Our communities are under unprecedented stress during the COVID-19 pandemic. Nonessential personnel are isolated and quarantined at home. Some people may have to drop off an extremely ill family member to a hospital’s emergency department, creating psychological trauma for them and their loved ones. Some patients may be screened, treated, and discharged; but for others, it will be the last time they physically see their families. People at the end of life need a way to transition to death with dignity and for members of their support system to be able to say goodbye. It often falls on nurses to serve as a bridge from patients to family and to provide support for those who are dying. Nurses often suffer from the weight of this responsibility.

Now, more than ever, nurse leaders must think outside the box to determine how to support dying patients and the staff caring for them. The concepts of Jean Watson’s Caring Theory are ingrained in our nursing philosophy, empowering us to deliver compassionate and dignified care. In addition, Benner’s Novice to Expert Theory and Watson’s Caring Model have been used as our foundation to develop skills and expertise. As nurses take the humanistic approach that is second nature to them, they have cried, conveyed compassion, and wondered at the rampage this virus has created. We have found several strategies to be effective in helping families and staff during these difficult times.

Supporting families

One of the authors (Sanchez) provides this example of how to creatively support families.

“I was asked by a patient’s family if they could be present at their father’s bedside as he was dying. As a nurse leader, I was challenged with the dilemma of limiting exposure to the family of the COVID-19 positive dying patient or not having the patient’s son, daughter, and sister present at the bedside as a dying wish.

I decided to provide full PPE to the family so they could be with their dying father on his deathbed. I told them they must use social distancing with our team and with each other. They donned masks, gowns, gloves, and face shields.

It was brought to my attention that the patient was a U.S. Navy Veteran who was part of the team responsible for retrieving the Command Module Columbia capsule that carried astronauts Neil Armstrong, Neil Collins, and Buzz Aldrin to the moon and back after it splashed down. The family wanted to have some sort of naval salute to their father and requested that The Star Spangled Banner be playing when he took his last breath.

I reached out to the medical team, the nurses on the unit, and the nursing director. We found The Star Spangled Banner, recorded by the Navy band, on our personal smart phones. I also called on military veterans currently working in the hospital to come near the patient’s room, with full PPE, to say a few words to him, recognizing his service, and offer a salute to their fellow Navy shipman. As the families said their final goodbyes from 6 feet away in full PPE, we played The Star Spangled Banner and saluted the patient as he took his final breath, and we cried with them.”

 Nurses can use smart phones with videos (such as FaceTime) to allow family members to be “present” when the patient dies. Our nurses have propped the phone up in the room, held the patient’s hand, and prayed with the families, all while in full PPE. The clinical nurse is the hand for the families who want to hold the patient’s hand, the touch on the forehead of the dying patient, and the voice of the family members, as they watch, in their own isolation, their loved one take his her last breath.

If there are no family members or family members don’t want to view their loved ones’ suffering, nurses and medical staff can still be present with the patient. To ease the stress of this experience, we have all staff take a collective, unsolicited moment of silence to honor our fallen patients to COVID-19.

Supporting clinical nurses

Nurse leaders can apply several key concepts to assist clinical nurses.

 Recognize the moral dilemma nurses are facing.

• Allow moments for clinical nurses to talk and verbalize their feelings and fears in a forum where they can feel safe and supported.
• Use a team to help strengthen staff resilience. The team should consist of personnel from human resources, pastoral care, and mental health services. Team members can empower nurses to express the emotions they are facing, including the distress of seeing people of all ages suddenly die. The experience clinical nurses have with a dying patient often makes them conscious of their own, or their loved ones mortality, which can be difficult.
• Provide safe spaces in break rooms and areas in the hospital where nurses can decompress and relax.
• Find coverage so nurses with patients as they die can step off the unit or even go home, providing valuable time for them to process their grief.

Show gratitude.

• Recognize the heroic efforts nurses provide for the patient. Nurse leaders need to praise nurses, even when all interventions were futile, in order to recognize how they were able to provide the patients with dignity during the dying process.
• Follow up with a phone call, text, or face time with the nurse later that day when the nurse is off duty and/or later in the week to see how he or she is doing.
• Conduct interdisciplinary debriefing and care reviews. These provide a forum for sharing thoughts, emotions, and feelings. Knowing that coworkers are feeling the same way will allow for the team to become more empathetic and supportive to each other and help them feel less isolated.

Provide hope and encouragement

• Give positive messages of encouragement in daily huddles and briefs.
• Provide the daily total number or patients who have been discharged and fully recovered from COVID-19. Note any positive trends, such as fewer admissions to the ICU.
• When patients are discharged, celebrate by clapping hands or playing a song overhead. This helps nurses to know there is hope during a disaster that feels like there is no end.

These are difficult times for nurse leaders and their staff. By thinking creatively, leaders can support families and staff to help lessen the psychological strain of death during this pandemic.

Renee Sanchez is the nurse manager of The Crown Family Pediatric Center at Lenox Hill Hospital in the Upper East Side in New York City. Erin Smith is nurse manager of inpatient behavioral health, and Deirdre O’Flaherty is senior administrative director for patient care services and orthopedic program coordinator at Lenox Hill Hospital.

References

Cedar SH, Walker G. Protecting the wellbeing of nurses providing end-of-life care. Nurs Times. 2020;116(2):36-40.

Hebert K, Moore H, Rooney J. The nurse advocate in end-of life care. Oscher J. 2011;(4):325-29.

Taylor B, Montgomery HE, Rhodes A, Sprung CL. Protection of patients and staff during a pandemic. Intensive Care Medicine. 2010;36(Suppl 1):S45-S54.

Garcia-Dia MJ, O’Flaherty D, Arreglado TM. Cultivating resilience in the workplace: Relationship between demographic factors and nurses perception of resilience. J Nurs Practice Applications Rev Res. 2018;8(1). drive.google.com/file/d/1BC5kXNS3laMY9bpfBD0oI1fyIoR_ooFq/view