Sunday, January 29, 2006

Shakespeare Sonnet on Grief

In the tv show, Dead Like Me, there was a sonnet quoted:

No longer mourn for me when I am dead
Nay, if you read this line
Remember not the hand that writ it
For I love you so
That in your sweet thoughts
I'd be forgot
If thinking of me then should make you woe.

Curious as to whose sonnet this was, I, of course, googled it. Interestingly, I came upon this verse from Shakespeare's “Sonnets” LXXI:

No longer mourn for me when I am dead
Than you shall hear the surly sullen bell
Give warning to the world that I am fled
From this vile world, with vilest worms to dwell:
Nay, if you read this line , remember not
The hand that writ it; for I love you so,
That I in your sweet thoughts would be forgot,
If thinking on me then should make you woe.
O, if (I say) you look upon this verse,
When I perhaps compounded am with clay,
Do not so much as my poor name rehearse;
But let your love even with my live decay:
Lest the wise world should look into your moan,
And mock you with me after I am gone.

I had to laugh, reading the final line of the complete version...

There has been multiple delays in getting Orange Kitty's ashes back from the vet. Did I mention that next time I would handle transport to and from the crematorium on my own? ;-) Anyway... for reasons, I have not yet surmised, this delay has triggered a new bout of grief. I've been crying for Orange Kitty, as well as for my grandmother again. And I have been imagining my grandmother mocking me. She was not overtly sentimental nor demonstrative. So I keep imagining her impatience with my grief. That said, this is also the woman who saved her mother's journal and genuinely enjoyed writing her biography with me. So mock my tears, she may. Or she may not. Though at this point, it's of no concern to her really. These tears are not hers, they're mine.

Monday, January 23, 2006

Get Your Federal Hands Off My State Bill

In the Washington Post on 1/18/06, I heard that Justices Upheld Oregon's Physician-Assisted Suicide Law.

Of course, I was totally out of the loop and not aware that there was even a threat to this Oregon state legislation. So, of course, I have to share my two cents on this subject matter. Some of this content has appeared in prior post(s), but it seemed particularly pertinent in light of recent federal news...

In the U.S., our society reinforces the notion that each individual has a right to die. This philosophy is supported by the existence of measures such as durable power of attorneys, living wills, and advanced directives.

In this regard, passive physician-assisted suicide is already legal in the U.S. It is legal to hasten the death of a person by altering some form of support and letting nature take its course. For example:

-Removing life support equipment, turning off a respirator or
-Stopping medical procedures and medications or
-Stopping food and water or
-Not delivering CPR and allowing a person, whose heart has stopped, to die.

Who has the right to die?

As law now stands, when a competent patient with a terminal illness makes an informed decision to withdraw or refuse life-sustaining treatment, there is virtual unanimity in state law and in the medical profession that this wish should be respected.

Although patients can be hospitalized against their will on a 5150 for doing so, committing suicide or attempting to commit suicide is legal.

However, active physician-assisted suicide - whereby a doctor provides a prescription for a lethal dose of a medication that the patient may take to terminate their own life - is not legal in most states.

What does this mean for people whose illnesses will cause their health to decline excruciatingly slowly, causing prolonged suffering, possibly over a period of years? People who have no life-sustaining treatments to withhold?

One example I will use is a patient I had who had chronic obstructive pulmonary disease. At the point I met him, he reported that he was no longer able to engage in the activities that made life worthwhile for him due to the severity of his difficulty breathing. He admitted to me that he was contemplating suicide. Not having given much thought to physician-assisted suicide before, I followed the standard suicide protocol. I assessed that he did not have a plan in place. We made a contract that he would not try to kill himself while in the hospital, with the hopes that the treatments we provided would relieve his suffering enough that he might no longer wish to end his life. My approach made it clear that at that time, I did not believe that suicide was an acceptable option. Were the contract and the negotiation helpful or were they isolating him even further in his suffering? Might I personally want to die if I felt that I was slowly suffocating, breathing becoming more and more difficult over time?

