Friday, July 30, 2004

My First Pet Death

I must've been about 10 years old when I adopted Buddy from the pet store. Buddy was a MESOCRICETUS AURATUS, otherwise known as a golden hamster. I adored that little rodent. I would take him out of his plastic cage - complete with running wheel and plastic tubing that led to a balcony of sorts. While doing homework, I would set him on top of my head. And when he slowly made his way down into my lap, I would pick him up and place him back on top of my head again. This was before I learned about the myth of Sisyphus. As an adult, I worry that the poor little hamster felt tortured by this game. At the time, however, I quite enjoyed it. His little claws would slowly tickle my scalp then my shoulders then down to my knees. I'd occasionally plant a kiss on him before resting him back on top of my head. There was a certain meditational quality to this play that made homework somehow more palatable.

A year or two later, I woke up and went to feed Buddy, as I had done each morning and night since he'd come into my life. When I looked into his cage, however, I noticed he was laying on his back. His body was tensing up repeatedly and his front and back legs were crossed. His tongue was hanging out slightly from his tiny mouth. I was terrified.

"Mom," I called out, fighting back the tears. "Something is wrong with Buddy!" I refused to leave his side, even long enough to get my mother.

Ten minutes later, when it was time for me to be leaving for school, I still hadn't left Buddy's side.

"Mia, you have to go to school. Why aren't you ready?"

"I'm not going. I can't leave Buddy like this."

My mother clearly didn't understand the significance of this little creature in my life. "You can't miss school." My mother glanced briefly into the cage. "He's just having a seizure. I'm sure he'll be fine by the time you get home."

I still didn't want to leave him, but trusted my mother's reassurances. I hadn't hit adolescence yet and thus still did whatever my mother told me to do. So obediently I got dressed and went off to school.

When I got home from school, I knew in my heart what I was going to find, though I kept hoping very very hard that Buddy would be alive and no longer seizing.

Buddy's body was in the same position I'd last seen him in, but he was no longer seizing. Rolled on his back, his legs were stiffened into a crossed position. I felt a strong sadness that I hadn't been by Buddy's side when he'd left this world. I cried realizing he'd died alone. I felt a deep loneliness that I only imagined was his.

Saturday, July 24, 2004

Rest in Peace

Less than a week ago, I had admitted Mr. Jacobson into the hospice. Within an hour of arrival, he was pulling on his urinary catheter, trying to yank it out. When I walked into his room, I noted the small smears of blood on the sheets and quickly assessed what they were from.

"Mr. Jacobson, please don't pull on this tube. You're going to hurt yourself," I calmly and gently removed his hand from the tubing. As patients start to decline, they frequently become confused and pull at tubing. I immediately jumped to the conclusion that his mental status was becoming altered.

"But I don't want to die with this tube in me," he explained. This seemed a legitimate request. The catheter would help to keep him from developing bed sores as he became incontinent, which commonly occurs as one approaches death. However, the catheter was not necessary.

"Let me call your doctor and I'm sure she will agree to my taking it out for you. But promise me you won't try to pull it out by yourself until I come back."

Mr. Jacobson agreed. And within fifteen minutes I removed it for him.

The next day, Mr. Jacobson had already declined substantially and was no longer speaking.

I worked with him again last night. He was no longer opening his eyes when I walked into his room at the beginning of my shift. A small group of family members was assembled at his bedside. The tv was on and no one was talking. I attempted to engage the family and to involve them with my care for their loved one. But they seemed content remaining in their circle of chairs around the tv.

The family went home to go to bed and about an hour later, Mr. Jacobson passed. Families return to see the body about 40% of the time during night shift. But as always, I cleansed his body, combed his hair, and straightened his linens in case the family decided to make a last appearance.

The family arrived and I explained to them that the body begins a process of decay immediately after death and would be best kept cool to slow this process down, but with that said, I told the family they could stay as long as they liked. (this is standard protocol to keep the body on the floor until the family has finished their goodbyes). I expected them to stay one or two hours and then leave. They all looked very tired.

