Managing symptoms for a �good death� - page 18
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
Feb 9, '08Occupation: Hospice case manager Specialty: 21 year(s) of experience in Emergency, ICU, Psych, Hospice ; Joined: Jan '08; Posts: 58; Likes: 40I agree with "what the patient wants", but I also know what Michael means and he does NOT condone physical suffering. I have had patients go "consciously", but they also had their pain very well-controlled.Michael?
Feb 9, '08Occupation: Writer - on Dying Process Specialty: Med-Surg, ER, ICU, Hospice ; From: US ; Joined: Apr '05; Posts: 296; Likes: 136It is axiomatic that we live in a death averse society and that the majority of individuals know almost nothing about dying process. Therefore it is impingent upon the “experts” in the field to educate themselves as thoroughly as possible so as to maximize their ability to assist each pt in their particular situation. In that sense, what is best is situational. Dying process is highly complex, patients are highly complex, families are highly complex, and so what is “best” has to be matched to an array of factors, each of which is highly complex in its own right. Which gets back to the notion that hospice nursing is more art than science.
The scientific approach tends to boil things down to a simplistic maxim; e.g. keep the pt comfortable… that is all that matters. Or do whatever the pt wants… that is all that matters. Following simple rules is tempting at times… it sure would make things easier! But alas, as it turns out, life is complex.
Because of society’s aversion to death & dying John & Jane Doe have little hope of acquiring a deep understanding on that subject in the few weeks or days prior to their death, but one would hope that hospice nurse’s level of understanding would be somewhat greater.
Let’s say your (hospice pt) was born in Paris and 2 days prior to his death announces he would like to die there. Is your hospice agency going to fly him to Paris? If not, would you call that a bad death? Or (assuming his family did not have the financial where-with-all to fly him to Pairs) try getting him on to something more realistic and substantive?
Let’s say you have a pt who wants to be euthanized. Would you do it?
Let’s say your pt wants to emulate Christ and wear a crown of thorns and have blood trickling down his face from his scalp. Would you comply?
Few (as in- almost no) pt/fams understand dying process. Are you willing & able to assist them in deepening their understanding? Or will you merely hide behind the maxim: Whatever the pt wants… that’s good enough for me.
Also, when I speak of dying consciously as an ultimate goal that is an ideal, not situational.
I sometimes get the feeling that if I were to suggest that the ultimate goal for a major league pitcher is to pitch a no-hitter (an ideal) someone here would jump up and proclaim, “No, no! There are times when a pitcher’s “ultimate goal” is to have the batter hit a single.” (Situational.)
It is also apparent that many hospice nurses do not understand the concept of dying consciously; i.e. what it means, what it would look like, how it would be beneficial and in what context etc. Obviously, few (as in- almost no) pt/fams understand this. Should we then (since almost no pt/fams understand it) scratch it off our list of goals?
If a high school grad goes to see a counselor at a university, thinking he would like to enroll but has no idea how to go about it and announces, “I would just like to get in and do as well as I can until my money runs out.” But the counselor, because her experience, understanding and know-how are vastly greater, can see that the student’s grades & talent are sufficient to get some and ultimately graduate. But since the student’s level of understanding is quite low, should the counselor just keep her mouth shut and simply give the student what he wants… leaving him wallowing in his own level of misunderstanding?
Pt/fams don’t know what is possible… but hospice nurses should. The gist of your argument (zacsmimi) is that hospice nurses should just leave pt/fams at whatever level of ignorance they happen to be on. Your argument also suggests that most hospice nurse’s level of understanding of dying process is no greater than that of the general public.
On the latter count, there are times when I am in despair of the possibility that you may be right.
Here is an example of an ultimate achievement for a hospice nurse. While admitting a pt he whispers quietly, “When the time comes, I want you to give me an over-dose. Do you understand me?” But then, ultimately, the nurse is able to work with that pt/fam so effectively that the pt winds up crossing over, wide awake, in a state of pure bliss.
