Providing Compassionate End-of-Life Care as a Nurse

"Nurses are angels in training."

I was holding one of her hands as her husband held the other. Preciously. Tenderly. Dearly, he clasped her hand and laid a gentle kiss on it as she took her very last breath. She died with a soft, quiet, and peaceful smile on her lips. Compassionate end-of-life care can help ease the physical and emotional suffering of death.

Her husband, daughter, and granddaughter cried. As a nurse who provided care and comfort to this dying patient, a few tears also fell from my eyes as I shared this life-changing experience with the family of the patient who was with us in life just moments before and passed on before our eyes. The granddaughter knew at that moment that she wanted to become a nurse one day.

One Phone Call Changed My Professional Life, Forever

Miranda as a nurse working PRN jobs — Me playing with my son before leaving for a PRN shift around the time I cared for this patient.

How did I get to the bedside of this dying patient? I agreed to a PRN shift just a couple of hours earlier when the local nurse staffing agency manager called me at 5 a.m. and offered me a per diem 12-hour shift at a local community hospital about one hour from where I lived. I had already worked on several occasions at this particular facility—was aware of some of the challenges that came with per diem shifts—and was happy to pick up the work.

It wasn't a typical morning. Why? One of my patients was dying. In the healthcare setting, this is not uncommon. What made her situation so atypical was that she was screaming and crying out in pain. She was in agony and total misery.

Who was she? I can't recall her name at this time, to be honest, but she was around 90 years old and was dying of natural causes and old age. Her causes of death were nothing out of the ordinary. Her original plan was to die at home, but when the pain became unbearable, her doctor had her sent as a direct admission to the general Medsurg floor for comfort care measures. The physician who admitted her was the "head honcho," so to speak; he was the medical director of the entire hospital and had a bad reputation for telling off nurses when they called him for orders. Due to this bad rap, the night shift nurse I was relieving told me during the handoff report that she was too afraid to call the physician even though the patient was in so much pain. What happened in this situation was he had admitted the patient with a minimal amount of morphine for pain relief—"0.5mg IV every four hours as needed for pain"—but the meds hadn’t relieved her suffering, neither the first nor second time the nurse gave it.

Good morning. I am on duty now, and whether the physician liked it or not, the first thing I would do after assessing the patient was to give him a call.

Providing Comfort Care and Pain Management

Promethazine, which combats the nausea that morphine can produce, had also been prescribed but never given to my patient. During my initial assessment, the patient complained of nausea. I gave the Promethazine right away, which also provides a synergistic effect with the morphine, and immediately, the patient felt drowsy and started to experience comfort but still had complaints of pain. Nevertheless, the administration of an additional prescribed medication helped her relax and provided relief from the nausea.

Next, it was time to get to business. According to an end-of-life care study,

"Struggling with severe pain can be draining and make the dying person understandably angry or short-tempered. This can make it even harder for families and other loved ones to communicate with the person in a meaningful way."

I called the physician at home, explained the situation, and received a new order. "Morphine 1 mg IV as needed for pain every two hours." I immediately came to the room and explained the order change to the family. I counted and documented her respiratory rate, ensured it was above ten breaths per minute, and then slowly pushed the morphine as she sighed in relief. The family was at ease, and so was my patient.

The physician arrived at the hospital shortly after to do his morning rounds, and in particular, to check on this patient he had attended for most of her adult life, whom he had admitted over the phone the night before: my dying patient.

Other nurses were in fear of this doctor. I was not. He sincerely thanked me for calling him about this change in his patient's status. Shocked initially, the other nurses couldn't believe I didn't get told off by this guy. Less shockingly, he did go on to reprimand whoever the "dumb" nurse was who worked the shift before me. He made a couple of statements about her neglecting to give the ordered Promethazine as needed for nausea and for not calling him to increase the dosage of meds when the initial order was not enough to relieve the patient’s pain. He told me that the hospital needed to hire more nurses like me. I took the compliment in stride as this wasn't the first difficult colleague I had worked with and won over in this facility where fear was a language barrier.

Taking Care of a Dying Patient Includes the Family

Up next on the agenda was to complete my morning rounds and fully assess my patients. Once done with this, I got onto the needs of my dying patient’s family—a hospitality cart.

