Alicia Dumont

It was a Monday morning, around 7 a.m., when I was given my assignment to float to the Special Care Unit (SCU) at the hospital where I was completing my medical-surgical rotation. It was my first time going to this unit, so I was nervous but eager for the new experience at the same time. As my preceptor and I walked through the doors to the unit, my preceptor cautioned me that it had been a challenging and demanding night for the nursing staff on the unit, so I was a little anxious about what I was about to walk into. My preceptor then guided me into a female client’s room where the nurse I would be working with that day was receiving a handoff report from the nightshift nurse. The moment I entered the room, I could sense their immense concern and I could see the worry flooding their eyes.

The nightshift nurse voiced that the client was transferred to the SCU around 6 a.m. that morning from a different floor in the hospital because her status had been radically deteriorating. The nightshift nurse continued to explain that the client had been suffering from a severe case of chronic obstructive pulmonary disease (COPD) for a very long time, which has been noted to be due to the client’s chronic history of smoking cigarettes. Notably, the significant damage to the client’s lungs caused her to retain high carbon dioxide levels and low oxygen levels and led to a depressed level of consciousness, so as a result, the client was placed on BiPAP in the attempt to normalize the carbon dioxide levels. At the same time, the client’s worsening condition of COPD led to chronic inflammation in the pulmonary vasculature, which consequently led to an excessive strain on her heart and failure of her right ventricle. In attempts to optimize the functioning of the client’s heart, the client was placed on a continuous IV drip of amiodarone for some time which had thus far been unsuccessful.

Following the receipt of the handoff report, the nurse and I conducted an assessment on the client. My adrenaline surged and I was able to fully digest how profoundly the client was decompensating. The client was unresponsive, had a respiratory rate of 18, a heart rate in the 140’s, a blood pressure of 71/56, and saturation pulse oximetry of 90% on BIPAP.  She had bilateral diminished breath sounds with inspiratory wheezes. In addition, the client was pale and clammy with ABGs of 7.21/93/35/4.9/62/86.4, and there was no urine output since their arrival on the unit despite fluid resuscitation. The nurse and I locked eyes, and we swallowed hard as we sadly realized the sad truth that the client was nearing end-of-life.

Immediately, the nurse and I contacted the attending physician to voice our concerns about the patient’s current health status. The physician took a moment to review the client’s chart and assess the patient, and consequently, came to the decision that the damage to her heart and lungs were so extensive that it appeared she did not have much more time to live. In that moment, the physician took a deep breath and looked at us in the eyes with a sad gaze. The physician advised us to contact the patient’s family to educate them on the client’s condition and to advise them that it was important they come to the hospital as soon as possible. Subsequently, the nurse called the family, and, in that moment, I could feel my body go pale and my stomach felt as though it was in my throat. I never imagined that my first day on the special care unit would be to assist a client and their family with end-of-life care. Admittingly, initially, I felt sick to my stomach as I was overwhelmed with emotions, however, I shortly realized how important my role was about to be as part of the client’s and family’s support system. I walked to the nursing lounge for a moment to collect myself, and the nurse I was working with that day came out to check on me. We spoke for a short time as she allowed me to express my feelings of sadness as I wished I could do more for the patient and about the uncertainty of what was about to occur, as I had never been involved in end-of-life care prior to this case. The nurse said that in the client’s history, it was known that she had been fighting her disease for a long time and had already considered hospice prior to the transfer on the unit as there is nothing more that can be done for her condition. The nurse explained further that the client will rest peacefully with the support of the medical staff and love from her family by her side as she passes. Everyone has their time, she said, and sadly this patient has reached that point, and she explained that it is our role to ensure that she is comfortable, and her last wishes are honored. The nurse stressed it can be difficult to separate our own feelings from the situation at hand, but what helps her through these difficult times is remembering that she is doing everything in her power to ensure that her patients pass peacefully, and it is gives her pleasure to be a support for both the family and the patient during such a difficult and vulnerable time. Consequently, this conversation gave me peace and comfort, and taught me a lesson on how to care for myself and manage my emotions with end-of-life care. Now I know that during such a time I will need a moment to gather my thoughts and emotions so that I can be prepared to be the best support possible for the client and their family. Recognizing that this experience was about to be an extremely sad and emotional time for the client’s family, I became grateful that I was about to be given the opportunity to be there as part of their support system that day.  I knew I would have an important role that day which would be so meaningful, which would be a gift, as sad as it is, that not all nurses are able to experience.  

After our brief discussion, the nurse and I returned to the unit to monitor the client’s status as we awaited the family to arrive. Per physician orders, we also provided the client with morphine to ease her pain through her transition to the end of life. Shortly afterwards, the client’s family arrived, and we brought them to see their loved one. The room was filled with tears and expressions of sadness, but they were understanding of the client’s condition and expressed that they have been preparing themselves this past week as they were aware that hospice was nearing. The physician and the nurse, both with caring and compassionate voices, expressed to the family of the process that would take place during that day. They communicated with the family that the hospital chaplain would visit to provide pastoral care and spiritual guidance and emphasized that the family can take as much time as they desired, and when they are ready, they will discontinue the current interventions assisting their loved one to live and transition her to comfort measures. I recognized how significant it is for the nurse to communicate to the patient and her family sensitively and comfortingly, all the information involved with the process so that they could be well-informed. Communication plays a profound role on the outcome for both the patient and the family. Accurate and sincere communication is key to the family’s understanding about the reality of their loved one’s situation, and it assists them with coping so that they can experience meaningful goodbyes with their loved one.  Likewise, a kind touch, offering a tissue to wipe away tears, and listening to the family express their feelings are simple gestures a nurse can offer to the family which can mean the world to them.

For the remainder of my time on the unit, I spent time with the family and the patient by providing them with support and comfort until modes of life support were sadly discontinued. During this time, I was able to identify the priority goals and focus of nursing care for terminal/end- of-life patients, which I recognized is not only to provide proper communication and support for the family and the client, but to provide exceptional nursing care as well.  One of the major priorities of the nurse is ensuring the client experiences the best quality of life while they transition. Therefore, the nurse and I frequently assessed the patient’s current condition and comfort through physical assessments and monitoring vital signs. At the same time, we followed the physician’s orders to administer morphine to ensure optimized comfort and the elimination of pain.  Not only were the interventions of care to treat the client physically, but measures were taken to treat the client holistically, including her mental and emotional state. Although the client is unconscious, the nurse I was working with emphasized it is never truly known what the client can hear or feel, so it is imperative we treat them like any other patient. So, we sat at her bedside talking to her, holding her hand, and rubbing her arm gently giving her comfort and reassurance.

Sadly, the time came. The time where I was moments away from taking my patient off life supportive measures. The tears and the crying of the family was all I could hear in that instance, but I continued to remind myself of the gift I was given. The gift to support and ease the pain of a family and a patient at their most vulnerable and dreadful time. It was this personal experience that became the catalyst that led me to an undeniable realization that my passion is to work in a critical care setting. Being with this patient during their final breaths was both an honor and a privilege. I learned many valuable lessons this day. I learned how to care for myself and the family of the deceased client during these treacherous times. But, most of all, I learned how to care for the client by applying supportive nursing interventions that were not aimed to prolong life, but to optimize comfort.  As a result of this experience, I plan to dedicate my life to ensuring people receive the best possible patient care when faced with the life-changing moments of transitioning to the end.