The Conversation

I know this is a difficult conversation for you. It is hard for me too. While I was walking down the hall to this room, I was secretly hoping for a miracle, a sign that we had made a mistake and everything was going to be okay.

I have been taking care of your loved one for a while now. We have used every tool we have available to heal him. Unfortunately, it does not appear that he will ever be the person he was before. No, he is not going to wake up and be okay. I understand you believe this is all in God’s hands, but it is time to make some decisions about where to go from here.

His body cannot survive without the machines that are supporting him. I know he has made some progress. His blood pressure and heart rate are normal. However, he is now dependent on dialysis because his kidneys have stopped functioning. He is not going to be able to breathe without the ventilator.

Where do we go from here?

Have you ever had the discussion with him about his wishes?

There is are no further medical interventions left to try. This is the new reality. There are few resources available for people in this condition. What quality of life can one expect in this condition?

I know you had hoped for a different result. Yes, he is a fighter.

This conversation never gets easier. It always hurts and I always wish I could be anywhere else. I often wonder how I would feel if it were my family member, and I try to remember the fear I would feel. I try to imagine what my concerns would be.

I do everything in my power to be able to answer the questions the family has. I make sure I have time to listen. I make sure I am completely honest. I try to keep my personal feelings out of the conversation. This is about this patient. Sometimes acknowledging the reality of the situation is the most important act I can do.

The conversation about goals of care is difficult for many healthcare providers. For some of us, especially early in our careers, it can feel like a personal failure when our patients do not survive. The crux of the situation is that everyone will die someday. Perhaps the best thing we can do is offer dignity and peace when death is looming. Comfort measures does not mean giving up. Dying is a natural part of life. We should feel lucky we have the tools to help ease suffering.

Your Nurse Practitioner is only human…

  I may have underestimated the power of human connection. As a Nurse Practitioner, I am fortunate to get to meet and know so many different people. You can try all you want to keep an emotional distance. You can attempt to maintain “professional boundaries.” You can almost convince yourself these patients and their family do not affect you.

Sure, this is reasonable. It is all about self-preservation. You have to be able to leave work at work. Otherwise, you would be entrenched in stress and grief all the time. I have to be able to laugh while I am at work. I cannot allow myself to be mired down in the misfortune of the sick and suffering. I am not only a Nurse Practitioner, I am also human and I cannot help but to forge a connection with people.

It may be your wit and charm. Perhaps you told me a dirty joke I was not expecting. Your face may light up when you talk about your children and grandchildren. It does not matter what causes me to allow you into my heart, it just happens. We are humans.

When I am at work, I pour most of my energy into evaluating what you may need. I am filled with self doubt, so I agonize over every decision. (Well, as I mature and have more experience the agony is decreasing.) I hold myself to nearly impossible standards. Sometimes I am inexperienced in your particular condition. The panic sets in and I have to start reading. I rack my brain and try in vain to remember everything I have ever heard about this situation. I do not take my ignorance or inexperience lightly. I ask questions and I am very forthcoming about my need for assistance. My ego is not so fragile that I can’t ask for help. I work hard to remain teachable.

Keeping in mind when I am at work and I make a mistake, the consequences can cost lives or cause irreparable harm. I am invested. The boundaries have to be blurred a little. This makes it difficult when a patient is not responding to the course of action we have laid out. It is especially hard when we run out of tricks to try. Sometimes there is nothing we can do. This is the hardest part of my job.

Now, if you come to me looking for answers and I reach out to the experts and there is nothing else to be done… what now? I don’t get to sign off and retreat back into blissful ignorance. I am now tasked with explaining the situation and helping you decide on which actions are appropriate for further care.

I find this job especially cruel when I think you are going to do well. I see initial success in our last-ditch efforts. The Hail Mary pass seems to be working. Then, despite the successful catch, we fumble the ball. I am going to scramble to try to recover it. Sometimes the damn ball just disappears.

This is the worst part. Dying is part of life. We are all going to die someday. Yes, we can try to help people live as long and healthy lives as possible. There is going to come a time when I have to be willing to sit with you and discuss whether or not you want to continue aggressive medical care. If you tell me you are done, I have an obligation to honor wishes and to support your family through that transition. It goes against every thing in my heart. I want everyone to live happily ever after.

I can try to have boundaries and walls. I can try to keep work separate from real life. Sometimes, I will fail. In order to heal from this grief, I have to acknowledge I am experiencing it. I have to allow myself to feel. I do not want to become a cold, unfeeling person. This opens me up to heartache. I am okay with that. It also opens me up to feeling sincere joy when my patients do well. It is not all just another sad day, there are lots of victories. I get to feel them too. Yeah, it is exhausting at times. It is hard. I would not want it any other way.