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https://www.infirmiere-canadienne.com/blogs/ic-contenu/2022/07/25/lacceptation-a-calme-ma-detresse

No matter how good nurses are, death is ultimately out of their hands

By Barbara Morris
July 25, 2022

The day I got my second COVID-19 vaccination, I was elated. My immune system was attacking the foreign bodies to miraculously create more antibodies that would protect me from serious illness. I know that vaccines aren’t perfect, and there’s still a chance I will catch the virus. But if I do, it’s unlikely that I’ll be hospitalized and extremely unlikely that I will die from it.

I exhaled, letting go a huge sigh of relief. But on the tail of that sigh crept another emotion: guilt. A disturbing thought cooled my elation. Why have I survived this pandemic when millions have not?

Death is just part of life. Or is it?

Life and death — it’s a cycle, right? You’ve heard this said many times. In pre-pandemic days, we were able to hold our precarious existence and the dread of its end at bay. During this struggle with COVID-19 however, nurses and caregivers have not worked in normal circumstances; they have not witnessed the usual frequency of deaths that their jobs, unfortunately, entail. Instead, day after day, now into our third year, nurses have witnessed multiple deaths over short periods of time. In spite of their dedicated care, millions have died.

What nurses see, feel, and risk their lives to prevent, is unimaginable for most people in Canada. Yet most nurses have survived. Why? It’s partly because they are knowledgeable about virus transmission and wear personal protective equipment head to toe when they’re working. They save many lives, but first and foremost, they need to save themselves or be kept safe in order to save others.

When a nurse loses a patient, they have to quickly move on to the next bed. It isn’t until much later, exhausted at home, sometimes just minutes before collapsing into sleep, that grief and doubt can slip in through the cracks in their worn-down souls. “Did I do enough? Did I do anything wrong? Why didn’t I stay just a little longer for that person? Maybe I could have... I should have…”

So, yes, death is a natural part of life. But for many caregivers who survive their patients, it can be a traumatizing and guilt-ridden experience.

The insidious creep of survivor guilt

Survivor guilt is a sign of trauma. This underappreciated, often invisible, trauma is real for many people.

Survivor guilt is a mental state characterized by a nagging, unsubstantiated feeling that you are the cause of another’s misfortune or should have, at the very least, been able to prevent it. Sufferers may also worry that they have done something wrong to have survived a trauma when others have not.

Researchers at a traumatic stress clinic in the United Kingdom found that 90 per cent of survey participants who had survived a deadly incident experienced survivor guilt (Leonard, 2019).

First responders and witnesses to a traumatic event are particularly susceptible to developing this type of guilt response. I imagine that most pandemic front-line caregivers have found themselves, at some point, questioning their own luck at having survived.

A secret shame

Survivor guilt is felt in secrecy. Survivors initially feel lucky for being able to carry on living, but that quickly withers, replaced by feelings of shame and grief. The shame of not being able to prevent death can easily devolve into guilt and is usually suffered in silence.

Mental health professionals consider survivor guilt to be a symptom of post-traumatic stress disorder (PTSD). A sufferer of this type of guilt can have other PTSD symptoms, such as flashbacks, irritability, intense fear, feelings of helplessness, headaches and disturbed sleep. Even suicidal thoughts from feeling undeserving of further life are not uncommon.

Careful what you wish for

As a teenager, I spent months visiting my grandmother in the hospital. During her slow decline, I had been challenging her to come back and visit me after she died. We’d laugh about me wandering into the living room to find her knitting away as usual. But during some of those visits, I was aware of harbouring darker thoughts. Annoyed that I had to visit so often, the shameful thought of “When will you die already, so I don’t have to do this anymore,” would invade my self-centred 15-year-old mind.

The morning after my grandmother died, I woke up soaked in dread. I was already being haunted, but it wasn’t by her — it was by my own guilt. The exciting prospect of a spirit visit had twisted into the terror of a haunting. Our whimsical plan became a nightmare by wishing for her death. In my mind I had made it happen, and she would surely come back to punish me.

