A nurse sits in a long, dark corridor with flickering fluorescent lights, consoling themselves over the death of a patient. Another hospital worker slowly walks up to them and sits beside them. The worker breathes down the nurse’s neck and makes their heart go cold. This worker works at every hospital, and sees every patient. Sometimes, they just poke their head into a patient’s room. But, they’re present every time a patient takes their last breath. This mysterious hospital employee is death, itself. Death intertwines with every aspect of a nurse’s life. Nurses constantly work with death–not only protecting patients from it, but when it’s time, easing them into it.
Death is dark. Nurses navigate its darkness by providing light in the care they provide. Katie Czaplicki—who’s been an RN for 22 years—works in the Cardiac Intensive Care Unit (CICU) at Hospital of University of Pennsylvania (HUP). She says, ”Death is a very unique experience. No two 18–year–olds’ deaths are the same. No two 88–year–olds’ deaths are the same.” The reality of the loss of a patient for a nurse is real and can be terrifying. When the integrity of someone’s livelihood is in your hands, you’re no longer “just a nurse”—you’re a guardian of life.
Jason Lai, a recent graduate of Penn Nursing, also works in the CICU at HUP. His first experiences with death as a nurse came to him as a shock. “It was a reality check,” he says. “This is a real thing that happens in hospitals.” There is a price that nurses pay and a burden they carry when they’re protecting the lives of their patients. Nurses know when they walk into their job that death is a possibility, and they’re trained on how to navigate it.
We’re shielded from the fact that death is natural—constantly attempting to escape the inevitable with more medications, more procedures, and more treatments. For years, healthcare fought to get people on life sustaining machines, but now providers are fighting to get them off the machines. In the last moments of someone’s life, part of respecting their humanity is letting them go. “It’s a fine line because you don’t always know what the patient wants for themselves, especially if they are sedated or intubated,” Lai says.
During the years Czaplicki has served as a nurse, she has realized that ”If somebody wants to pass and there’s nothing else you can do to improve their quality of life, you have to be accepting of that.” Recently, one patient she was caring for took his pain medications and fell asleep. After he woke up, he looked around the room at his family sitting beside him. He quickly grew angry about the fact he was still alive. He was prepared to die. ”Patients will be emotionally ready to let go, but their body hasn’t done it yet,” Czaplicki says. She understands this can be hard for both the patient and their family. Nurses must ensure they’re providing care “for” the patient and not “to” the patient. This distinction is difficult, especially when fighting the possible denial of death from loved ones or emotional connections with patients.
Nurses not only take care of their patients in death—they also take care of their patients’ loved ones. Czaplicki knows families feel anxiety when making sure their loved ones die “correctly.” “It is very hard to not feel guilty and wonder if you are doing the right thing,” she says. Patients are humans and deserve treatment for their best interest. Nurses view death with acceptance. They understand that the human mortality rate is 100%, and that they must come to terms with the intricacies of death’s process. However, acceptance is not always guaranteed.
While nurses may have seen death a thousand times, it doesn’t make these heavy feelings easier. Nurses are allowed to feel—each death is different than the last—and grief can be a lonely journey. ”Sometimes right after someone passes, you might need to just get back to work and see your next patient,” Czaplicki says. In a 2021 study about the emotions nurses experience during death, the most common were helplessness, sadness, compassion, and anger. Managing grief and the complexities of how death happens is difficult. Nurses must take care of themselves before they take care of others.
Grief is a journey each person must take alone. Even with a support system at your side, you must be the one to endure each stage of the grieving process. “Conversations are a good method to release grief or talk about something that's overwhelming, and it can be very therapeutic for people,” Czaplicki says. Both Czaplicki and Lai appreciate the culture of support that their unit provides. After a death, the CICU takes a moment to debrief, hold space for the patient’s death, and facilitate therapeutic conversation for the nurses involved in the death. “It creates a work environment where you don’t feel alone,” Lai says.
Czaplicki chooses to not confide in her family, as she believes work should stay at work. Lai, however, finds his friends to be a good place to go when death becomes too overwhelming to handle alone. He also makes sure to take days off when he needs a break. “It’s important to put the hospital life in the backseat every once in a while,” Lai says. Oftentimes, nurses can start to blame themselves for the death of a patient and compartmentalize their feelings because it is “part of the job.”
Nurses confiding in therapists and mental health professionals can be stigmatized. Both Lai and Czaplicki feel that Penn makes an effort to support their healthcare providers. COBALT—a mental health program started during COVID–19— is a service Penn Medicine offers for their employees. However, this service isn’t an option at every hospital. Alternatively, Philly Geek Therapy is a group that specializes in mental health care for health professionals. They provide specialized services tailored for health professionals and respect the fact that their job can serve as a barrier for getting the help they need. Their mission statement reads: “Stigma, the culture of medicine, fear of losing confidentiality or being reported to the board don't need to stand in the way of getting the help that will support you.”
Nurses experience the deaths of loved ones in their personal lives, in addition to patients at work. “I think nursing has helped me to be comfortable around those who are dying,” Czaplicki says. “Physically sitting there, the power to do that is completely immeasurable.” The coping strategies and sense of acceptance nurses develop toward the process of death are powerful. Nurses wield these abilities as they hold the hand of someone they love in their last moments. “It’s about being present,” Czaplicki says. “Sometimes that is the greatest gift you can give.” Lai feels that, sometimes, the death he experiences at work can negatively impact how he copes with loss in his own life. “You kind of can be desensitized in a way. It can impact your personal ways of coping if you aren’t careful,” he says. It's important to allow nurses to feel on and off the unit. They may shed tears and feel helpless in a guaranteed end, but they understand that death is transcendent.
Death can be slow and understood, or sudden and unexplainable. “Families and patients can be quiet and calm during death, or they could be on the opposite spectrum, screaming and hollering and very loud grieving,” Czaplicki says. Culture and spirituality can also impact how people perceive death. Some ethnic groups and religions oppose “pulling the plug” on a patient, or physician–assisted suicide and euthanasia. Lai reflects on the different cultures of his patients, and even his own culture: “I certainly can relate to this because in my culture, we don’t really talk about death.” Working with the different beliefs of patients and their loved ones can be difficult, but it becomes an essential part of the death process.
It’s an honor for nurses to guide patients in their deaths. Sometimes, nurses are the last people to touch them in their final moments. ”Some people unfortunately pass by themselves,” Czaplicki says. “Therefore, we’re the ones holding hands with patients. I am honored to do that.” Nurses have pride in being able to help a patient and their loved ones find the light in death.
The more we see the connection between the human spirit and the natural world, the easier it is to understand how beauty and death can coincide. Czaplicki hopes that people will grow to understand that “just like life, death needs to be respected.” Finding appreciation for the steps in the death process and having dignity for a patient’s passing is an art that nurses practice. Similarly, Lai wishes more people wouldn’t fear death as much: ”Don’t be scared of death and dying. It’s a life cycle, and fear can make people act or feel a certain way towards death.” Life is a constant, unpredictable circle, and nurses position themselves at the start and the end.
