One Foot In Heaven
By Heidi Telpner
Copyright 2010 by Heidi Telpner
ISBN# 9780982678435
Smashwords edition published by Jupiter Gardens Press at Smashwords
Smashwords
Edition, License Notes
The scanning, uploading and distribution of this book via the Internet or via any other means without the permission of the publisher is illegal and punishable by law. Please purchase only authorized editions and do not participate in or encourage the electronic piracy of copyrighted materials. Your support of the author’s rights is appreciated. Permission is granted to make ONE backup copy for archival purposes.
This is a work of fiction. Names, characters, places, and incidents are either the product of the author’s imagination or are used fictitiously. Any resemblance to actual events, places, organizations, or persons, living or dead, is entirely coincidental.
This ebook is licensed for your personal enjoyment only. This ebook may not be resold or given away to other people. If you would like to share this book with another person, please purchase an additional copy for each person you share it with. If you're reading this book and did not purchase it, or was not purchased for your use only, then you should return to Smashwords.com and purchase your own copy. Thank you for respecting the hard work of this author.
The scanning, uploading and distribution of this book via the Internet or via any other means without the permission of the publisher is illegal and punishable by law. Please purchase only authorized editions and do not participate in or encourage the electronic piracy of copyrighted materials. Your support of the author’s rights is appreciated.
Author's Note
The stories are true. Names, locations and certain details have been changed to protect patient confidentiality.
Well it’s all right, even if push comes to shove.
Well it’s all right, if you got someone to love.
Well it’s all right, everything will work out fine.
Well it’s all right, we’re going to the end of the line.
“End of the Line”, Traveling Wilburys, 1988
What is a Hospice?
Hospice, in the earliest days, was a concept rooted in the centuries-old idea of offering a place of shelter and rest, or “hospitality”, to weary and sick travelers on a long journey. Dame Cicely Saunders at St. Christopher’s Hospice in London first applied the term “hospice” to specialized care for dying patients in 1967.
Today, hospice care provides humane and compassionate care for people in the last phases of incurable disease so they may live as fully and comfortably as possible.
Hospice is a philosophy of care. The hospice philosophy recognizes death as the final stage of life and seeks to enable patients to continue an alert, pain-free life and to manage other symptoms so that their last days may be spent with dignity and quality, surrounded by their loved ones. Hospice affirms life. It does not hasten, or postpone, death. Hospice care treats the person rather than the disease; it highlights quality rather than length of life. It provides family-centered care involving the patient and family in making decisions. Care is provided for the patient and family twenty-four hours a day, seven days a week. Hospice care can be given in the patient’s home, hospital, nursing home, or private hospice facility. Most hospice care in the United States is given in the home, with a family member or members serving as the main hands-on caregiver.
- The American Cancer Society's Official Statement on Hospice Care
Introduction
There’s always a beginning, whether we realize it or not. My beginning happened long before I ever interviewed for a position with hospice or ever considered the possibility of entering nursing school. Shortly after my sixteenth birthday, I was in a serious horseback riding accident. I nearly died.
Who knows? Perhaps it’s entirely possible I became interested in hospice because of my own near death experience. However, that’s not why I’m a nurse. I became a nurse because my original plan for my life didn’t pan out.
I majored in English at the University of Iowa. The plan was to publish my first novel by the age of twenty-five, be a complete degenerate by the time I turned thirty, and dead long before I was over the hill at forty. Unfortunately, though I managed to get some poetry published, my first novel was rejected. I found I had little interest in teaching, but I wasn’t qualified for much else with an English degree. My college roommate had been in nursing school. I frequently helped her prep for her tests and along the way discovered that her classes interested me. Since I had nothing better to do at the time, I completely shocked everyone who knew me, including myself, by applying to nursing school. The biggest shock came when I found I liked it.
