As a nurse, I have seen death, again, again, and again. Without a doubt, it is the hardest part of my job, the part I have the most difficulty sharing. Yet, I’ve seen it again, again, and again. Death in a hospital is not uncommon as it used to be. According to most recent Center for Disease Control data, about 1/3 of Americans died in hospitals and short-term rehabilitation centers though most want to die at home.
Death is a very uncomfortable subject, but we will all experience it. I’ve learned there are two kinds of deaths: good deaths and bad deaths. Even though both end in losing a loved one, a trusted friend, a supportive sister, a benevolent brother, a father, a mother, whomever, there are two kinds of deaths: good deaths and bad deaths.
My first patient death was a good death. At the time, I felt like I failed.
As health care providers, we are so used to doing things. Blood pressure low? Give a fluid bolus (250, 500, or 1000mL of fluid given quickly). Heart rate low? Give atropine (a medication to chemically stimulate the heart). Heart stopped beating? Start CPR (compressions on the sternum that need to break bone in order to physically stimulate the heart). Patient not breathing? Intubate and ventilate (a plastic tube down the throat, into the start of the lungs, pumped to breathe via a machine).
As students and professionals taking certification courses, we will literally recite these interventions repeatedly until they are memorized. Interventions are ingrained in us. As a new nurse of 4 months on an intermediate care unit, I was not used to doing nothing and having that be a victory.
Frank was a spunky elderly man with a life-limiting condition of chronic heart failure. He was slowly dying of heart failure though his quick wit would indicate otherwise. Frank and I were introduced after he became extremely short of breath after working with physical therapy on a less acute hospital unit. He was an arterial blood gas (a test to see how well the body is oxygenating, abbreviated as an ABG) away from getting that tube down his trachea.
After getting report, I was expecting to get a patient near death, struggling to breathe, much like my last mental image of my grandmother. Instead, I got a stubborn old man who kept trying to talk over and take off his BiPap machine, making it beep almost constantly.
I settled Frank in and went to update his wife Althea. I vividly remember walking to the elevator to meet her. She was extremely nervous and so was I. As cool and collected as I seemed talking to Althea about her husband’s change in condition, I had no idea if what I was saying was comforting in any way. Heck, I don’t even know if I appeared cool and collected. Nevertheless, I brought her in, tears clearly hanging dangerously on the bottom of her eyelids.
To complicate the situation, Frank had legal end-of-life documents at an outside hospital, expressing his wishes to have Althea as his power of attorney, meaning in case he was intubated or could not make his decisions, Althea would speak for him. His papers also listed his desire to be a DNR/DNI. DNR means do not resuscitate, meaning no CPR, no broken ribs, no last-ditch efforts to force the heart to pump blood. DNI means do not intubate, meaning no plastic tubes down the throat, no machines forcing air in and our of the lungs, no last-ditch efforts to ventilate the body. He was currently listed as full code, meaning if he stopped breathing or his heart stopped breathing, we would do everything possible to keep him alive.
If I struggled to explain to Althea what had happened, I absolutely fumbled through asking Frank about his code status. Somehow, they understood what I was trying to say. With the help of the medical staff, Frank became officially DNR/DNI.
We kept trying treatments to improve Frank’s breathing. After a few days, the treatments were working. Frank was doing better and better. By my next shift, he started eating again, complaining about his horrible heart failure diet. His urine output picked up, his lungs sounded increasingly better, and he was able to wean to oxygen through his nose.
Althea, Frank, and I started talking about discharge planning. I transferred him back to the unit he came from before leaving that day for a few days off, feeling good about the work I had done.
Imagine my surprise when I saw his name on the assignment sheet next to mine about half a week later. I had pictured Frank at a nursing home, Althea lovingly at his side, slowly recovering so he could get home again.
Not so much.
Turns out, Frank became short of breath back on the other unit, buying him another round in our higher acuity bed. This time, Frank decided he was done with aggressive medical treatment. His son was flying in the next day to wish him goodbye. His wife was loving at his side, holding his hand when I came in.
I will never forget the look in Althea’s eyes as he asked me if she could go home for the night. I wanted to say no because I had no idea what was going on, what to say, how to act. I told her yes because I wanted to think I had the power to get him through the night, get him through to see his son, get him through all of it.
As I got more familiar with his condition that night, I wished I had told Althea to stay.