Next time I entered the room, the family asked for pillows and bed linens. They said they would like to stay until the mortuary picked the body up in the morning. It is very untraditional for the family to ask to spend the night. I have never received this request before. Normally, in a case like this, the charge nurse would set a time limit. However, in addition to being their nurse, I was also the charge nurse last night. We had other empty beds and thus didn't need his bed vacated immediately for any incoming patients. I explained we would definitely need the bed by change of shift, but that they could stay until then.

As I left their room, I felt a warmth inside. This man was clearly very loved. The family was more distressed at the thought of leaving his room for the last time than they were of staying at his bedside and witnessing the beginnings of decay of his body first-hand. People used to keep the bodies of loved ones at home for a day or two, possibly more. But nowadays this is very uncommon in the U.S.

An hour before change of shift, the family left and I entered Mr. Jacobson's room a last time to prepare the body for the morgue.

In the bright light of day, the decay that had progressed through the night was clearly apparent. Mr. Jacobson's skin had become a vibrant yellow, rigor mortis had set in and his body had begun to leak. There had been one other occasion when I'd kept a patient's body on the floor for this long. In that case, however, we had difficulty contacting the family and that had been the reason for the delay in getting the body to the morgue.

Seeing Mr. Jacobson looking so unlike himself, I wondered how the family had felt awakening from their sleep to seeing their loved one like this.

So often in this society, we turn away from death. Many families don't want to see the body at all, except during a wake. Some families don't want an open casket wake. My feelings were mixed, as I bagged Mr. Jacobson's body. I usually strongly believe that we should be more aware of death and this would extend to believing the family should see the body like this. But fighting off my own disturbance with his appearance, I had second thoughts. Our entire funeral and mortuary system is based on maintaining appearances of life - or turning to cremation. Death can be amazingly powerfully beautiful, but in some ways it is not pretty. Is there a good reason for protecting family members from the realities of death? What do you think?

Tuesday, July 20, 2004

Exit Intuition

I was sitting in our break room cramming down some lunch when I felt it. He was gone. He had just left; I sensed his departure. I contemplated getting up from my lunch to verify that his breathing had stopped and his heart had ceased to beat. But decided there was no need to hurry anymore.

When I finished eating, I forgot for a moment that I had intuited his exit and distractedly went to get my charts to fine-tune my notes for the evening thus far. When I approached his door to grab the binder hanging from it, I suddenly remembered. The fact that I'd forgotten set my heart into a quickened, panicked pace. How could one forget something so significant?

I walked straight into the room, set the pile of charts I'd been carrying snugly against my breasts onto a table and slid the curtain aside to approach his bed.

One look at him and I didn't even need to lay my stethoscope on his chest. The color had left his face; in its place, a pallor known only to the deceased. I fell into routine and felt the last trace of warmth from his body as I listened for the rhythmic sounds of respiration or pulse.

Hearing none, I took my time removing the pillows from underneath his knees, flattening his bed, straightening his bed linens, laying his arms out straight at his sides. As I left the room to call the doctor and ask her to officially pronounce the death and notify the next of kin, I felt a peace and quiet calm that spoke louder than the New Age music playing lightly on the stereo by the bed.

Monday, July 19, 2004

Help Her Die

Last night, the son of one of my hospice patients asked me to give his mother more morphine so she would die. His mother appeared to be comfortable, despite clearly being within hours of her death. This is not the first time I have received this request. In the past year, I have been asked to do the same with three different patients and their families. My response is always the same.

"I will make sure your mother is not in any pain. I will not hesitate to give her more medication if you or I see any indication that she might be uncomfortable." I make it clear I know what they are asking by explaining, "If I give her too much medication, she would quite possibly die immediately."

