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.

[sharona97, BSN, RN]

Thank you Michael for your explanations. I admit I had to laugh about the smart white men and the half-drunken Navejo. Not for any other reason then how you helped put the picture together.

Sharona

[req_read]

Chybil…

Good idea. Enjoy the fragrance!

However, this stuff (thinking about things like life, death and reality) is my flower… the fragrance I enjoy (one of them anyway.)

Yes, everyone’s death is different, just as everyone’s life is different and everyone’s fingerprints are different. Yet there is an overarching pattern to all fingerprints, lives and deaths.

Reality, like so many things, is a function of how one defines it. Our usual (western) way of thinking about reality is that it exists independent of us. Quantum physicists however have conducted a lot of experiments which demonstrate things are not quite that simple… that physical “reality” is a function of an observer (you, me et al) observing an infinite matrix of possibility (pure abstract thought) which then collapses (or creates) physical manifestation. In that sense what we (observers) collapse (create) is indeed “real,” or at least, as real as anything can be.

I have a sound clip on my computer (which I got online somewhere) that is apparently from a movie (I have no idea what movie)… but it makes me laugh. With a tone of utter astonishment a woman says, “Virtual reality is real!” Yes… one could say that. One could also say that what we usually refer to as “reality” is virtual.

One could also say (as did C. S. Lewis (1898–1963), British author. A Grief Observed, pt. 1 (1961).

“It is hard to have patience with people who say “There is no death” or “Death doesn’t matter.” There is death. And whatever is matters. And whatever happens has consequences, and it and they are irrevocable and irreversible. You might as well say that birth doesn’t matter.”

The point I am trying to make is that things like “reality” and “life” and “death” are not what they seem to be on the surface, and that for people (such as hospice nurses) who are engaged in the business of caring for the dying really ought to develop more sophisticated perspectives than the general public.

In another thread I commented on the movie, Two Weeks (about a dying woman.) In it the pt’s 3 children adopt a typical lay person’s view of pain control; i.e. keep hitting the button on the PCA pump until you know for certain she is getting all the narcotic allowed… even when she is already unconscious. The philosophy being, I intend to drug you until I feel better.

We often hear hospice nurses say, “I would rather err on the side of too much rather than too little pain control.” That is fine… perfectly understandable. But it can get to be an excuse for not expanding our knowledge base to a point where we do a little less erring in the first place.

I have, for example (while in ICU) seen a man coded and pronounced dead. About 10 minutes later he woke up. He only “lived” about another day, but in that day maybe he had a conversation with his wife that was important to him. Had he been heavily drugged maybe he could not have found his way back.

Sometimes we don’t really want people to come back. I think probably one of the reasons why we embalm people is to insure they don’t wake up in a coffin. Sometimes we don’t want people coming back so we slam that door shut… for good. As previously noted (somewhere in one of these threads) I once pronounced a pt dead but had an overpowering sense that he was trying to get back into his body. I was very reluctant to just pronounce him dead and leave, even though I was pretty sure he could not “wake up” (he didn’t.)

Hospice and hospice nurses are supposed to be expert in the business of death and dying. Therefore it is their responsibility to study and think about these things… not just say that death “ends life” so just drug them down until they stop breathing… keep hitting their ‘Dose’ button until I feel better.

The more hospice nurses know about life and death and reality the less likely they are to err at all… and the more likely they are to bring families up to speed on what is actually happening. Understanding really does help… and sometimes valuable, in-depth perspectives come from unlikely sources; e.g. people we habitually look down upon as primitive or uneducated.

Hi sharon97…

Good to hear from you.

The conversation with the half drunk Navajo was fascinating. As you might suspect, there was more to it than I described above. He was a Vietnam vet and talked about how unreal his Vietnam experiences seemed… as opposed to how real his dreams of Monument Valley were (to him) while he was there. It was a fascinating little vignette into the nature of reality.

Michael

[sharona97, BSN, RN]

That little dittie adds even more to a very important story and lesson. Thanks!

[req_read]

sharona97…

I’m glad you enjoyed it… a welcome switch from the tedium of school perhaps?

Chybil…

When Einstein states that the world is an illusion I would not be so quick to dismiss it. He is, after all, considered by most to be one of the greatest minds of the 20th century… deserving, I should think, of some contemplation.

