By Cathryn Domrose Rowena Orosco, RN, BSN, had been working at Johns Hopkins Bayview Burn Center in Baltimore for three years when a family with seven children was brought to the hospital after a fire destroyed their home. The one survivor, a 7-year-old girl, was transferred to the burn center with burns over 70% of her body. As the medical team worked desperately to save the girl, Orosco sat with her, crying and holding her hand as she died. This moment haunts the nurse 15 years later. "?I got through that day, but after that I thought about quitting,"? Orosco says. Instead she attended a debriefing, exchanged many tearful hugs with colleagues in the halls, talked a lot with a co-worker and kept working. "?You kind of put your emotions aside because there are other patients waiting for you," she said.? Nursing students might learn how to help family members grieve, but seldom learn how to deal with their own feelings of sadness or loss. Research about how nurses cope with patient death is scarce and mostly anecdotal. But what studies there are suggest nurses go through a unique grieving process when patients die, and how they manage this process is important to their well-being.
Only human
"?We feel that when people die, it doesn'?t affect our care, which is absolutely ludicrous because we?re human, too,"? says Tina Brunelli, RN, CSN, MSN, ANP-C, a nurse practitioner with Novant Health in Kentucky. Brunelli, who has worked in oncology, hospice and critical care, wrote a concept analysis as a graduate student, published in Nursing Forum in 2005, about how nurses cope with patient death. Stifling personal emotions about patient death has been equated with professionalism for nurses and physicians. ?These fields evolved from the military and there are still feelings of, ?"Suck it up and move on,"?? says Robert S. McKelvey, MD, a professor of psychiatry at Oregon Health and Science University, Portland, who wrote a book titled, ?"When a Child Dies: How Pediatric Physicians and Nurses Cope.?" But in interviews with nurses and physicians about the subject, McKelvey found ?nurses, on the whole, did a better job of coping. "They were more open to talking about these things than their physician colleagues.? Those who allow themselves to go through a grieving process seem to be healthier," McKelvey says. Those who hold it in, he says, ?pay a price by not being able to deal with their feelings at the time and place.? They may feel reluctant to get close to other patients, have difficulty with personal relationships or have trouble sleeping or eating properly. How a nurse responds to a first death -? and whether he or she is supported by colleagues and supervisors -? seems to affect how that nurse reacts to future losses, says Lisa Gerow, RN, MSN, a doctoral candidate at the University of Kansas, Kansas City, and associate professor of nursing at Tulsa (Okla.) Community College. She is the lead author on a report, published in the February 2010 Journal of Nursing Scholarship, which uses interviews with 11 nurses to describe the grieving process after a patient dies. "Nurses may be especially at risk for problems in coping with patient death if they believe they had some responsibility for it or didn'?t do enough to save the patient," Gerow says. Many ICU and ED nurses become angry and upset after seeing very sick or elderly patients die in pain after extreme and futile treatments to prolong their lives, says Catherine Miller, RN, MSN, CCRN, clinical education program manager for the ICU and special care units at Howard County General Hospital in Columbia, Md. "They might feel they didn'?t advocate enough for the patient to experience a ?good death,"? she says.
Self-care
Some coping strategies, developed over time, nurses say, include
- Rituals to help the patient and family feel better, such as bringing the family food
- Attending funerals or posting obituaries
- Praying or drawing strength from spiritual beliefs
Some nurses use exercise and relaxation therapies, such as a hot bath, to help ease stress caused by patient death. "?The nurses who care for themselves will grieve better,?" Miller says, "especially if they recognize their limits and turn down extra shifts or working with insufficient sleep." If they don'?t care for themselves after a traumatic event, she says, they put themselves at risk for eventual burnout, compassion fatigue or moral distress. "Nurses often use humor to deal with death, though they must take care not to use it inappropriately, especially in the presence of family members," says Terry Foster, RN, MSN, CCRN, CEN, a clinical nurse specialist in the ED at St. Elizabeth Medical Center in Edgewood, Ky. ?"Ask any nurse, the most pressured laughter they have ever heard is in the presence of a dead body. Because it?'s so awful, but there'?s something funny that goes along with it."? An ED nurse for 35 years, Foster has given many clinical lectures, but the most requested, he says, are those dealing with nurse humor, including humor about death. ?"Sometimes it?'s just the way you maintain your sanity,"? he says. "?This is just one way that someone can channel the anxiety and stress.?" Talking with co-workers is probably the most helpful coping strategy in getting through a difficult death, nurses say. Spouses and family try to be supportive, but they can'?t know what a nurse goes through, Brunelli says. ?"The people who don'?t talk about it with their co-workers probably don'?t survive in the long term," she says. "It?'s unbelievable how much people can suffer before they die. If you?'ve never seen it, you can'?t understand it.?" Hospitals and supervisors can be supportive just by acknowledging that patient deaths affect nurses, she says. "Just giving nurses time to talk to one another would be helpful," she says. Some hospitals hold voluntary debriefings after difficult deaths. McKelvey says people who have gone through traumatic experiences may be better able to express themselves in private counseling sessions or meetings without administrators present. ?They really have to feel safe to grieve and talk about what is on their minds,? he says. He thinks hospitals should make one-on-one support available to those who want or need it as soon as possible after a traumatic death. Some nurses in Gerow?s study said they wished their hospitals had supported them more during difficult deaths, or they had learned more about the grieving process in nursing school. But they also talked about how patient deaths, though upsetting, changed them and helped them to grow. Foster vividly remembers an ED patient who begged to see his daughter. Foster brought her in and watched the patient tell her he loved her, minutes before the man unexpectedly died. ?"I am so glad I brought that daughter in,?" he says. ?"I think, ?'Who am I to keep people out of the room.??'" Miller has a letter on her wall from an angry, difficult patient who came to her unit with advanced pulmonary disease. Two days before he died, he wrote to his caregivers, praising those who showed passion and compassion in caring for him and helping him overcome his fears. "Thanks to them," he wrote, "?I have become ready to march on.?" For Orosco, a turning point in her career -? which made her decide not to quit her job ?- was a thank-you letter from a relative of the girl who died holding her hand in the burn center. ?"Even though we didn'?t make any difference [by saving her life], that moment was a big thing, that she didn'?t die by herself,?" Orosco says. ?"Since then, I have never let a patient die alone.?" Cathryn Domrose is a staff writer.
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