Without Warning
A patient's unexpected death forces nurses to cope with family's shock, grief and anger - as well as their own

By H. Cheever Griffin
December 5, 2002

As Ginger Chichwak, RN, left her post in the adult critical care unit at Community Hospital East in Indianapolis for a quick lunch one day, she was confident that at least one of her patients was in for a good afternoon. A woman in her early 70s had been recovering from a massive heart attack and was about to be discharged. As Chichwak stepped down to the cafeteria for a bite, the woman was sitting in her room combing her hair, nibbling from a food tray and waiting for her family to come take her home.

So when a Code Blue call brought Chichwak rushing back to her unit, she was shaken when she saw whom it was for: the elderly woman waiting to leave. Despite frantic efforts to revive her, the woman died on the spot-the victim of a ruptured ventricle, which occurs on rare occasions after a heart attack.

"She was feeling so good when I left," Chichwak said. "It was such a shocking experience."

Several months later, it happened again.

This time, Chichwak and her colleagues were preparing to discharge a middle-aged man after helping him for weeks to recover from a stroke. Chichwak had just phoned his family with the good news when she passed by his room and saw him slumped in his chair. It was over quickly after that, as the man died from a massive blood clot.

"It was the same eerie thing," Chichwak explained in a voice that still sounded a bit incredulous. "He was cheerful and more sociable than he had ever been, and then suddenly he was gone."

Death's toll

For many of the nation's nurses, particularly those who work in intensive care and other serious illness units, death is an unfortunate part of the job. Few nurses, however, will tell you that they ever get used to seeing patients die-especially when it occurs unexpectedly. As sad and difficult as the passing of the terminally ill may be, it is the sudden death of a patient who appears to be on the mend that many nurses find particularly difficult to handle. Such incidents, they say, often force them to deal with a number of complex issues that usually do not accompany an expected passing-issues that, if not properly addressed, can eventually take their toll.

First and foremost are the range of emotions that arise from such a traumatic event. In addition to feeling intense shock and grief, many nurses tell of feeling confused and helpless-and even guilt-ridden that the death somehow was the result of something they had overlooked.

As many in the profession can attest, taking time to digest all of these emotions during a rotation is a luxury few nurses can afford.

"The pace of nurse work is relentless and so there is little time to stop when we lose someone that way," said Alice Weydt, RN, director of patient care services at Immanuel St. Joseph's Mayo Health System in Mankato, Minn.

What's more, it is often the nurse's job to attend to the body after death-and so many nurses must quickly move from trying to save a patient to the grim task of preparing the deceased for the family. "We have to pull out all of their tubes and lines and clean them up to make them look as nice as possible for their family," Chichwak said.

She and her fellow nurses then must prepare the deceased for the mortuary-which sometimes involves the surreal exercise of shrouding the body, or wrapping it in plastic to better preserve fluids.

"Our environment usually does not allow us the opportunity to grieve," Weydt said, "and over time, that can take a toll."

Weydt and others say that despite the hectic pace of a nursing shift, a growing number of hospitals around the country have recognized that incidents of sudden death cannot go ignored. As a result, they have developed small and informal ways of coping with such occurrences, ranging from holding quick "debriefing sessions" right after the death with someone from social or psychological services to bringing in the hospital chaplain to hashing out the whole affair with each other over food and drinks after the shift.

"What helps me the most is talking with other nurses," said Laurel Galletch, MA, RN, nurse manager for medical/surgical services at Alta Bates Medical Center in Oakland, Calif. "We have informal debriefings where we'll step into a conference room and quietly walk through the events that just happened and how we feel about the loss of this person."

Many nurses say, however, that they ultimately try to come to grips with such deaths on their own. "I have a 40-minute drive from work, and I may cry the entire way home," Chichwak said. "You spend the whole day holding yourself together and doing what you have to do, and you need time to let go."

But most nurses agree that what would help is a greater effort on the part of hospitals to establish more organized outlets-from group therapy sessions to stress management seminars-for opening up.

"We desperately need it," Chichwak said. "It's so hard to find the time to talk to each other about what happens here, and it's hard to get this stuff off your chest at home. You need to be with people who understand what you're talking about." Weydt agrees. "We need to design a system that provides the staff time during their shift to process their grief," she said.

St. Joseph Hospital in Orange, Calif., is an example of a facility that has done just that. Katie Skelton, MSN, RN, vice president of patient care services, explains that officials at the hospital recently devised what is known as a critical incident stress debriefing policy. Within 12 hours after a particularly traumatic occurrence-including a sudden death-the hospital dispatches a team led by a specially trained stress manager to meet with employees and help them to better cope with what they've encountered.

"It's a way for us to help our nurses and other staff members stay emotionally and mentally healthy," Skelton said. "Police officers and firefighters receive this kind of attention and nurses should, too, because we also deal with such difficult life-and-death circumstances every day."

Family support

In addition to coping with personal feelings of shock and loss, nurses also must gear up to face the families. Family members often react to the unexpected death of a loved one with anger and frustration. They want answers-and they're not always polite about getting them.

"The family issue is a tough part of all this, and it really can wear on you mentally and emotionally," said Randy Smith, RN, nurse manager of medical intensive care at The Ohio State University Medical Center in Columbus. "You expect people to get loud and upset, but they can also get very abusive, and that's when it gets to you."

Smith said that the center has tried to create a less explosive atmosphere by dispatching a team from the various service-related departments of the hospital-pastoral and customer services, for example-to talk with families who have suddenly lost a loved one. "We want them to know that the entire hospital community is there for them and ready to address the many different issues they may have," he said.

Chichwak added that it helps to develop a good relationship with the family from the beginning. In comparing the sudden deaths that she had encountered so closely together last year, Chichwak said she was much more comfortable dealing with the family of the stroke victim. "I had gotten to know him and his family well, and so they trusted me and the other nurses on staff," she said. "It was certainly difficult emotionally, but there was never a sense from them that we had done something wrong."

It is not only sudden death but a dramatic and unexpected decline in condition that also can put nurses in the middle of thorny family situations. When seemingly stable patients suddenly take a turn for the worse and wind up on life support, many loved ones insist on continuing treatment-often against the declared wishes of the patients. This opens up a host of moral and ethical dilemmas, which usually engulf nurses as well as doctors and administrators.

"We get caught in the middle of this a lot and it makes the nursing staff very uncomfortable," said Theresa Murray, MSN, RN, clinical specialist for critical care at Community Health Network in Indianapolis. Murray explains that because of their position on the frontlines of the hospital, nurses often end up talking a great deal about this issue with family members and trying to help them to do what is right.

"We like to think, at least conceptually, that we're taking care of the entire family unit when we care for a patient," she said. "But in the end, we are really working for the patient. They are our first priority."

Murray, a veteran of critical care, comes across as tough and unwavering-even in the face of crises such as an unexpected death or deterioration. She said that as a leader of her staff, she needs to remain calm and collected at all times. "You have to be able to manage yourself in order to manage events," she said. Even so, she acknowledges that handling death-especially death that springs up suddenly and claims those patients you'd least expect-is extremely trying. "Even today, I do it better on some days than on others," she said.

She added, however, that it is important for nurses to find some way of coping with the range of emotions and issues that accompany sudden death-whether it be a good cry or a regular grief session with colleagues or friends. "We have an obligation to manage it and carry on," she said, "because the next day, your patients aren't going to care what you went through the day before. They need you at your best right now."

Contact H. Cheever Griffin at cgriffin@chi.syn.net