there,” Kirchhoff says. “The work of dying is saying goodbye and getting affairs in order — spiritual, financial, and family. If the patient is conscious, find out what is helpful for them. If they are not, then make sure the patient is comfortable. Then your concern is the family and how you can support them.”

Inexperienced nurses should not be alone in the room with a dying patient, Davidson says. “Call someone else in to guide you through the process, so you don’t have to wonder if you did it right.” By the same token, nurses shouldn’t leave a dying patient alone. “Death is a sacred moment,” she says. “This is one of the most important things we do — an honor, a duty, and a privilege.” After a patient’s death, nurses need to talk about the experience and their emotions. This debriefing can be especially important with unexpected death, where it is normal for nurses to have moments of doubt. More experienced staff members can provide reassurance about what could or could not have been done.

Debriefing needs to occur within two to four hours, says Mickey Bumbaugh, BA, MEd, LPC, senior nurse counselor at the University of Texas M.D. Anderson Cancer Center. A nurse can talk about the experience, and others can provide support, talking about their experiences and providing reassurance.

A first death, even an expected one, will be difficult, Bumbaugh says. It is important that nurses grieve in their own way.

“There are as many ways to honor grief as there are nurses,” McGregor says. “One nurse keeps a notebook with the name of each patient who dies. Another plants flowers for each person. Some go to the funeral.” Others keep journals, participate in expressive art like dance or drawing, or talk with a counselor or another nurse on a regular basis.

Support is particularly important because nurses may experience one death after another without normal recovery time in between. “When people lose a loved one, it may be years before they lose another one,” Matzo says. “But nurses don’t always have time to recover and they don’t always have the support system. If it doesn’t get talked about, it gets manifested in warped, dark humor. Sometimes it just gets pushed down and nurses burn out.”

“Your first patient death is an emotional experience,” Kirchhoff says, “and you’re trying to deal with your own emotions while being supportive of family and friends at the bedside. You’re doing something that is difficult to do when you’re not at your best. I think it is underrated.”

Leaders in Change

New nurses today may know more about end-of-life care than the people they work with, and can be leaders in making changes, Matzo says. “Students can say, ‘As a nurse of tomorrow, I’m going to make it one of the things that I do better.’”

“We used to say, and maybe people still believe, that death is a failure,” McGregor says. “The best advice I learned was show up, pay attention, tell the truth, and don’t be attached to the results. The last one is the hardest, if you feel you should have done more or that you screwed up. You have to let it go and take the lesson from it. If you’ve done a good job, let that go, too, because around the corner is another unexpected death.”

The level of support for nurses following a patient death varies greatly around the country and even within institutions. Oncology units tend to be equipped to take care of staff with debriefings and support, but the intensive care unit, for example, is thought of as a place where lives are saved, Kirchhoff says. So the grief an ICU nurse experiences may not be as recognized as that of an oncology nurse. “There could be more formal support for nurses in different settings,” Kirchhoff says. “It depends on the sensitivity of the administrator and strength of the unit.”

“Nurses are privileged and honored to find ourselves in moments that change the history of the lives of those around us,” McGregor says. “To witness a birth, to save a life, or to be there when someone loses a loved one: Just honor it and be present for it.”

Melissa Gaskill is a freelance writer. To comment on this story, send e-mail to editorca@nurseweek.com.