Before that could happen however, the nurse would have to understand that it is even possible. Then s/he would have to have some idea of how to get from point A to point B. And of course there are always those irksome details like, the hospice agency would be willing to give the nurse time to accomplish such a goal.
Feb 9, '08Joined: Apr '00; Posts: 24,611; Likes: 35,453it's frustrating to read the posts who endorse, "always what the pt wants".
it is because the pt does not want to deal w/their current reality, that death s/b as opaque and unaccountable as possible.
it is only when they have consciously tidied up loose ends, that hindsight supports what they truly want.
and an effective hospice nurse, knows this.
and still, it's disconcerting that many don't get this.
michael, i bow to your perseverence in upholding this truth.
Feb 9, '08Occupation: Hospice case manager Specialty: 21 year(s) of experience in Emergency, ICU, Psych, Hospice ; Joined: Jan '08; Posts: 58; Likes: 40Let's clarify this...we do, in fact, "do what the patient wants" when we work with the patient and family in facing the unresolved issues, unhealed relationships, whatever it is specific to our patient. And, that isn't in a "cookbook for hospice nurses". It takes listening, really listening, an acute awareness of our patient and his or her significant others, it takes our presence in the moment. Fortunately, my hospice agency gives me that time. They actually encourage it!
Hospice nursing is FAR more than mitigating symptoms with pharmaceuticals. It's looking and listening to what's spoken and many times to what's NOT said. As someone here said...it's opening yourself up to die with this patient and I know exactly what that means. A sad fact is that many patients are referred to us way too late...but, even then we can assist them in this process as best we can.
Feb 9, '08Joined: Apr '00; Posts: 24,611; Likes: 35,453good post, em.
i am specifically referring to those pts who would prefer to be snowed throughout the dying process, in attempts to shield themselves from further anguish.
or those pts who feel condemned to hell, refusing any/all interventions, as forthcoming punishment.
or those pts, who defer to their family's wishes, 'wanting' to keep the peace.
and it goes on.
these people need to accept their death, w/all of its inferred values, if it is to have any semblance of substance.
many times, these pts don't know what they want, until they've arrived there.
again, that hindsight thing.
no doubt, you get what i'm talking about.
Feb 10, '08Occupation: Writer - on Dying Process Specialty: Med-Surg, ER, ICU, Hospice ; From: US ; Joined: Apr '05; Posts: 296; Likes: 136Okay… now let’s get back to business.
I have noted, and often remarked, that the dying teach us how to live. However, that does not necessarily occur in a straight forward way. Just as in life, many of the lessons we learn are taught in reverse so-to-speak. By their actions and the results thus obtained, people can teach us what to do, or they might teach us what not to do.
When you see someone touch a hot stove and jerk his hand away with a scream you think, “Ah-ha! Touching hot stoves is a bad idea.” So that lesson is taught and learned, but in a negative way.
Many people watch their parent’s die while being aware of their parent’s peculiarities… or one might say- their “character flaws.” No one is perfect. I’m not… and my parents sure as heck weren’t. I see what my father is going through as he traverses his dying process and can see quite clearly how his “peculiarities” played into what he is going through now. In fact, I predicted (to my siblings) that he would go through what he is going through now before it came to pass (based on my study of dying process.)
All of which is to say…
A) If you understand dying process, plus B) you are familiar with a dying person’s life-style, attitudes and thinking patterns, you can C) predict, with a fair degree of accuracy, how that person will die.
Which, by the way, includes your Self.
If you understand dying process and if you understand your Self you can predict how you will die.
Now… one might well ask… why the h___ would anyone want to do that!?!?!?
Because, if you see it coming you can change it. If you can see it coming and don’t like what you see… change it.
Thus, dying teaches us how to live. It is a lot like some of those science fiction movies you see where someone travels into the future, finds it to be rather troublesome, then comes back to the present and frantically attempts to avert the coming calamity.
Well, that notion is not so far-fetched. If you know your Self (harder said than done of course) and understand dying process (few do) seeing into your future (seeing your own dying process) is no great trick.
