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Short pieces on a new theme every month
 
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This month...
  The Phone Call
 

Going Solo

Amanda Anderson

I softly scrub blood from the teeth of a man who died moments ago. From the chair where I sat quietly writing nursing notes while he quietly ended, my patient's sallow skin and sunken cheeks looked so peaceful. But the weeks of stagnant residue on his teeth bothered me.

To brush the teeth of someone who was in the process of dying would have contradicted my orders to provide comfort care, and my own good sense. So I waited until he took his last breaths before I closed my computer screen and gathered my tools--washcloth, water, toothbrush.

I brush now, so briefly, for the pride of this man I didn't know, and I brush for the family that I wish was here to care about him. He does have family--it is they who authorized removing his life support, in keeping with the wishes expressed in his living will. Their brief go-ahead over the phone satisfied their legal obligations, but their absence during his actual passing has left me feeling oddly confused.



As I brush, I think of my role as a seasoned ICU nurse in easing so many deaths--typically so frantic and full, but this time so quiet and empty.

I'm shocked at how strange this particular passing has felt.

Sure, I've had solo deaths before: on my first day of nursing, my patient died fifteen minutes after I'd come on duty, the color fading from her pink lips and rosy cheeks before her husband could arrive to see. But this felt different.

It was the first time, I realize, that I've given end-of-life care to someone whose family was willing to advocate for his death, but not to attend it.

I missed the cast of characters and unofficial rituals that normally surround the switching off of the life-sustaining medications and the removal of the breathing tube. Where were the nervous mother and the teary uncle, the tissue-box requests and the stale bereavement cookies? What about the clumsy face-shave, given more to console the living than to care for one soon to grow slack and cold?

I missed caring for family members, I realize. I know how to reassure them about agonal breathing: "When the breathing tube is removed, sometimes there are noises." I'm adept at finding extra chairs and strategically placing tissues. I advocate for extra pain medicine as ferociously as if it were for a member of my own family. This time around, having no one but my comatose patient to tend to, I felt lost.

Without any family, life story or tradition to shape them, his last minutes were governed only by a set of instructions:

      1.  Administer pain dose once, prior to extubation.
      2.  Extubate patient.
      3.  Administer pain dose every three minutes for respiratory rate greater than twenty,
           or obvious signs of pain, as needed.
      4.  Notify house staff at time of asystole.

Before beginning the extubation process, I paused to take a breath. I know exactly how to do this work; the steps are not difficult or new. Carried out with no one else to witness them, though, they felt foreign and frightening. The enormity of my power at this point in this man's life, compared to my utter absence throughout the rest of it, paralyzed me.

In the face of the heavy silence, I stalled. I combed his hair; I meticulously labeled and color-coded each syringe of medication. I wrestled with the illogic of giving him a clean gown, but did so anyway.

I can't let him die with tube-feed glop on his shoulder.

The resident popped in, her flinching smile telegraphing that the emergency-room doctors had admitted a patient who was now waiting for this bed: Hurry up! Our eyes met, shared the same sad question--Where's this man's family? Then she was gone.

I wanted to keep the man's death from being just a procedure, but knew nothing of his preferences regarding the last moments of his life.

Nervously, I created a ritual: a bit of quiet, some jazz playing on my cell phone, a moment to note the setting sun.

But the jazz felt presumptuous. What if he hates jazz? I shut it off and stuck to my simple directions, carefully documenting them:

      1640  Pre-extubation pain dose given per order.
      1645  Extubated per order.
      1650  Respirations 26. Post-extubation pain dose given per order.

Some breaths, but not many. Some work, but no pain, my simple, silent assessment.

      1720  Asystole.

Silence.

I called the resident. She came in and made the pronouncement. When she left, I took a few seconds to gather up the toothbrush and cautiously set to work.

Who am I doing this for? I wonder, gently massaging the spit off of the dead man's front teeth. Am I doing this out of guilt that no one has asked me to do it, or because this is what I do for all of my patients, and without it, my care would seem like euthanasia?

To be sure, my actions have mirrored his wishes. I could do no other: his living will clearly stated that he wanted no heroic measures. But without the usual complement of "nurse-y" tasks, such as consoling the family, I've felt too powerful, somehow. It's a jarring sensation. Now I'm clinging, as family members often cling, to the tiny aspects of life that remain.

His teeth finished, my patient looks better. How odd that death can look better than life.

