Managing symptoms for a “good death”

I disagree with you on this one req read. This is an excellent article
and much needed for Hospice nurses. They don't teach this in
nursing school. I believe the goal of the Hospice nurse is to manage
symptoms and allow the patient to peacefully and comfortably work
through the transition from this life to the next.

perhaps i misinterpreted req's position, but i got the impression that he was stating that spiritual/emotional/mental pain is necessary, to successfully transition from here to there.

the article clearly focused on pathophysiologic palliation; much more concrete interventions.

i agree that it is important to address physical pain before one can address the other types of pain.
and i do not believe that pharmacologic intervention should be the sole means of abating any mental stressors the pt is experiencing.
taking the edge off is one thing.
totally blunting someone, to the point where all (mental) pain is repressed, is not synonymous with a good death.
revelation is the journey to truth, even if it entails pain.
truth is the journey to a deeper, spiritual awareness, with a resultant enlightenment and peace.

i do understand why req referenced the article as nsg 101, although the information was helpful and valuable.
yet, there is just so much more to dying.
i do think this is what req was talking about.

leslie

leslie

Thank you Leslie.

Good pharmacologic palliation is one thing. Good symptom management is another. But a good death is something truly unique and extraordinary. The author of this article seemed to equate good pharmacologic palliation with good death… and that is nonsense.

Good pharmacologic palliation is a means to a possible end (good death.) Good symptom managements is a means to a possible end (good death.) Both require training and skill. But good death is the end game… the ultimate goal. It is the no-hitter in baseball, the 300 bowling game, the undefeated season in football. It is the person who works through all of their unresolved life issues successfully and then crosses over consciously… wide awake… stepping into eternity fully aware of who they are and what they are doing… stepping from this physical realm into the beyond wide awake and fully conscious.

Manipulating drugs so someone can finish a crossword puzzle is nice, but it does not a good death make.

I realize that in today’s hectic world of bottom line economics, hospice nurse may seldom have the opportunity or the time to witness someone cross over consciously. But when we start to equate dying in a coma with good death we are in real trouble.

This article described good pharmacologic palliation? Yes.

Good symptom management? Well, pretty good. There were some weak spots.

Good death? Not even close.

earle58 and req reader, clearly you are over my head and somewhere that
I may be someday, but for now, you lost me with your rhetoric.
Until I get to where you are, I'll continue to equate a "good death" with
a death without suffering. I hope, for your patient's sake, that you
know for sure your equilization of a "good death" may include physical
suffering is accurate. We'll all find out someday! God Speed!

I am sure I speak for us both when I say the objective is not to speak over anyone’s head. Quite the contrary.

Let me give some examples...

I once had a patient who constantly claimed his pain was 11 on a scale of 1-10. He was really a very interesting guy with a wonderful sense of humor, but his pain seemed uncontrollable. We eventually pushed his pain meds up to levels that would have knocked a horse off its feet but still he would grin and say his pain level was 11. I spent quite a lot of time talking with his wife and one day she related to me that her husband (my patient) had moved from the South to California many years ago rather suddenly. The rumor was that he, his brothers and his father had lynched a man (a black man) and skipped town one jump ahead of the sheriff.

Now I don't know if that was true. Maybe it was... in which case, as he was dying and attempting to resolve the unresolved issues in his life, that probably would be something that would come up.

Or maybe it had something to do with a story he told me himself. He entered the army near the end of WW II. He was not involved in any of the fighting, but he was a crew member on one of the first planes flying atomic bombs around the world. He was told to shoot first and ask questions later if anyone came near the plane. As it happened, one night some drunk English soldiers wandered out near the plane when it was parked on an air strip in England. He said he shot one of them.

Maybe that bothered him as he worked through his dying process. Maybe it had something to do with his pain... I don't know. But I do know that I've had lots of patients for whom there seemed to be some sort of connection between the subjective level of pain they reported to me and past events in their lives. They seemed, in effect, to be passing judgment on themselves. The saying about, "As you judge others so shall you be judged," seems to me to be quite true... literally.

I have spent a fair amount of time trying to assist patients resolving these kinds of issues... with mixed results. But it always did seem worthwhile to make the attempt... as opposed to just burying it under some medication or other. And the reason why I felt it would be better to at least try and deal with it was because I always felt death would not "end" either their lives or their life issues.

