Managing symptoms for a �good death�

[NRSKarenRN]

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

What's a good death? Most patients facing the end of life say it means freedom from pain and other distressing symptoms. 1 as nurses, we can play a major role in easing their way to a good death.

Managing symptoms in the last phase of life is especially challenging because you probably won't have the benefit of diagnostic studies to help you assess signs and symptoms. But as a nurse, you bring unique qualities to the table: assessment skills, a partnership with the patient and her family, and the determination to bring comfort.

In this article, I'll present a case study to illustrate the most common end-of-life symptoms, including pain, fatigue, dyspnea, and gastrointestinal problems. Whether your patient has all of these symptoms or only a few, you'll learn how to keep her as comfortable as possible.

[leslie :-D]

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!

[leslie :-D]

but it is the american mentality that drives us to 'think' in terms of being successful;

and what is success?

that we'll never amount to anything unless we have 2-3 cars, live in a 4br 3ba house, our incomes are a minimum of $100k and that we attain every material possession available.

it doesn't matter that we are stricken with stress-related ulcers, htn, obesity or other afflictions that represent our blind determination in being successful.

it doesn't matter that the divorce rate is 50%+, drugs and etoh are the rule rather than the exception, that seemingly functional families are probably some of the most dysfunctional....all of this because of our need to succeed.

what's wrong with this picture?

people compulsively buy themselves a little something, in hopes of masking the true pain that festers beneath; only to find that one is left feeling barren and empty anyway.

people will experience that rush, the adrenaline high only to see it plummet as quickly as it rose.

we are not a peaceful america.

and we have our societal values combined with the media, to thank for that.

you're no one if you've got nothing.

you're someone if you've got something.

that's the stark reality of who and what america is.

i'm just as guilty in buying a little gift for someone who's feeling poorly.

but you know what feedback i get?

it wasn't the gift but the gift of my company that soothed their soul.

so to me, it seems that people truly crave the company of fellowship, recognition, validation, appreciation.

people think they want the latest gadget, the latest craze, until they fall into the trespasses of a neighbor's embrace.

if such encounters happened more frequently, perhaps we could unbrainwash the damage that has been so abundantly effected.

betchya never knew i was such a cynic, no???? :)

leslie

[BeExcellent]

Cynic was a Greek philosopher that believed in virtue through self-control, so I am not sure if you are a cynic.

The problem with all the "stuff" is that it gets distracting. There once was a young woman sitting in the sun fishing in her boat with her children. Everyone was having a great time (except the caught fish, of course). Along came a another woman to the dock. She was dressed great, looked good and was skinny ,too. "Hey, says the woman on the dock. Looks like you really know how to fish. Let me buy all your fish, then you can afford another boat. You can then hire some others to fish for you. Pretty soon you can be another Pike's Market, lots of boats, big market, you can be rich!" "Why would I want to do that?" asked the fishin' Mom. "Oh!" was the quick reply, "so you can be rich enough to fish all day with your kids." TeeHee

[req_read]

I’ve been so busy the last few days I had no idea all this was going on (all these posts.) How wonderful!

Leslie… you are right of course (about the abusive father’s inner struggles with his own demons.) And I agree 110% with your view on trying to get stuff resolved ahead of time… so that my own dying process can go as smoothly as possible. Although I never seem to do quite as well as I would like.

It is interesting to ponder just how aware people are of their blunders in life. Are murderers aware of what they did? Or do they block it out somehow? And if they do block it out is that the kind of thing (blocked out blunders) that feeds “terminal anxiety?”

Considering anxiety as a vital sign is an excellent idea. More important, at least in my mind, than the usual VS.

We humans are inclined to think of the physical world as “real” and “concrete,” whereas we think of things like imagination, intent and even love as sort of gauzy & ethereal. In truth it is just the other way around. This physical world and everything in it is transient. Just watch some of the science channels and observe the long list of events that can and will destroy this planet sooner or later… it is only a question of when. Imagination, intent & love are what persist and endure. For example; we use imagination & intent to produce a car. The car never lasts… rusts away to nothing… but the imagination & intent are still there. What we think of as ethereal is what is “real” and actually generates the transient phenomena with think of as being concrete.

We tend to view our infinite needs (learning on a spiritual level) as finite. We go to church, learn the rituals & songs, get the traditions and doctrine down pat and figure that’s pretty much it. Then we are squared away spiritually… or so we think.

We tend to view our finite needs (food, clothing, shelter) as infinite. No amount is ever enough. If we have a house, we need two. We always “need” more outfits & shoes. And food? Well… I’m getting hungry just thinking about it.

I’m rambling again. Sorry guys.

One more comment (I can’t help myself.)

Good story Excellent. Yes… the point of fishing is in doing it. A “living” person (as in, not yet dying) would be likely to say, “I caught a BIG fish.” Whereas a dying person (as in, living with focus) would be more likely to say, “I went fishing.”