Physician-assisted suicide has been legal in the state of Oregon for over seven years now. It has been legal in the Netherlands for over twenty years. It has been legal in Japan since 1962. It has been legal in Switzerland since 1941. It has been legal in Germany since the year 1751.

Why might People Choose Suicide?

Let’s take a look at the statistics in Oregon for some answers:

Is it because they are not aware of other options?
86% of patients who utilized physician-assisted suicide in Oregon over the past seven years were enrolled in hospice. In 2004, that percentage increased to 89%. Hospice is generally the best thing we have to offer people at the end of life. What other options are there?

Who is using physician assisted suicide? Is it the poor and disenfranchised, whom nay-sayers suggest doctors are wanting to "kill off"?

Of the 208 patents who have utilized PAS in Oregon, 98% were white; 99% had insurance. Oregonians with a baccalaureate degree or higher were 8.3 times more likely to use physician-assisted suicide than those without a high school diploma.

What diseases are these people dying from?

Patients with ALS are by far the most likely to utilize physician assisted suicide. The life expectancy with ALS is 2 to 5 years. During these two to five years, slowly progressing paralysis and muscle wasting occur. These patients frequently die when they are paralyzed throughout their entire body and then finally their respiratory muscles become paralyzed and they can no longer breathe. I cannot imagine wishing such a torturous death on anyone!

My aunt had ALS. She had saved all of her prescription pills for many years before her diagnosis, perhaps having some premonition of what would come. Her diagnosis with ALS came after she went to the doctor because she was unable to swallow. Unfortunately, her first symptom, took away the only option she saw for herself. Instead of being able to end her life before becoming debilitated, as she had planned, she rode out the following three years until she was able to move nothing more than her eyes. If she had the option to kill herself, her sister believes that she would have. And I would have supported her in making that decision.

Suicide has been decriminalized for many decades in most jurisdictions in North America. So why make it unavailable to those who need our compassion the most?

Physician Assisted Suicide is about:
1. Respect for autonomy
2. Justice
3. Compassion for suffering
4. Individual liberty
5. Openness of discussion: Assisted death already occurs, albeit in secret. Keeping it illegal prevents open discussion between patients and physicians.

Legalization of PAS would promote open discussion. It would assure dying patients that they would not be put in a hospital on a 5150 for saying they’re contemplating suicide.

Although much of the opposition to physician assisted suicide has come from religious organizations, some religions have issued statements in support of physician assisted suicide including:

• The Unitarian-Universalist Association
• the United Church of Christ,
• the Methodist Church on the US West coast
• The "Episcopalian (Anglican) Unitarian
• The Presbyterian church
• and the Quakers

Legalizing physican-assisted suicide does not take away one's right to choose to live out their life throughout the disease process, it simply provides another option for those who would choose to forgoe further suffering.


Friday, January 13, 2006

Music Thanatology

Thanatos is the Greek word for death. A music thanatologist is someone who specializes in creating a music therapy prescription as part of the dying experience - both for the patient and the family.

At some points in your life, I am sure you have noticed physiological responses in yourself that have related to music. Personally, my choice in music varies depending upon whether I am excited, sad, or angry. And music can help to either shift my mood or to enhance it. At the end of life, we continue to have physiological responses to song.

In the United States, music vigils at the end-of-life frequently consist of harpists. Live harpists can adjust the music tempo to the rhythm of the patient's breath.

Many other cultures also have musical traditions that pertain to the end of life.

The traditional Hindu song "Praan Tanse Nikle" is a musical prayer to Lord Krishna, seeking liberation at the time of death.

In Chinese Buddhist culture, the chanting of sutras and mantras may be accompanied by musical instruments. The most commonly recited sutras are Amitabha Sutra, the Heart Sutra, the Diamond Sutra, and the Earth Treasure Sutra. In my work setting, the same Chinese Buddhist chant has been used with multiple families. It's very beautiful, though I haven't figured out which one I've been hearing yet.