So there are two prerequisites for improving one’s future; 1) understanding dying process and 2) understanding your Self.
Which underlines the value of studying dying process (and makes one wonder why we don’t) and points to why so many spiritual teachers throughout the course of history have advised us to “know thyself.”
Feb 11, '08Occupation: Hospice case manager Specialty: 21 year(s) of experience in Emergency, ICU, Psych, Hospice ; Joined: Jan '08; Posts: 58; Likes: 40Micheal...I hear what you're saying and that's why I am very verbal about reaching out into the community with educational offerings re: hospice. It provides a vehicle to open the lines of communication and to encourage people to THINK and TALK about living and dying....now. And, who better to lead a discussion than a hospice nurse? I include our social workers when I plan these community events. I also reach out to the schools as kids do want to talk about dying and living, despite people telling me I "should spare them". That gets my blood boiling.We avoid and deny so much in this society. And, by this avoidance, how can people know themselves? Just a thought.
Feb 11, '08Occupation: Writer - on Dying Process Specialty: Med-Surg, ER, ICU, Hospice ; From: US ; Joined: Apr '05; Posts: 296; Likes: 136Posts # 218 (Em1995) and #219 (ingelein) were both very interesting.
Would you mind sharing a description, as best you can, of the example of conscious dying you mentioned?
Also, I have spoken to lots of groups but kids? Brilliant! You go girl!!!!!!
I’m a badger too you know. Most folks know us as “cheese heads,” but we were badgers first… which came from the first white settlers (after the resident Indians were ripped off and slaughtered.) Anyway, the first wave of whites were lead miners. They dug holes in the ground to mine the lead, then lived in the holes… like badgers.
But I digress…
The idea that some whose lives seem rather a mess may, in the proverbial “end,” turn out to have had the greatest opportunity for growth.
Also… just throwing this out there… my wife is an oncology nurse. One of her recent pts (terminal) remarked to her the other day that his sense of time is changing. She didn’t get a chance to ask him more but hopes to see him again next week. Has anyone else come across similar comments by a terminal pt?
Feb 12, '08Michael and all..yes, I'll share the experience with one of the people who had a "conscious death". She was 92, as sharp as a tack and just a love! She lived with her daughter who was a devoted caregiver. Now, being in a small community, this elderly woman knew my mom. My mother used to do her hair once a week and every Christmas this wonderful woman would make all of us a special Christmas dessert with exquisite pastry and custard and chocolate! So, this past Christmas, she was my patient and told me she was making me this treat, once again, for Christmas. She was end-stage cardiac and was quite comfortable, but did treat her dyspnea with a little morphine. She was very open about her dying and shared so many feelings with all of us. I'll never forget her sitting in her adorable, snugly cozy living room and happily sharing memories of her life as a young woman. These memories included wonderful times and not-so-wonderful times. But, we listened intently and somehow I knew she would never get to make that Christmas treat. It was clear she was ready to make her transition. She died that night, in her sleep, with a smile on her face!
Some asked "well, what was different for this patient? She had her family there, people were truly present for her, no one was afraid to talk about dying, feelings were compassionately expressed....the FEAR wasn't there because the avoidance wasn't there.
Now, this doesn't mean to say that everyone has to "die awake" so to speak....to me, dying consciously is a process where everyone works together to help that patient feel our connection because we are all united by a common thread. It encompasses mindfulness and presence...something our society needs to re-learn as life is oftentimes such a "race" and we forget that we can be still and look and listen. Our awareness of death deepens our commitment to awakening and to living a life of value and meaning. Oh...I'm probably getting too philosophical......
Thanks for listening...
Feb 12, '08Joined: Apr '00; Posts: 24,611; Likes: 35,453i agree w/you, em.
that one needn't be awake at the time of death, in order to qualify it as a conscious one.
as long as the pt, family/friends, have accepted death's limitation here on earth, and can prepare for the next transition, then all is whole...and conscious.
sounds like your 92yo pt's death, was indeed, very meaningful.
