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Topics About 'Palliative Care'.

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  1. The elderly patient stared back at me with watery, vacant eyes while I leaned over to listen to her lungs and complete my assessment. Her lungs were clear and her heart rate remained steady and slow. She reached up to pull at her nasal cannula and her daughter quickly replaced it, saying, "Now, momma, leave that be. It's your oxygen. It's gonna help you." I sat down near the bedside with the daughter and granddaughter and we talked about the patient's course: she had ongoing dementia and recently suffered a fall and a broken hip. After surgery, she had a stroke that affected her ability to swallow and the family was faithful to follow her wishes not to have a feeding tube. Because of some pain from her hip, and some restlessness, we had admitted her to inpatient hospice care for symptom management. Now, two days later, her pain was well controlled and the patient was resting comfortably with no further need for interventions that could only be provided in a hospital/hospice house setting-care often referred to as general inpatient care or GIP. I talked with the family about what had happened over the previous two days: her pain was better. Yes, they agreed. And she was calmer and appeared more comfortable. Yes, they saw that, too. I also pointed out that while she continued to take the occasional bite of ice cream or applesauce, she was not able to take in enough calories to survive over the long term or to be able to go through rehabilitative care. As gently as I could, I told the family she would need to be discharged to home or to a nursing home setting; either place, hospice would come and take care of her there. Although we had covered this thoroughly during the hospice admission process, it seemed to be new news to the family at this stressful time. "What are you talking about? You can't make her go home! We can't take care of her! I have a bad back, and I can't pay caregivers. No! You cannot send her home." She crossed her arms and leaned back in the chair, her face set and angry. I listened and made a conscious effort to open my hands, palms up, while working to keep my facial expression neutral. I asked her a few questions about the home situation, looking for clarification. She raised her voice and became more agitated. Her daughter, a young woman probably in her 20's, put her hand on her mother's arm, obviously trying to calm her down. The daughter got up and stormed out of the room. The daughter raised her eyebrows and shrugged as if to say, "What do you do about that?" Hospice's goal is to primarily take care of people in the home. The team is set up so that the nurses, aids, social workers and chaplains, visit and care for patients in their familiar home setting. Sometimes the "home" is a nursing home or an assisted living or even a family member's home. Wherever "home" is, hospice will come to them there. The hospice services in and of themselves are almost always covered by insurance and they are covered 100% by Medicare. But the "home" itself, is private pay. So if the patient needs to be in a nursing home, hospice comes there to care for them, but they are responsible for the room and board at the facility. While this makes good sense when we are cool and rational, it can come as the final straw for an overwhelmed family who has used up all their emotional, physical and financial resources caring for a loved one who has been ill over a period of time. People generally don't understand or don't remember that this is the place where those who can afford it employ long term care insurance. For others, it can be a time of real financial hardship, taking the last of meager resources. For those who are indigent, Medicaid will often be involved in helping cover the nursing home expenses. During these tense times, the questions can come fast and furious"What do you mean you don't pay for the nursing home?""What do you mean my loved one has to go home?""What do you mean she is stable? She is dying!"In hospice, our job is to listen, to be able to show some empathy and to help the family come to the best solution for them. I left the room to allow the family some time and space. After discussing the situation with my managers, I waited until a social worker arrived and we went back in to talk with the family again. After more conversation, we were able to reach a solution that seemed to help the family with what they needed the most: time and rest. We kept the patient in the hospital for a few days of respite, allowing the family time to process, recovery physically, and make arrangements to care for her well at home with a rotation of extended family members. By the end of the day, there were hugs and comforting words all around as the family resolved to go home for a bit and get some "real sleep," but most importantly, the patient was resting, comfortable and appearing to be at peace. What has been your experience with GIP/respite/home care and the interface between these three? Do you have any insights on how to make these transitions easier for everyone?