"What is a hospitality cart?" you might be asking. The funny thing is, that was the exact response the dietary department gave me when I called and asked for one. In the hospital system where I worked for four years as an RN and three years prior as a nursing assistant, a hospitality cart was a cart full of drinks and snacks sent up to the room of a dying patient for the family.

Why? When your loved one is lying in bed dying, you either forget to eat or you don't want to leave their side to do so. Luckily, the dietary aide loved the request and asked their supervisor for permission to send one to our unit. Within moments, I had a cart chop-full of water, milk, juice, and sodas on ice on the top rack and crackers, apples, bananas, chips, cookies, and other snacks on the next shelf. Beyond providing nutrition for the family and quality time with the patient, a hospitality cart shows the family and the patient extra support when they need it most. This interaction is also a great example of effective interprofessional collaboration in healthcare.

Once the cart hit the floor, I delivered it to the room, and this was the moment when I got to know the family and the patient better. The granddaughter was 16 years old, and she and her grandmother were very close. It was difficult for her to process this, and my kind words and interventions for pain management and nausea relief were in full effect for the patient, and this help put the family at ease.

My Most Memorable Patient Care Experience

Lunchtime came. The patient wanted her clear liquid diet tray. The dietary aide brought up what would become the patient's last meal and a free meal for her husband (another request I had made on the patient's behalf). He ate at her bedside with her and gave her a couple of sips of soup by hand. That was the last meal they had together on earth, and I was happy I had been able to facilitate it.

A few short hours later, she looked to the sky, and her husband rushed to her side and held her hand. My patient stared off to the right upper corner of the room, looking beyond any of us present, and then gave a soft smile and closed her eyes as she drifted off to eternal sleep.

I felt a deep sense of compassion, and the family mourned her death with hugs, tears, and raw emotions. A profound sensation of empathy and warmth came over me, and I felt incredibly proud at that moment that this woman who, just eight hours earlier, had been thrashing in pain had passed away peacefully and lovingly with her family by her side. I looked out in the hallway as a couple of tears rolled down my cheek, and my head nurse and personal mentor stood there observing the entire scene. She smiled at me and gave me a sincere nod of approval and the assurance that it was okay to cry as a nurse. After I left the patient's room, the head nurse hugged me at the desk, but I never felt like I would lose composure as the entire experience felt natural.

I lost a patient and gained a guardian angel that day.

Four international moves later, and I still have these precious reminders from the family of my patient that day.

One week later, I was passing meds and working in the intensive care wing of the small general floor when in walked that family with smiles on their faces and a gift in hand. It was the only time a patient or a patient’s family gave me a gift in my professional career.

All of them were there: the husband, daughter, and granddaughter.

Inside the gift bag, I found a coin with my name and an angel on it, assuring me I now had a guardian angel, a heart-felt card from the family in which they expressed gratitude for easing her pain, along with theirs, and a stone with the phrase engraved on it; "Nurses are angels in training."

I never felt more honored to be a nurse than I did at that very moment. It became clear to me the impact my actions had not just for that shift but for entire lifetimes.

Nurse Feelings and Emotions Related to Patient Deaths

Caring for dying patients extends beyond just hospice and palliative care facilities. Losing patients is inevitable for nurses. Regardless of whether you work in acute or post-acute care settings, the fact of the matter is that patients are sick, and many of them are terminal. Therefore, nurses play a huge role in the end stages of life. So, how do nurses deal with losing patients? The answer depends on the nurse and the circumstances surrounding the death.

"Nurses experience a high level of stress and strong emotions triggered by the observation of dying patients."

This sentence was part of the conclusion of a study that found compassion, sadness, and helplessness are the most common emotions nurses experience due to the death of a patient and that 53.90 percent of participants experienced a high level of stress.

To this day, that was the only time I have seen a person die before my eyes. I must express that I was not part of that 53.90 percent that experienced stress, but rather, I felt a deep sense of gratitude that I was able to be her nurse for that shift and that she didn't die in pain. However, I met death that day as part of a natural process, it's critical to consider every day nurses encounter horrific, untimely, accidental, and traumatic deaths.

This interaction was the most memorable I have had with patients and their families throughout my entire bedside nursing career.

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