Feb 13, '08Thanks Leslie & Em…
I agree that it is not necessary to be awake at the moment of death to die consciously… and confess to having muddied the water on that account with some of my posts. Thanks for the clarification.
Conscious death has to do with choice… being aware that death is imminent and choosing to embrace it. Whether one happens to be awake at the precise moment of crossing is irrelevant.
Against a backdrop of the consensus definition of “death,” i.e. “end of life,” choosing to die seems strange, or even macabre.
Against a backdrop of a rational definition of “death” however; e.g. a “transition” to another level of existence (having completed most of the tasks one came to this level to work on) then such a choice seems perfectly sensible and appropriate.
I believe there are cases when a person chooses to leave while in a dream state. From our perspective, these folks would appear to have “died in their sleep.” Even though they were not “awake” at that moment, they still moved on consciously and as a matter of choice.
Then there are cases where it seems that a person might have seen into the future… seen their death before it happened. We have all heard of (or perhaps know of personally) these kinds of cases… and they are interesting to ponder. One might wonder, if a person knew he was going to die, why would he not try to avoid it? One possibility of course is that he might also have seen where he would be following death and was content with going there.
Conscious dying, like conscious living, has many forms or ways of manifesting. Probably most hospice nurses have seen examples, although might not have thought about it in those terms.
Mar 4, '08Joined: Mar '08; Posts: 24; Likes: 13Managing symptoms for a good death is indeed an atribute of a good nurse. I work for a hospice and this is part of what I do not only as a requirement for being a good nurse, I do this because it is humane. It is degrading to the dying person to be pittied and watched to have distress and not be given the comfort he or she deserve. Most of us have led comfortable lives. Lives without too much pain, suffering. Death can be our friend true enough; but, when someone tells me that " I know my loved one is going to be healed of this disease" and I know that they won't in the way that they think they will be, I then explain to them, death is a healer. To be healed, we see that a person no longer suffers the affects of a disease riddled body; pain, temperaments, confusion and so on. Does not death end this? As we know it, death causes a transistion form life to another form. Life after death now or life after death later, or no life after death at all, it depends on what is accepted by the believer. As for me, I believe, when we are absent in the body, we are either with the Lord or where ever it is designated for us to be. No one came back to tell us. All of this is important for the loved ones of the person who is dying. Lets give people the best celebration of life at the end of life that we can give them. This also manages symptom for a good death. Enjoyed everyone of your threads. They are truly great ones. Coralyn
Mar 17, '08Occupation: RN on a Medical ward Specialty: 16 year(s) of experience in Med/Surg/Respiratory/orthopaedic ; Joined: Apr '05; Posts: 35; Likes: 2[font=bookman old style]wow!! i remember you guys! i participated in this thread back in 2006! i've been trying to work out where to 'break in' with my practical issue... it's all very interesting, your thoughts. thanks....
i'm writing to you from new zealand again. thank you for any advice from you experts.
i'm a medical nurse currently working in long term care and i've found myself disagreeing with colleagues recently about when it's right to give morphine. i'm very happy to give morphine for pain, respiratory distress and perhaps anxiety but once i was caring for a patient who'd had a large stroke and was unconscious. the decision was made not to hydrate or nourish her - to 'let her go'. the doctor prescribed a morphine/antiemetic/anxiolytic mixture in a syringe driver but the patient looked peaceful and didn't appear to be in pain so i talked to the doctor who was happy for us to use the prescription when we thought fit. another colleague strongly disagreed and said i should give it to the patient, to keep her comfortable. i prefer to give medication to control symptoms otherwise i feel like i'm doing euthanasia.
it seems to me that some nurses move into a mindset of "this person is dying now and we will do the thing we do for dying people - give them morphine." i don't like to sedate people unecessarily - they might still be able to talk to relatives. (perhaps not the pt in the example, but others may).
thank you for your thoughts. i know the issue of conscious death/alertness has been covered. i guess if i just read all the pages of this thread i'd have all the info i needed!
[font=bookman old style]jeanette