I’m going to be very blunt and just say it: you will come across the body of a dead patient at some point during your training. I have noticed that people find my blog everyday by searching for information on the death of a patient, and what to do as a student nurse.
It can happen in all sorts of ways – you can start your shift and just hear that a patient has died, you can be there while they die over a time period, they can die all of a sudden from a cardiac arrest, you can discover a dead patient in their home or you can discover that they are dead when you approach them on the ward.
More than likely you will be asked to take part in a procedure called last offices. This mainly involves stripping the body of all tubes and lines, jewellery, plasters etc, washing the body and wrapping them up ready for the morgue. It can be a rewarding experience and a very nice thing to do if you wish to gently pay your last respects to a patient, whether you cared for them or not.
My tip here is to try to get involved as early as possible. Experience is the only way you will get accustomed to dealing with dead bodies however frightened you may be. There are students who are at the same stage as me (about to begin 3rd year) who have not yet had a patient die during duty or have been too afraid to perform last offices. There is nothing wrong with being afraid - a fear of the unknown is understandable. The best way to deal with this is by throwing yourself into it and just saying ‘yes’ when you are asked to do this. However you should also make sure that you work with someone you know and trust, who will respect the body of the patient, and who will accept that you may not feel like you can continue with last offices. A good nurse/HCA who asks you to help them perform last offices will explain the procedure to you and let you know that you can stop if you need to.
If you have any questions about this please don’t hesitate to ask me! For now, good luck with your first experience
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I was discussing nursing with my boyfriend Kov a few days ago (something we often do – he questions me a lot about healthcare and seems to find it very interesting) and he said something that really made me think: “You can’t save everyone.”
It reminded me of the time I trained on an Intensive Care Unit (ICU) and witnessed death in a very different way. I had seen and heard about patients dying on other wards after being very ill for some time. But on ICU it wasn’t like that – people were being brought in from A&E with severe illness and were at high risk of dying.
During my first week there I witnessed a consultant tell a woman in her seventies that her son was going to die that day.
I had been caring for her son who was in his fifties and very unwell, under sedation, ventilated and not improving at all. His only other family was his younger brother. I was collecting a blood sample from him earlier that day as his family arrived, and I stayed with them for a little while just to chat to them and see what they were thinking and feeling. They told me that they were expecting the worst, and that a consultant had already explained that he may not pull through. They seemed to accept this, and eventually left to go and get some lunch.
While they were gone, the patients consultant found me writing at the patients bed side and told me that the decision was made – they were going to have to let the patient die. He needed to tell the patients family.
I couldn’t believe my eyes when I saw the consultants behavior for the next thirty minutes – he was extremely nervous. I found him leaning against a wall away from the bed areas, thinking about how to break the news and looking very sad. I approached him and asked if he was okay – he told me that even after years of working in healthcare he had never hardened up to breaking bad news like this to patients families. He was upset and the fact that it was the patients mother he was breaking the news to made the situation even worse.
I told the consultant that I had already met the family and that they were expecting the news, which brought him some relief.
When the patients family came back, they were escorted into a private room with the consultant, myself and the nurse I was working with that day. There I witnessed the consultant break the news. It was heartbreaking – the mother cried and found it difficult to speak, and her other son was comforting her. It was clear he was trying to be the stronger one through this. They accepted the news and returned to the bedside. The patient was taken off the ventilator and all invasive treatment was stopped immediately. He died later that day.
I found this particularly upsetting as the man was around the same age as my Dad, and the mother around the same age as my Grandma. They even looked similar to my Dad and Grandma. I heard the nurses saying that no parent should outlive their son, and I couldn’t help thinking about how the mother was there when her son was born and there when he died.
It has come to my attention that a majority of people who stumble upon my blog are searching for information on what it’s like to experience the death of a patient, or how to deal with a dying patient.
So after much publicity on Twitter (and perhaps other forms of media) I wanted to post a link to the campaign website Dying Matters.
The website aims to raise awareness on the issue of dying by featuring valuable information on the subject.
Although the website is aimed at the public and people who are affected by the subject of dying, I feel that it is useful for student and registered nurses to learn about dying from the public perspective.
It can be a difficult experience to talk to a patient about dying. You have to find the right moment and time, and be able to determine if a patient does not actually want to talk about it, no matter how much you think they would benefit from it. This isn’t always easy to accept, and sometimes it can be a waiting game.
I recently looked after a patient with cancer who I had bonded well with, and during my first night shift she decided she would like to talk. It was 3am, pitch black on the ward and the other patients were asleep, but for the patient it was the perfect time to talk as she could not sleep. She sat in her bed under the sheets while I sat on her bedside chair under a blanket, and we talked (whispered) in the dark until she felt she could fall asleep. I did not know she was dying until the next day (none of the staff had told me!), and her feelings suddenly made more sense. Luckily, I did not saying anything or comfort her in a way that suggested that she was not dying, and she felt content after we had talked. The patient thought I knew she was dying. I feel very privileged that she had chosen to talk to me, and proud that I was able to offer her comfort even when I did not know she was fearing her demise.
