An estimated 20% of all deaths in the United States occur in the intensive care unit (ICU).1 However, no 2 deaths are the same. Critical care nurses must be prepared to handle each death with utmost respect and responsibility. There are times when families are unable to be present at the death of a loved one. This article highlights how Haley, 1 of the authors, stepped in to be "present" because the patient's family lived outside the United States. The story is told from her point of view.
HALEY'S STORY
"Gustavo's" story began on a fall morning when he was admitted to the ICU with diabetic ketoacidosis (DKA). In his late 20s, he was from Guatemala. He has been living in Mississippi for 3 years but had been in this town for only 3 days. He was married, and his wife and children were in Guatemala. He did not speak English and been brought to the emergency department (ED) by 3 men who had just met him 3 days before. They could not offer any significant medical or social history. Gustavo was very ill but he was able to tell the interpreter in the ED that he had no history of illnesses and had never seen a physician. He appeared to be confused at times. The 3 men described Gustavo as just "not acting right." The 3 men left after giving a brief description of what they had witnessed with Gustavo. A routine work-up in the ED indicated that Gustavo was in DKA. His glucose level was greater than 1000 mg/dL. He has varying degrees of responsiveness with confusion at times. His respirations were rapid; thus, he was admitted to the ICU.
After receiving report from the ED nurse, I could tell that Gustavo was going to require most of my attention that night. Within a short time, his condition began to deteriorate rapidly. His physicians and I closely monitored his laboratory values, including sodium bicarbonate and calcium. However, when 1 laboratory value was corrected, the other would be affected. His respiratory function deteriorated as well and he advanced from nasal cannula, to bipap, and then intubation. The physicians were baffled by this young man's presentation. Everyone knew DKA was present: (1) ketones in his urine, (2) carbon dioxide level was less than 10 mmol/L, and (3) his blood glucose level was extremely high in the thousands. The team of nurses and physicians considered other illnesses, which included pancreatitis, sepsis, or even foul play.
After Gustavo was intubated, the 3 men who brought him to the ED came to visit in the ICU. They spoke to Gustavo in Spanish and I then obtained contact information for Gustavo's wife in Guatemala, although they were very reluctant to share this information. Because they had known him for only a short time, his wife's telephone number was all they shared. I asked for a contact number in the event Gustavo's condition worsened. Finally, 1 of the men gave me his telephone number. I explained to the men that Gustavo was critically ill and it was important for them to stay. However, when I left the room to obtain medication, they had left. After the men left, I began to think: "What if my husband was in critical condition in another country and I had no idea." So I attempted to get in touch with his wife and determine if it was possible for her to come to the United States. I first spoke with the charge nurse and then the administrator on duty, who both suggested calling a social worker. The social worker suggested calling the US embassy in Guatemala to see if they could provide a medical visa. If they were willing, the social worker could start on the paperwork the next morning. I then spoke with a physician caring for Gustavo to see if she would be willing to complete the necessary paperwork right away for the wife to come to the United States. She agreed, and then I called the embassy. Because it was after business hours, the embassy was only able to work on emergency military visas.
The charge nurse and I saw that Gustavo's vital signs were worsening. I called the physician, and as she entered the room, Gustavo had a cardiac arrest. Cardiopulmonary resuscitation (CPR) was initiated and medications were administered. After a few minutes, a pulse could be palpated and he converted to a normal sinus rhythm. The team debriefed and formulated a treatment plan. The physician ordered more laboratory tests and medications. Two hours later, Gustavo's vital signs deteriorated again and I called for help. This time, Gustavo developed a dysrhythmia without a pulse. The team administered CPR and defibrillation and administered medications to try to restart his heart. After several minutes, his pulse returned and the monitored showed a normal sinus rhythm. This time, the physician did not leave the room and she sat beside his bed. After 30 minutes, Gustavo developed asystole. Medications and CPR were given. This arrest lasted 30 minutes. Before the physician ended the resuscitative efforts, she reviewed everything the team had done and asked for any suggestions. There was nothing else to do, and in the early morning hours, the physician pronounced time of death. Everyone in the ICU had become involved with Gustavo. He was not just my patient; he was everyone's patient that night.
After Gustavo's death, the nurses discussed the events of the night and what we thought had gone wrong with this young man. We also discussed if there was anything we could have done differently. The process is similar to a debriefing. The physician stayed to make sure all staff members were all right and to answer any lingering questions. Some staff shed tears for Gustavo.
The physician then asked if anyone had contact information for Gustavo's family or friends. I told her we had a local number of 1 of the men who visited him and his wife's number in Guatemala. The physician asked me to try to get someone on the telephone. I tried the number the man had left, but it had been disconnected. I had Gustavo's wife's home telephone number but needed an international calling card. The physician let me use her card and I placed a call to the wife hoping she would be able to understand some English. The physician said she would be willing to speak with the family as long as they understand English. A woman answered the telephone in Spanish. I repeated "English" over and over, in the hope she would give the telephone to someone who could speak English; however, she hung up the telephone. I prepared Gustavo for the medical examiner. I began to cry because he had died with no family or friends at his side. Then I was reminded by the charge nurse that Gustavo did not die alone. He had a team of nurses and physicians with him all night. The charge nurse reminded me that I never left his side.
The next morning, an interpreter was available. The interpreter and I called Gustavo's widow to tell her what had happened to her husband. We told her of all efforts taken to care for Gustavo and that he did not die alone. As soon as the wife hung up, I was at peace, ready to go home and get some rest since I had to work the next night. Today had been a great day to be an ICU nurse.
LESSONS LEARNED FROM HALEY'S STORY
As ICU nurses, we often care for patients who are gravely ill and not expected to survive. For us, it may be easy to forget that although death is common in the ICU, for each patient and family, it is the patient's only death. In Gustavo's case, I knew that Gustavo's wife would want to know what had happened and everything had been done to care for him.
Caring for patients who do not speak English, may be from another country, or have English as a second language poses challenges for all nurses. Not having family or an interpreter nearby poses an even bigger challenge. After my work was finished for the day, I realized that "caring" is a force not only for protecting and enhancing patient dignity but also for protecting and enhancing our dignity as ICU nurses.
Acknowledgment
The authors gratefully acknowledge the vision, inspiration, and editorial assistance of Ms Elizabeth Tornquist, MA, FAAN, Kathleen Ahem Gould, PhD, RN, and Vickie Miracle, RN, EdD, and the wonderful assistance of Mrs Dawn Wyrick with this manuscript.
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