Friday, December 30, 2005

I Just Don't Feel Like Going to the Morgue Today

I just don't feel like going to the morgue today.

Maybe it's the rain.
Though I'm thankful for
the rain today.
I stepped in a puddle
of pee from where my patient
urinated on the floor.
And now the rain puddles
will wash it away.

I just don't feel like going to the morgue today.

It could be the time of the month.
After all,
my hormones can increase
my sense of smell
at certain times.

I just don't feel like going to the morgue today.

Perhaps it's the holidays.
I'm prone to the winter blues and
the morgue
certainly wouldn't bring me
much cheer.

I just don't feel like going to the morgue today.

Two of my patients died today.
And almost a third.
It was a day like today
that coined me my nickname,
"Death Maiden."
Though I think
they just
go in threes.

I just don't feel like going to the morgue today.

I took care in
cleaning their bodies.
And I tried to be gentle
as I bagged them.

I just don't feel like going to the morgue today.

I just don't feel like going to the morgue today.

Thursday, December 29, 2005

I was intrigued by this quote. No doubt, I have been accused of taking life too seriously at times. But what do you think of life being as toys? Posted by Picasa

Sunday, December 18, 2005

End-of-Life Care Challenge: Exsanguinating Patients

Recently, I have had a number of patients bleeding during their hospice care at the end-of-life. Patients may bleed out for a number of reasons. End-stage liver disease frequently causes bleeding, as the liver is essential to the creation of clotting factors, without which, the body is not able to clot properly. Complications, such as DIC or post-surgical may also cause patients to bleed at the end-of-life. Bleeding can vary between scant amounts of blood on linens to a very heavy flow that continues until death.

For any signs of bleeding, the use of green surgical towels may be helpful. The green color obscures the bright-red color of the blood, which may make it less disturbing for visiting friends and family.

Keep universal precautions in mind as well. A mask with goggles may be appropriate if the patient is bleeding in a way that is creating a spray, despite the barrier they create between you and the patient.

Following are recommendations for bleeding from specific orifices:

rectal bleeding:
A rectal tube may be inserted, attached to a catheter bag, to collect the blood.

nasal bleeding:
The nasal cavity may be filled with gauze. You may cut a respiratory mask to hold pressure on the nostrils while keeping the mouth exposed.

oral bleeding:
Suction may be necessary if large quantities of blood are coming from the mouth.

These are just some of the tips I have used with my limited experience with patients who are bleeding at the end of life. Although this is not a common occurrence, it is very distressing for patients, family, as well as staff, and is thus very memorable. I welcome anyone to comment other ideas or suggestions for how to manage bleeding at the end-of-life.

Saturday, December 03, 2005

Symptomatology: Terminal Restlessness

When people are getting very close to the end of their life, they may experience aggitation and/or restlessness. This symptom may appear as tossing, turning, fidgeting, or attempting to get out of bed. There are many things that can contribute to this restlessness.

First, assess for urinary retention or uncontrolled pain. A urinary catheter may be necessary, especialy if high doses of opioids are being used, which may contribute to urinary retention.

If these are not obvious sources of the restlessness, I recommend families help address any potential emotional sources of distress. This can be done by using the "five things to say" list:

1. Thank you - acknowledge their accomplishments in life
2. I'm sorry - apologize for anything you've done you may feel regret over
3. I forgive you - let them know you forgive them for anything they may have done that they may feel guilt over
4. I love you
5. Good bye.

The book "Final Gifts" provides wonderful examples of interpretting the emotional sources of distress in confused patients at the end of their lives.

There is some discussion of the use of minimal hydration to help improve restlessness (Fainsinger & Bruera, 1997). The understanding is that the accumulation of metabolites in the body may be the cause for the aggitation and thus some hydration may facilitate the kidney's clearing those toxins. Hydration should be minimal, however, to prevent complications from fluid overload.

Finally, if these interventions are unsuccessful, restlessness may be treated with sedatives:
1. Versed - an anxiolytic sedative with amnesic properties
2. Compazine - commonly used for nausea and vomiting, this drug was originally developed as an anti-psychotic
3. Haldol - particularly useful in confusion/delirium associated with AIDS
4. Phenobarbitone - may be used as an adjunct to the above three if they are insufficient alone

Similar recommendations for the treatment of terminal restlessness may be found in the article "End of life care in patients with malignant disease" by Stone, Rees and Hardy, published in the European Journal of Cancer (issue 37) in 2001.