Sunday, September 25, 2005

Your Truth: "It's not important to me."

Stella is a 78 year old Japanese-American woman. She was recently diagnosed with metastatic cancer and is not expected to live more than 6 months. Her health had deteriorated so much that her elderly husband was no longer able to take care of her at home, so she has moved into a nursing home. When you enter her room, she immediately starts talking, almost non-stop.

"My family lives an hour away and it is too difficult for them to make the trips to come see me. It's not important to me."

You try to engage her to say more about how she feels. When you ask her if she is sad or worried about her family, she says no. When you ask if she misses her family, she simply repeats, "It's not important to me. They have jobs that they need to be at. You learn to accept life when you're old." But when you try to ask her questions, she quickly returns to telling you that her family can't visit and again explains why.

How do you respond?

Wednesday, September 21, 2005

Nurse Mia, Doula Mia

I have begun training to serve as an end-of-life doula for a woman in my community. This particular doula training is for nursing and medical students with an interest in end-of-life care. We are being trained explicitly NOT to provide medical advice, but to instead focus on providing psychosocial support, friendship and companionship to a person at the end of their life. I'm kind of excited about this opportunity to take off my nursing hat, but also a bit nervous. I've grown comfortable with death in my role as a nurse, but this experience will likely be something altogether different. See the link above to find out more about end-of-life doulas throughout the country.

Wednesday, September 14, 2005

Your Truth: God is punishing me

As I have mentioned in previous posts, nurses are responsible for addressing the spiritual distress that many patients face in the end of life. Many hospitals and hospices provide chaplain services. However, nurses cannot rely completely on chaplains to address these needs. For one, some patients who do not identify as religious may refuse these services, even when it's explained that chaplains are non-denominational. Additionally, spiritual needs come up organically during conversations at the bedside of dying patients.

Although my "Your Truth" posts have focused primarily on ethical issues, I have realized that I can apply this same exercise to just about any communication issue. So, as usual, please read the scenario and tell me how you would respond.

Ms. Page is a 53 y.o. who was recently diagnosed with ALS. During a visit with her she tells you somewhat matter-of-factly, "You know, God is punishing me. That's why I have this disease."

How do you respond?

Tuesday, September 13, 2005

Practical Information: Death Certificates

This post is a bit of a different twist from my usual ethical debates, nursing care instructions, symptomatology of dying, or film/book review. This is the type of information that is usually obtained through a mortuary or a funeral home, however I thought it may be of interest, particularly for nurses. When a patient dies in a hospital, family members frequently inquire about receiving a death certificate. Hospitals vary as to how the death certificate is made available. Some hospitals provide the death certificate; some hospitals deligate that job to the mortuaries.

Some reasons you might need a copy of a death certificate:

-Airfare reimbursement to attend death or funeral of family member
-Probate issues
-Life insurance proceeds
-Sell or transfer of stocks and bonds
-Sell or transfer of real estate property and for real estate tax purposes
-Sell or transfer of title to car, boat, mobile home, or modular home
-Employee benefits and pensions
-Bank and loan transactions, such as to close a bank account
-Income tax records
-Veteran monetary benefit claims
-Transfer of remains outside of the United States

Generally it is recommended that at the time of death you request four more copies than you expect to need. You can obtain a copy of the death certificate after the fact. See where to request a copy of a death certificate for more information. However, keep in mind that it may take weeks to months to receive a copy of the death certificate and it's usually preferrable to not have to wait to complete closure on a personal loss of a loved one any later than you have to.

Some of the previously mentioned companies may return the original copy of the death certificate, so that you may be able to reuse it with another business. Inquire with each business as to what their policy is.

Cause of death will not be on all death certificates. States differ in their statutes with regards to who may obtain information as to cause of death; your state may or may not allow this information to be given to the deceased's spouse, parent, child, grandchild, sibling, or any family member who provides a will, insurance policy or other document that demonstrates the family member's interest in the estate of the deceased.

Cause of death cannot be included when requesting copies for probate issues. Cause of death does not need to be listed on death certificates used for real estate taxes, property claims, vehicles title transfer, or the closing of bank accounts. Life insurance companies, however, often require cause of death to be included on the death certificate.

Any questions?

Sunday, September 11, 2005

Request for Death

This is a conversation I overheard between a patient and a doctor. What are your thoughts on the doctor's responses to this particular patient?

Patient: Can you just kill me?

MD: No.

Patient: That's too bad.

MD: For one, it's illegal. And for two, the Hippocratic Oath prevents doctors from doing that. But we can relieve suffering.

Patient: Oh, good!

MD: Any questions?

Patient: Yes! How can I die?

You may want to check out that link to the hippocratic oath if you haven't already read it.

Now that you've read the scenario, I will provide you with some background information about this patient. She has a history of a stroke that left her wheel-chair-bound and that altered her personality, making her a bit cantankerous at times. Her husband died two years ago and she has just been diagnosed with a curable type of cancer. Does knowing these details change your thoughts any?

Thursday, September 08, 2005

Movie Review: Big Fish

Per a co-worker's recommendation, I recently rented the movie Big Fish, directed by Tim Burton. This story is told from the perspective of a father and his estranged son in the last days of the father's life. The son realizes that he's been told so many dramatic and unbelievable stories by his father that he has no sense of what his father's life has truly been like. His father's mythical tales involve siamese twins and a giant (just to give you a sense of how far-out-there they are). These fantasies are woven into the main storyline. When reunited by his mother with his father, he is only given more vibrant stories when seeking the truth. But the way that the two finally come together in the end was quite touching.

