As a nurse that has been there for too many patient’s deaths, it is very difficult. It is a responsibility that every nurse I know takes very seriously. It is our goal to make our patients passing as gentle as possible and to assist the patient’s family in any manner we can.
I have previously written about patient death of an actively infected COVID patient, they die with only medical staff in attendance. That has not changed. This is for COVID patients that are no longer actively infected. There are some individuals that believe once the infectious phase of the disease has passed, the patient is cured—I sincerely wish that was true but it is not. We have gotten better at getting our patients through the infectious stage but the aftermath is still causing deaths. With new variants popping up and all the other nonsense, sometimes it just seems so..so..well…bleak. I fight like hades everyday to keep the bleak at bay.
The patient’s physician issues orders to end life support. The physician is usually present but most often the RN carries orders out. The duties and responsibilities to the patient and their families during comfort care are much the same—how they are carried out them out may differ. These words are based on my own personal experiences with both active and post-infection COVID patients, including those on ECMO.
Before any process is started, the family is asked if there are any questions. Some families are so numb with grief they are totally silent, some have so many questions. Some just was some reassurance that they are doing the right thing. It is easier when the physician is present because the family will address their questions to the person with the most authority, but not always. I never refer to my patient as the ‘patient’, I use their last name and title—Mr. Mrs. Miss. I didn’t learn that in nursing school but from my Grandmother and my Mother—under the heading of good manners and there is no excuse of bad manners, ever. As far as hugging, I believe it is totally appropriate but let the family guide my actions. I sometimes touch the back of their hand or their forearm lightly with my fingers. If they hug, I hug right back.
This is my usual procedure, first thing is the IV morphine , then extubate the patient and remove the NG tube that is used to provide nourishment. If it is an ECMO patient, the machine is turned off but the cannulas remain in place. All the IV pumps are turned off, except those for the morphine and the sedation. The IV sets remain in place. I leave the EKG leads in place but turn the alarms off. My mind goes to a quiet place but my focus is 100% on my patient.
Usually the family is frightened because they don’t know what to expect or what happens during the process of death. The physician may have left by this time, they carry heavy patient loads, I have one patient. I try to answer their questions with honesty and compassion. Frequently they want to know if the patient can hear them. I don’t know, but hearing is the last sense to leave. I encourage the family members to speak to their loved one. Yes, you can touch your loved one, hold their hand, kiss them. No, we are not “putting them to sleep” we have removed the mechanisms keeping the body temporarily functioning and death is the natural outcome. Are they in pain or scared, I don’t believe they are. We administer opiates (morphine, mostly) via their IVs which relax the patient’s body but it does not kill them or hasten their death. I offer to give them privacy but will stay with them, it’s whatever gives them the most comfort. The hardest question to answer is how long will it take for the patient to pass. I don’t have an answer except to the patient is not in any pain.
Death can take up to 60 minutes but that has not been my personal experience. I have seen death occur in less than 3 minutes and as long as 30 minutes. Generally, COVID patients are on the shorter end of the scale, especially those on ECMO. Patient’s that have a TBI and that have suffered brain death will usually be on the longer end of the scale. All my patients have been unconscious and mechanically ventilated. Patients that are organ donors have the withdrawal of life support in OR by the organ recovery team.
Once the patient has passed, I ask the family for a few minutes to provide final care but if they wish to remain, that’s fine also. A family probably feels they have so little control that any small gesture that gives them some sense of control is an act of compassion. Even families that support the decision or even requested comfort care have no control over the actual process. Even though I have had a nursing relationship with the patient and quite possibly family members, I am not family. I am the stranger in room with their loved one, I am the stranger performing the actions that will allow their loved one to die. I am always keenly aware of that.
It’s called packaging the body but with families I say final care. I clean my patient’s face, remove all medical equipment, and replace any dental appliances. Rigor has not begun yet so I place their hands folded on their abdomen at the waist and held in place with soft gauze. I do this at the ankles also. Finally, I wrap them in a sheet. Once rigor had set in, it would have to pass to change the position of their legs or arms. Somehow it seems disrespectful to leave my patient with arms and legs askew. Once the family has said their final goodbyes, I call the morgue for transport. Quite often as I am providing this final patient care, I pray silently to myself, the 23rd psalm. This is how I close the circle of life and I do it because I care.