My first real area of interest, my calling if you will, was obstetrical nursing. I still love it. Every aspect of the pregnancy and birth process amazes me. Each birth I attended during my training reduced me to tears. I even apprenticed briefly with a lay midwife in Utah. I intended to apply to the Frontier School of Midwifery in Kentucky after nursing school graduation, and it was my dream to spend the rest of my life birthin’ babies. However, a quickie marriage, a baby of my own delivered by a midwife, a divorce that left me without any financial support whatsoever and looming Government Student Loan payments forced me to make an abrupt change in plans. After graduation, I got the highest paying job I could find. I took a position as a staff nurse in the Intensive Care Unit of a regional Trauma Center.
I’m a quick study. Within eight months, I’d been promoted to Night Charge Nurse for the ten bed Coronary Care Unit, managing both cardiac patients and overseeing another ten-bed Intensive Care Unit. I also monitored the Telemetry Unit and covered resuscitations, or Codes, throughout the hospital. In addition, I scheduled staffing for our after-hours Recovery Room and became the hospital’s official IV-starter.
My first months of trauma care were an adrenaline junkie’s dream. Between working nights and single-parenting an active toddler, sleep didn’t really factor into my life. At the time, I didn’t mind because I considered myself part of a special breed of health care providers. We were doctors and nurses who could look serious injury and death in the face every day, yet leave the hospital in a good mood. In fact, the more trauma patients the staff handled successfully, the better our collective mood at the end of a shift. By necessity, immunity from emotional distress came with the job description.
In my defense, I was young and like almost everyone else I worked with, caught up in the crazy business of keeping people alive. Frankly, I didn’t have time to get attached to my patients. I’m not entirely certain I even saw them as people. They were more like a set of complicated systems. At the start of my shift, I’d break every patient down into a series of tasks and assign staff accordingly. It was the simplest and most effective way to keep each set of systems running. That was my job, to keep systems, or patients, alive long enough to get them out of my Unit so I could receive the next admission. If patients didn’t transfer to the step-down unit, it was because they Coded and died.
As Charge Nurse, I deliberately assigned myself the most complicated patients on the Unit because I enjoyed the challenges. I took exceptional care of everyone. It’s funny that to this day, I still remember the most difficult procedures I performed, both on my own and those I assisted with, but I can’t recall a single patient’s name.
The suffering, the deaths, and even the success stories were never personal. I took them all in stride. We very often cared for people who had suffered horrific injury, illness and loss. “Personal” would have made my job impossible. “Personal” would have traumatized me. I figured out pretty quickly how to compartmentalize in order to survive. For better or for worse, it seemed to come naturally to me. I made every effort to leave my work behind the closed doors of the hospital. After all, I had a young son depending on me to be a normal mom during my off hours.
In four years of deaths, only a single one really got under my skin. It was an extraordinary experience; something I carry with me every day. I assigned myself a gentleman who had been diagnosed with pancreatic cancer. He landed in Coronary Care because we had an empty bed and Med/Surg, the Medical-Surgical unit, was full. Pancreatic cancer is nearly always a death sentence. Death usually comes quickly, though I’ve since managed a number of hospice patients who survived as long as five years after experimental treatment before the disease caught up with them.
Early in the morning, after I had worked a grueling double shift, this very polite gentleman Coded. His situation was unusual because according to the monitor and my stethoscope, he had no heartbeat, yet he lay there wide awake, talking to me. I hit the Code button and the team came running.
At that moment, the patient’s own physician walked into the Unit on rounds. He waved off the Emergency Room doctor and elected to run the Code himself. All through CPR and repeated shocks, the patient continued to speak and I repeatedly apologized for hurting him. While he seemed unaffected by our actions, I was in agony. I had never Coded anyone who was conscious. Ultimately, beneath my compressions, this man’s sternum broke clean away from his ribs and remained depressed. I burst into tears. I could not continue the Code and informed the doctor.
He shrugged and said, “Call it then,” and strolled nonchalantly from the room. Everyone else packed it in and left.
The poor man was still awake. The monitor reading showed his heart at seven ventricular beats a minute. For those of you unfamiliar with the way the heart works, that’s pretty much dead. I got down on my knees beside the bed, leaned my head close to his and whispered, “I am so, so sorry.”
He lay a weak hand on my shoulder and said, very clearly, “Don’t worry, I’m no longer in my body. I didn’t feel any of it. I’ve been floating up here near the ceiling watching you all work.”