Please click here to take a look at the website and good luck in your training!
So as you may have guessed, there is a bad side of nursing.
The topic of death may be a depressing one, but I feel it is something that all student nurses must think, talk and learn about. Nothing will ever prepare you for that first patient death – it is something that everybody reacts differently to and deals with in their own way, but it can help to know a little about what to expect and how hospital wards manage death. Of course, some of you may have already experienced a death before becoming a student nurse and know exactly how it works already.
This is quite a long post, but I have included things I feel were very important with my experience.
My experience happened during my first ever placement – I think it was during my 2nd or 3rd week. I was not with the patient when he died, but I was given the opportunity to take part in the giving of last offices for this patient. If you are afraid of dead bodies, it is a good idea to combat this fear by taking part in or at least observing last offices with another nurse or healthcare worker. I myself had seen a dead body before and do not have a fear of them. It can be a valuable learning experience, a privilege and sometimes a way of bringing comfort if one is grieving over the patient’s death.
My first placement was on an acute stroke ward and it was a very heavy placement to say the least. I was definitely ‘thrown in the deep end’ as they say. It is an experience I never forget. The patient (whose real name I will not identify – I will rename the patient as Tom) was an elderly gentleman and was on the care of the dying pathway. He had suffered many ordeals during his last few weeks – several cancers had spread around his body and he needed help with all activities of daily living.
I grew quite fond of Tom – I felt that I had built quite a bond with him and I enjoyed attending to his needs. He rarely had any visitors as his family lived abroad. Being a student nurse, I found that I had a little more time than the registered nurses, which of course is understandable. I used most of this time to assist Tom with eating meals and drinking fluids, ensuring that he was comfortable and settled, and sometimes just holding his hand. Tom told me some things about himself. His wife had passed away some time before he died, and I felt honoured that he could tell me that he wished to die and be with her. He missed her everyday and she sounded like a caring woman who loved nothing more than looking after Tom. Tom was always happy to let me assist in his hygiene needs – it was always a pleasure to perform bed baths, shaving and toileting needs for him as he was very compliant, well-mannered and grateful for any help.
His last days:
In the last few days of Tom’s life, he had become increasingly agitated, distressed and angry. One of my worst memories was when a consultant wanted to send Tom for an abdominal ultrasound scan (USS) during his last few days to see if any more tumours had appeared. Tom was in pain and wanted to be left alone. Myself and the nursing staff were so angry – we found it pointless at that stage and could feel his frustration. We tried to change the consultants mind. Even so, the USS went on and I was chosen to escort Tom down to the USS department. Just me. No other staff from the ward. I was terrified – convinced that Tom would have a stress-induced cardiac arrest on the way. All the the way there, Tom lay shaking his head, desperately trying to express that he did not want to leave the ward and wanted to be left alone. At this stage he could no longer open his eyes or speak. I was absolutely heartbroken and very angry. I did not feel like I had the power to stop this from happening as a student nurse and could only do my best to be supportive to Tom despite what we were putting him through. When the porter left me and Tom in the waiting area, all I could do was stand beside him and hold his hand as he shook his head.
The death:
A few days after Tom’s scan, I began an early shift at 7am. When handover had finished, I went onto the ward to begin my duties. The curtains were drawn around Tom’s bed, so I went over to see him. He was dead.
The nursing staff had been with him as he died during handover, and when he did, they lay him flat, tidied his bed area and drew the curtains. They had folded a pillow in half and placed it under his chin to push his jaw up, so that his mouth would stay closed as rigor mortis set in.
I felt very numb – I did not ask any of the staff any questions as I was very unsure about what I had seen. I continued with my duties.
Ten minutes later a healthcare assistant (HA) came over to me and asked, “Sarah, one of the nurses has asked me to ask if you’d like to take part in the last offices for our Tom. You don’t have to.”
I told her that I would not mind and would like to as it was something that I knew I wanted to do for Tom when he died. She told me that Tom died peacefully and that we were able to begin last offices very soon as no family were coming to see his body.
Last Offices: Now this is the unpleasant part, and was nothing like what university had taught me (months later) using dummies in the clinical room.
The HA was however very lovely and made the experience very easy and dignified. She gave me some information before we started: 1. That it was ok for for me to want to stop and leave at any time throughout
2. That I can observe instead if I wanted to
3. That sometimes when you roll a dead body over, they can make groaning noises as gas escapes
The last one frightened me a little.