For some patients, we play general instrumental, relaxation or meditation tapes. We have had some patients or family members who have brought in their own music, which included songs that they liked from pretty much any genre out there.

Since Orange Kitty's death, I have been craving songs about grief and loss and death. They aren't so easy to find! [Let me know if you have any suggestions].

One song I've run into, "If I Could" by Jack Johnson, contains this great line:

"I heard some words from a friend on the phone, didn't sound so good. The doctor gave him two weeks to live. I'd give him more, if I could. You know that I would now. If only I could."

When I hear that song, I am reminded that... Although I had Orange Kitty put to sleep, if I had been able to give her back her comfort and her function, I would have wished her an even longer life.

The song "Bowl of Oranges" by Bright Eyes has a line that really speaks to me. When I'm sad that we can't cure someone physiologically (one of my patients at work), this song reminds me of what I can do:

"I came upon a doctor, who appeared in quite poor health. I said, 'There is nothing that I can do for you you can't do for yourself.' He said, 'Oh yes, you can, just hold my hand. I think that that would help.' So I sat with him awhile, then I asked him how he felt. He said, 'I think I'm cured. Well, in fact, I'm sure. Thank you, stranger, for your therapeutic smile."

Although I don't expect a physiological cure from holding someone's hand and smiling, I am reminded time and again of what a profound effect these simple gestures can have.

Okay, I went off on a bit of a tangent there. Back to music... What kind of music or what songs would you want to hear at the end of your life?

For more information, Growthhouse Radio has a large selection of music that may be used as part of a musical vigil for someone who is dying.

Thursday, January 12, 2006

Orange Kitty's Final Hour

On Tuesday, at about 11:45am, Orange Kitty breathed her last breath.

Euthanasia wasn't exactly what I expected. I'd never put a pet to sleep before. This was a learning lesson. I would do things just a little bit different next time.

The vet came to our house. The poor man! To walk into someone's home and cause so many tears with your presence!

He gave Orange Kitty an injection to sedate her before the lethal injection. She hated it! It was an intramuscular injection in her left thigh. She turned and hissed at me and bared her claws at me as it was done. She'd never hissed at me before! Not even with all of the fluids I'd given her through a needle. I felt so bad that it hurt her so!

She then stood up and repositioned herself. And she layed down so naturally, but then her head got heavier and heavier.

Then she started vomiting as a side effect of the sedative! The vet clearly felt bad and apologized multiple times, saying that didn't happen very often. Orange Kitty had had stomach problems, so I didn't begrudge him that, though I was anxious for her to feel better.

The vet then shaved off some fur from her front left paw to find a vein. He asked if we had any final words to say to her. My mind went blank.

The lethal injection didn't work as quickly as I'd anticipated it would. She breathed several very infrequent but deep breaths for about two more minutes after. The vet turned his back on us after looking for a blink reflex and listening to her heart and said, "Well, I have to bag her now."

She was still having a few of those deep breaths! I said, pathetically / inassertively through my tears, "Can we wait until she stops breathing?" I felt panicked. He wants to bag my cat before she is fully dead!

The home vet had asked if we wanted to take her to the crematorium ourselves or if we wanted him to cremate her for us. I asked if he would take her, since we don't have a car. But then I realized afterwards that he needed to rush to his next appointment. Next time (we do have two more cats and a dog whom we'll likely outlive), I would take our pet to the crematorium ourselves, so we could spend as much time with him/her as we want.

I still feel good about the experience. He waited for her to stop breathing, per my request. And he left us a condolance card with a phone number for a 24-hour grief hotline. The only thing I'd do different next time is that I would take her to the crematorium ourselves.

It was very loving to get to hold her as she died, despite how sad I was to hand her limp body over to the vet.