You have, however, raised a core existential question. If one accepts the posit that we create (collapse) our own reality somehow through the act of observing it… if you let that possibility really sink in… then you will be overwhelmed (perhaps horrified even) by the thought that maybe, just maybe, you are utterly and completely alone! If everything (maybe even everyone?) out there is simply a projection of your own consciousness, then you are about as alone as alone can possibly get. You are the only one here… or anywhere… creating toys with your mind. Kind of like those crazy movies where some guy in New York City wakes up to find everyone has gone and he is the only one left. Spooky huh?!?

Like I said, you never know where or who you might run into who thinks about such things. I needed an electrician so picked one out of the phone book and as it turns out, we spend hours talking about things like reality and time. Luckily he can work and talk at the same time. I can’t, but he can, so it works out good when he comes over to put in a new circuit somewhere.

So I asked him one day, “Tell me Al, if we are all connected, why did Someone (presumably God, the Great Spirit, whatever) go to all the trouble of setting up this physical realm where people can individuate? What was the point?

“Well,” he said, “probably so He wouldn’t be alone.”

“Huh?” I said.

Al explained, “Spiritual teachers and now physicists say all things in this (physical) realm are manifestations of one, unified consciousness. If you’re the only one, that’s it… you’re alone.”

Hm-m-m-m… so if unified consciousness could figure out a way to separate itself out (from itself), to individuate, then it could at least create an illusion of having someone else to hang out with? If that illusion is believable it just might work, and most everyone here in the physical realm agrees… this world is very believable. So believable in fact, we have great difficulty imagining anything else could be as real as this. This is, in effect, our gold standard of “believable.” Like you say Chybil, this (physical realm) is no illusion… it is definitely real.

A student went to his guru and asked, “Teacher… is the world real or illusion?”

His guru replied, “It is a very real illusion.”

Michael

[Miss Chybil RN, BSN, RN]

LOL, req_read, your quotes have me in stitches! "Virtual reality is real?" LOL! I love it. And the world is a "very real illusion." That's a masterpiece!

I have a question for you... If I'm the only one here, and you're the only one here and the other billions of people are the only ones here and the other inumberable sentient beings, just on this planet, are the only ones here, where did everybody go?

I don't doubt Einstein. He was a very smart man. Much smarter than I'll ever be, but perhaps when he said the world is an illusion, he meant the way we perceive it is an illusion. Think about it. They say dogs see in black and white. We see in color. Now, does that make the objects we look at any different, in reality, or are these objects only different in the way we perceive them? Did my dog and I just dream up the kitchen cabinets and each other in the same place, same time,

but in different colors? Or did I dream up "dogs" who can only see in black and white and who imagine cabinets in the same place I do? LOL!

This stuff is fun and I'd like to go on all night, but unfortunately I have to go to bed. You see, I dreamed up this boss who expects me to be at a certain place at a certain time even though I really hate getting up in the morning! I'd like to call her and explain that she really doesn't exist, but I think she's dreamed up an employee who will do pretty much what she wants her to do! It's such a dilemma...

Ok, req_read, goodnight... On a serious note, though, can you send me a real PM with the names of your books? I love reading what you have to say. Your thoughts are very intriguing. You tickle my brain and I love that. (I hope you don't mind a little kidding around.)

[req_read]

Chybil…

I don’t mind kidding around at all. I enjoy it immensely.

The ideas & concepts raised by the great thinkers of our time are indeed puzzling. But in a very real sense, that is the point; i.e. to be puzzled… to be comfortable with and intrigued by being puzzled. Puzzled is a good thing.

We cannot possibly know all there is to know. The great danger is to grow lazy and fall into the trap of thinking that if I don’t actually know everything, I’ve gotten close enough to suit me… so I’m satisfied and will stop looking. If you’re not puzzled, you’re not looking… and if you’re not looking, you’ve stopped growing.

I was amused by Fred Alan Wolf in his book, A User’s Guide To The Universe, when he made some comments about “the C word.” I thought, “C word? What’s that?” In my work I refer to the “D word” (death or dying) but what the heck is the C word? Well, in the world of physics and physicists the word consciousness was apparently shunned for years. Scientists don’t like being puzzled. They like to be able to explain things… and consciousness is utterly and totally inexplicable. We have it. We’re in it. But we (including scientists) are entirely clueless about what it is. And since scientists don’t know what it is they simply ignore it. It’s the elephant in the scientific living room. Until relatively recently that is. Now some of them are talking about it, although they still don’t know what it is. What we can do however is take note of what it does… which is interesting of course. For example, it always becomes more, and since we are consciousness, we can assume that we too will always become more.