Michael

[req_read]

Oh… I almost forgot.

Self-awareness is, by definition, awareness of the whole self, not just the good parts or the parts we happen to like. It means being aware of our dark side… our not-so-wonderful self.

So as one becomes more self-aware, one also becomes a bit cynical about humans in general. Once I come to understand what makes me tick I can see it in others as well. That’s the cynical part.

But there is a good side to it as well. It fosters tolerance. Once I begin to understand what a jerk I can be, I am more likely to forgive you for being that way too.

Michael

[leslie :-D]

Oh... I almost forgot.

Self-awareness is, by definition, awareness of the whole self, not just the good parts or the parts we happen to like. It means being aware of our dark side... our not-so-wonderful self.

So as one becomes more self-aware, one also becomes a bit cynical about humans in general. Once I come to understand what makes me tick I can see it in others as well. That's the cynical part.

But there is a good side to it as well. It fosters tolerance. Once I begin to understand what a jerk I can be, I am more likely to forgive you for being that way too.

Michael

first and foremost, beexcellent said i wasn't a cynic...waaaa.

i wanna be a cynic too.

on a less serious note (:) ), self awareness is only productive when we can acknowledge the less desirable parts of ourself.

through this inner journey of initial denial, self-doubt, disbelief, anger, contempt... a beautiful butterfly emerges and lets the truth soar.

(i don't know if i said it right but i'll be damned if i try to explain it again).

ultimately, it's our shortcomings that enable us to grow.

so yes michael, the less we like about ourselves, the more we're apt to like in other people. for through this process of the qualities we shun, we eventually come to accept and yes, tolerate, and yes, even come to appreciate.

btw michael, i've missed you. (kiss kiss)

leslie

[req_read]

Well you guys have brought up so many interesting topics now I can’t concentrate on my chores.

I have heard that sometimes people just decide to leave (their body.) I can certainly understand that. The older my body gets the more fed up I become with it… danged piece of junk anyway! In hospice I saw it all the time… patients deciding when to move on. My own mother died unexpectedly in surgery and I have this nagging suspicion that she got out of her body and decided not to climb back in. And remember the lady who I have told y’all about who died consciously with her son& best friend right there… what about her? What if her son & best friend had not been there? Then some bright nurse probably would have come along after the fact, sized up how she looked and declared, “Yup… died in her sleep.” So I think there are lots of ways to die consciously… and I also think it happens a whole lot more often than we realize. Humans have an amazing capacity to heal… and by “heal” I don’t necessarily mean staying in a body.

Bodies don’t do well without a person in them. If the person decides to leave, the body is hung out to dry. Then a pathologist does an autopsy and says, “Died of a heart attack… yup, yup… sure did.” But I’ll bet that sometimes what happens is the body died from lack of a person… and then it filled in the blanks by having a “heart attack.”

I missed you too Leslie. I thought maybe you were on vacation or something.

Michael

[leslie :-D]

interesting story.

when my grandmother died, my grandfather was literally devastated and did not want to live w/o her.

he asked me to move from boston to queens and live with him.

as i was readying myself for the move, he ended up being hospitalized.

it appeared it had been a tia- he came to and about; alert & oriented x 3.

he shared with me (and me only) that grandma had come to see him.

she told him it was time to come home, and she would wait.

yes, he could see her patiently sitting in the room as he and i talked.

all i felt was an incredible draft.

but while in the hospital, that noc, he died.

the doctors were confounded and did not know what to think of this medical mystery.

although he was 78, he had the heart of a 50 yo.

my father allowed an autopsy.

there was nothing wrong with the man.

the doctor hesitated in writing "natural causes" although he did indeed write cardiopulmonary arrest.

but in a conversation between him and me, he shared that my grandfather died of a broken heart.

i just told him it was his time to go: that he had loved ones waiting.

around a month later, i saw him in a dream.

i had been grieving deeply and in my dream i asked him if he finally got to see grandma.

he put his hand on my face.

i could not feel the flesh, but only the warmth of his hand.

and he said something to the effect of "it's a long way from new york but yes i'm with grandma"....then everything faded out.

i had awokened with tears flowing down my face.

i know to this day, i had actually spoken with him.

so yes, people can and do will themselves to die.

i speak of my grandfather but i've seen it dozens of times in hospice.

they're ready to leave and so, they do.

it's such an amazing, amazing process.

something i'll never get used to.

leslie

[BeExcellent]

Well, Leslie, ok you can be a cynic and Michael,too.

