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THE CHALLENGE
They were waiting for a miracle. Surely, of all the people in their family, the one they felt was most deserving of a miracle was Susie. She still had two children to get through college. She had never smoked, so it wasn’t like she’d done anything to get lung cancer. And she was so sweet, the sweetest of all the sisters. Susie deserved a miracle. All her family were believers. They prayed every day. Her mother sat by the hospital bed, her thumbs racing over the glistening rosary beads with a determined set to her jaw. Miracles happened when you put your mind to it, when you faithfully begged God, when you believed enough to say, “We still think she can beat this.” That was why they refused to make Susie DNR. They had to give her every chance for that miracle. Susie herself said, “even if all I am able to do is to smell my children and husband, it will be enough for me.”
Many miracles had occurred already. Susie had outlived all the predictions. On the unit, we called her the energizer bunny; she kept going and going. We cheered her on, encouraged her to be positive. But all of us knew. The steady progression of her cancer would be stopped only by a true miracle.
She was admitted with difficulty breathing. It was more than an infection, more than pleural effusions. More than the cancer taking over her lungs. It was all of those things, and time too. Time had worn her down. A rock skipped across the water can skitter and hop only so many times before it slips underneath the surface and is lost.
When her O2 sats fell and she could barely say two words without becoming dyspneic, it was time to intubate. Susie was moved to the ICU, tubed, and put on a Diprivan drip. Alive and breathing, she was unresponsive and unable to smell her husband or children. They kept vigil, praying and hoping.
Her move to the ICU meant that the oncology nurses who cared for her during other hospitalizations lost the opportunity to be there when she needed them most. One of her nurses, Marie, told me it was hard to support the decision because she knew it would only prolong the dying process. As a care coordinator, I follow patients throughout their stay, regardless of where they are cared for. So I was there when her family decided to extubate. Susie’s kidney function had deteriorated, and there was no chance for recovery. She died an hour later. I was able to talk with the family afterwards and to learn all the details from them. I knew the oncology unit nurses would want to hear about her passing.
Sure enough, when I was next on the unit, Marie asked what had happened. After I told her, she said, “I just wish she didn’t have to go through all that.” When one of the other nurses realized who we were talking about, she joined our conversation, adding some comments of her own. “It is so unfair. She never even smoked.” We stood at the nurse’s station and talked about Susie, about how we had all liked her, about what a great family she had, how it would have been nice if she had died at home instead of in the ICU. There was more to our conversation than reviewing her care; it was a chance to review our feelings about her care.
THE SOLUTION
Debriefing is the technical term for analysis of a critical incident after it has ended. But a situation does not have to reach a critical level to warrant a modified version of debriefing. Retelling stories is a form of debriefing—an opportunity to ventilate feelings, to spend time reflecting on the impact of the situation, and to help reduce the stress experienced. It also helps to activate effective coping skills.
In a case like Susie’s, nurses have a natural tendency to wonder if things might have been done differently, if a way might have been found to change the outcome—not changing the fact that she died, but changing the way she died. Because of her multiple admissions, many of the nurses closely identified with Susie. That kind of close identification can be a significant factor in the need for some kind of debriefing. Often we can feel guilty that we should have done more or feel a sense of overwhelming sadness. It is easy to get overwhelmed by the constancy of loss. Sometimes the simple thing is to go on to the next patient, to check off our boxes of tasks and move on. Marie’s comments suggested a need to review the case. One reason to examine the situation is to stabilize the grief and sadness we feel when someone we have grown to care about suffers and dies. Retelling the experience while the details are fresh allows us to identify problems, and it teaches in a way that is distinct from textbook learning.
We stood there for several minutes, sharing our thoughts about Susie and her family. Our conversation gave each of us a chance to deal openly with our feelings about her passing. Nothing monumental was uncovered, and no drastic changes were suggested. Instead, we each walked away satisfied that someone else shared an understanding of the situation. That was enough. Another nurse stopped by when we were discussing Susie, but she shook her head and said, “It’s just not right to waste all those resources.” She didn’t want to talk about Susie, she wanted to move on. Maybe she needed to move on. In debriefing, no one should be forced to participate. None of us disagreed with her or challenged her. Her feelings and reactions were as valid as ours.
Recently I took my 3-year-old nephew to the beach, and we had fun building a huge sand castle. We patted the sand around the top and firmed it into place; then we sat back on our heels and admired our work. But when it came time to leave the beach, it wasn’t enough to let the waves melt it away. True to the nature of an energetic boy, my nephew took the same shovel he’d used to carefully build the castle and smashed it to pieces, kicking with his feet and pounding with the shovel. When we got home, he ran to his mother and told the story of building the sand castle and how he smashed it. She asked him how it felt and then listened while he told her. Telling the story was as significant to him as the actual doing was. Retelling our stories, whether it is a formal debriefing or standing at the nurse’s station talking about the experience, is important too.
Discussion questions
- Does your unit have a protocol for discussing cases? Do you feel that talking about the experience is helpful to you?
- Are there some patients you have cared for that you have trouble talking about? ONA
Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.
