The Great Cremation Ground

One of my colleagues just came back from a trip to India and told me about a place called Manikarnika Ghat, also known as "The Great Cremation Ground."

According to Hindu mythology, being burned here provides an instant gateway to liberation from the cycle of births and rebirths. Karmic bonds are suppose to be burnt along with the body, which is how one is liberated from needing to be rebirthed. It is said that the funeral fires at the Manikarnika ghat have been burning for thousands of years. A constant stream of corpses come to this ghat to be burnt, day and night. According to my colleague, most corpses do not get enough time to burn properly and are often unceremoniously dumped, half burnt into the sacred river.

I have never traveled to India, but if I do, this certainly seems like an interesting place to check out.

Estimating Time of Death

I am not in the practice of having to estimate time of death, as generally patients in the hospital are being watched routinely, and thus the time of death is already known. But I am on a list serv where someone posed a question that elicited this link. I thought the link was an interesting resource and might be useful to others, so I thought I'd post it here. This link is to a tool for estimating time of death, according to the Method of Henssge. It is based on temperature and puts into account various environmental factors including clothing. Check it out.

Your Truth: Dementia and Grief

I apologize, once again, for my on-going silence on this blog. I've received a number of emails from readers encouraging me to post again. I appreciate the dedicated interest in this blog from my readers.

I recently attended a fascinating lecture on dementia and grief. Inspired by this lecture, I am going to pose a hypothetical scenario for your consideration. As per my standard format, after the scenario, I am going to ask some questions and will later post my response to the scenario.

Mrs. Horton is an 86 year old with middle stage dementia. She is no longer able to recognize family members nor dress herself. She is able to walk, using a walker, and frequently gets lost in the hallways of her nursing home.

Mrs. Horton's 61 year old son recently died of heart attack. Prior to his death, her son had come to visit her in the nursing home at least three times every week. Mrs. Horton was informed repeatedly of her son's death, but she does not have the short-term memory to retain this information. She asks where her son is multiple times every day.

1. Do you repeatedly inform Mrs. Horton that her son died, even though this news is distressing to her? Would telling her the truth be retraumatizing her or banging her over the head with the news?

2. Understanding that disclosing this news can be distressing to both Mrs. Horton and to the bearer of this news, what are some different ways you might respond to her repeated request for her son?

Thank You, Blue H News!

blue-H-sign
Originally uploaded by miaadams.

I have been rather neglectful of this blog as of late. Despite my silence, I am delighted to report that Blue H News picked up one of my blog posts and published it in the January 2007 issue of their newspaper.

Thanks so much for the press, Blue H News!

Your Truth: Chemical vs. Physical Restraints

Another hypothetical scenario for your consideration...

This patient is an 86 y.o. female with dementia who is actively dying. She has become delirius, but still has the strength to get out of bed and is at a high risk for falling and injuring herself from the fall. In addition, she has a intravenous (IV) line that is being used for pain medicine that she keeps trying to pull out. The doctor has suggested the use of sedating medications to keep her from pulling out her line and from falling. But the family states they would like to keep her alert and thus they refuse the medications offered. Instead, the family prefers that wrist restraints are applied, tying the patient to the bed rails to prevent falls and to prevent the IV from being pulled out. NOTE: Both types of restraints are avoided while the family is visiting, but the family leaves to sleep at night.

1. What education could be offered to the family to ensure they are fully informed of the options to ensuring this patient's safety?

2. What other options might be considered beyond pharmacological or physical restraints?

3. What are your own feelings about chemical verses physical restraints and how might these feelings impact your attitude towards this family's decisions?

Grief - the Written Word

As I've mentioned before, JennyNYC and I have been working on a poetry project where we write a poem a day to one another. We are now up to about 115 poems. Though I haven't been keeping up to the every day pace the past week or so, I am still getting a lot out of the experience - both in expressing some of my more uncomfortable emotions creatively and in the inspiration that has come from reading Jenny's words. This is one of Jenny's more recent poems that she consented to letting me post on this blog.

