Learning to care for a dying person can be an overwhelmingly frightening experience for a nursing student. Although the consciousness of nurses has been raised through continuing education programs on the needs of the dying, nursing students have difficulty finding an appropriate role model who intervenes, based on the needs of the dying person.
The purpose of this article is to describe the learning needs of nursing students as they care for elderly persons who are dying. The following presentation describes the experience of a student, who was successful in supporting a person in the final stages of living.
During morning report, I heard about Mrs. M., a patient whose prognosis was terminal. Although I was not assigned to care for Mrs. M., one of my classmates was to give her an injection for pain and Mrs. M. had refused medication the preceding day. During morning conference with our instructor, the clinical group discussed Mrs. M. 's refusal of pain medication, her demonstrated fear, and her need for supportive care.
Throughout that morning, I heard the call bell from Mrs. M 's room ring every ten minutes. I answered the bell twice between my own assigned patient care. Mrs. M. 's calls were for ice chips or the bedpan. However, her fear was clearly evident in her calls for attention. As soon as I would get near the door she would request to have her pillow fluffed or she would want another ice chip. Her face appeared tense as she touched my arm or clothing. Her actions indicated a need to reach out to someone. This urgency frightened me. As the other staff members had done, 1 did what she asked and didn't waste any time in leaving the room.
1 was in conflict all morning; I felt uneasy with her, yet 1 knew in my heart that she needed someone to sit with her. I spoke to my instructor and she encouraged me to sit with her. After much discussion with two other nursing students at lunch, I decided to spend the rest of the afternoon with Mrs. M. I didn't know how long I could stay in her room but I was willing to try.
That afternoon, 1 finished my charting on my assigned client and proceeded to answer the call bell from Mrs. M/s room. As I walked down the corridor, a multitude of thoughts raced through my mind. I tried to imagine all the questions she would ask and the various textbook approaches suggested for dying persons. I could not recall clearly the textbook interventions. Finally, I decided that 1 would let my approach come from within and with that thought, 1 entered her room. 1 knew Mrs. M. needed me.
As 1 approached Mrs. M., I found her in the same position as earlier in the day. She was lying very still, on her back, and gazing at the ceiling. She was a thin woman with extremities that looked as though they would snap with any attempts to move them. Her face was so sunken that her facial features were masked by her prominent brown eyes. Her movements were slow and it seemed to take so much energy for her to simply move her hand onto her chest. She turned as she heard me enter the room.
"Honey, could 1 have some ice chips, please?" as she pulled at my uniform to bring me closer to her face. I nodded and moved slowly to get the ice chips from her bedstand. As I turned to reach for them, 1 heard the next question come from over my shoulder. "What's the matter with me, honey? Am I dying?" Like a knife, the words dug deep into my back. I could remember saying to myself, "Well, Barb, what pat answer do you have for this? Should she know the truth? Does she know the answer?"
I turned to see those big brown eyes boring deeply into mine. Without really much focused thought, I pulled a chair to her bedside. She was still waiting for an answer and I struggled to think of one. I couldn't find the courage to say yes. Instead, I clumsily asked her what she had been told. She continued to look at me with a worried, uneasy expression and said she didn't know. Her face was filled with anguish and she struggled to lift her head slightly off the pillow. She said she didn't understand what was wrong with her and why she could not control her bowel and bladder.
"I'm so bad. I keep the bell near me but everytime 1 call, it's either a false alarm or too late.! don't mean to be a pain. I don't want you to hate me." I assured her that I did not hate her.
Mrs. M. stated consistently that she did not know what was wrong with her. At first, it seemed that her elimination habits were of major concern. She stated that previously, she was always able to control herself. Now she felt frustrated and embarrassed by her lack of control. As she continued to talk, though, 1 realized that this element fear for loss of control went far beyond her elimination.
"You know, Honey, I was never like this before. I raised all of my children and took care of my husband for many years. I was always taking care of others. Now look at me. I cant find the strength to sit up, let alone get out of bed." Again she turned to me and asked, "Am I dying?"
