To be or not to be - Staying present for the hard conversations

If you ask people how they want to live out the last few days, weeks, or months of their life, it is unlikely they would say, hook me up to some dopamine, drop a tube down my throat and if my kidneys fail, give me some of that dialysis.

Yet because we live in a society that fears death, we rarely entertain end of life decisions until confronted with them. Often that comes with an emergent hospital admission and when push comes to shove, without a prior conversation, fear naturally prompts us to choose life, regardless of the consequences.

One of the privileges of working as a nurse is the front row-seat it provides me to intimately witness the sacredness of life and death. As a critical care oncology nurse and a Zen hospice volunteer, I’ve had the opportunity to be with people at the end of life. Post about my first death of a patient I’ve helped families make decisions to end life support, held many hands, hugged survivors left behind, and also sat as silent support for others.  I’ve tied string under the chin and the top of the head to close mouths of dead bodies before rigor mortis arrived, turned off respirators, and I have placed bodies in bags, and zipped the white nylon sack closed in a permanent fashion before transporting to the morgue. 

While working as a nurse, (primarily in critical care, oncology and obstetrics), end of life situations have been some of the most uncomfortable yet rewarding moments for me to experience. When we as nurses are able to be vulnerable and connect with a patient who says: “I’m scared I’m dying”; and if we have the courage not to turn away, even though it is so incredibly hard, we can provide a rare opportunity for healing. When a family member anxiously asks what you would do if you were in their shoes? Don’t turn away, busying yourself with a familiar task to avoid feeling the emotion. As we know physicians are rarely at the bedside. Nurses have an enormous opportunity to open a dialogue about what is often unsaid.

These days, I don’t find myself having the same end of life conversations that I had when I worked in Oncology, ICU or Hospice. They are different, yet still painful and difficult. I work in Obstetrics, an area of new beginnings not endings. When death happens here, it is unexpected, unwelcome and inconsolable. With so much hype around wanting the perfect birth, some couples even write out a birth plan for their dream birth. It is never on anyone’s radar that the baby may not survive - and certainly they don’t expect the mom to die in childbirth. It is rare but these deaths do happen. Certainly when Carlos Morales brought his wife Erica to a hospital in Arizona this January to birth quadruplets, I’m sure he didn’t anticipate going home without her, yet that’s what happened. The cause of her death has yet to be released but we do know she developed hypertension, which compounded with carrying quadruplets, created considered risk for hemorrhage.

Erica Morales memorial page via facebook

Erica Morales memorial page via facebook

Like many nurses, I have aging parents. They are entering their eighth decade with a number of comorbidities. My mom has witnessed the passing of all five of her siblings. I’m sure she has some concerns about the dying process but this year she openly shared with my family that she would like no interventions to prolong her life when the time comes. She lives in the reality that life in a body is impermanent. She is not actively dying, she has no terminal diagnosis, she is simply aware that she is aging and death is inevitable. My father on the other hand, despite a significant medical history and a complicated four-month hospitalization is not as comfortable with dying and definitely doesn’t want to talk about it. Earlier this year, my dad was septic and nearly died. The mere mention of a rehab center can trigger PTSD for him. Actually, it can trigger PTSD for the whole family. Rehab did not bring out his best qualities and he had little will to live. When asked if he wanted to be resuscitated, to the dismay of my brother and me, my father who was mentally sound at the time, clearly said, “yes I would like CPR and a respirator”.  Despite our many life experiences, sometimes fear and uncertainty are too strong for us to consider alternatives. In the meantime we can offer support and keep an open dialogue.

Death doesn’t just show up when we get a diagnosis of a terminal illness. Sometimes we are caught by surprise by the MI, CVA, or trauma. The conversation needs to happen prior to being sedated in the ICU. Have those conversations with your patients prior to the ICU admission. Have those conversations with your friends, your colleagues, your family members and your patients, even if you think they are healthy. When I admit a patient, I need to ask whether they have a health care proxy or not. Post about my last will and testament It is a rare obstetric patient that has one, but when they inquire about it, I open it up for a conversation. Inevitably they say we really need to do a will too with the baby coming into our life. While you are filling out that paperwork, have a chat with your parents about what their wishes are for end of life care. Chances are, it will be a new conversation.


