Wednesday, August 31, 2005

The Last Minute of Life

When I came onto shift tonight and walked into my first patient's room, he was breathing at three breaths per minute. Just as a reference for non-medical folk, the normal rate of respiration for an adult is anywhere from 10 to 28 breaths per minute. So this man was breathing very very slowly. He was clearly within the last few minutes of his life. He was a DNR/DNI and was expected to die within the next few hours, so I was not alarmed by this sign of impending death.

It is rare that I get the honor of being with someone at their precise moment of death. Most often, the family will be there and will come and get me when the patient stops breathing. But this man had no family at his bedside. I thought to myself, what would I want in my last moment of death?

The patient's family had come to say their goodbyes and had said that they would not be coming back. When the family had left, they'd left the tv on. The noise was distracting to me. This was my patient's last moment on earth, so I turned the tv off to offer him some peace from the tinny sound of the voices coming from the tv's blue glow. The light over his head was bright, so I dimmed it to provide for more relaxed and muted tones. Even if he had not been dying at this moment, I would likely have done these same things for him. But somehow these acts carried more significance, knowing this would be his last experience of life in his body as he'd known it for only 44 years.

He had drooled a little on his pillow. I moistened a soft cloth and wiped the drool away, then got a fresh cloth and gently wiped the rest of this face. As I held his wrist with loose fingers, searching for a pulse, I wondered what else I could possibly offer him in this final moment. As I gazed at this beautiful man, I noticed the pulse in his neck slow and then stop.

Although I have been present at the final moment of life for a few other patients, somehow tonight, I was expecting something magical to happen. Perhaps as I have been on a spiritual quest lately, I expected those changes in me to create some clear change in my experience with death. But there was no obvious change.

Question for you, dear readers: how would you like your last minute of life to be? TV or music or silence? Family/friends present and/or medical staff present or alone? At home or in a hospice or hospital?

Saturday, August 27, 2005

Your Post: Please Comment

What word or words come to mind when you hear about death or contemplate your own death? Just throw out some single words or phrases.

Thursday, August 25, 2005

My Spiritual Awakening - part 1

Working with patients who are dying, I have become acutely aware of my need for a sense of spirituality in my life. This work can be emotionally challenging. Engaging with patients who are facing their mortality and who are grappling with finding meaning in their lives, I am frequently faced with these same existential questions with regards to my own life.

My chosen line of work - or my calling as it were - undoubtedly gives me a sense of purpose to my life. But my occupation, although a largely encompassing passion, is not all of who I am. My answer to the question 'What is the meaning of my life?' is not as simple as "I am a palliative care nurse." I am also a woman in a relationship with my partner; guardian to my four beloved pets; a friend to many; a daughter; a sister; and a life interacting in this world on a moment-by-moment basis.

Walking home from therapy today, I practiced walking meditation. My therapist has encouraged me in this practice, which I first learned at the Zen Buddhist center near my home. I realized something today: a huge benefit from walking meditation is that it forces me to slow down. I noticed the feeling of the cool breeze blowing my hair. I felt the warm sun against my face. I felt the firm, solid ground beneath my feet with each step. I let my thoughts meander without clinging to them.

I've been beating myself up for not committing to going to the Zen Center every Saturday. But today I was reminded once again that I don't need an organized religion to have a spiritual practice. Every moment can be a spiritual experience if I am present and open to it.

Although I am still uncomfortable with the word "God," I thank Him or Her and the many friends (including my blogger family) who have been supporting me through my recent difficult times (essentially ever since my grandmother died in March). Together, you have helped open me up to the infinite sense of peace that has been buried inside me. I finally felt connected with that peace today.

Thank you.

Tuesday, August 23, 2005

Dehydration at the End of Life

The standard of practice has been established for some time now that it is best not to provide intravenous fluids to patients who are imminently dying. This practice, however, continues to be an area of concern for some family members.

There are a number of reasons why we do not hydrate imminently dying patients:

1. Forcing fluids into the body intravenously can cause excess fluid build-up in the lungs, in the throat, around tumors, and in the extremities. This excess fluid builds up because the kidneys naturally slow down and are less efficient at processing fluids at the end of life. These excess fluids cause discomfort in a number of ways: fluid in the throat and lungs causes death rattle, fluid build-up around tumors can cause pain, and fluid build-up in the extremities can cause discomfort and decreased mobility.

2. Patients who are at the end of life are at an increased risk of developing bed sores or pressure ulcers. Increasing the frequency of urination with intravenous hydration increases the risk of bed sores, as incontinence occurs as death becomes imminent.

Some patients and family members are concerned that the patient will feel thirsty if they are not hydrated. A majority of patients who are imminently dying breathe through their mouths, creating a local dry mouth that would not be alleviated with intravenous hydration. Frequent mouth care using moistened sponges or swabs is more effective and may occur without the added risks of intravenous hydration.

Dehydration releases pain-relieving chemicals which may cause a feeling of mild euphoria and general well-being (Sullivan, 1993). However, severe dehydration can lead to metabolite imbalances that can cause confusion and aggitation. A current study is underway to determine if a very small amount of fluids (10-30 mL per hour of fluid as opposed to 75-150 mL per hour) may avoid the negative side effects of artificial hydration while preventing possible confusion and aggitation.