Good point about dogs seeing only black & white etc. I think they also see auras. Some people who are capable of seeing auras have told me mine is blue. One lady who told me that said she has always been able to see auras. She thought everyone could… until she was in school one day and a new girl in town came over to play with her & her friends. She asked her friends, “Do you think we should play with a blue girl?” They all looked at her like she was nuts. After that she realized she was different and kept her mouth shut. And this lady was no flake either… she was a pretty tough business woman, CEO of a State hospital.

I think when physicists talk about material objects being illusions they are referring to the fact that they have found matter’s building blocks are not particles, but rather light, or vibration. In other words, there is nothing “solid” there. They have also found that their observations of an experiment affect the experiment’s outcome. In other words, there is no clear line of delineation between the observer and the observed, they are inextricably linked. They have even discovered that even just their intent can alter an experiment’s outcome. But anyway, that’s not my department so my explanations do not do it justice. Read Fred Alan Wolf or John Hagelin.

The 2nd half of the guru story goes like this (I think it may have come from Ram Das… I’m not sure.

A student went to see the guru one day and found him weeping inconsolably. The student was shocked and asked what was the matter. The guru told the student that his son had died. The student said, “But teacher, I thought you said this world is just an illusion.” The guru replied, “Yes… and the death of one’s child is the greatest illusion of all.”

Michael

[leslie :-D]

Good point about dogs seeing only black & white etc. I think they also see auras. Some people who are capable of seeing auras have told me mine is blue. One lady who told me that said she has always been able to see auras. She thought everyone could... until she was in school one day and a new girl in town came over to play with her & her friends. She asked her friends, "Do you think we should play with a blue girl?" They all looked at her like she was nuts. After that she realized she was different and kept her mouth shut. And this lady was no flake either... she was a pretty tough business woman, CEO of a State hospital.

Michael

i had a 6yo pt, who, towards the end of her stay on earth, complained about the bright, white light around my head.

with the neuro involvement, i knew she was photosensitive, but her eyes were locked onto this 'light' around me.

she was literally mesmerized.

the next day, i brought her in very pretty sunglasses.

and she giggled, and reveled in this light.

i never doubted it or her, for one moment.

such a gift.

leslie

[req_read]

Leslie...

Thank you.

Michael

[Miss Chybil RN, BSN, RN]

Chybil...

A student went to see the guru one day and found him weeping inconsolably. The student was shocked and asked what was the matter. The guru told the student that his son had died. The student said, "But teacher, I thought you said this world is just an illusion." The guru replied, "Yes... and the death of one's child is the greatest illusion of all."

This, I don't get.

[sharona97, BSN, RN]

Thinking out of the box, perhaps......?

[FranEMTnurse, CNA, LPN, EMT-I]

since i have pulmonary and heart disease, i'm constantly struggling with breathing issues, i want to die without struggling; meaning knocked out.

[FranEMTnurse, CNA, LPN, EMT-I]

not sure if this is the right thread to post this or not, so i apologize if it isn't, i happened to come across some documentation that a nurse had left lying around on her end stage cardiac patient, ( chf)stating that the family was concerned about the increased swelling the pt had and wanted to increase the lasix, the nurse told the family she didn't want to increase the lasix because she was concerned about the pts K+, and the increased voiding would make her uncomfortable, now i am def not a hospice expert but don't you all think the lasix should of been increased even if it was short term to let the pt be more comfortable and then if needed decrease it, put a foley in the patient, again short term if needed.......let me end it by saying the patient passed away that same night.!!!, i wish i had know this before hand, i feel terrible, i just hope that little lady didn't suffer. thanks for letting me vent

Cookie, you have a definite arguement here. I wasn't yet placed on lasix until after I saw a nurse pour black uring in my graduate. It was then I knew my kidneys were failing, and my bladder began to pain. Then my physician ordered lasix IV. I have no clue if posassium was run in too, because all I saw was the Lasix drip.

I was put to sleep via Ativan thanks to Leslie, and the next morning, a nurse told mine she had better empty my foley bag before it overflows. She is one super nurse in my heart.