Lessons from the Bedside: Life After [a Patient's] Death

Recently I took care of a patient who died.

The patient went quickly and without pain, but for some reason the death shook me more than usual. The next day, I found out a different patient had decided to go hospice. At home in my bed, I cried as I thought about how I'd gotten to know these dear people, and how their lives had or were coming to an end. Not in a painful or sudden or traumatic way, but coming to an end nonetheless.

Admittedly, lately I've been working extra shifts at the hospital and have been slightly overwhelmed by nursing in general, and maybe that's why these deaths seemed to affect me more than usual. Saddened by the loss of life, I sat in my bed begging my body to fall asleep while tears slid down my face. Sickness, sickness, death, sickness. Though I love my patients dearly, I was worn out.

Stock photo from Adobe

All I wanted was to help people succeed. It's what gives me the most fulfillment and satisfaction in life. In high school, I played competitive soccer. I only scored once the entire time I played, and the one time was sort of a fluke! I didn't care, though. My favorite position was center mid-field, where I could receive the ball from our defense, take it up field, and set up a scoring opportunity for our forwards. I may have scored only one goal myself, but I couldn't keep track of my assists. When I could create space on the field and send the perfect pass—just the right position, speed, and timing—for a goal, I was just as thrilled as if I had scored myself. Their success was my success. Nothing brought me more joy.

These setups for success were the kind of work I wanted to do every day, and working in a hospital, staring sickness and death in the eye every day, felt like just the opposite.

These thoughts swirled in my brain the next day as I drove around town after dropping by the hospital to say goodbye to our now-hospice patient. I cried in the car, and I told God I was sad, and I questioned what role I had as a nurse in helping others succeed.

In the car at a stoplight, tears slipping down my face, I wondered. I wondered if I had a limited view of success. I wondered if to the patient and to God, success didn't mean staying on this earth. I wondered if it meant them crossing over into eternity and feeling His embrace. I wondered if being one of the last faces someone sees, one of the last hands they hold, one of the last voices to say a prayer for them on this earth—I wondered if this was helping them succeed in moving to the next place they were meant to be, the place we were really all made to be: the presence of the Most High God.

This realization crushed me. I wept like a baby at that stoplight, and I can't help but cry a little now as I remember that sweet moment. We can only see part of the soccer field, and perhaps sitting with someone at the end of life is akin to assisting them with the most epic goal of their existence, the moment they see God face to face.

To be frank, though this perspective helps me process the experiences of this week, it doesn't make death any easier. It doesn't mean I won't cry the next time I have a patient who dies or who make the difficult decision to go hospice. It's easy for others to remind me it's special and important work to care for people in their last months, days, and moments, just like it's easy for others to tell me my work as a bedside nurse is honorable and impactful. Speaking or hearing these words is not the same as living out the moments at the bedside. People like to say nursing is a calling, but even if it is a calling for some, it's still a job. There is still the wear and tear of cleanups, medications, assessments, the moment-by-moment deepening of relationship between nurse and patient in every interaction, and the moment-by-moment decisions and realizations a patient is declining. The sweetness of helping someone succeed does not remove the deep sorrow of death.

Yet, I am thankful there is sweetness and not only sorrow.

Today, I'll keep hoping. Hoping for what's to come, for the day we'll all be on the other side of death, when there will be no more sorrow, only the sweetness of the presence of Jesus. Yet until then, I'll keep praying, and I'll keep crying. And I'll keep doing my best to be a part of the setup for success.

For Nurses in Developing Countries

You know you're a nurse living in a developing country when...

1. Every time you see a body of water you think about Schistosomiasis or some other water-borne parasite.

2. You're sitting on the commode with diarrhea and as you think about your lack of water intake and proper diet during the day, you literally say out loud to yourself, "I'm losing so many electrolytes right now..."

3. You dutifully use hand sanitizer every time soap and water isn't available, but secretly you're thinking of all the diseases only soap and water can kill.

4. You notice how dilated everyone's veins are in the hot, humid climate you're in and wish you could teleport your renal patients here for the fifteen minutes prior to starting an IV on them.

5. You're constantly telling people to change their diet to include more iron because you have a strong suspicion they're anemic after quick visual assessments, such as noting pallor in their nail beds.

6. You text your friends unashamedly about your abnormal bowel function overseas.

7. You adjust your diet according to your current bowel ailments. (More tamarind allowed today I'm constipated. More rice and less fiber when I have diarrhea.)

8. You're constantly reminding people to wear their motorbike helmets because safety always comes first, no matter the heat or discomfort. (You've seen one too many head traumas from motorbike accidents.)

9. It bothers you to the nth degree when you see people smoking on hospital grounds (considering all wards have open windows and doors and smoke can go everywhere).

10 Your heart breaks a little every time you see malnourishment. Which is pretty much every day.

11. You struggle because you have an overwhelming instinct to fix everything and make everyone feel better, but you're simply unable to. You find hope in helping one person at a time entrusting them to a Higher Power.

12. You are assessing community health needs continually, as you learn more and more about the culture, health care, and superstitions/beliefs affecting health practices.

13. Your friend in your passport country still sends you a picture of her infected eye to ask if it's pinkeye. (You reply yes, it looks like it is.)

14. Your days of running around a hospital floor getting cups of ice water so your patient will take their pills - all the while wearing a jacket because the a/c is turned up so high - seem like a distant dream.

15. Though your tolerance for super-entitled patients drops a few notches, you still respond to all with compassion and empathy because you realize in developed or developing countries, people's needs are the same: physical needs for food, water, medications, and hygiene, but also emotional and mental and spiritual needs. They just manifest in a different way. No matter if they're upset in a private American hospital room or in tears in a hot, crowded Cambodian ward, they are scared, stressed, and in need of healing and a Healer. So we respond with compassion to all. Because that's what we do. Because we are nurses.

