[req_read]

River…

I am not surprised the woman you describe was agitated.

I may have mentioned this in another thread somewhere but I too had a patient who sexually abused his daughters. He was very pious and did not know I knew of his abusive history. I asked him once if he had any regrets. He said he had lived an exemplary life and had no regrets whatsoever. One of his abused daughters was sitting next to me at the time and quietly wept.

As death drew near this man experienced physical discomfort which was controlled with medications, but he also had quite a bit of inexplicable anxiety… which was more difficult to manage. He never did acknowledge his past and died unconsciously.

You may fool some of the people all of the time, and you might even fool all of the people some of the time, but you can never, ever fool your self… the self always knows. And it is the self with whom the dying come face to face.

The daughters did their duty and helped with their father’s care all the way through, but it was hard for them. They did it, but they suffered.

Michael

[earle58]

Originally Posted by req_read

He never did acknowledge his past and died unconsciously.

Michael

i'm not sure i agree with this, michael.
his anxieties served as a catalyst for his consciousness.
just because he didn't verbalize remorse, or openly share his woes, doesn't mean he didn't wrestle in his own private hell.

anxiety, fear, agitation, depression are all forms of pain.
even the abusive mother that river spoke of, she might have benefited from some blatant 1:1 earlier in the process.
in the absence of anything pathologic, people on their death beds need to hear the truth.
these truths can be positive, fluffy and beautiful and they can also be horrid and evil; as long as they are truths.

so when i'm on my deathbed and a perceptive person tells me, "you spent way too much time alone during your life and as a result, you weren't available"...that will be a truth that stings and i may choose not to publicize my reaction but nevertheless, it doesn't make this truth any less plausible.
i would certainly imagine this truth manifesting itself as anxiety, perhaps agitation, distance, depersonalization....who knows? but i do know, it will manifest itself in some way and so, that makes it conscious.

we cannot will one's behaviors and responses to neatly fit into the text of a bestseller book.
we can only observe that one person's reaction is not synonymous with anyone else's.
and so we can always expect the unexpected-albeit ea response being as valid as the next one.
consciousness catapults a myriad of ambiguous phenomena.
ultimately, it's up to us, to find the door which leads to the much needed closure.

leslie

[river1951]

Which leads me to a place I always wonder about. I have only had terrible problems managing symptoms a few times. Occasionally, in these cases, some light is shed by someone in the family on an unresolved issue. If the patient is able to resolve the issue (with help usually ), symptom management becomes easier. I remember two particular cases- both middle-aged folks. One was not speaking to his dad, the other had issues he felt were unresolvable. In the first case, the dad came around to talk when he found out his son was so ill; in the other case we held a healing ceremony so he could let go of the issues with intent that people he harmed would be healed. Both persons had far better symptom management after the events.

But occasionally I wonder. What do other folks experience? Maybe we should make anxiety the 6th vital sign.
Love reading everyone'sdiscussions.

[earle58]

that's a valid point, river.
ever since i've worked hospice, i've always consciously (and i'm sure, unconsciously) used anxiety as the 6th vital;
or whatever undesirable feeling the pt is experiencing.
plus i loathe the dx of terminal agitation.
if you look at it as a transient occurence, chances are it will indeed be transient (in the absence of pathological variances).
how did your pt respond to the healing ceremony?
i know you said that symptom mgmt was easier afterwards.
but was he aware of the intent of this ceremony? he knew it was to heal those he felt he had wronged?
now that's what i would call a good death-everyone is healed, returned to balance, 'normalized', 'stabilized'.
but whenever i hear of a pt being profusely medicated for terminal agitation, i would give my right arm to be able to spend as much time with them as humanly possible.
i'm that confident this agitation could be resolved.
every person on this earth, has the right to leave here with boundless, positive energy and so, all loose ends must be neatly tied before their bodies die.
an ideal?
yes.
but i don't know why, in this day and age, this couldn't be a reality.

leslie

[river1951]

Yes, Leslie, it was for that reason. He had been a bomber pilot in WWII.
No easy fixes- my ownb father in lawfelt guilty he had volunteered to bomb Dresden- of course that was after he had worked flying folks out of the concentration camps, we all understood, but he worried over it.
Talking and spending the time always seems to be the answer. How we're going to get around this damn managed care, I don't know!

