Shift Change Stroke

This story is special to me because it was one of the times I had the opportunity to help family through a patient's passing. Most of the time, family isn't around at night. So if someone passes on my shift, pretty often the family isn't there.

Sometimes at work we joke about how things tend to unravel or descend into chaos at shift change. Whether it's a rapid response, a code, multiple admissions, or suddenly every patient needs something, it seems like shift change is often the time for it to all happen. This day was one of those days. After getting report on my patients, I went to visit each of them to introduce myself. Unfortunately, I didn't get past the first room. I walked in and found that tensions were already high as the patient was acting strangely. He suddenly was saying things that didn't make sense, was limp on one side, and one eye was drooping. We quickly recognized these symptoms as stroke symptoms and called a "Code Stroke" over the hospital PA system. Usually when you think of an emergency in the hospital, you'd think of someone in cardiac arrest. But strokes can be just as deadly almost as quickly. While we waited for the stroke team to arrive, I started my assessment on the patient. I will call him Jim.

Jim was advanced in age, maybe in his 70s. His wife was there at the bedside, beside herself as we expected Jim to be discharging soon. He had been doing so well... What changed? I did a neuro assessment on Jim. It was pretty severe, and I started to get very anxious as we waited for the stroke team to arrive. Every second matters.

They finally arrived at the room and came in hot with a flurry of questions. When was he last normal? What is his baseline orientation? Does he have a history of stroke? What are his latest vitals? and of course, most importantly, What's his code status? It didn't take long for them to decide he needed to get a CT scan of his brain to check for a stroke. We rapidly moved him from his chair to the bed, ripped the plug from the wall, and started running him down the hallway, leaving his poor wife in his room to fear the worst.

We arrived at CT and urgently transferred him to the scanner bed. I stepped into the control room as they fired up the CT machine. My heart dropped heavily as our worst fears were confirmed.

"It's a massive hemorrhagic stroke. Look at the size of it..." the house doctor said quietly as he stared at the image of Jim's brain on the computer screen. I leaned in and looked, and sure enough, a massive white blob dominated a large area of his skull. (For any reader not in medicine, the massive white blob was bleeding from an artery in the brain that leaked into the space around it.) I had never seen anything like it, even in textbooks or online. It covered almost half of his skull.

The stroke nurse and house doctor arranged to have Jim moved to the neuro ICU. I called my charge nurse to update her, who then updated the wife and gave her his new room number. She made her way across the hospital to the neuro ICU. I was there giving report to the ICU nurse, and then I stayed to watch them work on Jim for a bit. He was unresponsive at this point, intubated, but his vitals were stabilized. Unfortunately, with strokes the vitals don't necessarily reflect the condition of the brain.

The wife arrived and was talking to me outside the room about what was going on. She was so afraid, but so grateful to me for being there as all the other staff was tied up in caring for Jim.

The neuro critical care doctor came out asking for the wife and said they should talk in private. I looked at her, and she gave me a look of fear. Something in her eyes told me she didn't want to be alone.

"Would you like me to come?" I asked quietly. She nodded eagerly, happy to have even a slightly familiar face with her. I called my charge nurse again to update her that I was with the family, and she wanted me to join her in talking to the doctor. Typically, this is less than ideal. I did have my own patient assignment to return to, but night shift is usually much less chaotic. Ten extra minutes shouldn't hurt, and I was still helping with who was supposed to be my patient. My charge nurse was very supportive and understanding about it. So, I followed the doctor and Jim's wife into a conference room.

I knew exactly what was coming, and I think the wife did, too. But she was holding herself together, facing the discussion bravely and ready to make a choice that would be best for her beloved Jim. The doctor sat in a chair across from the wife and I, was quiet for a moment, and then spoke.

"Jim had a massive hemorrhagic stroke. It developed very quickly and did a lot of damage. We can keep him on life support, keep his body alive, but I'm sorry to say the odds of him living any kind of meaningful life beyond this are incredibly small. He would be unable to do anything by himself for the rest of his life, would spend months in the hospital recovering, and would never be the same Jim you knew." I looked at his wife with pain and tears in my eyes, but she was still holding herself together.

"He would hate that," she said, her voice shaking. "He was very active. If he had to continue living by relying entirely on others to do everything and couldn't walk or do anything on his own, he would be miserable." Tears were streaming down my face at this point. "I could never put him through that," the wife finished. Tears started to fall from her eyes as well, so I reached over and took her hand. She gripped it tightly and fixed her gaze on the doctor. There was a brief pause, and then she continued.

"You can let him go," she said, her voice breaking. I closed my eyes and dropped my head upon hearing those heartbreaking words. So often, the family is not ready before the patient is. So often, the patient is suffering and miserable and deteriorating, sometimes even begging to be allowed to die, but the family doesn't allow it. I can't call it selfish, because I know it comes from feeling a great love and deep fear of loss, and it is only human to try to hold on as long as possible. But I will call Jim's wife selfless for putting his happiness before hers, even in the face of great pain and grief. She could have demanded they keep him on life support, putting off the inevitable grief she would experience for who knows how long. Humans are programmed to avoid pain and suffering... But I think what was most heartbreaking about this case was knowing that she was sacrificing her happiness for his chance to die peacefully.

The doctor gave her a sympathetic nod, expressed his condolences, and led us out of the room. Before heading back to my unit, I gave the wife a hug.

"I'm so sorry," I said, tears still falling. She took my hands.

"Thank you for being here with me. It meant everything to me to not be alone during that conversation. I'm heartbroken, but having you there with me helped me be strong. Jim will be happier up in paradise above. I'm happy for him." She smiled weakly through her tears. I hugged her again and looked back at Jim. I stepped into his room and stopped at his side and placed my hand on his arm.

"I'm sorry, Jim," I whispered. Then I stepped back and started the long, lonely walk back to my unit.

Moral of the story: Nursing isn't just about medical treatment and healing, and the one who is sick isn't the only patient of a nurse. Nurses also care for the family in times of suffering. Providing emotional support is one of the key roles of a nurse, and after that night, I learned to never underestimate the importance of that.

• Bella, RN