This movie is a great example of a life review, which is such a huge part of the end of life process for many people approaching their death. Though this movie gives this process an interesting twist - it is the son who is going on this journey through his father's life rather than the father himself.

The moment of death was a bit unrealistic. I have yet to see someone suddenly stop talking and then peacefully close their eyes and nod their head to the side. But I suppose within the artistic context of a fantasy-based film, it worked.

My one big complaint with this movie was when the doctor says, "I hate when people talk to patients who can't hear them." In end-of-life nursing care, we always tell families to assume that the patient can hear. When people come out of comas, they frequently report that they were able to hear - and they often recall things that were said. So we always emphasize that hearing and touch are the last senses to go. This line has the potential to miseducate anyone who sees this film and may make it more difficult for people who, as it is, may have been shy about talking to someone who can't talk back to them.

But some things that I liked about this film - it was very playful and silly. I'd never seen a tasteful film that was able to successfully incorporate light humor into the subject of death and dying as was done in this film.

Has anyone else seen this film? I'd be curious to hear your thoughts.

Wednesday, September 07, 2005

Life After Death - part 2

Laying on the table in my acupuncturist's office yesterday, I started wondering again as to whether or not there is an afterlife. I've pondered this question before on this blog. But this time, the question presented itself in a different manner.

I mean, how could there be an afterlife? I think of the negative traits of my grandmother - prejudices she held. I think of the unresolved conflict between my aunt and I. If there is an afterlife, wouldn't that imply that they carried their negative traits with them for an eternity as well?

As someone in an active process of dismantaling some of my character defects, I have come to realize that these negative traits are mine and will likely involve a life-long pursuit of extricating myself from them. But if there is an afterlife and I died with these traits unresolved, I wouldn't really exist without my characteer defects. But would I even want to?

Then my mind jumped to the memory of my Dad calling me before my grandmother died to tell me that she'd cried to him on the phone. He told me how frightened she sounded. I knew intuitively that she was dying. I felt suddenly panicked and desperate and scared. I had never seen nor heard nor even heard about my grandmother crying before. Perhaps those tears were her last gift to me. May I not wait until my last few days of life before letting my loved ones see me cry.

Sure enough, as I'd intuited during that phone call with my father, my grandmother died four days later. I had struggled with whether or not to go visit her and in the end, my denial overshadowed my intuition. I didn't go.

From 1993 to 2004, I'd written my grandmother a letter just about every other week. But in the last 4 to 5 months of her life, I sent only 3 letters - the last of which likely arrived after her death.

I have many regrets about my grandmother's death.

As soon as I arrived back in town from the funeral, I tried to bury my guilt over my absence at my grandmother's death by becoming more actively involved in the last few weeks of my aunt's life.

I was spinning in my grief. I cried to and from my visits with my aunt. I am still not sure if I was crying with anticipatory grief for my aunt or with the fresh new shocking grief from my grandmother's unexpected death. In my rational mind, I thought I was successfully holding off my grief over my grandmother in order to be fully-present with my aunt until she died, wanting to put her needs before my own.

During my last visit with my aunt, I choked out an apology for not visiting more often. Was I apologizing to my aunt or to my grandmother or both?

I now wish I had told my aunt about my grandmother's death. (They were not related to each other and had never met). As I wondered if there was an afterlife, I wish I'd asked my aunt what her beliefs about an afterlife were. Perhaps if she believed in one, I might have asked her to tell both of my grandmothers that I love them. Not that I'm sure I believe in an afterlilfe myself, but perhaps, just in case.

What do you think - is there an afterlife?

Friday, September 02, 2005


One of my partner S's best friends and his partner were living in New Orleans when Katrina hit. We had been very worried about them as the news reached us about the devastating effects of the hurricane, but we weren't able to reach them. Both their cell phone and their email service providers were operating out of New Orleans, so neither were working. Fortunately, we got a voice mail message from them, giving us word that they are both okay. They left town when they were given the warning and have been staying in Atlanta ever since.

Sometimes the news seems so unreal. Even the stories about this hurricane seemed almost unbelievable. But reality set in as S and I offered our friends a place to stay while they figure out what to do next. They are actually quite hopeful that the house they'd just bought about six months ago may still be standing. Apparently they live in a part of town that wasn't hit as hard. Based on the news footage I've seen, my hopes are not as high as theirs, though I will be ecstatic for them if they were one of the few who still have a home to return to.

It is an interesting coincidence to me that my life is so water-oriented right now, though in a much more positive way than killer floods. I went surfing today with a friend from work. Tomorrow, S and I will go sailing with a different friend. And then Sunday, S and I are going on a whale watching cruise.

Somehow this balance between the positive and negative sides to water seems fitting. It is so easy to label things as "bad" or "good," but life so rarely falls along neat polar opposites. And although water can clearly bring utter devastation to an entire nation, as has been demonstrated, it can also be a source of peace and serenity.

I am wishing and hoping and praying for some peace and serenity for all who have been affected by Katrina.