It is not for me to say whether the discomfort people feel is deserved, but I have seen that discomfort often results from certain types of acts; e.g. acts that cause pain to others may very well fetch pain in return. I always tried to address it at the source… but often had to resort to drugs in the end.

Nowadays hospice nurses seldom have the luxury of being able to spend much time with patients. But I did have that luxury and enjoyed digging into things as deeply as I could… always looking for root causes and not just pharmacologic quick fixes. I don’t know… pharmacologic quick fixes may be just as good in the final analysis. But I have always had the feeling that if something could be resolved in the here and now, it would be beneficial in the hereafter.

Of course if you assume that death ends life… as in “end of life care”… then who cares? If that is true, it really doesn’t matter.

The author of the article in question seemed to think the best approach is to just keep them sedated (“peaceful”) and call it good… or a “good death.” That may be… I don’t know.

As we baby boomers begin clogging up the healthcare works in the coming years that may very well be the best we can hope for. And perhaps that’s just another example of what goes around comes around. We were the “druggie” generation… maybe that’s how we’ll “end” our lives too.

But I have seen patients work through their life issues and then cross over consciously. That, for me, is the ultimate goal. Most hospice patients don’t get there… maybe I won’t either. But it is still the goal.

Happy Holidays

admittedly i'm a bit perplexed about pain issues within our pt population.
when i have a patient that c/o pain, the physical aspect is frequently the most obvious type to try and eliminate.
but keeping the holistic nature of nsg in mind, i never assume their pain is only limited to the physical.
even if a pt professes tremendous relief from their physical pain, i still need to wonder if there are other mental/emotional and/or spiritual issues at hand, other than the obvious stressors r/t dying.
even with the ever-available pharmacological agents assuring immediate escape from the world of conscious despair, i still notice that their sleeping patterns are not restful.
i note the various facial expressions, the frequent bodily shifts/movement, and often talking aloud while sleeping, leads me to believe there is much stimulus preventing them from achieving the ubiquitous 'peace' that we hospice nurses aspire to reach for our pts.
i was fortunate however, to have worked so long in an in-pt facility, where often i had 2-3 pts.
yes, they were high maintenance, high acuity.
but during their hours of stability, they were left alone with their thoughts.
and all the meds in the world, could not mask their innermost fears and anxieties.
so for me personally, it has always been a priority to let them die with as little baggage as possible.
often, a conversation r/t my thoughts of God and what He respresents, my vision of an afterlife, would suffice in appeasing my pts.
and yes, often, we would opt for stronger doses of sedation, when it was apparent that some were inconsolable.
but one thing hospice has taught me, is many, many people are spiritual beings.
and if i can get across that one's prior and undesirable life moments, are not permanent marks of judgement, then hope can be and is restored to many.
we are human and fallible.
God is loving and all-embracing.
when dying pts are reminded of this, many feel they can go on (and die) w/o the paralyzing terror of self-destructive behaviors.
whatever it is that i do or say with my pts, it's been working.
sometimes merely acknowledging one's anguish is enough to validate and so, lessen, the pain that lingers.
as hospice nurses, ea of us brings something unique to the patients.
except for clinical pathways that have shown notable successes, the rest is all gray, and we can only do our personal best.

leslie

Thanks req red and earle58 for sharing your thoughts and experiences. I've
only been in Hospice 3 years and still learning much.
I've had patients that had very challenging symptoms i.e. pain, anxiety,
terminal agitation when "pharmacologic fixes" were not suffiecient and the
patient had to "work through" with some anguish. I tried to facilitate
as best I could with prayer, soothing environments, and encouraging
families/friends to take an active role in the process. I've had cases
when I thought I experienced a patient "cross over consciously", but
I still believe that symptom management is of upmost importance to
allow the patient to peacefully (or maybe not) and comfortably (if
possible) to transition, and the article in question did address (as
adequatley as may be achieved in such an article) this goal.
I don't know if it is the "druggie" generation or a generation that
just can't deal with death that drives Hospice care today, and I'm
not smart enough or philosophical enough to try to discern; but,
I'll try to remain open minded and flexible. I enjoy both of your
threads and appreciate your input. Take Care!

Perhaps the next logical direction for this thread to go would be a discussion of "conscious death."

What does that mean?

How often does it happen?

What is the point of achieving it?