I sat back on my heels for a moment, pretty choked up. While his words didn’t surprise me because I’d once been in his position, I felt myself overcome with awe and could barely speak. My voice shaking, but ever the pragmatist, I finally croaked out, “Well, let’s get all this stuff off you and give you a bath. The least I can do is send you to heaven clean.”
He replied, “Thank you.” Those were the man’s final words to me.
Though my shift had ended an hour before, I waved the day nurse away and stayed with him myself. I bathed him gently, covered him with a clean gown and then pulled up a chair and held his hand until he died. He took his time. After a while he sighed deeply and left his body.
You can always tell when someone dies because up until the very moment of death, up until the millisecond a person leaves his body, he or she is still present. I guess I would describe the phenomenon by saying that you can literally see someone inhabit their body because you can watch them leave it behind. The instant the person dies but not a moment before, every cell gives up the ghost, or the soul, or the spirit, or whatever you choose to call it, and the body grows waxy and lightless.
To me, it seems obvious that the body is a shell, a wonderful machine built to house the soul. There’s a Star Trek episode entitled Spock’s Brain, in which aliens remove Mr. Spock’s brain and use it to power their environmental systems. Thanks to Dr. McCoy, Spock’s body lives on as a soulless automaton until his brain is reattached. That’s the body. However, another Star Trek episode may be even more descriptive of death. Its title is, That Which Survives. In that episode, Ensign Wyatt, one of the Enterprise’s typical expendable crewmen, dies in the transporter room because the holographic projection of a woman touches him. After examining the body, Dr. McCoy says, “It’s as if every cell in his body’s been disrupted, Jim.” That’s death. The soul inhabits every single cell and death disrupts every one of them.
In my capacity as a hospice nurse, I see dead people every working day. Well, sometimes they’re not all the way dead, at times they’re almost dead or they’re on the road to being dead fairly soon but who isn’t? Birth and death are two sides of the same coin, and they’re two of the most intimate actions a human being can witness. The only other act that compares in terms of intimacy is making love. Obviously I don’t make love to my patients, but it is a service of love that a hospice nurse renders. Patients and families I’ve just met become my closest friends in a matter of minutes. They give me an all-access pass into their homes and their lives. They entrust me with the management of their death or the death of their loved one. It’s an enormous responsibility and one I do not take lightly.
Under no circumstances can this be considered a “how to die” book. Nor is it an instruction manual designed to teach the layperson how to care for a dying patient. It’s a collection of true deaths that have touched my heart and my soul, changing me in the process. Dealing with patients and their families, or caregivers, as they go through the dying process can be rewarding, touching, tragic, frustrating, frightening, disgusting, enlightening, spiritual, chaotic, hysterically funny and all of the above at once. My work as a hospice nurse is never dull.
I’ve cared for incredibly wealthy patients living in isolated compounds with their own staff of private-duty nurses and desperate, homeless people who travel along the road of death in the backseat of a old van parked at a strip mall. The end is the same. Movie stars and politicians have mothers, fathers, grandparents and aunts and uncles who use hospice services. Drug dealers have brothers who get cancer or suffer strokes. Criminals have mothers too and sometimes they die on hospice. I’ve cared for the family members of CIA agents, police officers and district attorneys and at the same time I’ve been the nurse assigned to patients dying in homes that have been converted into meth labs and grow-houses. Like I said, my job is never boring.
My role is to midwife every patient into the next world with as much grace and dignity as possible. I guess the most astonishing thing is that I’m good at it. I no longer see my patients as a set of systems or think of them as a series of tasks to complete. They are real to me. I laugh with them; I cry with them. Their stories are written on my heart. I remember their names.
Chapter One
How We Die
The Fisherman
I only met Robert Smith once, but his death made a lasting impression on me because he died so well. The day of his admission to hospice, he was already unconscious and had been for over twenty-four hours. However, even if someone is unresponsive and, as we say, actively dying, protocol requires that I complete a brief physical assessment. I feel it would be rude of me to touch a complete stranger without an introduction, so despite his closed eyes and irregular breathing, I introduced myself to Bob.