Some people also see hydration as an ethical issue. "If we have the technological means to provide support that may extend a person's life, even if just by a few hours, aren't we obliged to do it?" First of all, I have not seen evidence that hydrating an imminently dying patient will extend their life. And as many of you have pointed out in previous comments, the ethics of these decisions must weigh into account: what is in the best interests of this person and their potential suffering as well as the financial implications for our society (though hydration is relatively cheap and therefore may not apply in this particular scenario).

What are your concerns about hydration at the end of life? Would you want intravenous fluids if you were at the point where you were dying and were no longer able to swallow liquids on your own?

Friday, August 19, 2005

Poll Results: Physician Assisted Suicide

Should physician-assisted suicide be legal for patients who are terminally ill and have six months or less to live, pending a second opinion?

Out of the 81 people who voted via my website's sidebar:

62% said yes (50 votes)

19% said no (15 votes)

11% said yes, but only if every patient undergoes psychiatric evaluation for depression (9 votes)

9% said yes, but only under rare circumstances (7 votes)

The nature of this poll does not allow for discussion when voting, so here is your chance to say your piece. Or if you didn't get a chance to vote, what would your vote have been?

Thursday, August 18, 2005

Thank you, NurseWeek!

It's been a long night, but a good one. I worked with some lovely patients last night. I then went directly to the Pain Committee meeting for my hospital and gave a presentation on palliative care at 8am this morning (Useful info for my own future reference: I am much less nervous giving presentations when I haven't slept for 20 hours straight). And as if my night shift could possibly get any better - what a delightful surprise was awaiting me at home!

Thank you so much to Janet Wells of NurseWeek magazine. I got my hard copy of the latest issue of NurseWeek magazine in the mail today with mention of my blog in her article on Nurse Blogs. You did a fantastic job, Janet. Thank you so much for inviting me to be a part of your piece. And what an honor to be included in an article with such esteemed nurse bloggers!

Wednesday, August 17, 2005

Your Truth: Demented Grandfather with Cancer

Before I post this scenario for your ethical debate, I wanted to let you all know that my biopsy results came back today. Good news! It was "nothing." So now, if I can just get the scar to fade where they cut away "nothing," all will be as good as new. ;-)

In this next scenario, a 78 year-old gentleman, Mr. Smith, has Altzheimer's disease and has just been diagnosed with advanced prostate cancer. As a reminder - Altzheimer's is a terminal disease. The cancer has spread enough that chemotherapy and radiation are both recommended, if the goal is to cure the cancer. Cure is not guaranteed, but is possible. The chemotherapy is expected to cause hair loss, nausea, vomiting, and fatigue. Mr. Smith is still able to eat, but has been bed-bound for three months without expectation of ever regaining his mobility. He is aggitated a lot of the time. Radiation will require him to lay still. Due to his frequent aggitation, this will likely require him to be sedated every day for radiation treatments. He does not recognize anyone. He no longer has the cognitive abilities to make treatment decisions for himself. Please imagine that Mr. Smith is your father or grandfather and you have been asked to decide whether or not to pursue curative measures for the cancer.

Would you choose to pursue the chemotherapy and radiation therapy? What other information might you want to know before making your decision? What are the most difficult aspects of this decision? Would your thoughts on this decision change if you were Mr. Smith?

Monday, August 15, 2005


With all of the comments I've gotten wondering where I am, I feel like a total schmuck for being so neglectful of this blog.

As for the biopsy - I will get the results Wednesday. I'm not sure why that doctor's lab takes so long. But the doctor who did the biopsy said he wasn't worried, but to call to get the results just to be certain it was nothing. Keep your fingers crossed, just in case.

I finished up my clinical rotation at Radiation/Oncology, where I'd had the somewhat accidental radiation exposure. I learned a lot about radiation. I'm not sure I'll be the one to take it on, but there is definitely a great opportunity for someone with that interest to dive in to developing a palliative care program for a radiation oncology setting.

I also spent a few days with my Palliative Care preceptor whom I will be doing my residency with this coming Spring. It was a pleasure to work with her again. Returning to her hospital felt like returning home.

I had some remarkable patients I met during those two days, too. One patient's spirit in the light of his dire prognosis was particularly inspiring to me. He couldn't speak due to the disease that was killing him. And his frank honesty in the questions he asked in his written notes to us was impressive. Most people don't seem to want that kind of honesty, especially when it relates to their potential death. I had to wonder if writing his thoughts down made him more open with us than if he'd been able to speak to us.

I gave a one-hour lecture for some new grads (newly graduated nurses) recently on end-of-life nursing care. I was very excited about the opportunity, but quite frustrated at how little I could fit into a one-hour period of time. I am devoting my career (and much of my free time) to educating myself about end-of-life care, so to try to condense all I've learned thus far into one hour is almost insulting. But I hope that what little I was able to say inspired at least some of those new grads to explore end-of-life issues on their own as well.

Sorry I have been so neglectful of this blog. I haven't forgotten you all. I will start school again in September. I've kind of taken the summer off from my self-learning, which is usually what inspires my blog posts. But I'm sure my classwork will get me back into gear here, too.