Laura made me do it

I wasn’t going to post and, in fact, have resisted posting even though my little sister has been nagging me to put something up. So, this one’s for you, Laura. =)

It’s an interesting thing, watching someone die. As a new nurse, I’ve had the opportunity to stand by at least half-a-dozen people as they took their last breath and left my shift knowing that others wouldn’t be alive when I returned to work the following day. I don’t think nursing school does, or can, prepare one to handle the dying. We talk about healing, caring and comforting but there is something very strange, surreal, sacred and odd about being in a room with a person who is about to die or has just died.

I’m not sure why we don’t talk about it very much. Sometimes I wonder if it’s just our aversion to admitting that we are all dying, if it’s our unspoken fear of our own death. I wonder if it’s just that we like to think of death as very spiritual when in fact it is very uncomfortably physical. Death can be awkward, painful, unpleasant, gross even. Does it sound immature to say that death can be gross or disgusting? It can be, I think.

Recently I had a patient on a ventilator (a breathing machine) that died. She was DNR, so there was no intervention for her, we just waited as she died, tending her as best we could – changing her position so she didn’t develop pressure sores, cleaning her mouth and speaking with her while we cared for her. The odd thing about this poor woman was that the machine was breathing for her, so it was difficult to tell if she was really dead. The telemetry, which monitors her heart rate, was signaling a wide variety of pulses (from 30 to 120 beats of her heart a minute) something she had been doing for hours so when her heart went into pulseless electrical activity (PEA) we were unable to tell she had no pulse without checking her pulse at her radial (wrist) or other location.

If you’ve never been on a hospital unit working, then maybe you’ve been a patient and wondered what all the nurses are doing when they aren’t in your room. Well, we’re generally in other people’s rooms or doing tons of paper and computer work. So occasionally we would glance at the telemetry machine and note that her pulse was varying widely, that her oxygen saturation (the amount of oxygen in her blood) was good and of course, because of the breathing machine she was still breathing. As a new nurse I wasn’t really sharp enough to put everything together – but I assumed that her oxygen saturation would drop noticeably when her heart failed to push the blood through her lungs and this would be my indication of her death.

Well, it wasn’t so. Eventually I went into the room to check up on her and noticed she was the color of wax, a dead person’s color. She was breathing because of the machine but she was cold (and had been cold and mottled for most of the day as death approached) but I couldn’t get a radial pulse. I then checked her pulse at her carotid (her neck) and couldn’t find one there. It dawned me then that her heart was either quivering ineffectively or the breathing machine that was making her lungs work was stimulating her chest just enough to convince the heart monitor that her heart was still working.

It takes two RNs to confirm death so I checked a few other ways – corneal reflex, noxious stimuli, and blood pressure. None of which was successful. Oh, and I listened to her apical pulse (using a stethoscope to listen to her chest for a heart beat). Everything was negative. Since the respiratory people were present, I had them remove her from the breathing machine to determine if she would breath on her own. She did not.

The next thing I had to do was get another RN to verify my patient’s death so I could call the doctor and inform him and get clearance to call the family and send her downstairs to the morgue. I was surprised to see how unfamiliar my peers where with handling death. I don’t know if age is a factor – at 41 I’m a pretty old “new nurse” and many of my peers on the night shift are in their early to mid-twenties. I eventually had my charge nurse, a woman with many years under her belt confirm death with me, but it was odd to watch how these younger nurses, people in general and myself handle the dying and recently dead.

There is an odd fascination with the person lying there. They are vulnerable but you have to do things with them – things like bagging them up – wrapping them in the “death shroud. ” You have to clean them up and remove their lines and tubes (if they are not going for an autopsy). I don’t know if you’ve handled a dead person, but it is a singular experience, to say the least.

Some people get giggly, which annoys me, others get callous and others, like me, turn inward and get very quiet and “reverent” I guess. I don’t mean to make it sound holy, because it isn’t, but I think all three strategies are doing the same thing – helping us cope with the fact that there is a corpse in the room that used to be a person and we have to interact with that corpse.

Think about it. How exactly do you go about doing something like that? Especially a corpse that may not look very good (if the person was very sick) or leaking various fluids from various places, how would you handle this? We all have our ways and none of us learned them from school. It is an odd thing.

It is an odd thing to be a nurse and be exposed to this in a far more intimate way that most people.

I do appreciate the opportunity to take care of a recently dead person, especially if it’s one of the patients that I know fairly well or is one of “my” patients. I feel like it’s my opportunity to tie up loose ends and make sure the care is the best I can give up to the very last thing. I prefer to take them to the morgue myself, but often I cannot do this as I have other patients to tend to. I find this unfortunate.

There is also this aspect of being in a very odd place at a very odd time for me when I’m in a recently dead person’s room. I like being in there and tiding up before the rest of the crew arrives to help me manage the corpse. I like getting rid of supplies, straightening up the room and organizing things. I like it because I feel odd being there and I want to prove to myself that it’s ok to be there and give this care even though I would really rather be anywhere else. It is where I’m needed right then.

Actually, this reminds me of something else I experienced just last night. I had a patient (not dying yet – any more than the rest of us) who was, for me, a very difficult patient. I found that I did not like him. He was annoying to me, he was smelly, he was unmotivated and he was needy and had medical problems for which I could do nothing while I had plenty of other patients for whom I could actually do things for.

I am aware that wanting to help patients for whom I can feel effective and avoiding those that don’t’ allow me to feel effective is completely ego-based. Both types of patients need care and both want, generally, their nurse at their bedside the entire night. This guy, however, was just irritating me left and right.

So, at some point last night, after reading his extensive medical history, I went into his room and sat down on his bed (he was sitting in the chair) and let him talk to me about his depression, his hopelessness, his bizarre anxieties and his mistaken ideas until I could let go of myself and let myself develop an empathy for him. It reminds me, now, of how I feel when I’m in the room with a recently dead person. I don’t really want to be there, but I want to step outside myself and be present for that patient, even if they are dead or even if I don’t particularly like them.

I mentioned this to someone last night when they asked me why I was hanging out in “that guy’s room for the past hour” (no one else like the dude either) and I said “because I didn’t like him, I wanted to sit with him.” They said “You’re so nice!” They lauded me with a few other undeserved complements also.

Those who don’t know me very well might assume I’m preaching here or displaying how kind I am. This is not what I’m trying to do. What I’m trying to explain is that I am aware of my bias and ego-based perspective and trying, very hard, to get around that and experience the awaked heart of Bodhicitta. It was not me being nice at all. It was me recognizing my small-mindedness and having just enough mindfulness to look at it for what it was. I suppose that is what practice is all about.

I can’t say that I liked him after that, but I was able to have a far more “middle of the road” attitude about him. I’m glad for that.

This recalls, for me, a meditation that Robert Thurman performed in his book (I have the audio version) The Jewel Tree of Tibet in which he talks about visualizing three groups of people standing in front of you – to the left people you definitely don’t like, perhaps even hate (I don’t’ think he used that word), people in the middle whom you don’t care much for or against and people on the right for whom you have utter love and caring for. He then goes on to suggest we notice that some people that were in the middle at one point are now in one of the other groups, perhaps we love that person now or really dislike that person. The same is true for those we loved or disliked. We can then, through this meditation, realize that our feelings for people are quiet arbitrary and based not in qualities of the persons themselves, but rather based on our moment-by-moment perceptions of these people. Realizing this, I suppose we can learn to let go of our biased perceptions and treat all people with equal compassion and caring.

Well, there’s my blog post. Hope you’re happy, Laura. =)