Managing symptoms for a �good death� - page 5

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   req_read

    The most common way of dealing with dying in our society… a death averse society… is to avoid it as much as possible. The majority of people try very hard to not think about death and dying at all… until they absolutely must. And when they absolutely must they want all of the answers immediately. So it is quite natural for the dying to turn to the “experts” for advice. They have every right to ignore any or all of that advice, but it is a natural response.

    If you have a horse who is giving you some problem you call a horse expert. It would be rather disappointing if you called in a horse expert, paid him his fee, and then all he had to say was, “Well that is up to the owner not the practitioner.”

    I once had a counselor who I noticed nodding off while I was talking. My life may be boring but I thought his dozing represented a poor return on my investment. He never seemed to have anything to say and I finally told him I thought I could get as much out of taking his photograph and hanging it on the wall, then talking at it for an hour a week… plus it would be cheaper. He gave me an explanation filled with professional sounding jargon that basically came down to his not wanting to interfere in my life.

    It sounds to me like your professional philosophy is similar to his. You seem quite adamant that your job is limited in scope.

    I do wonder why you use the term “conscious dying” as though it were an epithet. That is strange coming from anyone, much less a hospice nurse. Actually, I never pushed anyone to “die consciously,” I just used techniques that would make that more possible if they so chose.

    Living and dying consciously is widely recognized as a good thing and I must say that I am surprised to find myself having to defend it. Perhaps you find the term distasteful simply because it was I who used it? If so you might ask someone in the mental health field whether they consider “knowing who you are” to be a good or bad thing. I doubt they will tell you, “Oh no… personally I’ve always been a devotee of self-delusion.”

    What I have said about pharmacologic symptom management (and will say once again) is that it is a means to an end, but it is not the end game.

    Your approach, if I understand it, is that symptom management IS the end game and the rest is up to the patient. Am I correct in that assumption?

    What I am having trouble understanding is why you seem so angry. You have addressed almost none of the interesting points raised in this thread but have chosen instead to attack those who raised them on a personal level. What is that all about?
  2. by   Katillac
    OK, one last try and I'm done with this.

    From your first post, you've maintained that the ultimate goal of hospice is to see that people die consciously.
    "Good symptom control in dying process is NOT the goal, it is a means to the goal. The ultimate goal in dying is the same as the ultimate goal in living; i.e. to do it consciously."
    I simply disagree that it's appropriate for you or anyone to decide what the goal for all hospice patients is. I don't use "conscious death" as an epithet; it's just your phrase for what should be a universal goal.

    As far as the horse expert analogy, I expected my vet and trainers to offer me options and let me decide, not presume to make the decision for me after deciding what my goals were.

    I'm not sure if I am communicating so badly that it's logical to come to the conclusion that symtom management is all there is to my practice of hospice nursing. There is certainly much more to it, including spiritual support and exploration IF THE PATIENT DESIRES IT.

    One specific example of my practice: through my hands, I have felt the chaos in the mind of someone who was having a huge struggle at the very end of his life, drawn that into myself and watched as the person relaxed and went on his way. I also did the hard work afterward of resolving the tumult I had brought into myself. Had he agreed earlier to work toward becoming more self-aware, he probably would have died more comfortably. But that wasn't my call to make. Was I colluding in his self-delusion? Not at all; I was respecting his preferences, and still supporting him as best I could.

    I haven't attacked anyone here. I haven't made it personal at all. I've responded to what several people have written, both content and tone. I disagree. And I became annoyed, not with anyone personally, but with the presumptious and condescending tone I recognized, as well as the stance that was taken by two posters, and I indicated that.

    And now, I wish you the best, and I am respectfully, quietly and calmly done with this.
  3. by   req_read
    Okay… so we went through all of that to learn that you disagree with my original thesis. Might I ask why?

    Also, you seem to have gotten the impression somewhere along the line that I advocate ramming my thesis down patient’s throats. Actually what I said was, I use techniques that make that option possible should the patient so choose. I also said patients have the option of disregarding any or all of the advice they are given. So your emphasis on “IF THE PATIENT DESIRES IT” has nothing to do with anything anyone posted here.

    And if you have not attacked anyone I would certainly hate to be on your bad side.
  4. by   req_read

    I am intrigued by the paragraph in the middle of your last post; i.e. the “One specific example.”

    I realize you were probably a little upset when you wrote it, but I’m not sure I’m following the story line. I wish you would elaborate because it sounds very interesting… the kind of thing I had hoped could be shared in this forum… safely… a sharing of personal ideas, experiences, thoughts etc.

    Hospice nurses are exposed to some of life’s most fascinating and dramatic events… yet there is this reluctance to share. Why?

