From the Archives: Grace

It’s really interesting to me to re-visit this reflection I wrote about *Grace. This was my first experience of a patient dying when I was a first year student nurse. It’s so interesting to look back on especially now that I work in palliative care, to see the knowledge I had, or should I say I didn’t have then and the things I know and have experienced and seen now almost 3 years on. There’s moments where I hear the voice of someone naïve here but I also know that so much of these things are still incredibly important to me now as I nurse people at the end of their lives daily.

June 2017.

Last week whilst I was working on the ward doing a bank shift as an HCA, a patient died. This is my first experience of seeing the life disappear from a person in my care.

I remember the lesson we had at uni last year looking at ‘end of life care’ and one of the first thing the teacher did was ask us to think of words for death or dying that didn’t actually use those words. ‘passed away’ ‘went to sleep’ ‘passed over’ ‘slipped away’ were just a few of them. His point in making us do this exercise was to show that ‘death’ is a subject people don’t like to talk of, so much so that they mostly don’t even use the word.

It’s something that impacts us all. It’s the only thing that we can guarantee in our lifetime. It’s the greatest loss we ever experience. Ironically death is an essential part of life.

I feel we were protected in the classroom, we were given the opportunity to leave the classroom at any time and no questions would be asked, we were able to ask uncomfortable questions, delve deeper into the things we didn’t understand, and we were able to distance ourselves from the scenarios we discussed. The lesson was to prepare us, to make us think and to know what to do should we be impacted by death whilst in clinical placement. But in the hospital setting there is no protection, what happens is very much in front of you.

The actual calamity of the person dying is not the paramount that it should be. It’s an event that warrants you to be mindful of your behaviour. To have sensitivity and compassion for the relatives, to try to conceal what has happened from the other patients, to be composed, prepared and sagacious. To not allow your own personal experiences of death and loss trickle in and taint the flow of thought. When a whole family’s world has just changed and one persons world has reached it’s end, the world simply ticks on around them and their grief. There are still patients to feed and change, the bells still ring out, the dinner trolley still comes round and there’s probably a tray on it for that person that is no longer in this world. The ward and the world carry on assiduously through that persons silence and stillness.

The significance of this event for me was that I wasn’t working on the ward as a student nurse, someone who can bow out of things if need be and is a supernumerary member of the team. I was a paid healthcare assistant there to do a job and to look after 7 very unwell and unable patients simultaneously. It was my job and my responsibility to take care of the aftermath of this death and also ensure all my other patients were also cared for and blissfully unaware that my 7 had just become 6. Doing a bank shift meant that it had been a week since I last worked on that ward and I had not built a relationship with this lady which probably made it all easier for me to digest and to handle.

*Grace had been in a side room on the ward. This meant she was by herself in her own room. She was fast asleep in the morning when I went in to get her breakfast order, so I just ordered her some porridge and some tea and hoped she’d be happy with that. I fed all my other patients before going back to her to see if she was awake. I woke her, she was lying on her side and she had clearly dribbled and a trail of it had hardened down her chin. I spoke with her and cleaned her face. “Would you like some breakfast Grace? I’ve got some porridge for you?” She faintly smiled and eagerly nodded. I had to try and reposition her in the bed in order to sit her up but also make her more comfortable. As grace wasn’t very mobile at all I needed assistance, luckily at that time an HCA from palliative care came in to see Grace, we changed Grace and her bed together and repositioned her. As Grace had been in hospital for a while and was bed bound, she had pressure sores which meant we had to ensure she was repositioned at least every 2 hours and that she wasn’t on her back too long to allow the sores to heal. As I looked at Grace’s notes the first page was a document entitled ‘end of life care’ there are often procedures in place for patients that are facing the end of their lives that they are not resuscitated at the wish of them and/or their families. I knew from this and that the HCA from palliative care had come to see her, that Grace probably didn’t have long left. The young HCA who helped me help Grace was so calm and gentle in everything she did. I watched and learnt from her. All her patients are always dying, she just had a different way that I can’t explain. When I saw her at the computer afterwards, I made a point to tell her how good I thought she was at her job, I’m sure she doesn’t hear it enough.

Once alone again I attempted to give Grace some porridge, she didn’t seem to take it despite how eager she seemed at the prospect of breakfast. I noticed that her breathing was slightly laboured, she sounded like she had flem in her throat, I asked the palliative HCA if she thought she needed some suction, she said no she wouldn’t do this as it would be too distressing for her and we just had to sit her up and hope that would help clear the mucus in her chest. I took the porridge away and grace went back to sleep.