The rest of the day, her body having left my presence prematurely, I wrapped myself in the blanket she died in and wore it around the apartment for the next few hours, just to feel close to her.

I made a crayon drawing of her as an angel (crayon, because I didn't want my ego invested in how the picture would come out, since it was meant to be therapeutic and not a source of frustration). And I lit a candle in her honor before going to bed.

The house has felt empty and quiet since she died. I wake up every morning with an ache in my heart, knowing she's gone.

But I feel that she is at peace and I have prayed that she knows that I loved her.

Monday, January 09, 2006

Grandma's Kitty

I have an appointment scheduled for tomorrow morning at 11:15am to have my cat euthanized. This cat was my grandmother's cat - the grandmother who died last March. The grandmother whom was obsessed with animals.

Orange Kitty (that's what my grandmother named her) is now 22 years old. She has been in renal failure for the past nine months. We'd been managing the renal failure fairly well up until the last ten days or so. I've been giving her fluids (lactated ringers to be specific for medical folk) with a needle under her skin ("subcutaneously" for medical folk). We started doing this every other day last April, but increased it to nearly daily for the past two months or so).

This has been a very difficult decision for me. It's so different being on the other side of this decision making. Orange Kitty used to respond so well to the fluids. I made jokes that it was kind of like watering her like a lawn. Shortly after the fluids would go in, her fur would look much healthier. She would also bounce around like a kitten. The fluids worked better than cat nip for her energy level.

But then the past ten days, she has had trouble walking. She has fallen numerous times. I am always so frightened after she has fallen, that she may have hurt herself. She seems stiffer and readjusts her position in a way that suggests she may be in pain. We've given her a hot pad to lay on and that seems to help some. But now she can no longer walk very far and has been urinating on herself. Cats are so obsessive about cleanliness; I can't imagine she is happy all covered in urine. No matter what I use to clean her, she still smells of cat pee. She hasn't been eating anything substantial for ten days now. I've enticed her to a paper-thin fish flake every now and then, but that's it. The last time she ate anything more substantial, she began vomiting continuously.

A part of me thinks I have waited too long - that she has been suffering for too long and that is inhumane. Another part of me thinks I should wait until she dies naturally. I had no idea how difficult this decision would be. I wish I had a "palliative care" option for Orange Kitty. I wish we could get her symptoms under enough control that I felt comfortable letting her die naturally.

I am sad that Orange Kitty's death is inevitable.

I am afraid Orange Kitty's death might trigger more grief over the loss of my grandmother last year.

I blame myself for Orange Kitty's death, even though I know it was inevitable (the cat is 22 years old!)

I am mad at myself for adopting Orange Kitty when my grandmother died, because now I am having to grieve again.

I feel guilty for feeling a sense of relief in Orange Kitty's impending death - the relief from the waiting and the relief from the emotional difficulties I had giving her the fluids. (She hated getting the fluids and cried out every time I did it, so I felt like I was torturing her. I could never be a vet).

I am worried that my friends will run from me, because I am grieving yet AGAIN.

I worry that I am not grieving the "right way" and this will draw attention to my deficits as a palliative care nurse.

I am frustrated that I am not stronger and thus am not grieving more gracefully - again a fear that people will run from the awkwardness of my grief.

I am relieved that I have an appointment scheduled to have Orange Kitty euthanized at home. I have been making phone calls for 5 days now to 4 different vets trying to arrange for a home euthanasia.

I'm sad that Orange Kitty didn't die naturally - before she got to the point I felt it was inhumane to keep her alive.

I have mixed feelings about the fact that Orange Kitty is having a good day today. I'm relieved for her happiness, but frustrated for myself as I now question my decision of scheduling the euthanasia.

I am frustrated that I have to lay a blanket on my lap before holding Orange Kitty, otherwise all of my clothes wreak of cat pee. It feels like an emotional barrier as well as a physical one.