The HA began by opening the window – many people believe that when people die, opening the window allows their released soul to escape. This is not a religious belief but rather a spiritual one.
We removed the pillow from his chin, which had successfully kept Tom’s mouth closed. I had to close his eyes a few times as they sometimes opened (this is possible after death as the muscles relax and the eyeballs shrink). I then removed his urinary catheter and disposed of it. We washed the front of Tom’s body with warm soapy water, cleaned his face and combed his hair, and dried him with a towel.
There was a moment where the HA needed to leave the bed area to go and get more towels. Being alone with a dead body was a strange experience and I found myself staring at his face and fingers to look for any movement. His hands felt very cold already, but his flesh did not feel that different compared to a living person. He looked very peaceful.
When the HA returned we began turning Tom onto his side so that I could wash his back. As we rolled him over, dark green bile poured out of Tom’s mouth and onto the bed sheets below him. This alarmed me and I began to panic. The HA quickly calmed me down and explained that was also normal and that it was just bile from his digestive system. Although we were trying our best to perform last offices in a dignified manner, the HA decided that it would be wise for us to place some tissue into Tom’s mouth to prevent any more bile from coming out as I quickly washed his back. His entire back was already blackening.
Once Tom was washed, dried and presentable, we placed his patient details on his chest and dressed him in a white gown to prepare him for the morgue. Before we covered his face, we said goodnight to Tom. This upset me a little. We then wrapped him with a bed sheet, like a mummy, and waited for the porters to come and collect his body.
The nurse I was working with that day asked me later on if I was ok and offered me the opportunity to talk about the death or ask any questions. I felt fine and could not think of any questions. When I finished my shift and went home, I told my mother and cried. Although Tom died at an old age and in peace I still felt very sad, particularly because no family were present.
This isn’t a very pleasant post, but a lot of student nurses talk about how a cardiac arrest experience is something they don’t look forward to (although some do want to witness one as they want to take part in the whole excitement of CPR).
My Intensive Care Unit post got quite a few views so I’m hoping this one is as interesting.
I’m over halfway through my nurse training now, and am currently training on an emergency surgery ward. On my first day on a Monday, my mentor asked me “Have you seen a cardiac arrest yet Sarah?”
I told her I hadn’t. She replied “Really? Well I’m warning you; I always seem to get them with my patients – you’re very likely to see one working with me”.
Four days later on the Friday it happened.
A had been caring for a very ill lady on the Thursday night – she had COPD (Chronic Obstructive Pulmonary Disease) and needed to wear a nasal cannula to deliver her oxygen. Unfortunately due to illness, she was very confused and agitated and was refusing to wear her oxygen. Her saturation levels had dropped to around 70%.
She was in severe pain and felt very unwell but refused all offers of treatment. With her daughter, I spent much time trying to persuade her to accept oxygen therapy and pain relief.
She eventually got very annoyed with me and my voice (which I’m not surprised about to be honest – it can’t be nice having some 23yr old kid staring at you and repeating things you don’t understand) and told me to shut up. With this, and the risk of causing her more agitation, I left her with her daughter and the night nurse and finished my shift at 8.30pm.
I was back on shift the next day (Friday) for 7.30am. My mentor and I decided that we would care for the same patients again – including the ill lady from the night before, for the sake of continuity. The night nurse gave us our handover and told us that the ill patient had been very difficult to look after – kicking, biting, yelling and continuing to refuse all care and treatment. Me and my mentor didn’t like the sound of it, but planned to do our best with her.
We left handover at 8am – a different patient was screaming in pain and needed a certain drug, so I decided to go to the ward opposite and ask if they had this drug in stock. I returned to my ward to see the crash team and my mentor gathered around the ill patient, about to start CPR on her. Someone had gone in to the bed area to wake the patient up for breakfast and realised that she was unresponsive.
This is an excellent and dramatic video demonstrating successful CPR – definitely worth watching:
It was quite chaotic. The curtains couldn’t be fully drawn because the crash trolley was in the way, so the patient opposite could see some of what was going on. There wasn’t enough room for everyone and a lot of patients were in earshot of what we were saying and doing. I was the only person available to run in and out of the clinical room to get syringes and flushes and any other pieces of equipment needed. The crash team kept going with the CPR for what felt like almost 10mins, whilst checking her blood sugars and giving her adrenaline. I couldn’t really take in everything that was going on, but sensed that this was not going to save her.
CPR looks a little brutal – her ribs were being forced down so deep it made me hold my breath, and the mayhem was quite overwhelming.
The crash team eventually stopped and declared the patient dead.
Before really having any time to think, her husband and daughter were on their way after a couple of phone calls. I helped the healthcare assistant with stripping the patients body of any cannula’s and plasters, wiping away any blood and tidying the bed area. I felt quite numb to what had just happened and was more concerned about how her husband and daughter were going to react. Later that day I joined my mentor in carrying out last offices for the patient.