I lightly brushed his forearm with my fingertips and explained that I would be listening to his heart and lungs and taking his blood pressure. Not surprisingly, because this happens all the time, he roused himself and smiled, acknowledging my presence with a direct look into my eyes, a look that said, “I know exactly who you are, what you want and what you’re doing, get on with it.” He deliberately winked at me before closing his eyes and drifting off into what I can only describe as a death-sleep.
A death-sleep is a kind of in-between state, where the person is still attached to the body and cognizant of everything around him but he or she may or may not respond. I like to imagine my patients adrift in a boat tethered to the body with a long rope. I always tell families that although their loved one appears to be unconscious, if he or she really needs to say something, they will wake up and say it. This is also the point in the dying process when things in the environment can most strongly affect the patient. For instance, if the room is crowded, if it’s hot and noisy, if there’s crying, screaming, breast-beating, wailing, or if for some reason the patient has not received enough pain medication, the person can have difficulty cutting that rope and moving on.
Bob was a fisherman who had inoperable, widely metastasized lung cancer. The cancer hadn’t responded to any treatment and his doctors had sent him home from the hospital with a hospice referral. Initially, he'd declined our assistance. He thought it might still be possible to beat this thing, by sheer force of will if nothing else, but then he had an epiphany. He and his son took their boat out for a three day fishing trip on the Sacramento Delta. According to Bob’s son, they had a great time, caught a lot of fish, drank a lot of beer and on the last day, Bob, in a quiet moment, which is a rarity on the windy Delta, said, “I’m going to die, aren’t I.” His son told me Bob wasn’t asking a question.
When they returned home, Bob called his family together and made it clear that he would be gone very soon. He, his wife, and their three children sat around the kitchen table drinking coffee and they had the opportunity to say everything that needed to be said. Then Bob stopped eating and drinking and refused any medication. He showered, brushed his teeth and put himself to bed. He very quickly sank into a semi-comatose state.
By the time I became involved in his care, three days later, the family was psychologically and emotionally prepared for his death, and in fact, they were looking forward to it for his sake. It was very simple in their minds. Bob wanted to die without too much interference, and his family wanted to be with him. He’d given them very specific instructions, he did not want diapers, and he refused a hospital bed.
His wife matter-of-factly informed me, “If he poops, we’ll clean him up. If he needs to be turned, we’ll turn him. He’s instructed us that we are not to hover. We intend to follow his wishes.”
Bob’s family didn’t need my help, not really. Like Bob, they were a self-sufficient bunch, self-contained, strong and quietly confident. All I did was provide them with medication to keep Bob comfortable in the event that he needed it, and instructions for care that would ease his passing. The family didn’t want any hand-holding. No hovering.
~* * *~
When I was a kid growing up in Iowa, I used to fish every Saturday at Lake Manawa. It was an all-day kind of activity that required patience and the ability to stay still and be quiet for long periods. I had to learn not to fuss with the line. That is the waiting for death. Don’t fuss with the line. Be patient and be still. Death will bite when it’s good and ready. No hovering.
Bob died peacefully twelve hours after my visit. When he died, his son had been sitting quietly at his bedside reading a book. His wife and two daughters were asleep in the other room. He died the way he had lived, without a fuss and on his own terms.
I find that people usually do that, die the way they’ve lived. If their life was weird, their death can be even weirder. If family dynamics were negative, they don’t usually improve as death approaches. As a matter of fact, any negativity typically gets worse and makes the death drawn out, difficult and often fills the actual death scene with unnecessary drama.
I’ve found that some of my patients will attempt to avoid a scene altogether by waiting until the watching family member steps out to “just get a cup of coffee” or “use the bathroom” and then they hurry and die before anyone can get back in the room. Sometimes I think my patients do that to spare everyone they love the pain of having to witness the actual death. Other times, I think they see their opportunity to bolt and they get the hell out. Nothing is harder for me as a hospice nurse than to witness a patient take his last, peaceful breath, and as I prepare to pronounce them dead, a hysterical family member will hurl themselves onto the dead body and drag the soul back in with a terrible, rattling gasp. On rare occasions I’ve seen this push and pull last for hours, until the body can’t take anymore and finally gives up. It’s very tragic for everyone when this happens.
