Managing symptoms for a "good death" - page 17

found at nursing 2006: november 2006 volume 36 number 11 pages 58 - 63 managing symptoms for a "good death" marylou kouch aprn, bc, msn contact hours: 2.5* expires: 11/30/2008... Read More

  1. by   sharona97
    Quote from req_read
    I've been thinking about the possibility of ego being a survival mechanism (in the physical realm) for a couple of days... sort of in the sense that wearing scuba gear is necessary to go scuba diving. After leaving the water the gear is no longer necessary (indeed, is quite cumbersome) and is then removed.

    It has been a very interesting couple of days... wrestling with this hypothesis. It has brought together a variety of concepts... into a rational stream. Yesterday morning, after talking (rather excitedly) about all of this with my wife, her comment was, "Boy, you sure are wired today."

    Thorough (or even an adequate) discussion of this subject would require a chapter or two in a book. I would say however, the loss of self-identity equates to- loss of self... which equates to- ceasing to exist (from self's perspective.) So if we assume we discard ego (like scuba gear) then we are likewise discarding our self. This is the existential horror faced by dying people... the horror of ceasing to exist.

    Which is offset by the longing to- go home (etc. and so on.)

    We have two extremely powerful urges: 1- The urge to preserve self (self-identity) and 2- The urge to be re-absorbed into an expansive (single) identity.

    These two powerful urges are, I believe, paradoxical... in the sense that both are relevant and exist... despite the intellect's insistence that only one can be relevant and exist. In other words, we are both ALL ONE and EACH UNIQUE simultaneously.

    The grass is always greener... so when we are in Self-Awareness we long to be connected, and when we are in Atonement (at-one awareness) we long to be just little ol' "Me." We're never happy... at least (presumably) not until it finally sinks in (to our rather thick-headed intellect) that we are BOTH.

    Like Dorothy (Wizard Of Oz fame)... Honey, you've always had the ability to go home.

    What is really interesting (and would require a couple of chapters) is thinking about and observing how folks who lean towards one side or the other of this paradox behave... and particularly (since we're in hospice) how these thinking and behavioral patterns play out in dying process.

    Michael
    Hi Michael,

    I guess I wasn't that far off as I understand completely the paradox. I agree that the two very powerful urges are in us all, (and that it takes a chapter or three for me), your explanation and examples like I said I get it. Really thank you.

    But where does this mental illness part come in regarding ego. The reason I ask is that I maybe naively believe that there are folks out there that do get it, from day to day, and deal effectively with life's surprises! Which helps obviously at the time of their death. Not so much baggage so to speak.

    For those other folks who are "too busy" with life to ponder the what if's (and when's) I can understand how frightened they may be and the light bulb goes off. Ah Ha, ("So this is how it's always been, really") so what do I need to do?

    Which leads to me to almighty question, which book Michael? lol! Seriously, I am committed to this and really appreciate all info from the hospice nurses. You know who you are!!!!

    I appreciate your tolerance with a (not yet hospice) nurse!!

    Take Care,

    Sharona
  2. by   req_read
    Sharona…
    I sent you an email.

    In General…
    It does seem to me there is value in individuation… the process of developing personality & character… and that it would be a shame to discard that at the so-called end-of-life.

    I once heard an interesting explanation of ego versus negative ego. The gist of it was…

    Ego is a good and necessary thing. It is a helper, sort of a clerk that one employs to tend to certain, rather menial tasks. But we get lazy. Little by little we allow ego to take over more and more of our routine chores until eventually it begins to usurp control. Finally it reaches the point where it has taken over complete control of our lives. At that point it is no longer a good thing. In fact, if we try to grab control back, it tries to kill us.

    So ego winds up with a bad reputation and takes the heat for lots of objectionable behavior patterns. Yet in and of itself, it is good and necessary… if we just manage it properly.

    Michael
  3. by   req_read
    Regarding suffering…

    In a wonderful interview with the late Joseph Campbell (I have it on tape) he describes an Eastern god (from India as I recall) that is depicted as simply a head. I can neither spell nor pronounce this god’s name, but that is beside the point. This particular deity is carved into the entrance of certain temples and represents “life” in the physical realm.

