1. Section Editor(s): Brandolini, Jenna Marie BSN, RN, CCRN

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Being a nurse in the pediatric ICU (PICU) isn't all that different from the boy scouts. We both follow the same motto: "Always be prepared." In the PICU, we have a plan for everything. Trauma on the way? Sick admission? Line placement? We have a plan for that. Somewhere in the back of my mind, I have an acronym or checklist from which to draw. I can tell you what supplies I need, what medications are warranted, and how to set up the room. Although these checklists aren't fool proof, they're similar to the mise en place in the culinary world. The more things I have in place, the more prepared I can be for whatever might happen.


We even have a checklist for death. I've helped families make handprints with their dying child. I've cut locks of hair, played favorite songs, and taken photographs of families on their last days. We've done baths, performed last rites, faced beds toward Mecca, and consulted with Gift of Life. I've participated in meetings between families and the medical team-the type of meetings during which we know we have to look parents in the eye and tell them their child isn't going to grow up. I've been to patients' funerals, hugged families, and said goodbye with a sense of closure.

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After a while, you learn what to say. You tell a family who's withdrawing care that they're doing the right thing. You tell a father whose praying for a miracle what one ICU mom told me at her son's funeral: "We don't always get to choose our miracles and maybe it was a miracle that we had him for as long as we did." You tell a mother who's about to help her child exit the world that we should all be so lucky to die in the arms of our mothers. And when you leave your shift that day sad and heavy-hearted, you also leave with a greater sense of self. Some days at work I don't get to help children live, but I do get to help them die.


In the worst situations, when there's no time for meetings and death is sudden, there's still a sense of closure in resuscitation. As medical professionals, we're counting every round of epinephrine and each minute of compressions, until we're convinced that it isn't working, until we're certain that the end result would leave a family with a child who's nothing like the one they used to know. There's a moment when you see a look cross everyone's face and you know what you're doing isn't going to work. And then we still go for one more round so we can take comfort in telling the family that we did everything we could do.


As nurses and as human beings, we all try to do the best we can. But this job is full of unexpected twists and turns and sometimes no matter how many checklists and plans we have in place, just when you feel like you know the lay of the land, something comes along that knocks you off your feet. What can you do when you aren't prepared for your patient to die?


More often than not, when situations arise for which we aren't prepared, as nurses, we simply push on. We fill assignments quickly, turn rooms over, and go about the shift. We aren't always encouraged to talk about death and dying, especially in situations that don't necessarily go as planned. Stifling emotions has long been associated with professionalism of medical staff. When a patient dies, should we act as if death is simply a part of our job? Or is there another way to cope?


Communicating with patients and their families is an integral part of the process of coping with death and dying. Talk to your coworkers. Work with your medical team to initiate debriefings on particularly difficult or traumatic cases. You may want to talk to your friends and family, but remember that outside parties often find it difficult to relate to these intense situations. Many hospitals offer private and confidential mental health professionals and grief counselors to nurses and staff. Find out if your hospital has a program and spread the word to your coworkers. Hospitals and supervisors can offer support with the simple acknowledgment of a patient death. Giving nurses time to talk and grieve together, and admit that death can affect us, can be extremely helpful.


The truth is, no matter how many lists we have in place, we can't always be prepared. I encourage you to share your stories. Not only can we learn from them as nurses, but we can also help each other cope as human beings.



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