Death is far more than a mere physical process. There’s a lot of other stuff going on—spiritual, emotional, and mental stuff—but unless you work with it on a daily basis, unless you make death your career, it’s difficult, if not impossible to see beyond the obvious. The obvious being the loss of someone you love, or the loss of someone with whom you’ve at least had a relationship, good or bad.
There are two main pieces to the dying puzzle: the family and the patient. In Bob’s case, his family understood, without any input from me, how to let him go. But Bob accepted his role. He agreed with the process. He agreed to die. There was no pressing need for him to die right at that moment; he had a choice. Bob was relatively young and other than his lung cancer, reasonably healthy. He could have lasted several weeks to several months. He chose not to linger, my emphasis being on the word, chose. Sometimes my patients choose to die. Sometimes my patients do the exact opposite. They choose to outlive their own bodies. Unfortunately, they turn into what I’ve come to think of as, walking corpses.
Mrs. Brown
Take Mrs. Brown, for instance. She became a walking corpse out of necessity. The matriarch of four generations, she lived with her daughter and her daughter’s boyfriend, her two grandchildren and their significant others, and her two precocious great-grandchildren in an immaculately clean but crowded, two bedroom, one bath condominium. Mrs. Brown had raised her daughter and her two grandchildren, and at the time of her cancer diagnosis, she was also responsible for rearing her two great-grandchildren. So many people depended upon her that she was unwilling to accept her terminal diagnosis. Although she agreed to hospice services to satisfy her daughter, it quickly became apparent to all of us involved in her case that she intended to live in the Land of Denial until the bitter end. I always say, a little denial can go a long way.
Mrs. Brown had advanced stomach cancer and her physician expected her to live two weeks at the most. She lasted four months post-discharge from the hospital. To describe her state of being as alive would be an exaggeration. Mrs. Brown seemed to mummify before our very eyes, yet she somehow miraculously continued to inhale and exhale and manage her household affairs in her utterly desiccated condition.
Sometimes I’d arrive at the crowded home for a scheduled visit, expecting to find her in bed, only to be guided to a small walk-in closet or the storage shed on the patio by the great-grandson. I’d find Mrs. Brown propped stiffly against a wall, frozen in the middle of some task, looking exactly like a log of wood set out to cure. She’d appear to have been dead for centuries, dehydrated in the sands of the Sahara, or freeze-dried in the snows of the Andes. Sometimes I feared that one touch from me and she’d crumble to dust. Quite frankly, the experience shook me. I found myself both horrified and fascinated by her tenacity.
Mrs. Brown tried to avoid Death by clinging with desperation to her usual tasks. Unfortunately, she’d quickly become exhausted, lean against something to rest and stiffen in place. At one point the social worker and I were forced to carry Mrs. Brown out of a clothes closet. I took her upper body to protect her head, the social worker took her lower body and we literally carried her beneath our arms like a two by four. Under other circumstances, it could have been a comical scene, instead the feeling was one of tragedy.
When Mrs. Brown finally died, her family didn’t even realize she’d gone and her body sat stiffly on a stool in the linen closet for four hours. I made the death call, or visit, and I genuinely understood their mistake. Her eyes were open and she looked exactly as she’d looked for months. To my great relief, the family opted for cremation because I was terrified Mrs. Brown would spring back to life during the embalming process. Unlike Bob, Mrs. Brown was definitely not ready to die and her spirit outlasted her physical body. She had made a choice.
Thanks to Mrs. Brown, I learned not only to respect such determination, but I learned how to accept and care for patients like her on their own terms. I learned how to meet her very unique, but special, physical, emotional and spiritual needs.
Mrs. Brown didn’t avoid death because she was afraid. She had no fear of death. She refused to die until she was certain her great-grandsons were taken care of. The very day of her death, adoption papers had come through for the boys, and they were officially adopted by Mrs. Brown’s daughter, their grandmother. That’s what Mrs. Brown had been waiting for.
