Saying Goodbye

These days, DNR (do not resuscitate) often is seen on patients’ records. Ideally, it indicates that the person has weighed the pros and cons of having life extended by “heroic” measures. Sometimes, however, a life goes on longer than would seem humane, even without heroic measures.

Recently I cared for a 74-year-old woman who weighed less than 100 pounds. She had brain cancer and was emaciated, with broken-down skin and a broken spirit. The morning I entered her room, she was huddled under a quilt from home, curled in a fetal position and crying. She had cried all night for the past few nights, her pain and confusion worsening until she was calling out for her Daddy. The night nurse had left a note about the patient’s refusal or inability to take anything by mouth.

I tried to keep the patient’s wounded skin dry despite her incontinence and rigidity. As I explained my plan for her care, she made no eye contact. Between her cries, I heard one coherent phrase, “I want to say goodbye.”

Others may have thought this woman was confused. But I think I understood her meaning. I assured her that I respected her wishes, that we would not prolong her life. I told her I would be giving her medicine intravenously to ease her pain before I turned her. I called the physician to obtain orders for more effective pain medication. I called her daughter and explained the option of hospice care. When the daughter came, we clipped the woman’s nails so she wouldn’t continue to injure herself.

I wish I had asked whether she would have desired pastoral care. I didn’t even check her chart to learn what she may have claimed as a religious affiliation. I did, however, hold her shaking hand and say, “I will help you be comfortable. I will try to help you say goodbye.”

Sometimes patients understand sooner than their families when it is time to die. When we as nurses recognize this, we can be an advocate for the patient who is not able to communicate clearly, explaining signs to the family: cessation of eating, loss of eye contact, and a request to say goodbye. The family may need as much or more spiritual care than the patient. Gently guiding the family toward resources such as pastoral care, hospice, or each other may be ways the nurse can facilitate the family’s readiness to hear an unspoken goodbye.

Kristin Sandau PhD, RN, is an Associate Professor at Bethel University, St. Paul, MN.

--reprinted from the Journal of Christian Nursing, April-June 2008