I placed my other hand on her hand that held the callbell and could feel my tears coming but I fought them. All the energy seemed to drain from my face. Mrs. M. continued to scan my face. I felt a strong desire to maintain some hope although I knew her prognosis was hopeless. Again, something in the back of my mind kept telling me, "Well, Barb, you got yourself into something over your head this time. Why couldn't you find a more experienced nurse or a priest to do this. Say yes, you are dying, and run out." Then I thought, "Wait a minute. There had been other nurses in this room and they avoid her. Is it really important to have much experience? Empathy comes from within. I can't leave her now. She needs me to be here and listen. This is her time. I care! But, what can I tell her? She says she wants an answer, but does she really want a yes or no response?"
I still couldnt tell her the truth. Holding my tears, I stated slowly and objectively, "Mrs. M., you are very sick, probably the sickest you have ever felt. You seem very afraid and in much pain."
At this, her body became very stiff. Her facial features tensed as she clenched my hand. In a frantic, pleading voice she stated, "No, I don't want to be doped up with medicines. 1 can't control my mind with that junk. Honey, my mind is all 1 have left!"
Continuing on the same subject, Mrs. M. began to describe how the medication would cause incontinence and how she couldn't recognize or hear the people who were around her. She also stated that the medication made her sleep and sleep frightened her.
As she looked away at the ceiling, I focused more intently on her facial features. Only then did I realize that the prominence of her eyes was not due solely to her emaciated appearance. She was consciously holding them open and the pouches underneath represented the hours she fought against her fatigue and her fear of falling to sleep. She turned to me and in an even more frantic voice, she stated, "Honey, I'm afraid that I won't wake up. I can't control my body anymore. I can't even lift my head long enough to see my feet. I'm so weak. As Mrs. M. continued to speak, she shook her head and stated, 'Tmsuchaburdentoeveryone. !was never like this before. Why me? Why me? Why does it have to be me? I never did anything to hurt anyone."
Mrs. M. remained silent for a few minutes. To me, this silence seemed to last for hours. She then began to tell me about her past life. She married at a young age and had four children. She mentioned, with a smile, that for many years she would awaken early in the morning to see her husband and children off.
Her face became grim when she spoke of the depression and the bad times her family endured. She smiled when she spoke about how she enjoyed dancing with her husband every Friday night for thirty years. Her face glowed as she hummed parts of a few ballroom tunes. In the same manner, she reviewed past weddings, births of grandchildren and her fiftieth wedding anniversay celebration.
Her husband had died last year and she became ill only two months later. During this life review, I found myself reliving her life with her. Although I remained silent, I felt joy over these happy occasions and sadness over her hardships. When she spoke of her husband's death, she cried and I, too, sat and let the tears flow.
At least five minutes passed as we sat there quietly weeping together. Eventually, she turned and patted my hand. She then faced the ceiling and stated, "?? be with him soon. We've been apart too long."
Mrs. M. turned abruptly and said "I have to tell you this. Last night, I dreamed that I fell from a great height, in the middle was darkness. I was just floating there with nothing above, under, or around me. I would reach out to hold onto something but I was all alone."
As though in deep thought, she remained silent for a few minutes. I realized that she was talking about death in this symbolic way. She seemed to fear the loneliness that she envisioned in her dream. Yet, in her statements there was an element of hope - the hope that she might be with her husband. Through this, I learned another meaning of hope. Hope did not have to relate to continued living. To break the silence, Ï asked if she felt her dream indicated what death might be like. She turned and stated, "No, death can't be like that. It can't be as bad as the life I've been living lately - but, who knows? You can't tell me. No one can. Honey, Ï doni want to be alone anymore. Please stay with me for a while longer. I don't want to be alone. I know something is wrong. I'm scared. Can I have some ice, please?"
I did not have any desire to leave her now. I no longer feared being with this person. She needed my presence and I decided to be there to listen. I reassured her that I would stay as long as I could. Her tense expression was disappearing. The relaxation seemed to be a sign of fulfillment. She managed to smile at me. Even though nothing was said, I felt that Mrs. M. knew she was not alone anymore.