How can it be encouraged by hospice nurses?

i'm glad you asked those questions req, because many nurses (myself included) experience more and prolonged sleeping patterns as death approaches.

so to perceive 'conscious death' as a concept of literally being awake as you die, could feasibly leave many of us scratching our heads as we ponder this image.

with or without meds, it is natural to start sleeping atc as death becomes more imminent.
my personal experience has taught me that many, many pts do alot of their 'work' while they sleep.
that's consistent with the restless sleep patterns i have observed over the years.
and when they awaken, many appear disoriented; or vague and confused; or fearful, agitated, anxious.
many are reluctant to talk of their dreams for fear of sounding crazy; or even more notable, their inability to accurately explain what had just transpired.

in the initial stages of sleeping more frequently, past life events appear, even if the pt had felt s/he had successfully suppressed it.

there are events in my life that have caused total amnesia!
but you can bet your bippy that i have been diligently working on these particular life issues for a variety of reasons....one reason being, i know these memories will indeed resurface when it's my time to die.
and i don't want to spend that time struggling with those demons.

it really is all relative.
if your life has been rather uneventful and stable, then so will your death.
if one has spent their life, jumping from relationship to relationship, or being a recluse, or battling any type of addiction, or blatantly sinning while rationalizing the sins away....these people are going to struggle when they die.
and there's no running from it.
somehow, you need to make peace with your actions, or the actions of others who have hurt you.
we're not talking about superficial forgiveness but rather, an understanding and acceptance that penetrates your inner core.
when one finally experiences the problem(s) of your past, and can reconcile then integrate it into your here and now (death bed), then peace can be realized.
that is a conscious death.
and all that unburdened energy can go forward, free as an angel.
the more irratic one's life has been, the more work you'll have to do when you die.....unless one has chosen to make their life a journey, leading to clarity and tolerance.

now i would LOVE to hear what req has to say....

leslie

Well, I was actually hoping to sit back and hear what all the experienced hospice nurses who participate here would have to say… what they have seen and what they have thought (about what they have seen.)

The conscious deaths I have been involved with were not really terribly complicated. They were just what the term implies… people dying (crossing over) fully conscious.

I think I described one of these in one of my books. The lady who, while in the middle of talking with her son & best friend suddenly stopped, looked up with an expression of amazement at something she could see (her son & best friend could not see what she saw of course), she reached out towards what she saw, then her arms slowly came down and crossed over her chest and she was gone. Until that moment she had been wide awake, fully conscious and engaged in conversation.

Another lady who lived with her niece (who she had raised as her own daughter and with whom she was very close) did essentially the same thing. She looked up, saw something and said she was leaving now. Then she turned to her niece and said, “But I love you very much.” Then turned to look at whatever it was she was seeing and said, “But I am leaving now.” Then turned back and said, “But I love you.” This back-n-forth focus occurred 3 or 4 times and then she left (died.)

In another instance a patient with whom I had worked for quite some time (she had ALS) called her best friend into her room and gave the ring from her finger. Her friend was overcome and left the room momentarily (as in 60 seconds) to collect herself and then returned. When she re-entered the room, the patient had left.

I did extensive work with a sixteen year old with a degenerative neurologic disease who, when the next inevitable crisis occurred, elected not to go to ER. Instead his family all gathered around… his mother, his brothers & sisters… and they all held hands as he left.

A man who had been in prison for smuggling drugs and had caused the death of at least one young man said to me as he was very near dying, “I am not going to die.” At first I thought he was nuts. Then it struck me what he was talking about. He had seen where he was going, was greatly relieved, and very soon thereafter he left.

A WW II vet I worked with told me about some of his experiences. He had been a forward artillery observer in Italy. He said he had never killed anyone directly, but that he had caused the deaths of a great many people. After getting this off his chest he seemed to relax, then moved on within the next 24 hours without any significant period of being comatose.

From what I have seen, if a person can achieve a fair degree of resolution of their life experiences, they can step out of their physical body and move on… consciously leaving the physical plane behind… while wide awake.

The off & on, round the clock sleeping pattern typical of the dying and the newborn does indeed seem to augment transferring in or transferring out. But if a person can get their work done they may step out wide awake.

Of course accomplishing this feat is made much easier if one has worked on his/her life issues all along and not left everything for the last few days and moments. And of course an understanding hospice nurse can be very helpful.

These are some of the things I have seen and been involved with. How about the rest of you guys?