In my experience, it’s extremely rare for patients to be afraid of death when it finally arrives. Maybe before, if they have the time and the wherewithal to think about it, but never when they die. As a matter of fact, I can only recall one patient in my entire nursing career, both in the hospital and with hospice, who was afraid up until the very instant of her death.
~* * *~
As a new graduate working in Intensive Care, I received a dump, in other words, I was assigned a patient nobody knew what to do with. She was dying; nothing could change that. The family refused to take her home. In their defense, hospice was not especially well-known in the United States at the time. However, they were unwilling to remain at her bedside. It fell to me to keep her company in her final hours. Lucky her.
In all honesty, this was not my finest moment. I had two other patients to care for who were in critical condition, and there were things I could do to help them. I could not help this woman. She was a direct admission from the emergency room, and she had no doctor listed other than the on-call physician who had never seen her. I had spoken with her family by phone, and they had made it crystal clear to me they didn’t want to be involved. They simply requested a call when she died. I had absolutely no medications ordered for her other than a very mild sedative/antihistamine.
I hadn’t been working on the Unit long, and I wasn’t sure how far I could push the on-call doctor. Back then, health care professionals weren’t as into pain control as we are now. I’m pretty sure some physicians at that time were still insisting infants couldn’t feel pain due to an immature nervous system; therefore, didn’t bother to medicate them before certain very painful procedures. I suspect very few of the nurses and doctors on duty gave more than a passing thought to my patient. Actually, I suspect everyone tried hard not to think about her. I, of course, didn’t have that luxury.
It was clear to me as soon as I admitted her to the Unit that I was in for a long night. Within thirty minutes, I realized I could not care for her along with my other two patients. Her violent struggle with death demanded all of my attention. Co-workers were willing to pick up my other patients, but they avoided this woman’s room like the plague.
As I said, I do not remember the names of my patients from those days, but I remember her demographics as if it was yesterday. I can still read the information sheet as if it’s printed in my memory. She was five feet, seven inches tall, and she weighed approximately one hundred and fifteen pounds. She was eighty-two years old, and she’d been widowed for twenty-five years. She had a daughter living in town and a son living somewhere on the East Coast. I don’t recall reading anything in the note about grandchildren. A neighbor hadn’t seen her in several days and she became concerned. She contacted the patient’s daughter. When her daughter had unlocked the front door to check on her mother, she found her breathing, but unresponsive, on the living room floor. The daughter called the paramedics. The patient had opened her eyes in the ambulance. The emergency room doctor diagnosed a severe cerebral vascular accident, or stroke, and her daughter requested, appropriately, that nothing be done.
By the time the patient was delivered to me, she was screaming at the top of her lungs and flailing her arms in every direction. As soon as we transferred her into a bed, everyone fled the room and left me alone with her. It’s not as if the rest of the staff were cowards, and I was the courageous Florence Nightingale. She was my patient. I couldn’t leave the room.
I attempted to calm this woman by every means I could think of, that I had actual orders for, and that common sense dictated, but I was unsuccessful. Nurses peeked into the room every few minutes or so and instructed me to keep her quiet for the sake of the other patients. It became increasingly clear to me that there was no way that was going to happen. This patient was doing battle with the Angel of Death.
As I said, I remember her stats, but I had no clue what had transpired in her life. What caused her to experience such a terrible struggle? I don’t know if she’d been a good person, a bad person, or had simply led a very difficult life. Did she have a whole lot of unfinished business? Was she toting major emotional baggage along with her?
Now, as a hospice nurse, I would recognize what we describe as severe end-stage agitation, and I would have plenty of medications on hand to deal with her suffering. Back then, not only was I unsure as to what was happening, more significantly, I didn’t have anything available to help her.
What bothered me most was the terror in this woman’s eyes. I couldn’t see what she saw, but I could look into her eyes and I’ve never seen eyes so filled with fear in my life. She frightened me. If the doctor had been willing to give me reasonable medication orders, I would have sedated her simply to help her close her eyes. All I had were orders for an antihistamine to be given intramuscularly. I gave her the maximum dose but of course it wasn’t strong enough to help her.