This time around, Frank was a lot sicker. Despite any attempts to get him to respond to me, he could only open his eyes. His eyes were missing their bright, mischievous gleam. His eyelids barely opened, and his eyes would not focus on my familiar face. His hands and feet flickered when I asked him to move them. His pulses were weak. Frank looked pale, and his chest rose unevenly on the BiPap. It didn’t register at the time, but he was actively dying.
Active death is the medical term for the cluster of symptoms patients exhibit before experiencing cardiopulmonary death. A person can die by either cardiopulmonary or cerebral criteria, but in either case, the person dies. Most of us conceive death as dying by cardiopulmonary criteria, or “breathing our last.” In brain death (not to be confused with the colloquial term of “brain dead”), the heart continues to pump and lungs continue to ventilate because of machinery, but the person is physically dead. Most of us will die according to cardiopulmonary criteria standards.
Frank was exhibiting typical symptoms of active death. He was difficult to arouse. He was having longer pauses in his breathing where the BiPap machine attempted to force air into his lungs and create a haunting whooshing noise. He could not control when he peed. HIs blood pressure was dropping. The tips of his fingers and toes were becoming purple. His body was becoming more rigid and stiff.
Our new goal of care for Frank was to keep him alive enough to let his son say goodbye. His old medications were replaced with medications to help ease the work of breathing. Throughout the night, a colleague helped me balance his pain with his breathing with his function. She talked me through the dying process, telling me about her first dying patients and how hard they were for her.
Despite everything she said and everything I did, I felt guilty. I felt as if I had failed Althea, Frank, and their son who I never met. I told myself I should have done more to help him live, though I did manage to get him through the night.
I cried the whole car ride home and let out a few desperate sobs as I drifted off to sleep.
The next shift, the next night, Frank’s room had a new occupant. Ironically, that occupant was also actively dying after a similar chain of events. I always associated that room with death and personal failure, despite all my efforts to rationalize my role in Frank’s care.
I learned that Frank had passed several hours later after I left, his wife by his side, his son still en route. I felt like a failure. I bet too his son was devastated he was not able to say good-bye.
I thought Frank had a bad death.
But then I saw death again, again, and again. I saw an elderly woman whose son said good-bye and then left her alone to die in a hospital bed. I saw a middle-aged man who was ready to die but whose family was not ready to let go. I saw an elderly man, cold and in active death, whose family insisted we do the impossible and do everything to save him. I saw time and time again middle-aged children bicker over their elderly parent like they probably bickered over toys as children. I compressed on already broken ribs in CPR, trying to force life back into a dead body, while family members cried in the corner.
Frank had a good death. He was comfortable. He was cared for. He was loved. He died in peace. That is a blessing that not everyone receives. I know. I’ve been part of the pain, the agony, the suffering at the end of life, and it haunts me more than a good death like Frank’s ever has.
Death often feels like a failure, but medical treatment never promised us the proverbial fountain of youth. It never promises that we will not die. It merely promises and attempts to give us the best health possible.
Without any medical treatment, Frank would have naturally died of heart failure years earlier. Even if his son was not able to be at his side at his death, even if he never had the chance to say one final good-bye, his son was able to be with Frank for the years medical treatment helped him live. Frank’s son missed his last good-bye, yes, but he had countless good-byes before the last that never would have been possible without modern medicine.
As Americans in our current culture, as human beings, we are so used to doing things. Do this, do that, plan on doing that, have a 5-year plan, think 10 steps ahead. It’s completely natural that we are tempted to “do everything” at the end of life too.
But sometimes the greatest victory is letting go. So too, good deaths allow the body to peacefully shut down instead of violently attempting to pump life back into a lifeless body.
“And the dust returns to the earth as it once was,
and the life breath returns to God who gave it.”
Good deaths allow nature to take its prescribed course, yes. But the best deaths are those with beloved family and friends having said their good-byes, with only enough medication to make agonal breaths comfortable, with affairs settled of both earthly and spiritual matters, with a heart trusting it will meet its Beloved Maker, and a soul ready to return home.
One day, we will all have to say good-bye. When we say that good-bye is not up to us and even a majority of how we say that good-bye is not up to us. But we can decide to accept that it is time to say good-bye. Trust me when I say it is a blessing to accept death as and when it comes.