Grief
by Jennifer

A mother comes in one day at the end of her rope.
Her two ten year old twin boys,
who I've been seeing for therapy
along with their mother,
are driving her nuts.
"Ever since their dad died
it's gotten worse and worse!" she explains.
"Their dad used to make all the rules
and make sure the boys followed them.
Now there are no rules,
and it's gotten out of hand.
They're nice boys
but I can't live this way."
The mother and I sit down and think up rules.
I tell her to stick with the basics,
both for rules and for consequences.
The boys join us in my office,
and we talk about how it is at home.
It turns out they don't like the chaos either.
Then I bring up the rules,
and after reading a few of them,
like, "No cursing,"
and "Brush your teeth before bed,"
the twin who is usually the unemotional, "tough" one, Sean,
throws himself onto the floor,
curls up into a ball,
and begins to sob.
It's late evening in the clinic,
and his lone, heartwrenching cry
fills the empty hallways,
as the three of us listen and look,
frozen witnesses,
shocked, worried, and awkward.
Sean's twin, Johnny, says, "C'mon, Sean,
these rules are easy," but Sean can't hear him,
lost in a painful moment.
Johnny muses aloud,
"He's crying more than he ever has
since Dad died."
Johnny and the twins' mother
slowly ease themselves to the floor beside Sean
and put their arms around him.
Knowing Sean's usual distaste for physical affection
I tense up, fearing that Sean will lash out at them.
But instead he allows his family to hold him
providing comfort and sharing in the painful knowledge
that his father is not coming back.


This is such a beautiful and moving poem. I can relate to this trigger for grief from my own personal experience with my divorce. I thought I'd worked through my grief, as my divorce happened over six months ago now and I've started dating and just generally feel much more centered and like myself again. But then my childhood best friend's grandmother died. She was a big part of my childhood. She was rather eccentric and being around her always put a smile on my face. Since my maternal grandmother died when I was young and my paternal grandmother lived in Florida (and was still living up a wild, youthful life), this friend's grandmother was much like a grandmother figure to me. But the trigger that came from her death had nothing to do with her really. I wrote and sent a condolance card to my childhood best friend. As I went to sign the card, I faltered. I hadn't signed a card since the divorce. For nine years, I had sent dozens and dozens of birthday cards, anniversary cards, graduation cards, and such - all signed with my name and my ex's. This was the first time I signed a card with my name alone. Alone. Solo. In moments like this, the last six months feel surreal, like a dream. How my life can change so drastically from the life I lived over the last nine years. I spent nearly a third of my lifetime with my ex. The things I am grieving are manifold. On top of the loss of the relationship and the family we had become, there is the loss of an identity - the loss of that "Me AND You" at the end of those cards.

Your Truth: "I Want to Drive Her Home."

"Your Truth" is a series of posts I have written describing end-of-life scenarios. These scenarios are in some way controversial - either due to an ethical dilemma or a particular communication challenge. Please read the scenario and then offer your thoughts on what you might do in this circumstance. Although these scenarios are all based on real-life situations, they are fictionalized so as to protect the anonymity of the person(s) whom the scenario was inspired by.

In this next scenario, we have a 82 y.o. Russian female who had a stroke that left her non-responsive (she is unable to speak nor move and her gag and corneal reflexes are absent). She had end-stage renal disease prior to the stroke. She is still in the hospital. The doctors have given her a prognosis of days to weeks to live. Her family, per her written advanced directive wishes (rare to have these done, but sometimes we're lucky enough to know what the patient would want), has decided to stop dialysis and start her on hospice care. The family would like to take her home to die.

The family is afraid, however, that she will die during the ambulance ride home. They are strongly opposed to her dying in an ambulance and so they would like to drive her home in their minivan. Despite education regarding the perceived improved comforts that would come with the ambulance ride (bed, pain medicine, gurney ride into the home), the family remain committed to driving her home themselves.

Now keep in mind that the minivan is not equipped with a bed and the patient would have to be phycially lifted into the minivan. Due to hospital liability issues, the nursing supervisor reports no hospital staff may help her into the van and therefore the patient must be transported home by an ambulance.

What might you do? What are the potential positive and negative ramifications of either option?