Pet Hospice

I have had to put two of my cats to sleep during the course of the past 10 years. Both of these decisions were terribly difficult and painful. In one case, I felt I let my cat Orange Kitty live too long and she suffered too much. My heart still aches remembering her walking a few steps, collapsing and urinating all over herself. She was such a dignified cat. I can't imagine that was how she would have wanted to die. In the other case, I still sometimes worry that I put my cat Ebony to sleep too soon. He wasn't eating and was moving very slowly, especially attempting to lay down and get back up. The vet told me he was in renal failure and he would not take to having fluids infused subcutaneously, as my previous cat had. For fear he would progress to the condition that Orange Kitty had, I had him euthanized as soon as I knew he was terminal. There are now so many more resources available for people who are grappling with this painfully difficult decision.

I just came upon a great site today, Animal Hospice that offers a FAQ section to help you make this decision. To quote, "We suggest sitting with the ailing animal and be very quiet. From this place of quiet and peace, share with the animal that the illness or old age is irreversible and that you are open to hearing or feeling what the animal's wishes are about the future." What a beautiful idea. As someone who meditates regularly, this seems like excellent advice.

Nikki Hospice Foundation for Pets is another excellent resource. Their site includes links to products such as wheelchairs for dogs, animal incontinence products, and harnesses that people can use to help support an animal who has difficulty walking.

The International Association of Animal Hospice and Palliative Care is a membership-based organization that provides information to both animal parents and to professional providers about animal hospice.

And sadly, a final resource, In Home Pet Euthanasia offers a listing of providers throughout the United States and Canada who will perform pet euthanasia in the comfort of your own home. If like I did, you feel that is the best option for an ailing animal companion, this site may be able to provide you with a referral to a provider in your area.

May all of our beloved animal companions live long, healthy lives!

A Unique Tribute to a Loved One: Turn Them Into a Diamond

I am in the process of planning my wedding. I haven't announced it here, as I didn't see its relevance to the topic of this blog. However while reading postings in a forum of a wedding community I participate in, I came across a post about turning a deceased loved one into a diamond. Literally! I'd never heard of this before, but was immediately curious to know more.

I'd heard of cremation jewelry that's made to hold the cremated remains of a loved one. But in this case, the cremated remains literally ARE the jewel in the jewelry. The cost makes it impractical at a minimum of $2490 (unless you purchase multiple gems which brings the price per gem down somewhat). But it's certainly a novel idea!

What do you think?

The Idea of "Death Panels"

I am so grateful to Dr. Atul Gawande's piece here acknowledging that end of life discussions are hard and his admission that he failed Sarah, a 35 year old patient of his, and her family when he neglected to have this discussion with her before she died.

When I worked as a Palliative Care Clinical Nurse Specialist at a local hospital, I was hired to have end-of-life discussions with patients who were in an acute crisis in the hospital. These were incredibly difficult conversations.

Imagine being told that you are dying. That alone is profoundly painful news to take in. Then on top of it, to be told this news while you are in a crisis. I would assimilate that to my spouse asking for a divorce while I'm in the hospital rather than talking about it before then or after the crisis has resolved. And on top of it? Here I was, a total stranger to this person, giving them the news that they are dying. Imagine a total stranger telling you that your spouse is divorcing you. Wouldn't you rather hear that from your spouse? I have been seeing the same primary care doctor for over 10 years. Although I only see him in the context of medical problems, we have established a level of trust that cannot easily be replaced. I would *much* rather have him break bad news to me than someone who doesn't share the history that we have with one another.

I think this video does a wonderful job at explaining what these so called "death panel" conversations are really about and the challenges that must be overcome in order to have them.

A Green Death Maiden: Esmerelda Kent Advocates Green Burials and Shrouds

Death is a deeply personal thing. Undoubtedly, it is often a heart-wrenching experience. Burial acts are rituals that provide closure to mourners, a final farewell to the deceased. Some cultures also treat burial as a way to help the deceased journey to the afterlife. The sensitive nature of dealing with death may explain why many conventional burial methods have remained largely unchanged for decades, despite growing evidence that these types of burials are environmentally damaging. Yet, as environmental issues grow in importance, more people are demanding eco-friendly funeral options. We found Esmerelda Kent, the founder of Kinkaraco, and spoke with her to learn more about how she provides grieving families a greener and more natural way to lay their loved ones to rest.

Green burials focus on delivering the body back to the earth in a natural state. This allows for the body to rapidly decompose without leaving behind any chemicals or remnants of things like non-biodegradable clothing or jewelry, lessening the burial's overall impact on the environment. In truly green burials, even the soil is carefully hand-shoveled and replaced in the order it came out of the ground so that the surrounding environment will remain undisturbed. These aspects of green burials, as well as personal experience in death, drew Esmerelda to the cause.