She and I could just as easily have been in a boxing arena as in a hospital room. She was the boxer, and I played the role of her trainer. Her bed became her corner, and when the bell sounded in her head she’d come out of her corner swinging. She punched, kicked and wrestled her way around the room, weaving and bobbing and shouting. Then I guess the bell would sound again to end the round, because she’d collapse into my arms. I’d haul her back into bed and unsuccessfully try to get her to stay there.
The worst part of it wasn’t the fighting, it was the pointing. There was something in the corner, something I couldn’t see. Her eyes would focus on it and open wide in horror. She’d point a long, bony finger at the corner, her mouth moving silently. She’d finally let out an ear-splitting shriek and jump out of bed to start the fight all over again.
Although I was unable to see what was in that corner, in my heart I believe the Angel of Death waited there, and I don’t think he resembled Brad Pitt. My hair stood on end whenever I was forced to dodge and weave my way past the back corner of the room. I tried to avoid looking that direction, but it was like passing a car accident on the freeway, you try not to rubberneck but you fail every time.
~* * *~
Patients frequently ask me, how will it be, to die? Will I be scared? I always answer them as truthfully as I can, that it will be fine, everything will be okay. Nobody is ever afraid when they die. They might be afraid before, but never when they die. It’s my guarantee, my promise to my hospice patients. When death comes they will not be afraid. This was true of my patients even when I worked Intensive Care, before I knew the first thing about hospice nursing. This particular patient, for whatever reason, was the one exception to that promise.
~* * *~
After seven hours, every muscle, every joint and every bone in my body ached. I was exhausted; she was still fighting. I took a chance and utilized Intensive Care standing orders. Because of new rules and regulations, standing orders, or emergency orders, no longer exist in most healthcare facilities. I used an order for a different medication. I intended to inject her with a strong muscle relaxant to see if that might succeed in calming her.
I discussed this with my nursing supervisor, and she agreed wholeheartedly. So, very young and inexperienced, but utterly determined, I marched to the locked med cart, unlocked it, drew up the medication under the watchful eye of my supervisor, relocked the med cart and returned to her room. As I entered, she bolted upright in bed, her trembling hand pointing to the corner, her mouth agape on a toothless scream. I wasn’t having any of it. I was going to help her, by God. She would calm down and die peacefully. If it killed her, I was going to make this work.
“Mrs. Blank!” I yelled over her screams, “Mrs. Blank! I’m going to give you another shot. I promise you this one will help you relax. I promise.”
She ignored me and continued to point at the corner, mouthing gibberish. I got a firm grip on her right thigh, picked a spot with some meat, cleansed a small area with an alcohol pad and shoved that needle in all the way to the hub.
Then it happened. Before I could even withdraw the plunger slightly to check for blood, her soul exploded out of that pinhole like air from a ruptured tire. I saw it. I felt it. An icy blast tore past me, blowing my hair straight back and whipping my baggy scrubs around my body. Frozen in horror, I watched a yellow ripple start at the site of the injection and flow up Mrs. Blank’s body until it reached her head. Her mouth still open, her hand still pointing at the corner, she fell back on the pillow, dead. I proceeded to do the only thing that made any sense at that moment, scream my bloody head off!
The nursing staff came running. The Charge Nurse slammed the door shut behind her and clamped a hand over my mouth to stifle my screams. She tried to shush me, and when that failed, she reminded me that we had critical patients who could hear everything. With those words, I regained enough self-control to stop shrieking, but I continued to hyperventilate. She wrapped a strong arm around my waist and with a hand still over my mouth, dragged me down to the emergency room. Someone shoved a paper bag into my hands, but I was shaking too much to hold it to my mouth. The ER doctor held it for me.
He patted my back kindly as I attempted to slow my breathing and he asked, “What? You’ve never seen a patient die before?”
“No, that’s not it,” I croaked from inside the bag.
“Well what? Did she bleed out then? That can be very disturbing.”
I shook my head, “No.”
“Well, what is it then?” He asked, impatient now.