    Life in the physical realm consumes itself. That’s just how it is. Living things here must consume other living things in order to survive. Even those things which we generally construe to be non-living (inorganic things like rocks & mountains, stars & planets etc.) are continually being created, destroyed and recycled as it were.) So life in the physical realm lives on (eats) itself. Hence the head… it ate itself, starting at its own tail and working its way up. Finally, only the head was left. This god is carved into the entrance of the temple, signifying that if you cannot accept it, you may not enter the temple (physical realm.)

    In Judeo-Christian lore this concept is depicted in the Garden of Eden story. It is allegorical of course, and has to do with eating in general, not with apples in particular. To “live” here (Earth) you must eat (consume other living things) and eventually be consumed (die) yourself. If you want to play on this playground you must don the appropriate gear (a body) and play by the rules (consume and be consumed.)

    If you accept the posit of the quantum physicists, not to mention all the great spiritual teachers of history; i.e. that all the diversity we see here in our “infinite” universe is manifested by a single (unified) consciousness (God, Allah, Jehovah, Great Spirit, whatever) then the allegory of the Indian head god (eating itself) is perfectly sensible. Which, no doubt, makes a certain level of suffering inevitable here on this playground.

    So the next time a pt dies and a family member turns to you tearfully and asks the inevitable, imploring question, “Why,” perhaps you will think about a head carved into the entrance of a temple somewhere.

    Which begs the question…

    Even if one understands life & death, does it matter? We sometimes think that understanding will take away the angst & pain etc. It doesn’t. So why bother?

    We often assume the goal of understanding is to remove the emotional component or consequences of our experience. Is it? Or are our emotions important in and of themselves. We are inclined to think that emotions are mere side-effects or by-products of our experiences. Perhaps they are the goal of our experiences.

    Why must we feel sad? Is there something in sadness that is valuable?

    Michael
  4. by   leslie :-D
    Quote from req_read

    Even if one understands life & death, does it matter? We sometimes think that understanding will take away the angst & pain etc. It doesn't. So why bother?

    We often assume the goal of understanding is to remove the emotional component or consequences of our experience. Is it? Or are our emotions important in and of themselves. We are inclined to think that emotions are mere side-effects or by-products of our experiences. Perhaps they are the goal of our experiences.

    Why must we feel sad? Is there something in sadness that is valuable?

    Michael
    i think it was carl jung who stated, "the foundation of all mental illness is the avoidance of true suffering."

    yet, esp in our society, not only do we avoid death, we avoid any type of suffering.
    we have a pill for every ill.
    still, it is difficult in coming to terms w/such powerful and negative emotions...
    precisely because they are powerful.
    they are primal forces in a modern world, and remind us that maybe, we aren't so civilized afterall.
    as a result, we lock up all of our creative and positive energies, in attempt to deny the primitive, primal, uncomfortable emotions.
    and so, we are unable to accomplish anything productive or meaningful in our lives.
    to repress the negative, we can never be whole or healthy.

    i have heard some say that fear, anger, despair, are the work of satan.
    yet it comforts me to observe that all who believe in a God, Buddha, Allah, we all look upwards during times of angst.
    love prevails.
    good over evil.
    our path to the astral world, is enlightened.
    my soul is comforted.

    can you imagine man not having emotion?
    we would either be walking, talking lunatics or welcome-to-the-world-of-robotics.
    nah.
    i'll gladly take the pain and suffering, that accompanies joy and exaltation.
    my intellect allows and embraces its emotional counterpart.
    aren't they what makes us whole?

    leslie
  5. by   req_read
    In our business we have unique opportunities to study human beings. But that is merely a potential. To push that potential into real understanding we have to be honest.

    Dying process forces a thorough, internal reality check like no other. It holds up a mirror and demands, “LOOK! What do you see?”

    The two major angst-producing factors in dying process are; 1- the fear of ceasing to exist, and 2- the thorough self-examination that dying process demands.

    Too often, caregivers attempt to gloss things over. Rather than assisting people to confront and actually feel the consequences of the not-so-pretty things they may have done, caregivers often encourage the dying to ignore, rationalize or flat out deny large chunks of their lives. This phenomenon gets carried over into funeral services where even the most unscrupulous characters are often re-invented in memoriam.

