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Changing focus from withdrawal of care to comfort care

An infected patient in quarantine lying in bed in hospital, coronavirus concept.

With so much death and debility caused by the Coronavirus COVID-19 over the past 9-12 months the terms “withdrawing care” or “withdrawal of care” have become notorious in health care. They’re such harsh terms for such a sacred path. The end of life should be calm and comfortable and peaceful and not feel like a dark and suddenly hopeless change of focus.

Death is not an uncommon factor with COVID-19. Over 356,000 deaths have occurred in the US alone, and the staggering rate of new cases has reached over 200,000 every day in the last weeks of December and continues to rise in 2021.  Nurse burnout is skyrocketing with escalating fears that there will be a mass exodus of nurses when the virus subsides, in particular many new nurses as well as those who were slated to retire years ago.

Death is part of life

Death is a part of life and nurses have all been educated to understand that death can be a part of their everyday work with patients. But for most fields of nursing, that part is normally an extremely low occurrence. Nurses have always held a high regard for hospice nurses who are “angels” and do the job most nurses know they aren’t cut out to do – until 2020 hit and the dreaded COVID-19 pandemic started sweeping across the world. Suddenly many more nurses were faced with dealing with dying patients on a daily basis and/or helping to educate the public in how to avoid getting the virus.

Today, nurses are asked to float from all over the hospital to COVID or even non-COVID units on med-surg or critical and intensive care units depending on acuity of the census. Some of the more difficult floating assignments seem to be sending Labor and Delivery nurses to these units. Saying “no” isn’t always an acceptable option although licenses may be challenged because they aren’t up to speed on the majority of what takes place in critical or intensive care. This doesn’t make for the best patient options, but sometimes there just aren’t alternatives.

From shortages of nurses (in particular critical care staff) to PPE to not enough ventilators, and shortages of treatments, nurses have had the hardest possible jobs this past year, and it’s escalating again as cases soar with no end in sight. The vaccine shortages and poor planning and logistics haven’t helped one little bit.

The added stress of having to deal with death multiple times each shift has caused increasing suicide rates in doctors and nurses for months. As this virus mutates and spikes post-holiday season, those rates are going to increase again.

Who gets care and who doesn’t?

Combined with a severe shortage of beds, there has also been a lot more discussion about having to choose who will get the bed, the treatment and the care as it comes down to who has the best chance of improvement and survival. Again, there’s that discussion of withdrawal of care. Looking at alternatives to “withdrawal” in a thesaurus, the choices don’t get any better. And in real time they don’t improve either.

For staff primarily untrained and inexperienced in end-of-life care, the stress levels are out of control. So, it’s time to stop and take some tips and clues from the palliative and hospice care play books to see some of the positives in the care and change the focus and attitude. Taking stock in end-of-life care isn’t any less sad but by centering on the positives that involve making the patient more comfortable and able to die with dignity nurses change the focus from the unthinkable to important last acts of kindness.

Facing death head on

Ask any nurse why they wanted to become a nurse and the answer will almost always contain some form of the statement, “I want to help people.” The important point to understand about facing

Angst with COVID-19

death head on is that the care doesn’t end when the curative stops; it’s about changing focus.

Nursing care at end-of-life is still all about assessing and meeting the needs of the patient. It won’t be about managing a multitude of tubes and lines and keeping O2 SATs above 85%. It becomes all a

bout comfort care, being present and helping patients transition to their next journey with peace and dignity. It’s about assessment and managing symptoms and anticipating needs. End-of-life care is more about hand holding, and hugs and helping family members who cannot be there have some final quality time with their dying loved one and having some closure. It’s not happy, or even less sad, but it’s still essential nursing care and it’s making a difference in lives that nurses may never fully understand or see. Death is cold and final.

Nursing has always been an extremely difficult job both physically and emotionally, but in most cases, watching the patient improve and go home is the ultimate goal and the reward nurses take to heart. Death feels more like darkness, losing and failure. It’s also so unfair especially when human touch is often missing, and family cannot be there for goodbyes. Or when the patient was young and vibrant and healthy just a few days ago with s loving spouse and children with their whole lives in front of them.

End-of-life care is so important, and it makes a huge difference for all of the lives touched. Death isn’t fair, but it doesn’t have to be cruel. With compassion and warmth and caring, nurses make a huge difference in the lives of their dying patients and their families. That’s the point and the reward nurses need to remember in this darkest season of their careers.