A Time for Hope & A Time for Grief
A Clinical Exemplar
Emily Duke, student nurse
When I met Mr. P. he was my patient in the intensive care unit at a community hospital where I doing a summer externship. Mr. P. was a 73-year-old man who had been very sick with chronic obstructive pulmonary disease for over twenty-five years and lung cancer for the last five. At the time when I met him in the ICU, he had not been at home with his wife for four months. He had been traveling back and forth between the telemetry floor, the ICU, and a cardio-pulmonary rehabilitation facility. About a week before I met him, Mr. P. had been recovering well in rehab and was projected to go home when he acquired pneumonia and was sent back to the hospital’s telemetry unit. After a day’s stay in the telemetry unit, Mr. P. began experiencing acute respiratory distress and was transferred to the
ICU, where he was intubated on arrival. I met him two days later on a Thursday.
I learned from the night nurse’s report that Mr. P. was breathing better and was scheduled to be extubated first thing that morning. When I entered Mr. P.’s room, he seemed surprisingly calm and serene. He made eye contact and gave me his best intubated smile. I introduced myself and reviewed the extubation plan. When the doctor was ready, I stood by Mr. P.’s side as his breathing tube came out. Extubation went smoothly and after taking a few minutes to get his breath, Mr. P. told me a joke. I could not believe it! Most patients I had seen extubated complained about how raw and sore their throats felt or how nice it was to have the endotracheal tube out, but Mr. P.’s first words were for my benefit – an attempt to connect with me on a human level. Perhaps this was his way of letting me know that he was taking the events of his illness in stride and had hope amidst the seriousness of his condition.
Throughout my twelve-hour shift with Mr. P. that day, he maintained his great sense of humor at every turn, and he repeatedly and graciously thanked me for my care. During this shift, I also learned that Mr. P. was a man of deep religious faith, and he had formed special connections with many of his caregivers in the hospital. Many friends, family members, and caregivers came to visit Mr. P. in the
ICU. Several nurses and environmental staff members from the telemetry unit even came to sing gospel songs at his bedside. I overheard one of the hospital doctors refer to Mr. P. as his most favorite patient in the history of his career. This was clearly a man who had touched many people’s lives.
After Mr. P. was extubated in the ICU on the day I met him, he never fully recovered respiratory ease or comfort. He was on 4-6 liters of oxygen and was consistently having oxygen saturations in the mid-eighties. His ability to talk declined as his energy was devoted to breathing.
Respiratory therapists gave him breathing treatments several times a day. On Saturday a doctor who had not cared for Mr. P. made morning rounds. He came into Mr. P.’s room while I was performing a morning assessment. When he spoke to Mr. P., his tone was ominous. He communicated that the medical treatment options for Mr. P.’s lungs had been exhausted. When the doctor left the room, Mr. P. looked at me and said, “Well, he doesn’t think I’m going to get better does he?” The light in Mr. P.’s eyes was not as bright, as if he just realized his mortality. I did not know how to respond to his question. I did not want to give false hope, and I did not want to be dishonest. I said, “It does not sound like it, but it is very hard for anyone to predict how long a person will live.” Mr. P. died the next day on my day off, and evidently his wife was completely surprised by this loss.
I still think about that uncomfortable moment when Mr. P. asked me about his prognosis.
During my time spent caring for him in the ICU, I witnessed the tremendous power of hope and faith in midst of suffering, but I also saw another phenomenon. It seems that the people caring for Mr. P. wanted to believe in his recovery almost as much as he did. Nobody wanted to or was able to separate himself or herself from the situation enough to prepare Mr. P. and his family for the end of his life. This was an important life lesson for me. The dying process and the subsequent loss for those left behind can be a very difficult experience, and open communication between caregivers and family members can be invaluable during this time. The role of the nurse is to provide honest information, attempting in every interaction to avoid giving false optimism without destroying hope. Achieving this balance may be one of the most challenging aspects of nursing for me.