Reflecting on Patient Death

Content Warning: This article talks about infant loss, pregnancy, and birth.

It was my second to last day on my neonatal intensive care unit (NICU) rotation for nursing school, just a few weeks away from graduating with my bachelor’s. While Completing 200+ hours in the NICU, I saw many conditions common with extremely premature babies, such as heart valve abnormalities, intrauterine growth restriction (IUGR), and persistent pulmonary hypertension of the newborn (PPHN). However, for this shift, I was training on the delivery team, attending high-risk deliveries to help the labor team care for newborns in distress. I was excited and eager to learn everything about the birthing process. What I did not know was the first birth I saw would also be my first patient death.

April 14, 2022, at 1433, “Delivery Team to the operating room (OR) 1” comes over our voceras in a monotone robotic voice. The nurse sitting next to me and I jumped out of our chairs and ran toward the OR hallway. Once we get to the OR, we throw on gloves, hairnets, and surgical jackets alongside the neonatologist, neonatal nurse practitioner, respiratory therapist, and pharmacist.

The team bustled in through the operating room doors and into the resuscitation room, where the labor nurse was waiting. It was a multiples birth, and the premature newborns had twin-to-twin transfusion syndrome (TTTS). TTTS is a rare condition in pregnancy where the twins share one placenta and a network of blood vessels (John Hopkins, 2021).

“Sometimes the vessel connections within the placenta are not evenly dispensed and there is an imbalance in the blood exchange between the twins. One twin — the donor twin — gives away more blood than it receives in return and runs the risk of malnourishment and organ failure. The recipient twin receives too much blood and is susceptible to overwork of the heart and other cardiac complications” (John Hopkins, 2021).

When delivering twins, one twin is designated “twin A” and the other “twin B.” In this case, “twin A” was considered the donor twin and “twin B” the recipient twin.” After receiving a brief report from the labor nurse, my preceptor and I flew into action, getting ambu bags ready, drawing up resuscitation medications, and preparing the warmers. No matter how physically prepared I was to save these twins, nothing could have prepared me mentally for what was about to happen.

Going into the nursing profession, I knew that I would be around death; it is a natural part of nursing. While in school, I worked as a registered nurse at a memory care facility, so when I thought about how my first patient death, I saw an elderly patient surrounded by loved ones. It’s not that I believed an older adult death would be less impactful; I just naively assumed that I could compartmentalize it in my head a lot better. I could tell myself that they had lived a long, happy life and got to tell those they loved goodbye. I did not expect my first patient's death to be a 24-week premature infant whose life had come and gone in a blink of an eye.

From the resuscitation room, I hear the surgeon yell, “twin A, incoming.” I ran over to the doors connecting the OR to the resuscitation room and was handed this premature infant that I swore at that moment was lighter than a feather. He was beautiful in his fragility, with skin so pink and thin you could see every vessel, with a body s not much bigger than my hand, and a hand so small that, even if he had the energy, he couldn’t wrap all the way around my pinky. I laid him down on the warmer, and the team bustled around. I was listening and feeling for any viable signs of life, with only a faint echo of a heartbeat being able to be detected. After two minutes of attempted resuscitation, the neonatologist called the time of death 1447. 1448 “twin B, incoming” yelled the surgeon. I stood frozen in the corner as the second resuscitation team attempted to keep “twin B” alive.

After resuscitation team two stabilized “twin B” to be safely transferred to the NICU, my preceptor and I stayed behind to clean up “Twin A.” We wiped his paper-thin skin clean and wrapped him in two blankets; blankets and all, he only weighed 1.1 pounds, a little over the weight of a can of coke.

Sitting in the parking lot, I tried to close my eyes to block out the image of this frail child lying alone in a warming bed next to his brother, who was fighting for his life. Driving home, I turned up the music in my car to drown out the sound of silence when the stethoscope was on “twin A’s” chest, to drive out the sound of the mother’s cries that were on repeat in my head. I told myself to make it home, and then I could start to process what happened, but as I turned right onto East 26th street after pulling out of the hospital’s parking ramp, a lump formed in my throat, and a flood of emotions came over me. I was sad about the loss of life, angry that this new mother now only has one of her twins to take home, confused as to why none of us talked about the death after it happened, guilty even though no one could have done anything, selfish for feeling the need to grieve even though he was not mine to grieve, and terrified that this was going to make me not want to become a NICU nurse.

My original intention for this article was to talk through my experience of my first patient death while also discussing my process for dealing with patient death. Since this happened, I have experienced five adult patient deaths, and with each death, I assumed the process would get easier, but in fact, it hurts just the same. No course or lecture in nursing school (or life in general) teaches you how to cope with patient death, and with all of our different cultures/backgrounds, we all handle death and grief differently. Finding a personal way to process emotionally traumatic experiences, like patient death, is crucial to surviving your nursing career. I encourage you to sit in your thoughts and the pain you feel in these moments and reflect often on them, to never let the next death become easier, and always to remember why you do what you do. Maybe these three things are the key to coping, or perhaps they were just what worked for me.

References

Johns Hopkins. (2021, August 8). Twin-to-twin transfusion syndrome (TTTS). Twin-to-Twin Transfusion Syndrome (TTTS) | Johns Hopkins

Medicine. Retrieved February 24, 2023, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/twintotwin-transfusion

syndrome-ttts