Her daughters arrived soon after, I left them alone in the room for a while as they were saying prayers and reading things to their mother. I took in Grace’s lunch tray just after midday and they both looked at me surprised and said – ‘she can eat?’ I explained that she had seemed keen for breakfast and that she didn’t have any so she probably wouldn’t have lunch but that I would leave the tray and if they wanted to try and give her some and I’d come back to check. Before I had gotten back to them one of the daughters approached me – ‘Nurse’ she said ‘mums breathing seems to be getting worse’ I went in to see her and it did seem worse. I repositioned her again and suggested we see if that helped her clear her chest a bit, I also gave her some mouthcare and the nurse I was working with had gone to get something from another ward so I said when she returned I would get her to come in and see Grace. After that I was pulled to help in another bay and put a patient on the bed pan and was leaving them for a moment of peace. As I came out from behind the curtain the daughter was there looking for me again just minute later ‘It’ getting worse, please can you come and please can you call the priest, I need the priest to come and see her’ she became more and more distressed. With my nurse still off the ward I ran to find the ward sister – explained the situation and said she needed to go in and see Grace as her breathing was deteriorating. I then bleeped the chaplain. I bleeped the chaplain 6 times that afternoon…sadly the chaplain never came.

The ward sister escalated the care and gave Grace some morphine and calmed her. The daughters sat either side of her bed looking at their mother who was slipping away before their eyes. She asked us if there really was any point in giving her any pain relief as she believed she would soon be gone. We explained to her that keeping her comfortable and not in any distress was important for Grace and for her daughters. I watched those daughters change over the next couple of hours, going from looks of desperation and words pleading with their mother to stay with them, to accepting what was facing them and just prioritising letting their mother know that they were there and that it was ok to slip away. They said prayers and laid an ornament of Jesus on Grace’s chest. They occasionally smiled through their sobs.

Within a few hours Grace took her last breath. And we all heard it because her breathing had been so loud in the lead up to it. An exhaled breath that was never followed by another inhaled breath, only silence. A stillness you can’t describe, a silence that inexplicably rings in your ears, a moment that you physically feel in your heart. That was the moment that Grace ‘passed over’.

The sobbing of the family members who came to see a lifeless Grace was a sound that rang through the ward. The sound of ultimate grief, the cries of a sadness that comes from deep within. As someone working on the ward all you can do is carry on – there are those 6 other patients. Leave the family to have their time with Grace and digest what has happened. I made them all some tea and got shouted at by the tea lady for attempting to do so in china cups rather than polystyrene. I guess that’s the tearoom owner in me. Tea in polystyrene is wrong at any time, but after a shock and a loss like this, these ladies needed china, but no, they got polystyrene – hospital infection control apparently.

The nurse and I went into the room after about an hour and asked the relatives to leave for a moment. There are things that need to be done before certain times. We straightened out Graces lifeless body, removing the Jesus ornament from her chest, and lay her flat on her back. We still spoke to Grace as if she were still alive, we explained what we were doing and gently held her hands as we closed her mouth and shut her eyes. It was a very peaceful moment for me, I wasn’t scared, I wasn’t inconsolably sad, I knew that Grace had come to her natural end, it was her time. She wasn’t taken too soon, and she was now free from suffering. Whatever we believe happens after we die Grace’s daughters made sure she was as connected with the god and the heaven that she believed in as she descended into her journey into her version of the afterlife. I truly believe Grace made her journey to a better place that night.

We disconnected Grace’s oxygen nasal spec, her morphine pump, the cannula in her hand and her catheter. We took off plasters and the electrodes from her chest. We made Grace human again even though she was no longer alive. We detached her from ‘the hospital’ and the pain and the things she had come to depend on, the things that probably made her frustrated and the things that we would no longer have to monitor. Her limbs were still warm to touch, we covered her up with the blanket again and covered her face with a crisp white sheet. The sheet almost drew the curtain on Grace’s life. It drew the curtain on her pain and it allowed her family to remember her face filled with colour and life and not the human frame that now remained of what was once Grace. Her daughter put her hand on my shoulder and thanked me as we beckoned them back into the room.

The nurse turned to me and said ‘how many times have you done that before’ I replied ‘this is my first time’ – her face completely changed, she looked horrified, she apologised to me and asked me if I needed ‘a moment’ and was utterly shocked that I had remained so calm and dignified throughout the incredibly personal and intimate moment we had both just shared with a dead body that was once Grace.

My shift finished just under an hour after this. On my way out I slipped back into the room to say goodbye to Grace’s family, they thanked me sincerely with their red and swollen eyes. They had no idea that Grace was my first patient to ‘pass away’ they have no idea that I will remember Grace for the rest of my life, her face – both alive and dead, the way her skin felt, the way the silence rang in my ear and the way I will always wonder why the chaplain never turned up. Grace is a part of my journey to becoming a nurse and becoming strong. The lessons she has taught me in her passing she will never know, the way she made me feel as I got into my bed that night she will never know.

God bless you Grace, you are in my heart. You touched a stranger and you accepted your fate gracefully in nature and in name. Rest in peace dear lady.

*Graces name has been changed.

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