Back to a "good death". We often orchestrate our own "good" deaths through our pts. I try to separate what I would want to focus back on pt. I have had a number of pts try real hard to die and couldn't. "Dammit. I'm still here." That process is so unique and so individual. Yes, I agree some can be conscious at that moment. The danger for us, is to have a conscious death as our goal. And when we struggle, view our death as a failure for ourselves. I have seen too many clergy and medical people, including nurses try to control their death and that just doesn't lead to a calm, comfortable death. Maybe, people have different deaths because of our unconscious bias. I can not read heart, so I can't judge anyone. People who do terrible things may be mentally ill or even possessed, for all I know. What will never be an the CHPN test is the question of how a hospice nurse develops that intuitive antenna for our pts and yes, ourselves that guides us to guide others into death.

I liked your grandfather story, Leslie. Just when we think our hearts can't stand it, we get comfort.

O The point of the fish story is that the the fishing Mom was already doing what she loved. She didn't need to acquire a fortune to do it in a bigger, better boat.

[leslie :-D]

O The point of the fish story is that the the fishing Mom was already doing what she loved. She didn't need to acquire a fortune to do it in a bigger, better boat.

what i got from your story is yes, she was fishing and loved doing so. but there lies the possibility that she fished because it was a hobby that didn't require $$ yet somehow the rich person managed to 'entice' her by alluring her with what $$ can buy.

anyway, i don't think people can literally will themselves to die.

well, yes and no.

some keep themselves alive until the grandson has married or the daughter has given birth.

we all know those stories.

but the decision to linger vs. checking out can be a conscious one.

how many times have i seen a pt die as soon as their loved ones leave the room?

many people choose to die alone.

and they exercise this right.

i don't understand the mechanisms involved but it happens.

yet, let's say a dying pt was listening to her husband chat and chat and chat and she thought to herself "God, i would really like to die now".

no, i don't think she could will herself to die right there and then.

yet there is plenty of evidence citing the phenomena of those dying alone by choice.

i think the body has to be actively dying anyway and the spirit is restless; it yearns to be freed.

so it's that delicate moment in time that this occurrence could materialize.

i'm trying to understand the intracasies and do not grasp the paradox.

but my belief is the body, mind and spirit all have to be in sync and be ready at a moment's notice.

once that criteria is met, then this is when we see those who seemingly die consciously and purposefully.

anyone?

leslie

[req_read]

Leslie…

Thanks for sharing the story about your grandparents. That was something else! Amazing!

The whole thing about how much choice we have in deciding when we move on is puzzling. Probably most hospice nurses would agree that many patients exercise some degree of choice. But the question is; how much choice? And what factors would tend to either increase or decrease the degree of choice?

As Excellent says, some patients want to die but can’t. Why? Others want to and do. So what makes the difference? Then too we’ve all seen patients who want to hang on and do, at least for awhile, sometimes despite lab results that are “incompatible with life.”

So there seems to be an interplay between physiology & psychology… spirit & body. Each affects the other.

My feeling has been that those who have the greatest degree of choice are the ones who have managed to resolve their life’s issues most effectively; either by taking care of those issues as they went along so that they have numerically fewer to contend with while dying or because, by virtue of having developed skill at resolving issues, are able to work through them faster while dying.

I suspect another factor may be in developing an attitude of purpose. A way of expressing that would be to ask the question, “What did you come here for?” And of course the follow up question would be, “If you don’t know what you came here to do, how would you know when you were finished?”

We don’t generally think in these terms. We tend to think our being here was some sort of accident… which is what the old, fast becoming defunct, “scientific” explanation of the universe has been for about the last 300 years or so; i.e. that the whole darned universe is just one big accident and we all are just a bunch of mini-accidents within that larger big (bang) accident. When you stand back and look at it… in “big picture” terms… that really is a screwball way of looking at the world… although it is the consensus, western perspective just the same.

But I think that if a person can think outside of the consensus box and has a sense of completion… of having done, at least to the best of their ability, what they came here to do, plus they have worked through their life’s issues, then they would have better luck at moving on when they chose to do so.

Some couples seem to have a sense of having come here to work together… to assist one another in their growth… so when one moves on the other has, in that sense, completed his/her work.

Conversely, I suspect that the person who is just fed up (as I expressed earlier about bodies that don’t work like they used to) would probably not do as well. Moving on because you have a sense of completion is one thing, but trying to escape because you’re fed up is something else. The former has more to do with moving into life, while the latter smacks of running away from life. And of course it is difficult to run away from life when all there is on the other side so to speak is more life. Running away from life doesn’t work. Everywhere you go, there you are. But completing phases and moving forward… that seems to work.

Many hospice nurses seem to have a sense of purpose… that one of the things they came here for was to work with the dying. It seems to involve more than merely nourishing self-esteem. Not that nourishing self-esteem isn’t a worthy goal… it is. But there are hospice nurses who seem driven by some inner force or passion to do this kind of work.

That’s it! My brain is shutting down. Goodnight.

Michael