As a nurse, we are invited in to some of the most important and intimate moments of life -from birth to death and everything that happens in between. There are some experiences that we are able to leave at work, but others go with us long after we've left. One of those moments can be when a patient dies. Nurses are faced with death and all the emotional turmoil that comes with it over and over at work. Whether you serve in a hospice setting, OR, ED or ICU, there is no escaping these events.

A recent piece written by an intensive care nurse captures a very personal and insightful narrative about what it's like to take care of a patient at the end of his life.

Nurse Amanda Anderson, RN, writes:

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.

She continues documenting the unofficial rituals that normally surround removing breathing tubes and care for mourning family members. She adds that:

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.

She captures perfectly the feeling of not wanting his death to be just a procedure as she, alone in his room, comes up with her own ritual: playing music from her cell phone as the sun sets. She continues:

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.

Read her piece in its entirety here and once you’re finished, let us know your thoughts in the comments section below.