An event that was meaningful to me as a nurse occurred during my clinical time at St. Michael’s Hospital. The event was my first experience with encountering a dying patient. During that shift, my patient’s doctor broke the bad news and announced that they decided not to give my patient any further chemotherapy or curative treatment and suggested to transfer him to palliative care. Since it was the first time I encountered this devastating situation, I did not know how to manage it properly as a nurse by adopting nursing interventions.
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The other people who were involved in the event were my patient and his wife, his daughter in law, my clinical instructor, and the oncologist. During the first day of the week, the patient was just being admitted to the hospital and therefore there were not many documents about him in his patient binder. I contacted my patient, measured his vital signs and finished my initial assessment and nursing activities. While I was taking care of my patient, we began talking and I found out he came from the same home town as me and he just lived two blocks away from my old apartment. We started to talk about the changes in the neighborhood we used to stay in, the same restaurants we both liked to visit, and the famous department store we liked that had been closed down. My patient and I mentioned almost every street name in our neighborhood by the end of our conversation. I quickly built a close connection with my patient during the first day of the shift and felt my patient was just like an old friend from home. During the second day of the shift, while I was charting, the oncologist came into my patient’s room and had a 15 minute meeting with my patient and his wife and his daughter in law. Once I finished charting, I went back to my patient’s room. The first thing I saw was my patient’s wife hiding in the washroom crying and the patient looked sad while lying on the bed listlessly. The daughter in law was staring at the patient with tears in her eyes. I brought the daughter in law outside the room and asked what happened. She told me the same oncologist who took care of the patient four years ago just broke the bad news and announced there was not much they could do for my patient now and suggested to transfer my patient to palliative care. Also, my patient agreed to go to palliative care after the daughter interpreted what the oncologist recommended. Once I heard this bad news I felt very sad and my mind just could not focus on anything at that moment. I thought my patient’s condition did not seem as bad as other patients I had seen and I thought my patient would have soon recovered and gone home. I simply could not believe the bad news. I was so occupied by my intense emotion that I did not know exactly what to do in that situation despite my intuition telling me I should adopt active listening skills and show my empathy to my patient and his family. I tried my best to hold back my tears and be there with the patient and the family and listen to them. I thought my patient, his wife, and his daughter must feel sad about the bad news and they must have felt unready to cope with the change.
In my point of view, the decision of going into palliative care suggested by the oncologist involved ethical, cultural, spiritual, and economic considerations. According to CNA’s code of ethics, nurses and other health care professional must be granted a patients informed consent before moving the patient from a general medicine unit to palliative care in order to protect the patient’s right to autonomy. The right to autonomy means that a patient with full understanding and capacity has the right to make choices based on what they think is best for them ( Potter & Perry, 2009). The patient’s Chinese cultural background also played a role in this event. From what I read from the patient’s kardex, and what the patient’s daughter in law told me, my patient was only partially informed by his family about the condition of his illness (prognosis and diagnosis). This is because in Chinese culture, the family is often reluctant to discuss an illness condition with the afflicted family member because they believe discussing such issues may lead to hopelessness or wishing death upon the patient. Family members may hide the information about an illness or pretend as if nothing were wrong (Kemp & Change, 2002). In terms of economic consideration in this event, I believe that it is not the best idea to continue spending extra money and extra resources on aggressive and costly treatment of my patient’s incurable disease, especially if it causes unnecessary pain and suffering to a patient. In this case I think palliative care would be a better option. In addition, I believe I should have remained accountable to my patient by coping with the emotions and adopting therapeutic communication when I first heard the bad news. This belief arises from knowing it is important for nurses to follow CNO’s practices during practice.
The key issue of the event was my ineffective coping skills when a patient is dying due to my inexperience in similar situations. If I have a similar situation arise during future clinical practice, I will know that effective coping strategies can be applied to handle the situation and improve my performance of clinical practice.
Shorter and Stayt completed a study on an ICU nurses’ experience of grief and their coping mechanism when a patients dies. This study gave me insights on how to cope with caring of a dying patient (Shorter and Stayt,2009).
Nurses reported that deaths are usually expected in the ICU, therefore being prepared for the death of a patient can made the dying experience less traumatic and allow the nurses to remain in control. Also, being in control of the dying situation can reduce the feeling of guilt after a patient’s death. For example, one nurse liked to make the patient comfortable, remove monitoring, stop unnecessary drugs, and keep the paperwork up to date. By being organized and in control, the nurse was able to provide good nursing care and contribute to a peaceful death for the patient and therefore negative feeling about the patient death is minimized Also, critical care nurses reported that their emotional reaction to a patient’s death could be balanced out when they provided physical comfort to a patient and respected their wishes (Shorter and Stayt,2009).
Secondly, nurses reported that they often “struck a chord” when taking caring of a dying patient. For example, a nurse will think of a dying patient lying on the bed as her own sister and feel it difficult to watch her die at a young age. Nurses in ICU take care of their dying patient with compassion and empathy which allows patients and nurses to develop a personal bond. This may result in positive or negative consequences (Shorter and Stayt,2009).
