Monday, July 31, 2006

Expired Poem

JennyNYC and I have been working on a poetry project. We have been writing one another a poem every day for 100 days now. I think part of my silence on this blog has been due to this new creative writing outlet. But I thought I'd share the poem I wrote last night. It's not my best piece of writing, but the subject certainly seems pertinent to this blog.

"Don't leave me,"
he nearly begged
in fear
as he reached out his hand to me.
His frail body was failing him.
His wife at his bedside
spoke the feeling
they both shared.
"I was scared."
She says the words
with her back to me
as she walks away from the bedside.
I massage his feet
to calm his nerves
and he falls right to sleep.

Two nights later,
I return to work,
looking forward to seeing him again.
Having bonded over the
touch of his hand in mine.
Having felt a connection
in his need for my companionship.

As I walk onto the floor,
my heart sinks.
His room is vacant.
The note on the clipboard reads,
"Transfer/DC to:

Tuesday, July 25, 2006

Thank you, Advance for Nurses!

Just a quick thank you to Terri Polick for including me in her recent article on nurse bloggers in Advance for Nurses.

Monday, July 24, 2006

from The Mystic Odes of Rumi via the 5th Season of Six Feet Under

Our death is our wedding with eternity.
What is the secret? "God is One."
The sunlight splits when entering the windows of the house.
This multiplicity exists in the cluster of grapes;
It is not in the juice made from the grapes.
For he who is living in the Light of God,
The death of the carnal soul is a blessing.
Regarding him, say neither bad nor good,
For he is gone beyond the good and the bad.
Fix your eyes on God and do not talk about what is invisible,
So that he may place another look in your eyes.
It is in the vision of the physical eyes
That no invisible or secret thing exists.
But when the eye is turned toward the Light of God
What thing could remain hidden under such a Light?
Although all lights emanate from the Divine Light
Don't call all these lights "the Light of God";
It is the eternal light which is the Light of God,
The ephemeral light is an attribute of the body and the flesh.

...Oh God who gives the grace of vision!
The bird of vision is flying towards You with the wings of desire.

Sunday, July 02, 2006

Symptomatology: Itching

For a list of symptoms I have reviewed in previous posts, please go to this symptomatology of dying link.

The next symptom I will address is itching (also known as pruritis). There are a number of reasons people who are at the end of life may experience itching. Some of the most common causes include:

-side effect of opioids
-uremic itching secondary to kidney failure
-jaundice secondary to liver failure and/or biliary disease

If the itching is presumed to be from opioids, then switching to a different opioid may be effective.

Uremic itching is more difficult to treat. The exact physiology of the itching is as of yet poorly understood. Therefore treatment approaches may move forward through trial and error.

Some of the medications that may be trialed for uremic itching and for itching related to liver failure include topical products such as:
-hydrocortisone cream - this antiinflammatory is very mild. If it's not effective, stronger steroids such as betamethasone 0.10% 15 grams twice per day may be used. However keep in mind that the stronger steroid puts the skin integrity at higher risk of breakdown.
-Lidocaine ointment 5% which numbs the surface of the skin.
-Sarna lotion, which is Camphor 0.5% and Menthol 0.5%, cools and moisturizes the skin and may help with mild itching.

Some oral medications that may be trialed include:
-Atarax (25 to 100 mg four times per day) is an antihistamine used to treat anxiety as well as for itching. It is primarily used for itching due to allergic reactions, but may be helpful with other types of itching.
-Benadryl, like Atarax, is best for allergic itching, but may be trialed as a supplement to other modes of treating pruritis. Antihistamines also make you sleepy. Some patients may report some relief if they are able to sleep through the itching.
-Questran (aka cholestyramine) is prescribed specifically for itching related to liver failure. It binds to bile acids in the intestine. This prevents their absorption, and the cholestyramine/bile acid complexes are eliminated in the stool.
Ursodiol (300mg twice per day)is a bile acid used to dissolve gallstones. Because it dissolves gallstones, it is suggested that it may also help with itching, but the effect is minimal.
-Doxepin (25mg daily) is an antidepressant/anxiolytic medication that has been used for pruritis. One of the side effects of the medication is peripheral neuropathy, which may be why it's been tried for this use.

Small studies have suggestd acupuncture may be effective in treating uremic itching in patients with chronic renal failure. Whether or not this may extend to patients at the end of life has not been studied.

See this link for more information on over-the-counter products for itching.

Saturday, July 01, 2006

Ethical Issues at the End of Life

If you are a regular reader of my blog, then you likely know that I have a passion for ethical dilemmas. Perhaps you even participated in a debate on one of my Your Truth posts.

I was recently asked to give a lecture on Ethics at the End of Life. Although I am passionate about ethics, I'd never given a lecture on the subject before. Having recently graduated from my Master's program, I dutifully prepared Power Point slides on concepts such as autonomy and choice, advanced health care directives, medical futility, quality of life, double effect, the spectrum of hastening death, moral distress of nurses, and the four-box method.

I *love* to teach. And no matter what the subject is, I always maximize interactivity between myself and my audience. Personally, I learn best when I am awake and I have a suspicion this is true for others. ;-) Fortunately, ethics is a subject that easily lends itself towards a lively discussion.

I have been wading through my email inbox, now that I'm done with school. I apologize to those of you whose emails have been sitting unanswered. I'm doing my best to get through them now. During this sorting of emails, I came across a link to an on-line excerpt from William Colby's book, Unplugged, where he writes:

"When surveyed, the majority of us say that when our dying comes, we hope to be at home, free from pain, surrounded by loved ones, and not hooked up to machines. In the abstract, that's likely true. We also very much want to be hooked up to those machines right up to the very moment when the doctor is sure that those miraculous tools can't fix us. Trying to find that exact line is no easy business."

This thought seemed particularly relevant to my last blog post, as well as to the discussion / lecture I gave this past week.

In the 1970's, it was accepted practice that any and all interventions should and would be taken to prevent death no matter how extreme the intervention (Drought & Koenig, 2002 - no, I'm not old enough to be speaking from personal experience, so yes, I used a reference for this). But as technology has advanced, we have vast and ever-growing means of keeping people alive, even while their bodies are otherwise failing them. As a result, ethical considerations in making decisions about treatment have become increasingly complex. This was a point I stressed in my talk; William Colby speaks to this in his book as well. Although technology has advanced dramatically, we are still no better at predicting when death will come. In my post asking how you'd like to die, not one of you said that you wanted to die hooked up to machines in the ICU. Why or why not?

If given the choice - to be kept alive as long as possible, but then to die in the ICU connected to machines or to possibly die prematurely but die peacefully at home, which would you prefer?