A couple of weeks ago I lost my first patients. Since I started working as an ER nurse I have seen patients die, and been part of that event, as in the case of The Vigil, but this was the first time that the patients I lost my were my own.

The first patient, who we will call Mr.Scott, rolled in at 7am. He was a 99yo male with no significant medical history except for well controlled high blood pressure. He took walks every day and had a helper who came in daily to help him with his activities of daily living and to keep him company. The previous evening his family had visited with him, watched TV, had a nice dinner and left him for the night. In the morning, when his helper arrived, he found Mr.Scott on the floor unresponsive and called 911.

Mr.Scott's head CT showed a massive bleed and his family decided to have him admitted for comfort care. By time I came in for my shift and received him as my patient, Mr.Scott was still in the ER because there were no comfort care beds available in the hospital and his condition had continued to deteriorate throughout the day. He was on a morphine drip and an oxygen mask to ease his breathing.

Around 8pm the second patient, who I will refer to as Mrs.Hanes, rolled into the ER. She was 86 years old and was brought in by EMS at her daughter's insistence. Mrs.Hanes had been complaining of a back ache all day, and finally her daughter decided to call 911 and have her brought to the ER. She was cranky as the EMTs got her settled in, and immediately asked to go to the bathroom. One of the other nurses walked her there and showed her how to put the light on to indicate she was done. When the light went on, I went in to get her out, and she seemed to be unable to get up on her own and was fussing about not needing to be in the ER. I called for help and a wheelchair. As soon as we stood her up she slumped over and passed out. We quickly got her on a stretcher and got her into the hallway where I assessed her. I thought maybe she had "vaso-vagaled" down or something but I couldn't find a pulse. We quickly grabbed the code cart and started coding her, all the time wondering what had happened. She had been talking and heckling the EMTs a few minutes prior and here we were shocking her. She started off in PEA and alternated between that and v-fib for duration of the code, which was about 35 minutes. Her daughter who had driven behind the ambulance arrived as we were coding her and could not understand (understandably) what was going on. Later on she told us she had had a bad feeling all day when her mother started complaining of a back ache. Finally she asked us to stop the code and we did. We cleaned her up and left the room to give them privacy and to start on the paperwork.

I stopped in to check on my other patients and finally to see how Mr.Scott was doing. He was still holding his own, but his family was starting to get really upset because he was still in the ER and because they felt they had been ignored for the last hour (when we were all in the code). I couldn't very well tell them we had been trying to resuscitate a patient, given that their father was there dying, so I did my best to placate them. I turned him, emptied his foley, straightened his blanket, brought everyone their beverage of choice, and sat with them for a while.

I then went and called the nursing supervisor to nag her for a bed for Mr.Scott, and started on the paperwork for Mrs.Hanes. Shortly after I had sat down, I was informed that a bed had finally been assigned to Mr.Scott, so I started getting his chart together and preparing to call the inpatient floor for report. I went in the room to let the family know, but looking at Mr.Scott's heart monitor, I knew death was imminent. I stepped outside, took a deep breath, checked with my charge nurse, and then went back in to talk to his family. I let them know that we had a bed for him upstairs and I could get him up there within the next 15 minutes. I then told them that it was my opinion that he would not make it to the 3rd floor, and that there was a great likelihood that he would pass away enroute. It was difficult for me to do this, knowing they had been waiting all day for him to be in a room on a hospital bed where they could say goodbye, and it was tempting to try to rush him upstairs, but my gut instinct was to not move him. I could tell it was a hard decision for them too, and that they didn't know what to do. I drew the curtain closed, pulled a chair in and sat with them, all the while hoping and praying that I had given them the right counsel. Less than 15 minutes after I had walked into the room, Mr.Scott's heart slowed down and finally stopped.

We stood up, and looked at each other, and everyone smiled, with teary eyes. They started removing his watch and jewellery, and I stuck my head out and asked one of the nurses to get the attending so he could pronounce Mr.Scott dead. After that was done I removed his heart monitor leads, his oxygen mask, and disconnected his IV, all the while listening to the gentle chit chat going on in the room.

I stepped outside and gave them some time to finish what they needed to do. But before I did that, I thanked them for letting me share Mr.Scott's last moments with them. And I expressed how sorry I was that he had to spend his last day laying on an ER stretcher.

As they were leaving, they called me over and we all exchanged hugs and goodbyes.

Later in the night, after things had quieted down and the paperwork was all done and both bodies had been moved to the morgue, we all sat around talking about the events of the night, with the more experienced nurses helping me "debrief", because they knew these were my first patient deaths. One of the other nurses casually said "I would never have done what you did. As soon as we got a bed I would have wheeled that stretcher upstairs as fast as I could and let them deal with the paperwork up there." I thought about that all night and for a couple of days after that. And I came to conclusion. I could never have done that. And I hope I never think in those terms.

His family got to sit with him, and to have the same people around them as they'd had all day when he passed. Attempting to move him to the floor could have played out in many different ways, but they would all have involved his family dealing with new faces and with the uncertainty as to did he pass away in the elevator, or was it in the hallway, or was it when we moved him from the stretcher to the bed.

Dying in the ER was bad enough. Dying in an elevator or on a stretcher speeding down the hallway would have been even worse.