"I had always been fascinated by all things funereal and Six Feet Under was where I wanted to live," Esmerelda said in an e-mail, referring to a television series that focuses on the life of a funeral director. However, it was Esmerelda's personal experiences with death and funerals that truly opened her eyes to the idea of working in burials. In the 1980s, several of her friends died due to the AIDS epidemic, the Kinkaraco website stated, and Esmerelda rapidly became exposed to death and everything that came with it. Soon, she began to realize the value of helping others through the grieving process. Her own organic lifestyle and Tibetan Buddhist practice, which emphasized death and bodhichitta the desire to help others, fueled her foray into producing green burial shrouds through Kinkaraco and spreading the word about green burials.

Conventional burials are environmentally taxing. Every year, the 22,500 cemeteries across the nation bury approximately 90,272 tons of steel, 2,700 tons of copper and bronze, and more than 30 million board feet of hardwoods, all from caskets lowered into the ground. In addition, about 827,060 gallons of embalming fluid is put into the ground annually, according to the statistics posted by the Glendale Memorial Nature Preserve. There are additional environmental impacts from creating burial vaults as well. Fossil fuels consumed through cremation or by using a backhoe to dig graves also add to the list of negative environmental impacts. Many of these extravagant practices involved with conventional burials come from the idea of "eternal preservation," as well as from funeral corporations looking to make a buck, Esmerelda stated. “In fact, state laws concerning green burials are largely dictated by the funeral industry as opposed to actual legislature.”

"The cemeteries dictate what is and what is not allowed in the cemetery," Esmerelda said, "and funeral homes and cemeteries are heavily wined and dined as well as gobbled up by huge multinational corporations who tell them what is and what is not allowed." The bottom line is profit, she said, which typically comes from the sale of caskets, embalming services, and maintaining the perfectly manicured look of a cemetery. "The grass is even sprayed green and the amount of insecticide is staggering," she added.

On the other hand, burial shrouds and green burials are much less costly in terms of actual finances as well as environmental impact, which is one big reason why Esmerelda began making them. "I make shrouds locally because they are lightweight and easy to ship. They are beautiful, simple, biodegradable, and easy for funeral homes as well as families to wrap and use," she said. The shrouds even come with their own attached biodegradable lowering device, which eliminates the need for mechanical lowering machinery. "It is composting at its finest and most reverant," she said.

Green shrouds are made from natural silks, cotton, linens, and wools and provide an alternative to solid biodegradable coffins as well as conventional hardwood coffins. Families who desire to give their loved one a green burial can carefully prepare the body by washing it, stripping it of clothing and wrapping it either naked inside the burial shroud or clothing it in cotton garments before wrapping it with the shroud. Religious practices, such as prayers and hymns, are encouraged to help families through the process of body preparation. When it comes time to bury the loved one, a hole is carefully dug by hand and the deceased is placed within the hole before the earth is placed back on top of the body. Instead of a headstone, many green burials will plant a memorial tree instead. The emphasis is always on returning the body to the earth as naturally as possible while still allowing for a respectful grieving process.

"A tomato sealed in a metal box will always decompose because that is its nature. The nature of the organic human body is to decompose. Green burial helps it decompose rapidly, which is very 21st century as opposed to the 20th century promise of 'eternal presevervation,'" Esmerelda said. Yet, she admits that green burials may take some time before they catch on as a popular choice. "Lavish funerals, jazz funerals, and expensive, showy funerals are the culture and the tradition, and I believe that it will take at least one or two more generations for a green funeral to not be seen as something cheap, creepy, and disrespectful," she said. But that is something Esmerelda has accepted.

"I am not a fundamentalist," she said. "Green burial is not for everyone, nor is cremation or embalming. I just want natural, green burial to be available as a choice for secular people as well as for specific religions."

By-line:
This guest post is contributed by Kitty Holman, who writes on the topics of nursing schools. She welcomes your comments at her email Id: kitty.holman20@gmail.com.

On Being an Injured Hospice Case Manager

I injured my back a few weeks ago and was told by Occupational Health that I should not be lifting more than 10 pounds until my injury heals. As nurses, we cannot work if we cannot lift or turn a 250 pound person. So... I have had to take time off work. This has been more difficult for me since I've been working as a Hospice Nurse Case Manager. When I worked on the floors in the hospital, I could always be assured that my patients would be seen even if I was out sick, because they weren't really even "my" patients to begin with. But as a Nurse Case Manager, I do, in fact, have my own patients. Of course, there are revisit nurses who see my patients when I am unable to. So I've been listening to my voicemail, even though I'm not technically working, and leaving voicemail messages with my supervisor to request visits for people based on what I'm hearing in my messages. But it's very difficult to feel so out of touch with the patients and families on my caseload.

