Saturday, 13 March 2010

My First - Death

I am back on placement, my final placement. After this I qualify and become a real nurse. The strange thing is I have spent the last two and a half years rocking every placement, walking around MY hospital with a confidence I have never really felt before(and in most of the situations i've been in over the last three years an outward confidence I didnt really feel). I have been dying to qualify, raring to go. Now I am nearly there I am petrified. I think it was Socrates who suggested something along the lines of - the more you learn the more you come to realise you know nothing.

Now I'm nearing the end of what has been a strange combination of the longest and shortest three years of my life I cant help but look back at the defining moments of my training. In this case the first patient who died under my care. This happened in my first year on my first placement, an elective orthopaedic ward. The patient was only on the ward due to lack of beds on the trauma orthopaedic ward. He had come in following an RTC, he had been stablised in A&E and went into surgery to repair numberous fractures and ruptured vessels. When they had finished with him he was transfered to my ward and remained unstable, his blood pressure constantly dropping, pulse rising and dropping with an irregular rhythm and the patient hadnt been conscious since A&E and a DNR order was signed by his NOK with his permission on presentation to A&E. I was working the night shift about a month into the placement, one of the other nurses had checked on him twenty minutes previously. I went in to check on him largely because there was nothing else to do. He was dead, my first dead patient. He looked just the same, I'd heard all these stories about how people change in death but I had to check for a pulse and watch for breathing to make sure. I walked out of the room and told the nurse. She knew he was taking his last breaths when she'd been in earlier, she just shrugged it off. Then it hit me, the shame that all I was thinking about was how hard his death was for me, the anger at her indifference to the fact someone had just died less than ten feet from where we stood(which I now understand is a defence mechanism and one that I use myself).

Two years on I've worked in A&E, I've worked on many acute medical wards and I have had many patients die under my care. The only way you can survive the reality of acute nursing is to distance yourself from the deaths, and make sure you did everything you could so you know there was nothing more you could have done and their death wasnt your fault.


Vincent said...

Thanks for satisfying a curiosity about how death happens these days. Our culture these days offers few images of this important event, this milestone towards which we all converge; except for violent images, inevitably portrayed as the most undesirable outcome and the result of evil or failure: murders, suicide bombings, civilian casualties in war, death by AIDS, starvation and so on.

None of these mental images reaches an acknowledgement that we will all go, and no one is exempt. Nature is not mocked by death.

So you are the ideal person to send dispatches from the front, to recount how death happens.

I've never seen anyone die, and the only dead body I've seen in the flesh, in nearly 70 years, was a waterlogged corpse floating down the Seine beside the Cathedral of Notre Dame, back in 1962.

So your account is fascinating, especially as it clinically records details of the individual threats to one patient's life, with a sense that perhaps any one threat could be fought successfully but when they accumulate, these threats gain the upper hand and it's pointless to resist them any longer.

In my mind, I've already written and signed my own DNR. Perhaps insultingly to your profession, I've constructed a fantasy death in which I refuse all interventions, pin on my Nil-By-Mouth badge & drag my weary bones to a spot under a spreading chestnut tree on the side of a hill, from which vantage-point I can say goodbye and slip away at some point over the long hours . . .

Which may indicate a hospital-phobia. Where does that come from? I was in hospital when I was 7, as described in a blog post.

Please write more about deaths in hospital. My phobia might thereby be cured---or more deeply entrenched!

Asclepius said...

Most hospital deaths are expected, not even as a result of trauma. As medicine advances the average age of our population increases. Eventually the body simply wears out. I have had patients who have not seen a doctor at all during their lives, now at 102/98/91 their bodies are just exhausted, in my experience its usually the kidneys that go first, followed the heart slowing down and then the lungs start to fail, but most patients are not aware of any of this we have (over many years of trial and error) developed a system for making the passage into death as comfortable as possible. The gold standard is the Liverpool Care Pathway which is a system of paperwork that forces the nurse to assess many elements of a patients condition every 12 hours. Most if not all patients in this situation have a syringe driver set up, this is a device with a small motor in which we place a syringe of morphine and an anti-emetic(anti-sickness) and allows the release of these drugs slowly over a 24 hour period so there is a constant release. The doses of these are evaluated as part of the paperwork.

I myself have an advanced directive set up. I think most healthcare professionals do. I have stipulated that if there is any question as to weather I have been in arrest without CPR for more than four minutes than do not attempt resuscitation. If CPR was started immediately I only want three rounds of CPR performed when I get to hospital(where the good toys are). I have also stated an immediate DNR if I am diagnosed with any condition that alters my mental state. My intellect is more or less all I have, I can handle having a failing body but not a failing mind.