“I’ve changed my mind, Grandma. Please don’t come back,” I whispered into the still air. “I’m sorry.”

The genesis of omnipotent thought

Renowned British psychoanalyst and paediatrician Donald Winnicott built a theory based on his idea that infants don’t exist. He said, “There is no such thing as an infant,” implying that there is always a mother/infant dyad (Winnicott, 1960, p. 587, footnote 4). His theory claims that at the beginning of life, an infant can’t tell where the mother stops and they begin. Everything the infant wants is right there, whenever they want it. It’s as though, for the infant, they control everything. They are omnipotent. When the infant is hungry, the nipple appears. When they’re cold, a blanket covers them. It all happens like magic. It’s an illusion — a fantasy that the mother sets up. Due to our total dependence at birth, the illusion is a necessary deception to ensure the infant feels safe.

But eventually, somehow, infants have to figure out that the mother is separate — not them — and that they are each whole, separate beings. The mother’s need to do other things makes this transition possible. Out of necessity, the mother neglects the infant for a second, here and there. Then it happens more and more often, for longer periods of time. If all goes well, the infant isn’t bothered by this progression. Gradually, the breast isn’t there right away when they want it, and their “omnipotent power” to obtain seamless gratification breaks down. Winnicott called this process “disillusionment.” It happens so subtly that mothers don’t even know they’ve facilitated this process.

Limitations versus omnipotence

Mental health professionals consider survivor guilt to be a symptom of post-traumatic stress disorder.

According to Winnicott, being disillusioned of our omnipotence is part of how we all discover our separateness and our limitations as individuals.

During extremely stressful situations that are out of our control, we can feel trapped. In that state, many of us will be unwilling to accept our limitations — our true powerlessness. I think we have an unconscious wish for our lost omnipotence. This can be a helpful way to understand how many nurses react to stressful caregiving situations. Under such powerful stress, we can dissociate. We can disconnect or split off from our rational adult self and seemingly retreat to a time when we were very young. When experiencing survivor guilt, we can go to the earliest time of our life, when we felt the safest and in control of everything — before the disillusionment. Our wishful thinking can return as a safeguard against feelings of powerlessness. But our unconscious rescue plan backfires because our omnipotence was only an illusion. It was unreal, and guilt arises to take its place.

Science versus senses

I provided massage therapy and end-of-life care to war veterans at Sunnybrook Hospital in Toronto for many years. I had the honour of accompanying several of them during their final moments. After many losses over my 15 years working there, I learned that no matter what I did — death still came — as it does.

I didn’t cause my grandmother to die, and I couldn’t have prevented it.

I trust science. I also trust my senses. It’s a tricky balance. I think there is much that we may see or hear or feel that is beyond the scope of science. Our desire to deny what is right before our eyes is crazily strong sometimes.

Nurses facing the death of their patients need to rely on both science and their senses — their intuition about what care is possible and what isn’t. But some nurses mistakenly view their intuition as an omnipotent superhuman power to save patients. Those nurses need to rein that feeling in. They need to remember that no matter how competent and compassionate their care is, ultimately, death is out of their hands.

The courage to let go

Death is a blatant example of the medical profession’s lack of omnipotent power. Death cannot be prevented forever. To accept this, some nurses may need to let go of their omnipotence fantasy.

American theologian Reinhold Niebuhr (1892–1971) wrote this prayer:

Father, give us courage to change what must be altered, serenity to accept what cannot be helped, and the insight to know the one from the other.

We are beautifully human and we are only human. We need to accept our limitations and accept the consequences of nature that are beyond our control.

References

Leonard, J. (2019, June 27). What is survivor’s guilt? Medical News Today. Retrieved from https://www.medicalnewstoday.com/articles/325578

Winnicott, D. W. (1960). The theory of the parent-infant relationship. The International Journal of Psychoanalysis, 41, 585-595.

Barbara Morris is a registered psychoanalytic psychotherapist in Toronto, Ont., with 25 years’ previous experience working as a registered massage therapist. www.barbaramorris.ca