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?