Mrs. M. broke the silence. "I have more to say." With that, I moved the chair even closer to the head of her bed. She turned away for a moment then said, "Yes, honey, I'm dying." Then she abruptly faced me and continued. "You know, that's the first time I've allowed myself to say it. Yes, my son knew but he couldn't even tell me. He can't face it either. That's why he hasn't visited. The nurses leave me alone or dope me up because they know it too. Honey, you are so young. You know that 1 am dying and it scared you, too. That's okay because you at least tried to stay with me. I'm not stupid. I knew that I was dying for some time. Please don't let anyone give me anymore dope. I want to die with a clear mind. I can take the pain. It's getting easier. My mind is all that I have. My husband is gone. He was my whole life. I want to be with him now. I'm tired of lying in this bed and depending on others to do everything for me."
By this time, I felt drained of much energy. Suddenly, I felt Mrs. M. holding my hand with both of her hands. She let go of the call bell. In a strong assertive voice Mrs. M. began to speak, "Lord, I'm tired of suffering. Take me in your arms and free me of this pain. I'm ready to stand in your presence." I felt Mrs. M. 's grip continue to tighten and I looked up to see her raise her forearm as though she was waiting for a response. Her eyes remained tightly closed and her facial muscles were very rigid. Several minutes passed before her body became relaxed. She turned io me and stated that I should leave because she wanted to sleep. She asked to have the call bell left within her reach. I reassured her that I would return. I left to get a fresh cup of ice.
On return to Mrs. M*s room, I found her asleep. Her breathing was much easier and her facial appearance seemed to be relaxed. She seemed at peace with herself and the world. Mrs. M. died that night.
Reactions to the Experience
As I reflect on my experience with Mrs. M., I now understand how she awaited her death. She needed someone to listen as she reviewed her life and verbally expressed her fears through her questions. She needed to be accepted for her humanness. She wanted to feel a sense of dignity and meaning in her life.
This profound experience for this nursing student contributed much toward her personal growth as well as to the growth of other students in her group. She shared her experience with her peers. The experience prompted the student to study further the nursing needs of the dying person. She learned that a dying person deserves to have another person to share the final experience of life with them. Nurses working with a dying patient can learn much from the student who recognized the needs of a dying person. This is not a simple task. Requirements include a critical analysis of the nurse's attitudes, a theory base related to the dying person, and a willingness to relate to the person who is dying.
Preparation of Nurses
Some nursing personnel, caring for the elderly in nursing homes, may have completed their formal educational program prior to the period when death education was a part of the curriculum. To compound the problem, the numbers of professional nurses working in nursing homes are limited. ' Federal standards and state requirements for the ratio of nurses to patients is more limited in a nursing home than in a hospital setting. ' Thus the nursing student in a nursing home is apt to see a nurse's aide most intimately involved with direct patient care. Work with the dying person probably has been very limited or absent in the preparation of this member of the nursing team.
The aged person may welcome death as a relief from suffering or believe that death will reunite them with loved ones.3 Although the patient may not fear death, there may be a fear of the dying process, especially of dying alone. There is a fear of loss of control as death approaches. The dying person may give clues that indicate his desire to talk about impending death. The nurse needs to listen and observe and be ready to assume the role of a helping agent. To do this the nurse needs to understand his or her own beliefs and fears related to the aging process and to death.4
- 1. Robb SS: attitudes and behavior in the environment of the aged, in Yurick AG, Robb SS, Spier BE, Ebert NJ: The Aged Person and the Nursing Process. New York, Appleton-Century-Crofts, 1980.
- 2. Haber D Tuttle J, Rogers M: attitudes about death in the nursing home: a research note. Death Education 5(1):2528, 1981.
- 3. Spier BE: Developmental tasks of the aged, in Yurick AG, Robb SS, Spier BE, Ebert NJ: The aged person and the nursing process.. New York, AppletonCentury-Crofts, 1980, p. 210.
- 4. McMahon M, Miller P: behavioral cues in the dying process and nursing implications. Journal of Gerontological Nursing 6(iy.l6-20, 19SO.