Grief is complex. It cannot be taught; it is learned only by experience. People dedicate themselves to the study of grief. Occurring across different stages, every individual navigates the grief experience in their own way and in their own time. Obstacles to facing grief include our own selves, the busyness and demands of life, and often the expectation of society that we will “grieve and get over it.” But that is not how grief works. It comes in waves. There are periods of happiness and comfort, then triggers that bring back floods of memories and pain. We grieve for our own loss, and we grieve for the person who has died and the future they will not live.
Grief is not limited to the death of a person, of course. We grieve the loss of a relationship, a job, a future we thought was to come, an experience (or the end of it), identity, routine, or of what we thought an event or life change would bring. In these most recent months, all of us have been challenged by grief in some way, including many who have suffered the loss of a loved one to both COVID-related and non-COVID causes. We cannot attend funerals or traditional mourning practices. Other challenges include a change in routine, the complexity of our once-simple daily living activities, loss of control, loss of the daily structure, loss of financial security, or the inability to travel.
Nurses have a very unique role. We care intimately for a patient, listening to hopes and fears, assisting both patient and family in processing a new or chronic diagnosis and its implications for a life once imagined. We stand at bedsides with people at their most vulnerable, when control is lost, and identity shifted. When parents, spouses, and children grieve a future which will not be, new life is suddenly radically altered, and a planned course comes to a traumatic stop. We, nurses, attempt to learn a healthy detachment through experience so that we can function as professionals and provide critical care while maintaining enough emotional distance to be as objective as possible. But we feel and notice the pain.
We usher life into and out of this world. We provide comfort and yet relay difficult information, educate families regarding changes in different organ systems with illness or approaching death, and are often the first to notice subtle changes (which can mean serious complications). We physically hold, touch, carry, and treat wounds of body, mind, and spirit. We are at the bedside day and night, serving as a trusted source of support and advocacy. At the end of a shift, we remove ourselves to rest and transfer the patient to the care of the next bedside provider. But we do not forget.
We reserve emotion, tears, and our own displays of vulnerability for the times we are not providing direct care, but they brim below the surface. We often fill the role of a family member who is not present. We counsel, encourage, provide insight and expertise, and track down the answers to the hard questions we cannot offer. We collaborate with our colleagues and the interdisciplinary team to provide the best possible experience for the patients in our charge. We hear hopes and dreams and try to fulfill what we can. We are creative and resourceful.
When sudden changes occur, a situation becomes traumatic, or a patient rapidly declines, we feel it. We become frustrated on behalf of our patients and families when complications ensue. We feel enormously responsible for changes, even when they are beyond our control.
We grieve when patients die. It is a multifaceted grief, as we are not family and cannot possibly know the patient in that way. And yet, we have been deeply involved in the care of the patient for days, weeks or months, and have watched the progress or decline of a condition. We have intervened and attempted to control complications as they have arisen, and we have assisted as experts have done the same. We have stood in the trench and fought alongside patient and family, and we search for ways to cope when the fight ends, regardless of whether it was an expected or unexpected death. No matter how death occurs, its effect is something for which we can never be prepared.
I have been a nurse for 13 years. Every death I have experienced is unique and personal. I have been present for traumatic and expected deaths. I have declared adults and children dead in field hospitals and as a hospice nurse. I have physically kept parents from collapsing onto the floor as they observed their children undergoing radical and terrifying intervention to save their lives. I still remember the sadness I felt when I learned the death of the first patient I had physically cared for. I did not know what to do with that feeling or how to adequately describe it, and the other patients I was assigned to for that shift needed my attention. That is how it so often happens with us: we have a moment to process devastating news, recollect ourselves, and move on to the next assignment or task in our day.
There are some particular experiences with death that remain as vivid as a photo in my mind. One little boy I had cared for during multiple admissions returned to the hospital with the beginnings of an infection, which seemed innocuous. He rode down the hallways of the unit in his red wagon, laughing and reaching up for my hand. I had come to know his parents well and had a good rapport with them. We had our picture taken on one such outing, a big smile on his face as he held my neck. His family provided me with a copy.
Within two days, he was in the ICU and on life support. An aggressive bacterial infection had attacked his heart and was causing severe damage. The only hope for recovery was a heart transplant, if his body recovered enough to undergo surgery. He remained on life support for several weeks as his parents begged for prayers and hoped for a miracle. However, it was not to be. The bacteria had entered his other organ systems, and they began to shut down. His family made the agonizing decision to remove him from life support when it was clear he would not recover. I learned of the decision and received permission from the team to be present when the time came. I stood and watched as his family embraced him, as life support was disconnected, and as his heart stopped. His mom came and thanked me for being there. She told me they would never forget me and that he loved me. After family left the room, I went to his bedside, squeezed his hand, and stroked his face. I then walked back to my unit and resumed the care of the patients assigned to me, who had been watched by other nurses during my time away. I pushed the pain and emotion to the side and continued with my day.
We walk a challenging, fragile line as nurses. We do our best to maintain professionalism, hiding and keeping our grief and emotion for private outlets and time away from work. At the same time, it is crucial to myself and many colleagues I know, to be genuine and authentic as we care for our patients. I discern whether to share my own experiences as a patient and will do so if it seems appropriate and my patients seek solidarity with their situation. And yet I do not want to take a patient’s experience and make it my own, as it is their story and journey. I am just a witness to that story and have the opportunity to be a trusted provider in their time of need. But it is their time, not mine.
It is easy to see where boundaries between nurse and patient become blurred, or to realize that attachments to patients become unhealthy. For this reason, many nurses choose not to attend the funerals for their patients, as that is their way of maintaining distance. It is also why there may be a rotating team of nurses caring for a particular patient, to maintain distance and objectivity in regards to our care and to share the burden of a case among several people as opposed to one person. Some situations intersect with our personal lives in ways we could not predict, and it becomes even more important to guard our personal space and tend to our hearts. I have asked not to be assigned to a specific patient, or to have a few days relief from a challenging assignment, to protect myself and the patient. Sometimes it is feasible, and sometimes it is not. But my obligation remains, to care for every patient in my charge with the same attentiveness and compassion, regardless of circumstance.
I have attended a handful of funerals and was asked to speak at one of them. I have found them both helpful and challenging, as each family and situation is different, and the grief is processed differently. Some have felt stark and forced, and others warm and celebratory. I am now in a cardiac intensive care unit, and the atmosphere is heightened because we care for the sickest children in our hospital and within the metro area. Emotions are raw, people are passionate and devoted, and it is hard work. We hold debrief sessions after patient deaths to assist in processing events that affect a whole team of caregivers. But the patient care does not stop. It is strange to pass a room where a patient recently died and see a new patient and family inhabiting that space.
We see. We hear. We witness and observe. We feel and process. We hold ourselves accountable. We experience the agony of loss and change. We grieve and notice, listen, and console. We embrace the challenge and understand the anger. We stand and sit beside our patients, and we experience the loss when death occurs. We continue to seek out, establish, and follow our own processes to cope with the impact these shortened lives have on ours. We cry and laugh, reminisce, and share our pain. And we come back to work and do it again.