This post was written as part of the Nurse Blog Carnival. More posts on this topic can be found at This Nurse Wonders. Find out how to participate.

Nurse Blog Carnival

When CPR Annie died, I had a lot to learn.

I met Roberta in the early nineties when she told me I failed to save my patient Annie.  It went something like this:

 

photo by Nicki Dugan Pogue

photo by Nicki Dugan Pogue

Eileen:  “Shock 360 joules, Epinephrine 1mg, CPR, stop compressions, check for a pulse, no pulse but she has a rhythm, she’s in sinus bradycardia.  Give Atropine 1mg.”  Roberta: “Sorry, you didn’t save her.”

 I was sweating, petrified and humbled, along with everyone else in my first Advanced Cardiac Life Support (ACLS) class.  Roberta had a clever and effective teaching style. Luckily my patient Annie was only a mannequin.  Lesson learned.  I still remember, whether you call it EMD or PEA, a rhythm without a pulse gets treated like Ventricular Fibrillation while you put your detective hat on to find the underlying cause. 

 So since she is such a smarty-pants…seriously, she is the smartest nurse I know.  I thought I would interview her for the blog.

Here is what Roberta has to say:

How long have you been a nurse and what areas of nursing did you or do you currently work in?

I have been a nurse for 35 years. I have worked in the critical care, oncology, and PACU.

 Tell me your biggest pet peeves about nursing.

Seeing nurses working who do not care about their patients’ outcomes or about the quality of care they provide. When I hear things like “I don’t care about the quality metrics or patient satisfaction” I get very sad.

 What do you love most about nursing?

Having the privilege of caring for patients in some capacity during some of the most vulnerable times in their lives.

 What throws you off balance and how do you know you are out of balance?

Tight deadlines. I am committed to quality work and do not work well under tight deadlines. I need time to deliver a quality product. I know I am off balance when I get frustrated that I cannot deliver the quality of a product that is possible if I had a bit more time.

What brings you back into balance?

Time and time off, particularly when spent scuba diving.

 What advice would you give to new grads starting out?

Be patient with yourself. Do not expect to be the expert on your first day (or even your first year.)

Ask questions over and over again until you understand the answer. Do not settle for mediocrity - Strive for excellence.

If you are taught the right thing to do and see others not doing the right thing, question it (in a kind and gentle way.)

Trust your gut; you are probably right

photo by Derek Keats

photo by Derek Keats

 


Tips from Rescue Dogs to Help you Prepare for Interview Day

It’s a tough job market out there. Even experienced nurses are struggling to find a job, or at least the right one - kind of like a rescued canine dreaming of the perfect home. Fortunately history repeats itself, as nursing shortages are cyclical. With the average age of nurses dangling at forty-seven, there are plenty of nurses flirting with retirement and putting down the stethoscope.

Luckily for you, you recognized the need for a change, networked with friends of friends, or connections on LinkedIn www.linkedin.com and landed an interview.  You’ve learned it’s more about who you know than what you know.

Here is a bit of advice from the rescue dogs:

~Be on your best behavior for meeting day

Dress professionally, research the company/hospital, look polished and don’t badmouth your previous owner – even if they dumped you at the shelter.  Show your resilience, and your ability to follow commands and learn new tricks.

 

~Tell your story

When I learned of my dog Stella’s anticipated death simply because at ten, she was the oldest dog in the shelter - it broke my heart.  During the interview, try to open the heart of your interviewer.  Give specific examples of how you made an impact with a challenging patient or family.  Find a way to share your passion for nursing.

 

~Show them you play well with others     

They will remember if you barked at others, so be polite to everyone – you never know who is observing you.  Everyone “says” they are a team player.  Prove it - describe situations that reveal that to them.  If you interview with a panel, make eye contact with everyone and ask pertinent questions.  If there is a staff nurse on the panel, ask to hear his/her perspective.

 

~Be confident but humble  

Enzo, the dog and main character in The Art Of Racing in the Rain by Garth Stein was brilliant.  He knew when to shine and when to take the backseat.  Know your strengths and weaknesses.  Don’t overinflate your experience or skillset. A good manager can read right through that.  Be clever about which weakness you share with them.  Avoid sharing your smart phone addiction – chose wisely and let them know you’ve improved upon this weakness. 