    It is not that we ought to condemn. That is not the point. The point is, no one is perfect. So we should work on being comfortable with imperfection; pain, angst, fear, resentment & regrets… as opposed to sweeping all those things under a pharmacological rug. It is hard to accept one’s own screw-ups, but if someone else can, (like a hospice nurse for instance) then we can start to think, “Well, if she can accept me, maybe I can too.” But denying, ignoring, minimizing or burying one’s faults is not the same as acceptance. To accept, one must first acknowledge… so we have to be honest… to look at who we are from all angles.

    Here is an example with a certain element of humor (some might say, “dark humor.”) As most of you know, I grew up on a farm. I have also hunted and fished most of my life. When I first got into the medical field I was an orderly and assisted pathologists doing autopsies. I have taken apart lots of bodies; from squirrels to trout to chickens to cows to deer to people. And I have to tell you, they all have the same basic operating system. They are all essentially an alimentary canal with various peripheral hardware and configurations. We are all just GI tracts on wheels. Actually, some critters are on wings, some are on fins, some on 4 legs and a few of us on just 2… but we are all basically mobile alimentary canals. Interestingly, the snake (of Garden of Eden fame) works so well in allegory because snakes are about the purist form of a GI tract in the animal world… little more than a tube with openings at both ends. To be physical you have to consume and be consumed. Pretty basic stuff really… being physical.

    The beauty (or lack of it) we assign to the various configurations of mobile GI tracts is, of course, subjective. My wife & I reached almost instantaneous agreement on this issue… the very first thing we both thought of was horses.

    Be that as it may, to really understand life & death one must, at least a little bit, pare down our usual, quixotic view of who we are. Not that a quixotic view is immaterial… it has its place. But for the literalist who thinks there actually is a Garden of Eden in the physical realm… if you really want to get literal… then do it! If you like literal, then by golly let’s get down-and-dirty literal. If humans were created in God’s image, does God have an anal sphincter?

    Or maybe… just maybe… could that be allegorical… just per chance?

    Michael
  6. by   sharona97
    Hello All,

    Adversity has taught me that pain and suffering brings "things" forward. To a bettter place, to a better understanding in life for me. And that is where it stopps.

    Your posts really drive home that it's ok that it doesn't drive Joe Schmoe home (yet), but that is where my confusion comes in. How come Joe doesn't care about the big bad ego, or intentionally putting pain and suffering toward someone and not think twice about?

    Yet when the pain and angst hit me, Yes, it hurts, but I grow and learn from it.
    So yes I believe pain and suffering have a specific purpose in our lives, it is up to the individual to use it and grow or bite their own head off........

    Thanks for such great posts
    Nice to hear from you Leslie, you are missed.

    Michael, thank you for the Email.

    Sharona
  7. by   req_read
    During my years of working in healthcare I observed that the practice of medicine is a combination of science and art. I also observed that when docs first start out their practice is mostly science, but as they grow older, more experienced and wise, their practice becomes mostly art.

    The same could be said of hospice nursing. The article that instigated this thread (remember that?) presented hospice nursing as mostly science (and that mostly pharmacology.) Now, all this time later (over 200 posts and 52-thousand views) it is apparent that hospice nursing is an art.

    We have all heard things like: Beauty is in the eye of the beholder, and good art cannot be defined… but I know it when I see it.

    Learning the science of hospice nursing takes some time and has is complexities, that is true. But compared to the art of hospice nursing, that is merely entry level… kindergarten stuff.

    The art of hospice nursing involves a deep understanding of life and death (that the latter has just as much purpose and value as the former), of human nature, a true ability to think outside of the box (as opposed to the trite lip-service that is paid to that concept these days), a willingness to feel and understand the potential value in pain, angst, fear and sadness as well as joy and hope, the vulnerability to reach out and expose one’s self to another knowing you may get hurt for your trouble, the willingness to open up to extrasensory perception (both your own and that of others), the ability to accept and forgive the ugly side of another human being, and perhaps more than anything else, the ability to look honestly at your self.