Unfortunately, with this being my first experience of a cardiac arrest, I don’t feel like I learned as much as I would have liked to. Perhaps giving myself the opportunity to take part in CPR would have made this a more valuable learning experience, but at the time, taking part felt like something I didn’t have the knowledge, skills or even initiative to do. It was a very sad experience, but I suppose now I can understand how very quickly a person can deteriorate, how people deal with the news of a death, and why the debate of patient restraint comes about so often.
So I’ve just finished a 5 week placement on the Intensive Care Unit (ICU) at a hospital in Manchester, and am currently enjoying a week off. I have done a lot of sleeping. It feels like I’d been on ICU a lot longer than 5 weeks, because the amount I learned was unbelievable.
I am currently studying the Acute Care in Adult Nursing unit at university, so ICU was a perfect fit for that unit. Acute care can be considered as an urgent event in healthcare, whether that means a person being in sudden pain from an injury, or a person choking on a bit of potato.
On ICU it can be things such as a patient’s O2 saturation levels suddenly dropping from 99% to 80%, or a patient going into urinary retention and not being able to eliminate toxins and waste.
The action taken in these situations is the ‘acute care’ given, such as sticking an oxygen mask on someone and giving them 15lites of O2 a minute, or inserting a urinary catheter.
ICU consisted of an awful lot of Intravenous medicine, bed bound patients, urinary catheters, blood samples, chest physio, machinery, ventilators, tracheostomies, suction catheters and death.
It looks a little like this, only the machinery is far bigger:
Above: I could not find the artist of the above image so I don’t wish to take any credit for it – I just really like it.
A typical day on ICU – a whole day of new learning experiences:
At this particular ICU, an early shift would start at 7.30am and finish at 2.45pm. A 7hr shift with a 15min break (I much preferred early shifts as more care was given than on a late shift). You look after 1 patient per shift.
If you want to learn how to prepare IV medicine then ICU is the place for you. Just as I’d finished preparing IV drugs for 9am (aseptic technique, syringes, needles, calculations, potions and all) it would be time for hygiene care to be given. Teeth brushed, Chlorhexidine mouthwash begrudgingly given (it tastes AWFUL), full bed bath and moisturiser massaged into wherever needed moisturising. Sometimes a patient would be hoisted into a chair (if they were conscious) to help them regain muscle strength. Fluid levels, blood gases and paperwork would then be completed.
By the time this was all done, it would be time for afternoon medication. Back to the clinical room! Once the afternoon drugs were completed, any other tasks to be done that day would be completed – this could be surgery, replacement of lines, inserting a tracheostomy etc.
Most patients on ICU have a Central Venous Line inserted for the majority of their drug administration. This is a catheter that is inserted into a large vein in the neck, such as the internal jugular vein:
Above: A patient with a triple-lumen CVL inserted for antibiotic drug use. Image taken from http://bit.ly/gvmQOj
Makes it much easier with CVPL’s as large veins can take the pressure of a lot of drugs being administered several times a day.
There is no doubt that ICU was one of my most difficult placements because of how much I had to learn about the ventilation system – I will not even start going into it. The majority of patients are also admitted under sedation and can be sedated for days – this makes the work heavier and more time-consuming as you are moving a patient’s full weight when they are unable to move. Plus there are a huge amount of wires and tubes going in and out of the patient – a patient can have 3 syringe drivers on at the same time, plus 3 or 4 suspended drips, an NG and NJ tube (you can google the difference), a urinary catheter and sometimes a drain from a wound or an infected bodily organ.
The clinical technology used can be intimidating. Blood pressure cuffs are not used on ICU – arterial lines are used instead to get a constant record of the patient’s blood pressure (check this out http://bit.ly/fy5XWJ). It can also be used to get blood samples so the patient’s blood gases (blood ph levels, CO2 levels, sodium, potassium, glucose etc) can be checked at regularly intervals.
Death was definitely something to get used to on ICU – my first patient died on my 2nd shift. 1 or 2 patients died a week during my time there, some of them not that old and some of them leaving behind people who then had no one to care for them.
Luckily for me, the staff at this ICU were more than amazing. Everyone was very keen to teach me and I was made to feel very involved in patient care. I was given many opportunities to do anything that I was able to as a student nurse, which gave me the confidence to use more of my intuition. Shame that ICU also meant that I was completely knackered most of the time.
If you get a chance to train on ICU, make sure you get stuck in and do everything you are able to do (obviously, administering IV medication is a no-no, as is deciding to mess around with sedation and morphine levels without being told to). You will leave realising that you knew less than you thought beforehand. Unless you’re a registered nurse of course.
ICU could end up being my elective placement in 3rd year
