NU2ICU acknowledges the incredible skill and balance required of all staff in the care continuum to deliver effective, compassionate and respectful  End of Life Care (EoLC)

The majority of the process, however, rests with the ICU nurse(s).   Moving to ICU from general ward nursing brings a different set of challenges, in the ICU the process of EoLC usually marks a transition from acute curative to palliative care.   You may have spent the last 6 shifts working every piece of medical and nursing magic we could muster, working as hard as you could to stop this very scenario, but today you come on shift and it’s all changed – the infusions are ready to stop, the various tubes are about to come out and the family’s hope has now turned to despair

Sometimes, the patient decides for us it is time to stop, things start to fail spectacularly or stop all together.  Sometimes, the ICU team in discussion with the patients family and/or partner (and occasionally the patient themselves) decide treatment has become futile.  Intensive care is seen as the natural place for the seriously ill.  More often the challenge is to recognise whether it’s appropriate to sustain life and put quality over quantity

The more time you spend in any form of nursing the more you’ll realise that 89 year olds don’t discuss dying with their children and the children, even though they themselves are in their 60s, never expect Nan’s time to come.    Nearly every patient is described as a good 89 year old and frankly, just getting to almost 90 is good.   Rather than preparing and knowing “what Nan would want” days, and sometimes weeks, of needless time is frittered away.   This is just the reality of 21st century medicine, it is nothing new

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Occasionally, death can help others and  organs and tissue can be used to help the living, and assist research, unfortunately in most countries donation rates are still comparatively low

If you find yourself allocated to a EoLC or a possible EoLC patient, discuss your plan and process with the Team Leader, as senior nursing staff have all felt just like you do now and offer a wealth of experience in this most important aspect of your nursing care

Unfortunately, not all stakeholders deal well with death and dying and there have been serious violent incidents in ICUs across the world.   Please NEVER hesitate to report your gut feelings, any threats or to involve security to protect both yourself and everyone else present in the unit.   You always should feel safe at work

So, as the bedside ICU nurse your role remains challenging, emotional and will bring out your best.    Dealing with grief doesn’t really get easier with time or numbers just more practiced.  Follow your instincts and know sometimes there truly is nothing to say and sitting in respectful quiet is completely appropriate.   Most ICUs also offer some form of pastoral care, where trained counselors or religious representatives will come and sit with relatives, not to preach rather  to listen and support

Knowing the religion of your patient will help you in appropriate care, for example for those of the Jewish faith from the moment of death until burial, the deceased may not be left alone.   Therefore, the family must arrange for a person called a shomer (watcher) to be at his side at all times.   Jehovah’s Witness tradition does not teach that those who die experience an immediate afterlife so it would be inappropriate to say to the family of a deceased patient anything like, “He’s in a better place now.”   Muslim practices state after a death, the family may request to wash the patient and to position his/her bed to face Mecca and the patient’s head should always rest on a pillow.  You can see it can be very easy to offend if you’re not properly prepared

Whatever interaction takes place in your bay make sure you listen carefully, this is truly when you will learn to craft your nursing care of the dying and their loved ones

After a while, you learn what to say, you’ll tell a family who’s withdrawing care that they’re doing the right thing by observing what they knew the patient wanted.   By telling a father whose praying for a miracle what another patients relative once told you  that  “Maybe it was a miracle that we had him for as long as we did.”   You may tell a daughter who’s about to watch her father exit the world that we should all be so lucky as to die in the arms of our loved ones.  Talking about death becomes more intuitive over time

The debrief is the recognised tool for addressing concerns regarding any process – whether identifying what went well and celebrating success or what went badly and planning for next time, debriefing in large groups or 1 on 1 gives opportunity to ask why things happened and its there is a better way even if it went well. 

Before you go home its good practice to ask for a debrief,  your T/L may discuss with the ICU consultant and even decide that the entire team would benefit from discussing what happened today.  Honesty is the rule at debriefs, nothing should be personal just a blameless discussion of process and events

When you finally leave your long shift that day feeling sad and exhausted, you will also leave with a greater sense of peace.   Some days at work you don’t get to help people live longer , but you do get to help them die better

Like has been said here before – remember to always look after yourself

Have a look, and get your entire patient care team to as well, at theconversationproject” for great ideas about how to start the discussion about truly beneficial EoLC and treatment limitations before we are forced into it!


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