I am angry that my Mom accused me of being inhumane when I told her Orange Kitty was dying. She said I should have put her to sleep a long time ago. I am resentful that my Mom didn't offer sympathy and support instead, which is what I needed.

I am relieved that I have had the opportunity to lovingly hold Orange Kitty in my lap, despite the blanket between us, and to give her affection in her last days.

I feel guilty because I'm writing this post, instead of just sitting and being present with my cat who is dying.

I am sad that I must say goodbye to Orange Kitty, who has been so affectionate and charming, the confident queen bee of the house, even in her frail years. I will miss her warmth in my lap, her soft fur under my fingers, her enthusiasm for treats, the annoying way she sucked at my earlobes and licked my face, the unique way she moved with her double-jointed legs, how passively she argued with me about her fluids - making lots of noise but minimal wrestling, and her cute but scruffy face marked with two small growths from her renal disease. And I will miss her because she was my grandmother's cat - a physical being whom I could hold and love as a reminder of my dear Bobby.

May Orange Kitty feel well-loved during these last 22 hours of her life and may her spirit be reunited with Bobby's.

Friday, January 06, 2006

TV Review: Dead Like Me pilot

I was cruising around my local video store, looking for something entertaining to keep me up the night before my most recent night shift, when I came across the DVD cover for Dead Like Me. Of course, any movie with a reference to death in the title generally attracts my attention.

Dead Like Me is a tv series on Showtime. Not having cable myself, I'd never heard of it before.

The plot is that this young woman named George dies in a freak accident and is then recruited to become a grim reaper. George had dropped out of college, was living with her parents, had no job skills to market and seemed generally miserable before she died.

I was not expecting much of this DVD. The premise sounded a little over-the-top. And it is! But that is what was so great about it!

George goes through on-the-job training to become a grim reaper. Grim reapers are given a last name and first initial of the person whose soul they're going to collect and the date, time and location of the death. Their job is to figure out who is going to die. If they're going to die in a painful accident, their goal is to take their soul before "impact."

The deaths in the pilot were mostly pretty ludicrous - one woman had a piano dropped on her and one man died after slipping on a banana peel. Despite the quirkiness or perhaps because of it, I found it refreshing to enjoy the silliness of this show's portrayal of death. Life needn't be so serious all the time. :-)

There were some little inconsistencies in the storyline that were a little off-putting. For instance, they're suppose to take the souls before they're dead. But when the woman was killed by the piano falling on her, the grim reaper waited until after the piano fell before taking her soul.

In addition, George tries to prevent the death of the person whose soul she is suppose to collect. (Sorry if I'm ruining the plot of the pilot for those of you who haven't seen it). Instead of somehow demonstrating why that doesn't work, the boss simply tells George that the souls will die inside the people. And that explanation somehow seemed kind of like a bandaid over a crack in the plot. Of course, I have only seen the pilot, so perhaps that way of handling the crack was a way to leave it open for use in a future episode.

That said, my favorite line from the pilot is one of the other things George's boss tells her after she tried to intervene in the death:

"You can't save any of them. All you can ever hope to do is make it easier. And that may not seem like a lot, but it is."

I couldn't agree more.

Tuesday, January 03, 2006

Spiritual Beings Having a Human Experience

During dinner with a dear friend last night, I had been talking about how I was struggling to "find my spirituality." My friend told me, "You don't have to search so hard...

"We are not human beings having a spiritual experience. We are spiritual beings having a human experience."

That quote was so perfect in the context of our conversation. I loved the line and wrote it down immediately. When I asked her whose words they were, she didn't know.

When I googled this quote, I was amused by the various different people whom have been given credit for these wise words. One site attributed this quote to someone named Sant Rajinder Singh. Another site gives credit to Ram Dass. Yet another site attributes this quote to someone named Jackie Small. The majority of sites give credit to a French theologian named Pierre Teilhard de Chardin. But who knows. I think it's a great quote, nonetheless.