Lastly, nurses in the study reported that they feel extra grief after the patients die when they have developed a bond with the patients and their families. Although developing a close bond with patients may cause nurses to suffer more emotionally after a death, nurses believe a bond with patient is necessary in order to provide good nursing care.
In the study, ICU nurses reported they have adopted several coping mechanism when taking care of dying patients involving formal and informal support, the normalization of death, and emotional disassociation (Shorter and Stayt,2009).
Firstly, nurses in the study preferred informal support over formal support. In informal support, nurses placed great emphasis on their relationships with each other and the informal support this provided. They reported that the informal support allowed them to share grief experiences with colleagues which brought them closer together with the feelings of being a close-knit team. Many suggested that other people who had not been in the same situation would not understand what they were going through. On the other hand , nurses found it is more difficult to open up and discuss their experience about dying and death through a formal support setting such as de-briefing and clinical supervision (Shorter and Stayt,2009).
The second coping mechanism is normalization of death. Nurses in ICU see death so often and will consider death as a normal process of life and part of their daily work. Due to the frequent exposure to death, nurses in ICU can normalize death which enables them to cope with the situation (Shorter and Stayt,2009).
The last coping mechanism of the ICU nurses is emotional dissociation. The nurses tried to distance their emotion from their patient. For example, a nurse reported she is able to switch on and off her work mode easily. Nurses in the study agree that they have to have control over their emotion otherwise they will not be able to continue their practice (Shorter and Stayt,2009).
In another study, Barnett and Copper explore what aspects of caring for a dying patient cause anxiety in first year nursing students. The authors provided five recommendations to support nursing students while taking care of dying patients which include ( Barnett & Copper, 2005) :
(a) Recognition that the anxiety experienced by the nursing student in this situation is normal.
(b) Focus on the emotional aspects of care and not the practical aspects
(c) Discuss end-of-life ethical decision making such as do not resuscitate orders
(d) The involvement of experienced registered nurses so students realize their feelings are normal and not only due to their inexperience
(e) Make students aware that they may not always be able to solve the problems for a patient but there is value in other aspects of care such as listening to patients and comforting them.
Moreover, the authors suggest that there is a need to integrate formal teaching and clinical practice together to teach nursing students about dying and death experiences. Placement at palliative care facilitates will be useful for nurses to consolidate their knowledge and skills ( Barnett & Copper, 2005).
My thinking has change after analyzing the key issue. I used to think experienced nurses do not have emotional issues when caring for a dying patient, but now I understand both student nurses and experienced nurses can suffer from emotional distress when dealing with a dying patient or a patient’s death. Also, it is completely natural for student nurses to feel anxious while caring for a dying patient and I do not have to blame myself too harshly for not handling my first encounter with a dying patient properly.
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In my point of view, I would preserve the action of being there with the patient and listening to him and his family. With this action, I am showing I respect and care for my patient and his family. One thing I would change is that I would not only try to deal with my distress alone. Since I was emotionally bothered by the situation, I would seek formal and informal support to minimize my negative feeling about this event. For example, I could book an appointment with the counselor at school or I could talk to my clinical group member about my grief. This would also ensure my well-being and contribute to my practice as a student nurse.
If a similar situation arises again in my practice, I will adopt the coping mechanism the ICU nurses use and think of death as a normal and inevitable process of life, and that death is also a regular component of a nurse’s daily work. Also, I will try to create a curtain of emotional protection by compartmentalizing my emotions from my patient. I believe this will allow me to not be affected as greatly when caring for a dying patient so that I can remain professional and provide for my patient’s needs. Instead of avoiding communication with my patient, I should provide therapeutic communication to the patient and their family members. For example, the patient or the family may ask “what should we do?”, and in such circumstances I should be cautions in giving advice. As a nurse, I should focus on support and clarification of issues important to the patient and their family. Also, it is important to understand the patient’s perspective about his clinical condition by asking “what is your understanding of your condition?” Also, I think by saying “I need to know about your wishes so your care guide can follow them”. To show my empathy I can say “I understand it must be hard for you” or “I am sorry about your loss”. In addition, I will provide the chaplain contact information at St. Michael’s Hospital to my patient and his family so that they can gain spiritual support and professional consoling from the chaplain team.
In terms of recommendations, I believe most of the nursing students have not had exposure to the experience of caring for a dying patient or a patient’s death and therefore I think our school should provide a nursing excellence semester for nursing students which focuses on sharing the techniques of how to deal with a dying patient or a patient’s death. It would also be useful for students to read about end of life nursing care module on their own, for example, the Canadian Hospice Palliative Care Association website provides well of information for health care professionals, the family care givers and the patients about palliative care and end of life issues in Canada. In addition, we learn therapeutic communication skills from the text books, however, students are lacking the real life experience of how to communicate with a dying patient and his family members. Therefore a simulation lab where students can practice their communication skills would be helpful.
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