    Dying process is not studied, so those who become hospice nurses are, to a large degree, on their own. The art of hospice nursing is not taught, it is learned… mostly from dying people. About half of hospice nursing is teaching… being the teacher. The other half is learning… being the student. Those who aspire to be a hospice nurse need to understand that dying people can teach you how to live.

    Michael
  8. by   sharona97
    I, myself truly believe the angst, adversity, the "not so nice stuff" helps keep one whole.

    I can only imagine what the hospice nurses see in individual family members as "they all come together" to be next to their loved ones in their actively dying moments.

    I've come to conclude that in order to keep sanity and give all I can to help positively towards the dying individual is to let the others hopefully get to and accept the emotional opening up of themselves, by themselves instead of worrying why "they" are not.

    Teaching and learning........throw a little suffering in there (family stuff) and I think the nail has been hit on the head.

    Sharona
  9. by   Em1995
    I, myself truly believe the angst, adversity, the "not so nice stuff" helps keep one whole.


    Sharona and all:
    I am so grateful to have found all of you! I'm a seasoned hospice nurse (former ER and psych nurse) and have longed to find a group of people involved in an existential discussion. Yes, symptom control is important, but the unspoken, spiritual aspect of this work is what fascinates me. The onesness of us all is so apparent.
    There are moments I have found where my patient and I communicate without one spoken word. I distinctly remember a man who died while I was with him not long ago.I was exhausted and emotionally drained and not one word was spoken between us, yet volumes of feelings were processed.
    I hope we can continue this discussion.
    Em
  10. by   Em1995
    I continue to read all the old posts and this discussion reminded me of a patient who "died consciously". I know what Micheal means and it doesn't mean tossing symptom control out the window. He advocates utilizing meds when necessary, but not to the exclusion of the personhood.
    I had a woman who was dying of ovarian cancer. She was getting liquid morphine for pain control and the family wondered out loud to me:"do you think she is hanging on for something or someone?" I responded that this might be so and asked if she had talked to all those with whom she wanted. The sister then took me aside and told me that when the patient was a young woman, she had a baby out of wedlock (a sin in those days!) and she so wanted to see her daughter as she had never met her. She asked me if I thought that perhaps they should call this daughter. I left it up to them as they knew the patient very well. Pointed out that I sensed a longing, but I couldn't figure out what it was. They did manage to find the daughter and she came to visit the patient. They had a wonderful visit and the patient visibly relaxed the next day when I visited her. She was laughing and joking and I could feel a lightness in her heart. She died that evening, very peacefully, surrounded by her family....and, her long-lost daughter.
    There's more to this. A month later, I was asked to do an informational with a woman in a nursing home. I provided her with all the usual hospice information and attempted to answer her questions. Her family was present and they asked some very good questions. At the end of our meeting, one family member asked to see me at the nurse's station.She introduced herself and stated she had requested me as her mother's nurse. The woman was the long-lost daughter of the patient in the above paragraph!! She started to cry and told me that had I not encouraged the family of her biological mother to pursue some "unfinished business", she might never have met her mother. I still get chills when I remember this. Some might say I crossed boundaries and should have called in the social worker. The fact is, the family did not want a social worker. As a nurse, we need to listen to our gut instinct, that feeling that we can't quite articulate, because the energy we so often feel is the only way we can palpate an unspoken need.
  11. by   Simplepleasures
    This may seem a simplistic observation on my part, in light of all the deep thinking of the previous posters, but when in the presence of a dying patient I feel awed and humbled to be a part of a transition to a much greater existence,to something I have forgotten, like a song I am trying to remember, but just cant.

    I almost envy the dying, don't get me wrong,I love life, but it seems as if they are truly going "home", from their tasks here on earth. I was told that we are all great spiritual beings and the greatest ones chose the worst life for themselves here on earth in order to learn the greatest lesson.
    Last edit by Simplepleasures on Feb 5, '08
  12. by   req_read
    Interesting thoughts. Thanks.
    Michael
  13. by   zacsmimi
    I disagree with the idea that the goal of a good death is to die consciously. While I applaud the concept, my experience has been that the goal of helping patients die should ALWAYS be based on what the PATIENT wants.

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