To nurses in developing countries:

May your learning experiences, encounters with the sick, and poops be solid but not too hard.

May your heart, food, and water be purified and well prepared.

May the days you have the runs be blessed with plentiful access to flush toilets, toilet paper, and empathy for  patients with E. coli.

May your searches for soap and water, Lysol, deeper meaning in life, and a paradigm for suffering be fruitful and rewarding.

Most of all, may your compassion, immune system, and faith only be strengthened by your time overseas.

The HCAHPS Approach

Adobe stock photo

There is a problem on the floor. Not the literal floor. I mean the medical-surgical hospital floor that I work on. And every hospital floor, for that matter.

I have named this problem “the HCAHPS approach.”

For those who are not in the healthcare profession, let me briefly explain. HCAHPS [pronounced H-caps] stands for Hospital Consumer Assessment of Healthcare Providers and Systems. When patients leave the hospital, they receive a 32-question survey asking them to rate various aspects of their care. Examples include how quickly their call lights were answered, whether nurses and doctors treated them courteously, and even how quiet the halls were at night. The idea is to measure quality of patient stays and not just quantity, which is a good thing in of itself.

Here’s the catch. Hospitals’ reimbursement is linked to HCAHPS scores.

I could go on and on about the flaws in the system (like have you ever noticed the people who have dissatisfied are the ones who are more likely to complete surveys?), but that’s beside the point.

Broken system or not, I can tell you the effect it has on the hospital floor. Nurses and other staff are more stressed out, feel pressure to perform, and are always trying to please everyone, even when patients' demands are unreasonable. Hospital units track scores, huddle over scores, post graphs of scores. Sometimes we even talk about which patients wouldn’t give us a high score during shift change huddle. You would be amazed at how much time, money, and effort goes into trying to improve patient satisfaction scores.

But then again, maybe we shouldn’t be amazed. 

It’s Everywhere

When I look around myself—and more importantly, when I look within myself—everything I just described is present: high stress level, pressure to perform, working to please everyone…

Toward the beginning of this year, I sat across from my therapist and told her I felt like I was on a treadmill of perfectionism. I kept running and running and running, trying to go faster and work harder and be better, but I was getting nowhere. It was only exhausting me and made me feel like a failure.

I was applying the HCAHPS approach to life—and so is a large portion of society. We pressure ourselves and others to perform, and we measure our self-worth by what other people think of us. Many of us openly admit to being “people pleasers.” (The opposite response is also dangerous—dismissing everyone’s opinion and deciding not to care about what anyone thinks, even if they have valuable feedback. But that’s a whole different topic for another day.)

Though there’s nothing inherently wrong with ensuring quality patient care and assessing how others feel about us, there is a fine line between assessing and obsessing. 

When satisfying others and controlling their perception of us becomes the focus, toxic environments are created. That toxic environment can exist inside ourselves, in our work places, in our homes, etc.

Why It’s Toxic

When our whole focus is on what others think, we operate from a belief that we are not enough and maybe if we try harder, are nicer to that co-worker, answer that patient’s call light faster, we will be enough. We believe we will get all top scores and everyone will love us and we will feel worthy and loved.

Yet this feeling of enough-ness will never come from others. We may feel liked and valued for a while, but striving for worth is a vicious cycle that always calls for more. A little more work. A little more makeup. A little more money. A little more studying.

The truth is, we will never be perfect in the eyes of the people around us…because we are not perfect. And they are not perfect.

We carry around invisible satisfaction surveys and, gauging everyone around us, silently (and maybe subconsciously) rate ourselves based on our perception of their perception of us. I bet that person would give me a ‘1’ on promptness. He would give me a '10’ on friendliness. She would give me a ‘5’ on fashion sense. No wonder we’re stressed out and exhausted!

Toxic environments lead to sickness and death. In my case, it led to deepened depression and anxiety. For others it may manifest in physical sickness, anorexia, addiction…

Getting Out

Ironically, it’s when we stop caring too much about what others think that our relationships improve. When we direct all our energy toward pleasing others, we forfeit the opportunity to do our best work. It takes great courage to admit that we are not enough, and great humility to admit that we can never be enough. But there is freedom if we can embrace the truth that because God is enough, we don’t have to be enough.

When we believe this, we shift from operating from a place of frantic striving to a place of confidence in God’s enough-ness. We operate from a stable place rather than from a place where success is defined by others or even by ourselves. We are able to focus on doing our best rather than exhausting ourselves attempting to achieve perfection. We are able to be instead of do, and out of just being come our gifts to the world—the gifts that so often get squelched in our efforts to please others: our compassion for our patients, our ability to motivate our students, our passion for our workplaces, our unique skills and talents for serving and creating and inspiring.

Good News

The bad news is that we live in a society that embraces the HCAHPS approach to life. Regardless of whether or not you work in a hospital, I imagine that all of our workplaces have a tinge of the HCAHPS approach, subtle or blatant.

We may not be able to change society completely—or hospital reimbursement policy—but the good news is that we do not have to keep the HCAHPS approach as our approach to life. We can replace it with the liberating approach of recognizing our need and operating from a sufficiency outside of ourselves. Somehow, when our internal approach shifts, it doesn’t matter so much that the people around us—at work, at school, or at home—are hung up on performance and people pleasing. 

They can post it on a wall I see every day at work, but they cannot post it on my heart. I choose to leave the HCAHPS approach behind. What about you?