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Crit Care Nurse 2002 Feb; 22(1): 11-12
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Guest Editorial

Lessons for Critical Care Nurses on Caring for the Dying

Zara R. Brenner, RN, MS, CS

Zara R. Brenner is an assistant professor at State University of New York at Brockport and a clinical nurse specialist and clinical leader in care management at ViaHealth, Rochester General Hospital, Rochester, NY.

To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.

Members of the general public think that patients who die in an intensive care unit die in a flurry of code blue situations. Critical care nurses know better. Approximately 40% of patients in an intensive care unit die after care is withdrawn.1 Recently, I was given a new assignment, and it has turned out to be a wonderful opportunity! In my role as clinical nurse specialist/care manager, I added the patients and staff in a combined palliative care and hospice unit to my responsibilities. This new assignment has been the perfect addition to my experience in critical care nursing. Working with experts in the care of the dying has enabled me to increase my knowledge and skills. I would like to share some of what I have learned.

{blacksquare} Death is an acceptable outcome if the patient and the patient’s family are able to cope effectively with the event. In the critical care unit, staff frequently view deaths as "negative events." Deaths are interpreted as failures, and people don’t take pride in what they could not accomplish. In the hospice/palliative care unit, success is defined by the quality of the process, not by the outcome. Successes happen often, as patients come to accept death with peace and without fear. Successes happen repeatedly, as families are able to accept death by mourning their loss while valuing the comfort that they and the staff provided during the dying process.
{blacksquare} The most needed skills in caring for dying patients are listening and talking. Many critical care professionals are skilled at listening and talking about treatment options. In an American Association of Critical-Care Nurses Online Quick poll, 88% of the respondents reported that they are "comfortable talking with patients and families about advance directives."2 But talking about advance directives is not the same as caring for the dying. In the journey toward death, patients need to relieve their anger; they need to talk about their fear of dying, their unfinished relationships, and their family’s future without them. Nurses must give patients opportunity and active encouragement to talk these things out. As I spoke with a critical care nurse manager about my new experiences, she said, "I have lots of nurses who can do the technical things but not enough who can do nothing but be there." A skilled nurse is a component essential to the success of the death in the critical care unit.
{blacksquare} The needs of a patient’s family are just as important as the needs of the patient. Sometimes we can do even more for family members than we can for the patient. A patient can be admitted for "palliative care" so that nurses can work with the patient’s family to accept that death is coming. To become a "hospice" patient, the patient and the patient’s family must develop a concrete plan to deal with the process of dying. The plan is an acknowledgment of where the patient is going and a general time frame for that journey. Sometimes developing the plan is harder for the family than for the patient.
{blacksquare} Machines that support breathing are properly termed "ventilators," not "life support." Patients who are ventilator-dependent do not necessarily die within minutes or hours after mechanical ventilation is discontinued. One patient "hung around" the intensive care unit for 24 hours after mechanical ventilation was discontinued and was then transferred to palliative care. After 2 days, her lungs "woke up," her respiratory effort and oxygen saturation approached normal, her brain "woke up" and she went home. Several patients have not died until days after discontinuation of mechanical ventilation.
{blacksquare} Interdisciplinary is different than multidisciplinary. During interdisciplinary rounds, a hallmark of hospice care, representatives of many disciplines are present, but more is involved than just presence. Every one is equal; no one discipline sits atop the hierarchy. We do not use titles, no Nurse A, Dr B, or Social Worker C. Everyone is called by his or her first name, except for members of the Chaplain’s staff as appropriate. The input of all participants is sought. There is no set order. All professionals contribute to interdisciplinary rounds in the order of the priority of the patient’s needs and the needs of the patient’s family.

As I have learned much, I have also found more questions to ask. As an educator, I wonder how many critical care education programs, academic or hospital based, include the recommendations of the American Association of Colleges of Nursing? Their Competencies Necessary for Nurses to Provide High-Quality Care to Patients and Families During the Transition at the End of Life includes "promoting the provision of comfort care to the dying as an active, desirable, and important skill, and an integral component of nursing care"3 (see TableGo).


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  		American Association of Colleges of Nursing: Competencies Necessary for Nurses to Provide High-Quality Care to Patients and Families During the Transition at the End of Life

 
In how many units do nurses learn the skill of caring for dying patients and the patients’ families only through the trial and error of experience? A study by Kirchoff et al4 indicates that even though many barriers are present, experienced critical care nurses can describe and implement good end-of-life care. The nurses on my palliative care/hospice unit are all experienced nurses. Are there other ways for nurses to gain skills in the care of the dying besides gaining years of experience? How do we teach the skill of "just being there?" As a critical care educator told me, "I think every nurse should spend some time on a palliative care unit. I really feel you can care much better for the living once you have spent quality time with the dying and their loved ones." What can I do to make end-of-life care better?

Acknowledgments

I thank the staff of the Jennifer S. Hildebrant Hospice and Palliative Care Center of The Genesee Hospital and the Greater Rochester Homecare Association.

References

  1. Chapple HS. Changing the game in the intensive care unit: letting nature take its course. Crit Care Nurse. June 1999;19:25–34.[Medline]
  2. AACN online quick poll. AACN News. May 2000;17:3.
  3. American Association of Colleges of Nursing. Peaceful death: recommended competencies and curricular guidelines for end-of-life nursing care. Available at: http://www.aacn.nche.edu. Accessed November 23, 2001.
  4. Kirchoff KT, Spuhler V, Walker L, Hutton A, Cole V, Clemmer T. Intensive care nurses’ experiences with end-of-life care. Am J Crit Care. 2000;9:36–42.




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