“It was the way she died. She died,” I sobbed, “because I poked her with a hypodermic needle.”
His response was a resounding, “Huh?”
I pulled the paper bag away from my mouth and told him the story. He was nice enough to listen without laughing, and if he thought I was a lunatic, he kept it to himself.
Finally, he took my hand and said, “Look at it this way, you released her. She was obviously having trouble getting out and when you stuck her, you let her out. It’s okay, you didn’t do anything wrong,” and with that, he gave my hand a final pat and went to meet an ambulance.
I sat alone in the ER cubicle, ignoring the chaos around me and contemplated his hypothesis. I came to the conclusion that even if he was merely trying to humor me, he’d hit the nail on the head. I poked a hole in her and let her out. I have no explanation for everything else that occurred but I will say this, since becoming a hospice nurse, I’ve been with a number of patients who have dramatically escaped their bodies when they were poked by a needle or otherwise prodded in some way. Sometimes it happens during a simple dressing change.
Home Health Aides, specially trained nursing assistants, in particular are well aware of the phenomenon, and when they handle a patient very close to death they treat them like spun glass. I think it’s happened at least once to everyone I’ve worked with. You turn a patient from one side to the other, they exhale loud and long, and they die. It’s something I always keep in mind, and I warn families when I think there’s a need, but I’m cautious because I find caregivers are then reluctant to turn the patient. It happened to one of my families just two weeks ago. Forewarned is forearmed, I guess. It’s better to be prepared than to end up in the ER with a paper bag over your face.
~* * *~
All of the above brings me to the subject of Death itself. On one occasion I had a patient dying in a Skilled Nursing Facility, otherwise known as a nursing home. I managed her symptoms well with medication and positioning. She was dying very comfortably. As a matter of fact, her dying was textbook perfect. Her physician and I happened to be in the facility at the same time and we were both keeping a close eye on her. Her son was also present. This death business, as he kept referring to it, made him extremely uneasy. Sometimes I think family members need sedation far more than my patients. He could not sit still. He paced back and forth at the patient’s bedside, muttering, unable to bring himself to sit in the nice, soft chair I'd found for him. He was driving me a bit nuts, so I left the room and headed to the Nurse’s Station. Fortunately for his dying mother, unfortunately for me, he trailed after me. All the way down the hall he kept repeating, “But why? But why?”. There wasn’t a single answer I could give him that he found satisfactory. I found myself becoming very frustrated. Not with his mother, she was doing just fine, but with him and with my own inability to answer his questions in a way he could understand.
The doctor happened to be sitting at the Nurse’s Station. I pulled up a chair next to her and buried my face in the patient’s chart, hoping to discourage the son’s constant whining. He started in on the doctor with his but whys. The doctor, in typical doctor fashion, launched into a long-winded and very technical explanation of what transpires during the dying process. She proceeded to very specifically list all his mother’s many illnesses and how each and every one of theme contributed to her dying. I could tell by the look on the poor man’s face that he was growing increasingly confused and anxious with each word the doctor spoke.
He finally blurted out, “But what’s killing her? What?” The doctor turned to me in a mute appeal for help.
I looked the man straight in the eyes and told him flatly and in no uncertain terms, “Death. Death is killing your mother.”
He stood there for a second, a stunned expression on his face, and then he replied, “Ooooohhhh,” and he meandered back down the hallway.
The doctor crooked an eyebrow and gave me a funny look but she didn’t say anything more.
When next I looked in on his mother, I found the son in the soft chair, half-asleep, a hand resting gently on his mother’s arm. She died peacefully minutes later. It was a good death, and I stayed with her son until the body was removed by the mortuary and he headed home. He coped remarkably well once his question was answered.
Isn’t that the question, but why? Hasn’t that always been the great existential question man has asked throughout history? Or one of the two questions man has asked since he became self-aware? The first question being what is the meaning of life, and the second, a two-parter, why do we die and what happens after death? I can answer with certainty the first part of that question. Hospice patients die from lots of things, but in the end it all comes down to just one thing—Death. They all die from Death.
Chapter Two
Oh the First Days are the Hardest Days