I spoke to the company who is managing my disability payments while I am off of work. (It is so hard to even think of myself as "disabled," when I have a temporary injury to my back, but that's what they call me.) I asked about calling my patients while I'm off work and they essentially told me that would be in violation of my disability. I *want* to call my patients and their families, but then I'd need to chart those phone calls so the nurses following my patients would know what's going on. But then, ironically, I run the risk of not getting paid. *sigh* Something is wrong with a system that penalizes you for working to whatever extent you are able.

Fortunately, I go back to Occupational Health on Friday and expect they will release me to return to work. Cross your fingers for me!

Death Rattle 201

While I was in nursing school, I wrote on this blog about death rattle. Family members responses to that post revealed a lack of reassurance provided from the explanation. And some nurses I worked with reported that the interventions typically suggested (turning and repositioning and anticholinergic medications) sometimes either had no effect or even made the sound worse. So... I decided to do my Master's thesis on the death rattle (often referred to as "excessive respiratory secretions" in the medical field). Here is a brief summary of my dissertation.

Death rattle occurs in 51% to 70% of patients within the last 48 to 57 hours of life (Lichter & Hunt, 1990; Morita, Tsunoda, Inoue & Chihara, 1998; Bausewein & Twycross, 1995; Power & Kearney, 1992).

Anticholinergic medications, which are typically used to treat death rattle, block the parasympathetic innervation of the salivary glands by inhibiting muscarinic actions of acetylcholine on autonomic effects innervated by post-ganglionic cholinergic neurons thus reducing the production of saliva (Hockstein, 2004; Springhouse, 2002). As the death rattle does not always respond to these interventions, Bennett conducted further research into this phenomenon and came up with the conclusion that there is more than one type of death rattle.

Physiological Theory: Causes of Death Rattle

Bennett (1996) identified two different types of death rattle. Type I is caused by an accumulation of salivary secretions when swallowing reflexes are inhibited and type II is caused by an accumulation of bronchial secretions in patients too weak to cough effectively (Bennett, 1996).

Salivary Secretions

Salivary glands have an average output of 1000 to 1500 mL per day (Marieb, 1998). Salivation with eating is controlled by the parasympathetic division of the autonomic nervous system and the facial (CNVII) and glossopharyngeal (CNIX) cranial nerves; however, the sympathetic nervous system causes continuous release of a thick mucin-rich saliva irrespective of digestion (Marieb, 1998). Both the parasympathetic and sympathetic nervous systems have nerve endings in the salivary glands (Zeppetella, 1999). The constriction of blood vessels serving the salivary glands inhibits the release of saliva through the sympathetic system. Dehydration also inhibits salivation because low blood volume results in reduced filtration pressure at the capillary beds of the salivary glands (Marieb, 1998). There is no evidence, however, that salivary secretion decreases nor continues at the same rate in the end of life.

Impaired Swallow and Cough Reflexes

Swallowing and coughing reflexes are regulated by the autonomic reflex enter of the medulla (Marieb, 1998). The involuntary component to swallowing (pharyngeal-esophageal phase) is controlled by the vagus nerve (Marieb, 1998). Although many research articles empirically support the theory that the coughing and swallowing reflexes cease at the end of life, physiological explanations for this phenomenon are as of yet unknown (Bennett, 1996, Ellershaw, et. al., 1995, MacLeod, 2002).

Current Management Guidelines

Current practice guidelines for the management of death rattle include repositioning the patient to mobilize the secretions, anticholinergics, suctioning and reassurance or education (Poor & Poirrier, 2001; Enck, 2002; Doyle, Hanks & MacDonald 1998; Hughes, Wilcock & Corcoran, 1996; Spruyt & Kausae, 1998; Dudgeon, 2001). Morphine and midazolam have also been suggested concomitantly with anticholinergics to increase sedation and prevent central nervous system excitement caused by anticholinergics (Enck, 2002; Doyle, Hanks & MacDonald, 1998); morphine may also improve the frequency of death rattle by decreasing the respiratory rate. No research has been completed to evaluate the effectiveness of repositioning, suctioning nor education as management strategies for the distress caused by death rattle.