Still feeling uncomfortable, I move eagerly to the care I know--the preparation of the body after death. I am safe here, with the toe tags and cloth straps and thin plastic pieces. After death takes place, few family members ever ask about these rituals. The actions hold no human presence and are carried out in silence by the nurse:

Remove IVs and carefully dress them. Turn the patient to one side and give the back its last wash. Position a white plastic bag under the remains. Roll the body back in place. Gown the body in clean linens. Tag the great right toe. Zip up the bag and copiously label the outside. Cover the bag with a white sheet over raised side rails to hide the silhouette of death from curious eyes in the hall on the way to the morgue.

Done.

The room's space feels lighter, easier. And now, after hours of rueing the lack of people, I take comfort in being alone. Through the window that I cracked open for myself, I hear a car horn. I notice the pink light of the day ending as the navy night begins.

I turn from my work, unsure who might be pleased by it.


About the author:

Amanda Anderson, an intensive-care nurse, now works in nursing administration for the Mount Sinai Health System in Manhattan and as the director of a nurse-specific writing center that is part of The Nurses Writing Project at the Hunter-Bellevue School of Nursing. This is her first Pulse story; her works have also appeared in American Journal of Nursing and Scrubs Magazine and in HealthCetera (which she manages). "Writing is the reason I've stayed in nursing. It has healed me and helped me to offer healing care many, many times." Amanda's personal blog is This Nurse Wonders, and she tweets @12hourRN.

Story editor:

Diane Guernsey

 

Comments   

# Anthony 2015-12-31 22:17
when my time comes, I too do not want heroic measures. I do hope that I will have a nurse that will show compassion and honour my dignity as you have demonstrated. Follow the rules but do it with compassion, respect and honour to the deceased.

Thank you.
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# Deborah 2016-11-23 13:05
Beautifully said. Thank you.
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# Alison Fowler 2015-12-31 19:15
I'm a nursing student who, like Jackie, always thought birth was my calling. After my first year of nursing school, my heart is beginning to open. Your essay reminds me of a patient I had during my medsurg clinical this past fall. She was passing and her family was not with her. I held her hand, I stroked her cheek, I swabbed her mouth to moisten it, and quietly spoke to her. Responsive only to pain stimuli, I was surprised whenn she opened her eyes and showed a positive response to the water swabs. We made eye contact. I may have been the last person to look her in the eyes or hold her hand. She passed after my shift ended, so I'll never know if her son came to see her. Thanks to this woman, next week I begin my training as a hospice volunteer. I know that, as a nurse, death will be ever present. I have made my peace with that. Everyone deserves a good death. Thank you for sharing your story. I will carry it with me as I continue in my schooling and my calling.
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# jackie 2015-12-31 16:14
Speechless. Your eloquent way of sharing the emotions one often has trouble conveying is awe inspiring. As a nursing student I've always had my goal to be in labor and delivery, yet after reading this half a dozen times this morning I feel this tug at my heart and wonder where gods taking me on my journey. 3 years ago my uncle passed away and while reading this all I could think of was him and being in that room you speak of trying to find enough chairs for and strategically placing tissues. I watched the tube come out and machines go off. His room filled with family that loved him and a nurse that was gentle, kind and sensitive in the moment she was in with us. It's nurses like you, that make people like me, want to be a nurse. To go above not for the recognition but for the appreciation for someone's life. Thank you for sharing this experience and for making me think and pray about my journey. I feel so blessed to go into nursing to be aside people like you.
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# Joy 2015-12-31 13:18
I read this twice. Once quickly and realized you were writing something that I had experienced in my career. As time has passed and I now have time to reflect over the people who I watched and cared for during their last moments I remember the one who asked me to hold his hand, I remember the one who asked me to sing her favorite gospel song, I remember the one who was crying because she had no one.
These moments were so precious and meaningful to them and eventually to me. As nurses, the things we do outside of the chart are the ones most meaningful to the sweet life that is leaving earth. Thank you so much for your wonderful words.
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# Elliott Oppenheim MD 2015-10-18 18:29
Nice piece. I think we all know that hollowness... yet, this was a triumph and, as a nurse, you gave the ultimate gift, your caring. May you be blessed.
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# Anne 2015-10-16 13:21
This was an amazing piece of prose. Thank you for the difference you make each day in the lives of those you care for whether they know it or not.
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# J.A.Erskine chaplain 2015-10-05 13:35
Amanda:
The gift of writing well, displayed magnificently. You capture so well the give and take of emotions in the death process. It helped me remember how the members of my team (including me) are affected by the deaths we experience & the families (or not) we serve at death's door. Good on ya, mate!
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# Barb Moysey 2015-09-29 12:58
Your words resonated with me ... it seems like we all forget and even apologize for the RN humaness during the death of the patient. During my years of ICU nursing, it was those rituals that I performed that was my way of closure, of saying goodbye. I cannot tell you how many times I served as "family" for the patient who died without and I view that as a privelidge. Thank you for sharing.
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# Dianne Duchesne 2015-09-28 15:17
So beautiful, Amanda. You are a gifted writer and you have surely been able to bring others into that room with you and with your patient. You offered him your heartfelt presence, he was surely not alone.
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# Chris Murphy 2015-09-28 14:22
Very well written and evocative. I was a medical ICU nurse for quite a few years before going to medical school. I can still feel on my fingertips the white nylon type shell that we would put around the patient. It has that particular sensation that nothing else that I have ever encountered feels like. The circumstances often controlled me and my feelings--- the violence of an unsuccessful resuscitation with the blood and trash left everywhereversu s the more controlled leavings that Amanda describes. It is the rare doctor or resident at this time who watches the transition, or hears the last breath or even in pronouncing someone stays to linger a minute or two more than absolutely necessary.It is good to be that person. To bear witness and to tell the family that you were there. Some people and some families can't be there, can't bear it. Thanks to Amanda and the other nurses. Thanks to the witnesses.
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# Susan 2015-09-27 08:47
Beautiful! As a long-distance daughter I have been very grateful for the loving care of nurses at the end of my parents' lives - having visited week after week in their final days I just was not there at the end. They relocated far from me and my life and responsibilitie s with my own nuclear family. I've wondered if I would feel differently about their passing had I been the one to relocate far from the life of my parents and childhood.
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# Nancy 2015-09-26 19:05
This is a beautiful story which made me weep. Thank you.
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# carol lobel 2015-09-26 18:45
powerful. leaves the reader with thought and questions . thank you.
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# Margaret Fleming 2015-09-26 17:25
Your writing is so good. Your rhythm in this piece was perfect to reflect the calm and unease both present.
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# Yehudit Reishtein 2015-09-26 13:54
Beautiful, Amanda. As a critical nurse, I've also experienced patients' deaths. The gentle care we give at that time fulfills our need to care, whether or not someone is conscious of what we do.