    The poet said, “Tis better to have loved and lost than never to have loved at all.” Love involves a willingness to be vulnerable… to share… to get hurt and still be willing to take another chance.
  5. by   bogsnurse
    hi im a nursing student from the philippines. One of requirements is making a nursing thesis.... We decided to focus on the effect of music therapy on the hospice patient. The thing is we dont have any idea of how will be able to start the experimental study and what music we should use. can you give us some advice regarding the therapeutic care/palliative care they use as a nurse to help those terminally ill patient. God bless and we are hoping for your reply...
    bogsnurse from manila philippines.
  6. by   bogsnurse
    ei im a student nurse from the philippines and hoping to graduate on 2008 batch and also a new member of We are having a thesis about the effect of music therapy on terminally ill patient and planning to visit hospice institution. Can you give me some advice to help me and my group? what to expect? what the things we should or not do? What kind of therapy/communications and also what the best thing to do to help them and even the staff... thank you and god bless!
  7. by   req_read
    Just to put this thread to bed before it dies on the vine…

    “Conscious dying” is the epitome of patient-directed care. It implies, by definition, that the patient chooses to move on… cross over… die… whatever you choose to call it. It represents the pinnacle of patient choice.
  8. by   jerseyRN
    Hey Katillac

    Wow. What a mean comment!

    Even first-year nursing students know that if a patient's in pain, vomiting, SOB, or anxious, they're not going to even be able to think about "the real goal." Were you absent from Nursing 101 the day they taught Maslow?
  9. by   nurselearner
    Is there a way to "unstickey" this topic ?
  10. by   leslie :-D
    Quote from nurselearner
    Is there a way to "unstickey" this topic ?

    why would you want it 'unstuck'?
    it's a highly informational thread and also allows for multi-dimensional perspectives.
    i hope it remains a sticky.

  11. by   P_RN
    Unstickey? That's an unusual one.
  12. by   river1951
    Well, whether people want to discuss it or not, it is important.
    I have thought about it a lot and my conclusion is that we hospice nurses have to help patients be aware of their options. They shouldn't go into death without being informed consumers of their choice any more than patients should be allowed to have surgery without understanding their choice or what it will do.
    In our positions, we are the experts (if any could be said to be who live on this earth). Our assisting folks to comfort of both kinds is important so they can make an unencumbered transition. I don't think it is arrogance on our part to help with this, any more than it is arrogant for the ambulatory surgery folks to instruct on side effects to report.
    I don't like to have disagreements that at times become unpleasant, however as my dad used to say, if everyone agrees, it means no one's thinking.
  13. by   req_read
    Thanks Leslie & Beki…

    jerseyRN’s allusion to Maslow tickled a memory cell or two… way, way back to my first year in nursing school. His work is an appropriate analogy; i.e. his “ultimate goal” was “self-actualization” as I recall. Of course not everyone will reach that goal… perhaps not many from a statistical point of view. But we should still adopt techniques that would enhance that possibility.

    The great difficulty of course is that there is no study of “dying process” per se. There is pathophysiology, symptom control, bereavement counseling etc. But in academia there is no study of “dying process.” There fore, for hospice nurses to coach people through dying process means each nurse has to learn it on his or her own. Hospice nurses are on the cutting edge of an untapped field of study rich in its potential for learning about human beings.

    Which is why I think it would be useful for hospice nurses to share their experiences, thoughts and impressions in a forum such as this one. That is why I bring up questions such as: What is a good death? What is conscious dying? And of course, have any of you hospice nurses, with all of your vast experience, ever seen or been involved with such a thing?

    Dying well is like acing the final exam. When I see someone get an ‘A’ I just naturally begin to wonder how they managed to accomplish it. So I begin to re-examine everything I know about that person and take mental notes. If nothing else it will at least help me (since I am fairly certain I will die.) Similarly when I see people flunk dying 101 miserably I try to recall everything I knew about them and look for correlations (so I can avoid them.) Because hospice nurses deal with a lot of dying people over an extended period of time they have ample opportunity to keep mental tabs on trends.

    I have noticed… very definitely… that certain life-styles and thinking patterns tend to yield certain dying styles. I assume I am not the first hospice nurse to ever notice such things, so have asked others to share. The more we share the more we can fine-tune what we have learned and the better we can help patients, families and last but not least, ourselves.

    I have given up hope of the large national hospice organizations making such a study. The reasons for this are basically twofold:
    1- The separation of Church & State thing… which gets interpreted as separation of science & spirituality and 2- hospice is a business (their goal is to make money) and the people on the boards of directors of large national hospice organizations are business people (usually from the biggest hospice companies.)

    If anyone is going to make a contribution in this arena it will have to be front line hospice nurses… if for no other reason than because no one else has access to the raw data. No one else knows the patient as intimately and no one else sees close up & personal how they die. What gets learned about dying process will necessarily have to come from the ground up. In other words, from you.

    Again I urge all of you to share the incredibly valuable data to which you, and virtually no one else, has access.


    Serious students of religious thought study all religions not just one... just as serious students of botany study all plants not just daffodils.