1. Braun, Susan RN

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America has always been recognized for its diversity and for being a melting pot of cultures. I am a staff nurse on a 15-bed palliative care unit, and sometimes this diversity is evident. As a nurse, I have witnessed many deaths, and I can honestly say that no two are alike. Americans are just as diverse in the way they approach death as they are in all other aspects of their lives.


Some families are small, whereas others are large. People will come and sit at the bedside, waiting, watching, and remembering the person in the bed. Some people pray, whereas others hope for something different-and many wish for a miracle recovery, even within minutes of death. Visitors, friends, loved ones-some stay for a few minutes, whereas others stay all day and night, taking turns, and ensuring that someone is always at the bedside-keeping a vigil for the dying person.


Last weekend I cared for two different people in Room 42. I was particularly struck by the differences I witnessed in these two families and wanted to share my story.


Anna was admitted on Friday afternoon. She was a beautiful dark-haired 45-year-old woman who was losing her fight against ovarian cancer. Her parents, Pedro and Maria, were at her bedside, along with her husband Jose. Anna's family was a large loving Hispanic family that was devoutly Catholic. Prayer candles were lit and burned the entire time that Anna was a patient on our unit.


As Friday evening progressed, I learned just how large Anna's family was. Her 4 brothers and 5 sisters came with their families. Elderly aunts and uncles joined the group. There were lots of youngsters, including Anna and Jose's 3 children. The children played in our family room while the adults surrounded Anna's bed.


Anna was aware of her surroundings, but I never once saw her open her eyes. She had suffered a cerebral hemorrhage before admission and was actively dying. Despite her nonresponsiveness, her family members held her hand and talked to her. Her sisters told her they would help her husband and children. They caressed her, cleaned her mouth, and placed cool cloths on her warm forehead.


Several cousins came and brought boxes of food. The children were fed while the adults took turns surrounding Anna and supporting each other. At midnight on Sunday, Anna drew her last breath. At least 50 people came to Anna's body early that morning and prayed with her family.


The next afternoon, Elmer was admitted to Room 42. He was an 87-year-old white man with a history of stroke and associated right-sided weakness. He now had pneumonia and was not improving, despite respiratory treatments and intravenous antibiotics. He had slipped into a minimally responsive state and had long periods of apnea interspersed with periods of rapid breaths.


Elmer was alone when I started my evening shift. His hands were cold and blue, but his face was warm and pink. I brought blankets from the warmer and wrapped his cold hands. I adjusted the pillows and lowered the lights and tried to make him as comfortable as possible.


It was apparent to me that Elmer was dying, but it was not clear from the chart how much the family knew. I called the physician to discuss Elmer's plan of care and learn more about the family situation. After describing Elmer's physical appearance, Dr Nichols stated that it sounded like Elmer's condition had worsened considerably since the morning when he had last seen him. He did mention that he told Elmer's wife, Betty, that the situation was grave. Dr Nichols said he would call Betty to discuss Elmer's worsening condition and decide on a plan of care-which he did. An hour later, he called me back. Betty understood that Elmer was dying and agreed to stop the antibiotics. Other medications were ordered to relax his breathing and dry his secretions; oxygen was administered for comfort.


Soon after I had implemented these interventions, Betty called and introduced herself. She lived in the country and could not drive at night, so she was not able to come to the hospital. "Anyway," she said, tearfully, "Elmer and I have been married 67 years. We've said our goodbyes. I think he would want me to take care of myself right now." She asked that Rose Mortuary be contacted if he "passed" in the night. "Please don't call me in the night. I'd rather not know that he has died until I can come into town. My daughter is here and we will be able to drive in together." I told her she could call the nursing unit at any time and supported her in the decision that she had made.


As I hung up the phone, I thought back to the night before when Anna had occupied Room 42. In my mind's eye, I recalled the large family surrounding the bed and then came back to the present moment. Although Elmer looked as if her were alone, I knew he had a loving wife who was also at his side, not in person, but in spirit. At that moment, I was struck by the differences in families and their ways of saying goodbye to loved ones. I am touched by each of these families and appreciate their different ways of tending to the business of living-and dying.