I then explain my rationale for witholding the medication. "Your mother is probably sticking around because she either has unfinished emotional business or because she is waiting for her grandchildren to arrive tomorrow. [People often wait to say goodbye to loved ones before letting go.] Your mother has her own agenda and her own time frame for letting go of this life; I don't want to interfere with the process she is working through by forcing her to let go too soon." This son then revealed his true fears. He had already said goodbye to his mother and couldn't bear to spend more time with her. The doctors had said they might transfer her to another hospice facility if she lived much longer. The family was happy where they were and did not want to have to move their mother. By uncovering the true issues, I was able to address them specifically. I assured him that I would do everything within my power to ensure that his mother didn't get moved. And assured him that she was so close to death that she would not likely last long enough for the doctors to even make those types of arrangements. He seemed content with this answer.

This son's siblings were distressed by his request. They thanked me profusely for intervening on their mother's behalf and began to berate their brother. In response to their outrage, I told them, "Your mother is having trouble letting go. I imagine it would be even harder for her to leave if she senses that her children are not getting along well. This time is very difficult for each of you. Try to be patient and understanding of one another." Their anxiety quickly dissipated into calm.

I then brought in a print-out of the four tasks of living and dying and went over each of the steps with them. I explained how they could help their mother address these tasks and thus help her to let go of this life, which is something that all of the children reported feeling ready to let her do. They were all very receptive and quickly shared stories about their mother, exemplifying these four areas without even having been told the specifics of the tasks before.

After a bad month of work, having such a positive influence on this family's experience with the death of their mother made me remember why I love nursing.

Sunday, July 18, 2004

Do the Shuffle

Last night, I was working as the charge nurse.  One of the patients on my floor died and so I offered to help that nurse take her patient's body down to the morgue.   Many people, even in the health care profession, are squeamish about going to the morgue during the day, and even more so at night.  Though I've done it often enough now that it honestly doesn't bother me much at all.
There is one nursing assistant who I can't help but giggle at.  She gets all geared up for trips to the morgue.  She puts on two patient gowns on top of her scrubs, plus a disposable robe, cloth covers over her shoes and a hair net over her hair.  I should explain.  I wear my scrubs and usually add a pair of gloves when actually handling the bodies.
My one dread in the experience is the smell of the stale bodies in the refrigerator.  Some of the bodies were placed there days ago, not requiring an autopsy and not yet claimed by a mortuary.  I always assume they must be the ones emitting the strong aromas.
Whenever placing a body in the refrigerator, it is almost always nearly full.  The polite thing to do is to pull out one of the two-tiered gourneys.  (The top tier is almost always full.)  So then you must lower your body.  And with one person at the head and one at the feet, you transfer your patient's body (on its tray that you've rolled it in on via the single-tiered gourney) onto the lower tier.
HOWEVER...  For some reason I have yet to accept, the staff from the ICU's never fail to simply roll the newest body into the refrigerator directly from the floor, still on the single-tiered gourney they used to transport the body to the morgue on.  The problem then is...  The next person (which always seems to be me) must not only roll this single-tiered gourney out of the way to find room for the next body.  But I must remove the body from the single-tiered gourney, so I have a means of rolling my patient's body down to the morgue.
This seems like I am giving too much detail, which only makes it harder to understand, I'm sure.  So please just envision this... 
It is late at night.  My colleague and I flick on the light switch as we enter the cool, dark entryway of the morgue.  We unlock the refrigerator where the bodies are stored and hear a "whoosh" as the suction on the door is released (just like my refrigerator at home, in fact).  First, the smell hits me and I remember to breathe through my mouth.  I peak inside to find gourneys crammed together side-by-side and nowhere in sight to put my patient's body.  First, I shuffle the bodies around until I can empty one of the transport gourneys.  I roll it up to my floor to collect my patient's body.  Then I come back downstairs and shuffle more bodies around to find a temporary home for my patient while being polite (unlike the rude person before me) and leaving the transport gourney empty, so the next person might use it more easily.
And then, like a scene from Six Feet Under, the background music kicks in.  Do the Shuffle.  Doo doo doo doo doo-doo-doo doo doo.  Doo doo doo doo doo-doo-doo doo doo.