Suctioning may not be an effective means of treating death rattle for multiple reasons. For one, the secretions are pooling farther in the hypopharynx or the bronchial tree than an oral or Yankauer suction can reach. Even when a nasal trumpet is used to suction farther back in the nasooropharynx, repeated suctioning causes local trauma to the mucous membranes. This leads to inflammation and swelling, which eventually complicates further suctioning. Death rattle secretions may need to be suctioned as frequently as every two hours. Based on my clinical observations, after as few as four or five episodes of suctioning, edema may occur and may occlude the airway, preventing further suctioning. Suctioning is also thought by some to be undignified for the patient and may cause the patient distress if the patient is alert or semi-conscious. Nevertheless, it is frequently advocated in literature (Poor & Poirrier, 2001; Enck, 2002; Doyle, Hanks & MacDonald 1998; Hughes, Wilcock & Corcoran, 1996; Spruyt & Kausae, 1998).

In practice, many palliative care units and hospices limit intravenous fluids. The rationale for this practice is that intravenous fluids are forcing fluids into the body that the body is unable to utilize. Dying patients frequently have decreased serum protein levels, which shifts the plasma’s osmotic pressure; this causes fluid to leak from the vasculature, causing edema (Guyton, 1996). These fluids may collect in the lungs, the ankles and the oropharynx.

Type II Death Rattle

When anticholinergics are used consistently, yet the death rattle continues, there may be another underlying cause. These cases have been referred to by Bennett (1996); Morita, Tsunoda, Inoue and Chihara (2000); and Wildiers and Menten (2002) as type II death rattle. In most cases, it is difficult to distinguish between the two types because scientific investigation is rarely indicated in the last days of life. However, some causes may be identified and thus treated appropriately.

Treatment Recommendations

Identify each dying patient’s particular risk factors for developing death rattle to assess whether type I or type II death rattle is most likely to occur.

Family members should be encouraged to report any audible sounds to their health care provider as soon as they notice it to ensure early intervention.

Consider prophylactically treating patients at increased risk for type I death rattle by repositioning the patient every two hours and by applying a scopolamine patch. Simultaneously, the frequency of mouth care must be increased to every one to two hours in order to maintain the integrity of the oral mucosa with the reduction of salivary secretions.

Risk factors include: prolonged dying phase

If scopolamine is ineffective in preventing the occurrence of type I death rattle, administer an additional anticholinergic around-the-clock for continuous coverage, such as atropine ophthalmic 1% 1 drop sublingually every 2 hours.

If the death rattle does not respond to the second anticholinergic, treat the patient empirically for possible type II death rattle causes (CHF, pneumonia, pulmonary tumor). If patient is known to have heart failure, treat with a diuretic. If the cause is suspicious for neurogenic pulmonary edema, treat with osmotic diuretics (i.e., mannitol), morphine (to decrease respirations), and/or corticosteroids (to reduce intracranial pressure). If the patient’s secretions are malodorous, suspect pneumonia and consider giving a single dose of Ceftriaxone. However, it should be noted that there are challenges in performing some of these interventions outside of a hospital setting.

Evidence has repeatedly suggested that death rattle is distressing to patients, family members and nursing staff and needs to be adequately managed in dying patients. Our goal is to provide for a “good,” peaceful, dignified death, one in which family members are assured of their loved ones’ comfort. Therefore it is imperative that we, as health care providers, address the treatment of death rattle.

Breaking My Anonymity

Ever since I started this blog, I have been writing under the pseudonym "Mia Adams." My reasoning for this was based on my own personal experience of coming across one of my health care providers on-line and my fears that she would somehow reference me (even indirectly) in her posts. Not wanting to create that same fear in my patients, I decided to use a pseudonym.

As part of that, I opened up a separate email account for this blog. However, as you may have noticed, I have not been posting as frequently as I once was. And as a result, I have also not been checking that email account very often either.

Unfortunately, I am technically unable to change my email address for this blog (as both addresses are gmail accounts which conflict with the google-based applications for blogger). But I will at least unveil the woman behind the curtain, so to speak.

My real name is Melaina and my real email account is Melaina RN at gmail dot com. So please send any correspondence to that account if you would like to receive a timely response.

I have given a lot of thought to this blog recently and am considering picking it back up again. Of course, I am thinking of potential new directions to take it in. With the advent and increased popularity of video posts, I may explore that avenue. Though for the time being, revealing my real name seems public enough, I think. :-)

But I welcome your input as well. I have received so many wonderful and supportive comments on this blog, even during my own silences. Thank you so much for the feedback. I would like this to continue to be a space that enriches the lives of my readers as well as continues to stimulate me to explore new subjects and areas, especially pertaining to issues such as quality of life, palliative care, bioethics, hospice and the end-of-life. Please send any suggestions for topics or any questions that I have left unanswered. I'm hoping with a little attention, I can bring this blog back to life.

Thank you so much for reading!

Sincerely,
Melaina