Sherry from Muttville, the best dog rescue in San Francisco

Sherry from Muttville, the best dog rescue in San Francisco

 

 

 

 

 

~Find the right match

Know yourself and what supports you.  I am biased towards mellow senior dogs.  A puppy may be more your speed.  Do your research on the company/hospital, get the inside scoop (this goes back to networking).  Ask good questions of them as well as internally to yourself.

* How long before a day shift position will open up?

* Can I tolerate the next few years on a rotating day/night schedule?

* Can I work in a small cliquey unit with 5 nurses or am I better suited to a larger unit?   * Does a small community hospital suit me or would a teaching hospital be a better fit? 

* Will this job support me to grow into my highest potential?

 

~Use all your senses especially your intuition

Listen to what is under the questions they are asking.  In an interview, I was asked how I handled working with difficult people.  After the third poll of the same question, I saw neon lights flashing before me.  We both had a laugh when I said this doesn’t sound hypothetical anymore.  I took the job anyway and her question was absolutely warranted.  Sometimes you need to ask specific questions to get full disclosure.

 

~Rescue dogs and nurses have a lot of love to give, once they land in the right home

Good Luck.  Now, go out and wag your tail!

How do you deal with angry family members that interfere with care?

Working as a nurse can be tremendously rewarding. This week I received deep appreciation for my knowledge and care from my patient and her family after helping her safely deliver a healthy eight-pound baby boy. We even had a patient buy the staff an expensive lunch.  While it is lovely to be lavished with gifts, nurse also appreciate a simple thank you. That is not always the case.

Some days caring for a patient is a battle met with argumentative family members that lack trust in the staff and medical system.  A healthy dose of questioning and being an informed consumer is necessary but it should be done in a respectful manner and with the intention of optimizing the safest care of the patient.  Often our extensive training is challenged by a simple Google search that lacks the complex picture, which can ultimately create barriers to care.

This week a nurse shared one of her most difficult experiences of her career with me.  She cared for a 12-year-old boy in the ICU, recently treated with an allogeneic bone marrow transplant.  The transplant was offered as a last resort and fortunately for the patient, he had a successful engraftment.  The bone marrow transplant saved his life.

Anti-rejection medication is crucial for transplant patients to prevent the body from recognizing the new cells as foreign.  The patient’s father decided he “knew more than the doctors” (though was not medically trained himself). He refused to give his son the required medication resulting in the development of a life threatening condition called graft-versus-host disease (GVHD). 

 In simple terms, the new graft recognized the patient’s body  as foreign and began rejecting it. This boy’s disease was cured but he was dying from a potentially preventable consequence. His skin blistered and sloughed off his body. His arms became contracted and he was unable to bend them. His lungs failed, requiring a tracheostomy for long-term dependence on a ventilator to breathe.

During the patient’s lengthy stay in the ICU, the father, who was of an Orthodox Jewish background, posed several physical and psychological challenges for the multidisciplinary team. For example, each Friday night, he would light Sabbath candles in the oxygen-rich environment of the ICU – clearly a fire hazard -despite receiving electric candles from the hospital rabbi.

The father was verbally abusive and disrespectful to the nurses, physicians, and other members of the multidisciplinary team, which created challenges for continuity of care.  Consultations with the patient advocate and social worker were unsuccessful in mitigating his disruptive behavior, requiring security to remove him from the ICU frequently.  The father had previously been banned from a nearby hospital for similar behavior.

 After several months in the ICU, the patient was discharged home with a portable ventilator  and a home health aide.  The aides were unable to endure the father’s behavior. None made it through an entire shift. The patient’s sisters were not willing to provide care. Due to lack of adequate care, the patient was readmitted with pneumonia and died in the ICU.

The nurses in the ICU were deeply impacted by this very sad case. While it was exhausting physically and emotionally to care for this patient, what bothered most of the nurses was that the patient was cognizant of his family’s behavior and unwillingness to help care for him.

 For those of you reading who have had similar experiences, please share your comments of what helped or hindered situations you were involved in.

 

Let me know your thoughts. 

Should this be considered child abuse?

Should care providers be subjected to abuse from family members?