[BeExcellent]

That's what makes all this so GOOD. Some art, some science and mostly intuition. In the end, the only ones to ask are those left behind. Sometimes, WE are the only ones left behind. We juggle managed care, office morons (oops, did I just let a bias out?), scared folks, juicy pts, And we struggle with our own sense of life and death. To quote a commericial. It is priceless. We could not buy the intimacy, maturity and humility that comes with open hearted hopsice work.
To answer your question Michael, my big bellied pt died just fine. Not alert, liver failure dulls the mind, but just fine. He went to bed and went deeper and deeper into sleep. The day or so he was on auto pilot allowed his family to talk about the "little boy" he had been. Who is to say that he wasn't conscious behind those eyelids? Let me throw this out. Is there a difference in death when death comes swift and unexpected, car crash, fire, massive MI or stroke? Is that a conscious death? I read an interesting thing that said when black boxes as analyzed the most frequent last words recorded are expletives. Like birth, I don't think the traveler needs to be in control or retain the consciouness. For the most part, I like life just fine but I don't think I would judge it by what I experienced at birth.

[earle58]

Originally Posted by BeExcellent

Like birth, I don't think the traveler needs to be in control or retain the consciouness.

agreed.
conversely, a 'good', swift death will bypass all the evil yet necessary work to be done.
truly, who wouldn't just want to get it over with?
yet, through all the yrs of work w/my pts, i've consciously opted to start my life review now.
and hopefully by my life's end, i will have taken one of the finer journeys.
i prefer to be conscious throughout my life and not just at the end.
makes perfect sense to me...

leslie

[river1951]

Originally Posted by earle58

agreed.
conversely, a 'good', swift death will bypass all the evil yet necessary work to be done.
truly, who wouldn't just want to get it over with?
yet, through all the yrs of work w/my pts, i've consciously opted to start my life review now.
and hopefully by my life's end, i will have taken one of the finer journeys.
i prefer to be conscious throughout my life and not just at the end.
makes perfect sense to me...

leslie

Ok, guys, how I see it- this is one of the gifts from doing this work is to realize both the importance and uselessness of our lives. The importance refers to any moments we have the ability to touch another in a positive way; the uselessness of spending most of our life in a quest to pile up possessions.
The California hospice association is putting on a teleconference next week- "Vital spiritual components to consider at end of life"- actually looks pretty good-I'll let you know what I think.

[earle58]

i despise the materialism that penetrates every vestibule of middle and upper class america. i so rebel against it.
what people amass throughout their lives, virtually amts to a pile of stuff, albeit costly to many.
why can't we claim the material that resides within our souls?
this 'stuff' we possess from within goes beyond costly; it's priceless.
and yet, we treat it with utter disregard-it/we have no value.
only cars, ipods, jewels and bling-things are attributable to honor.
ah, thank you america, for blessing me with plastic embraces.
give me that 5-second ambience of warm, fuzzy serenity and i will be the richest person i know.
and that smile that can't be erased...some may say it's from the school of hard knocks.
i happen to think those knocks are golden.
and my feet are restless as they have a long journey ahead.
i hope my children aren't disappointed when i don't have the material goods to leave them when i die.
but if they ever experience an iota of what i've learned, they too will be rich.
all they have to do is peek inside of their souls.
it's there for all things wondrous and exhilarating.
you won't find it in saks or on rodeo drive.
it's so close that it's palpable.
breathe it, embrace it, live it, my children.
"to thine own self be true".
life will bring you far and you won't be carrying the extra baggage of all that 'stuff'.

leslie

[river1951]

It's not America, it's human beibgs doing what they do best, mistaking temporary comfort for hearts ease.
Other wise, well said!