And, yes, I've cleaned the teeth (and glasses!) of people after they have died. Even if the family will not notice, perhaps the soul of the deceased is still hanging around to be aware that he is still being cared for.
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# Howard Carter 2015-09-26 10:57
Such a wonderful piece, specific but universal and on many levels, technical, familial, emotional, professional, and deeply human. Nurse Anderson takes us to places not many people go. Many thanks.
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# Cortney Davis 2015-09-26 09:54
What a beautiful, moving and essential recounting of how nurses and patients share transcendent moments. Thank you, thank you.
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# Lee Kagan 2015-09-26 08:07
"Character is what we do when no one is watching." From whence springs this need to mark a passing with something "more" - a prayer, a cleansing, a moment in which time stops and routine shuts its eyes? Thank you for showing us who you are, who we can be. Beautifully written piece.
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# Ron Banner MD 2015-09-26 07:37
Beautifully written, Amanda, and touching on important themes. I hope that your work impacts many!

As to why to do it, "Though shalt not ... curse the deaf."
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# Pris Campbell 2015-09-26 06:52
A very compassionate narrative of those last rites. In reading this, I, too, felt the absence of any family member bewildering. Was watching his death too hard fir them? Were they relieved? Did they care? Questions that will never be answered.
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# Liat Katz 2015-09-25 23:41
Lovely. I was right there with you---you characterize the odd dichotomies in healthcare (familiar yet unfamiliar, routine yet not routine, an end of life yet a beginning to more rituals, etc), so eloquently.
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# Cordon Bittner 2015-09-25 23:34
Very thoughtful essay. A sad commentary on our social fabric wearing holes in it. You show a heart of servanthood.
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# Joel Potash MD 2015-09-25 21:34
Amanda, this is such a moving essay. Not only are the family absent, but also the doctor who inserted the endotracheal tube, spiritual care, the resident ( except momentarily to hurry you up). Don't we need to care for each other and be present to support each other. It seems easier to insert an endotracheal tube ( or feeding tube) than to remove it ( emotionally, professionally) so maybe that's why they don't show up. Thanks for what you do and who you are.
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# Deborah Pierce 2015-09-25 21:17
Beautiful story. Thank you for your compassion.
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# R C 2015-09-25 20:29
Beautifully written. Very moving. Thank you for sharing your experience and honoring this patient with your words.
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# Marita Grudzen 2015-09-25 20:21
Thank you for honoring this man and the way you companioned his death, as awkward as if felt at times.

And, finally thank you for bringing us into the experience through your discipline of writing. It makes me wonder how many of us have had similar experiences - times when we may have felt and not have been able to consiously be present.
You serve us well.
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# Maureen Hirthler 2015-09-25 20:15
What a beautiful story!
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