Reflection Assignment

Self isolation has provided ample time to go through documents on my computer. In the process of doing that, I stumbled upon an old reflection assignment from my clinical rotations junior year. I remember the patient so vividly, as if I took care of him yesterday. I’m not surprised that I still experience many of the same feelings, but am proud to report I have found successful coping mechanisms as I am in my third year as an RN. It also confirmed the importance of self reflection and acknowledging every feeling.

Today my preceptor and I experienced a code resulting in a patient death during the last hour of our shift. It was our first day with the patient and only his second day on our floor–he transferred down from the MICU. My patient was a man in his mid 60s who had been in and out of the hospital since January with a medical history including HTN, CAD, septic shock, pneumothorax, etc. His wife was a very present and involved part of his care plan. 

This morning, results came back indicating that he had developed amyloidosis. This news was delivered very frankly by a resident who left shortly after. My feelings towards this is that the information should have been shared in a more respectful manner. Yes, the resident ended his spiel by saying “do you have any questions?”, but at that point I’m not sure the patient would have even known what questions to ask. Amyloidosis is a very serious, complex diagnosis that should have been thoroughly explained using patient education materials. I spoke with my nurse about this, but we both decided to wait until the wife returned to have that conversation.  

My patient also had a bone marrow biopsy and abdominal fat aspiration done to test for suspected multiple myeloma. He presented with a depressed mood and anxiety related to these recent treatments/hospitalizations/diagnoses, as well as a decreased appetite and urine output. With statements such as “I’m scrap” and “I’d rather be slid than try pivoting”, his lack of motivation and optimism was quite evident as well. These statements lead the consultant of his med team to suggest a palliative care consult be added to his agenda for the day. He stressed that the purpose of this was to “care for the whole you, not just the diagnosis”. I thought the consultant did an excellent job explaining palliative care, because in lecture we have learned that it is often misunderstood as meaning “preparation for death”.

After a few bites of his lunch, he was transported to dialysis. A few hours later, it was reported that there was a Code 45 in dialysis. Shortly after the announcement over the loudspeaker, the phone rang on our floor asking for his nurse. My nurse and I rush down to find his wife off to the side crying and the code team around the corner (in a separated room) performing CPR. It had been going on for 10 minutes before we had gotten there and continued for another 35 before the wife instructed the team to stop. 

During the code, I felt everything but wasn’t allowed to show it. I was asked if I wanted to do compressions, but I knew I couldn’t. I was too close to a situation that was too new. I remember noticing how different the reality of CPR was compared to what I’ve read about and learned in the training course. It’s mechanical. It’s forceful. It’s not something you know the realness of until you experience/witness it for yourself. 

I was experiencing a unique mix of loss, helplessness, and shock. It was all so sudden. Like a car accident I just couldn’t look away from. I could feel my eyes welling up. Thinking about the patient’s wife and family, about how hours before my nurse and I were frustrated because he didn’t want to ambulate, how sudden his condition changed. I did what I normally do in shaky clinical situations and I focused on the technical side of the situation. I paid close attention to each code team member and their role, I watched and listened to the monitors and AED, and I spoke with a member of the nursing department about her previous experiences. Doing what I could to make sense of it all.

However, once the code was over, I was asked to help clean up the patient and the room. When I put on the gown and gloves, the situation seemed to normalize. I was a nursing student with a job to do that would help the patient and their family. Helping make the patient and room presentable for visitors again somehow removed my emotions from the situation and I was able to keep it together in front of his wife. 

There was one aspect of the situation that, although out of my hands, I felt unsettled by. Because dialysis closed at 7 and no one would be there to staff the room, we had to transport the patient back up to the floor where he would stay until his sons came to visit. While the code did occur at shift change, and staffing is a difficult thing to figure out, it still just didn’t feel right. I just kept thinking to myself, “Why can’t the floor staff someone down here?” and “Why isn’t anyone volunteering to stay past their shift until the family arrives?” I know it occurred at shift change, but I was still surprised at how insensitively it seemed to be dealt with. Just another part of the job I guess. 

The code was ended by the wife after 45 minutes of CPR. Following the conclusion of compressions and breaths, heart sounds were listened for and pupil dilation was tested to confirm absence of function/reaction. The patient and room were cleaned up and prepared for the wife to see if she chose to, which she did. A nurse brought her into the room where she was able to sit with the patient while transportation was being figured out. The wife found peace in a few aspects of the situation 1. Her husband was no longer suffering, 2. God has the ultimate time frame, 3. They had arranged plans for cremation as a couple beforehand. 

In terms of staff reaction, it was my preceptor’s first death as well so we were able to debrief on the situation afterwards. A member of the code team said that they would also have a debriefing session to talk over the situation. However, other nurses on my floor acted as though “dead” was just another diagnosis. It was interesting how removed and emotionless the staff seemed, even though I’m sure a part of them is used to this sort of thing. Like I said before, it’s all part of the job.

Should this situation happen again, I’m still not sure if I’ll be ready to perform compressions myself, however it is probably something I should work up to. My mind is finally accepting that I did the right thing by not performing compressions during this situation because I just simply wasn’t ready. 

Overall, I’m still a little unsure about how to feel about my last day because it was sad, it was a loss, but it was also an experience and a process and part of being a nurse. It was an unforgettable ending to an incredible clinical rotation. After talking with a handful of people (friends, family, faculty), my takeaway has been that everyone copes with this situation in their own way, and I just have to find something that works for me. 

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