  2. Nursula_rn


    We take any number of off-service patients. While we are a respiratory and infectious disease ward, we were known to be able to make a bed for anyone. Today is bipap, tomorrow is suicide protocol for a soldier from the local base. We could do it all. Sometimes, though, you wish it was just a little old lady with hankies up her sleeves. She arrived shortly after supper. She had the look of any new mother; tired but proud of her new son. Her bedside table held her favorite dog-eared books, including What to Expect When You're Expecting. Next to it, though, was a Holy Bible and pamphlets from our Palliative Care Team and local funeral parlors. The admission was brief. Postpartum would be supplying us a float nurse, as many of us were unaccustomed to postpartum patients. The nursery would be bringing the baby shortly, along with his own nurse. Mom identified herself as a Type-A lady. She had preferred to be in charge of everything. Until she received her diagnosis, at 32 weeks, that she had a large, aggressive breast tumour, she had been in charge of it all. She picked all the nursery furniture, purchased the new family-friendly car, and even put her tiny cottage up for sale so she could move her family to a new home closer to the park. Her husband was not only expected but encouraged to take a backseat in all things baby. Mom had it covered. Now, Dad was receiving a crash course in baby. Mom had waited until she had been given the report from the MRI that confirmed end-stage breast cancer with metastases to the lungs. bones and brain to give up. When Mom opted for a morphine PCA with a generous lock-out program, she chose to check out in a haze of narcotics. While Mom dozed in and out of consciousness, under the watchful eye of our nurses, Dad watched the in-house parenting class DVDs in our breakroom. He practiced holding and changing the baby with a borrowed teaching doll from the prenatal program. Dad was a mess. He cried some, smoked some, and contemplated his future. Our ward was great with all kinds of disasters. Patients from the federal prison who stabbed nurses with their own pens. Alcoholic patients who, despite massive doses of Librium, were able to fracture skulls and noses with their fists. Lousy managers who slept in their office while nurses sank in the mire of an understaffed ward. But this was different. We needed help. By day three, the baby had gone home with Dad. Mom wanted nothing to do with her baby, as she was never going to be able to raise him. No amount of emotional support from our social worker and palliative counselors would convince her to bond now while she could. Her husband was denied access as well, as Mom decided that he should stay with his son at home. (And it was a very nice home, situated next to the park, across from the large grassy playground of the elementary school, as pictures showed on her bedside table). The postpartum nurse returned to her ward, and the patient was signed off to us. No visitors came. The telephone never rang. The Mom layed in bed, pressing her PCA button like she was playing Jeopardy. By now, the books were gone from her bedside table- tossed in the garbage. The photos were turned over, except for the photo of the house. We wanted to be able to do something. Make her better so she could go home and start her new life as Super Mom, where she could grow organic vegetables for her baby as she had planned? That would have been wonderful. So many of our patients had been admitted at death's door but were returned home with a new, albeit short lease on life. We wanted that more than anything. Sadly, this 25-year-old new mother, with the shiny photos and the beautiful new baby that she had never held, was not that patient. Night shift started at 1900, as it always did. My partner and I arrived in The Pit as we called our observation unit to discover that Mom was our only patient. The other 3 had been moved to ward beds to allow for what was going to be a very memorable shift. At 1915, after report, a basinette arrived. A case of ready-to-serve formula accompanied it, along with tiny diapers and other baby items. Mom had agreed to have one night with her little family. Her high-flow oxygen kept her in the observation room for the night, with all the appropriate monitors, balances and checks. The two of us looked at each other. What was this? We had become resigned to a grieving mother, an absent father, and a feeling of misery in the room. We were not prepared for what happened that night. Football runs deep. Mom was a diehard fan of her home team, while dad was a local hometown boy. Tonight, though, everyone was on the same team. Baby arrived with Dad shortly after 1930. Full uniform of team jammies, little matching helmet and booties. Dad had on his own jersey. Both had the family's name on the back, to show family solidarity. Mom, who had not done more than play Jeopardy with her PCA and doze for most of our shifts with her, broke out in the biggest smile of all. Bigger than even the one in the fairy tale wedding photos we had seen when she first arrived. To top it off, Mom was given her own jersey, family name on the back. It was a very comfy, cozy jammy dress for Mom. I was about to help her put it on and feed the IV tubing through the sleeves. My partner asked her if she wanted to use her button as I would need to undo the PCA tubing briefly to prevent dislodging the saline lock. Mom surprised everyone, even herself. She smiled, said no. Just take it off not to hook it back up again for a while. Mom wanted to make some memories with her family, and wanted to be clear. We helped Mom into her team jersey, helped her pull her hair back out of her face. Dad looked hesitant. He had made this evening happen, and didn't want to jinx anything by pushing Mom too much. He held his infant son up to his wife to show her how beautiful he was. How much better he looked than the grainy ultrasound. He pointed out all the things that baby shared with Mom. Her chin, her forehead, her kissy lips. Then he sat down, in a nursing chair from the maternity, placing baby on the nursing pillow on his lap. It was the one Mom had picked out of a baby magazine. To match the rest of the nursery. Mom teared up. She called us over. That night, Mom held her baby for the very first time. We padded the siderails of her bed with blankets. We wrapped her saline lock to avoid any accidental scratching she was afraid of. We prepared the bottle just as she directed, even though it wasn't breast milk and wasn't what she would have fed the baby had she really been in charge. Then Dad placed the baby on her lap, on the pillow. Mom and Dad spent the next 3 hours with their little family, with their little boy. Baby cluster fed on and off. Dad showed his wife how to burp their son, showed her how he helped with the tummy gas. It was a magical end. By 2300, Dad and son had returned home. Mom's high-flow oxygen had stopped being enough, and she was now on bipap. Our magical moment was over and we were right back into respiratory nurse mode, with RTs and pre-code teams on the way. We directed traffic, started lines, gave meds. We moved furniture, took report and admitted 3 more patients. Business as usual. By next shift, Mom was gone. She had made it clear that she was to be a DNR. She passed away that morning in a private room. Her husband and son were not at the hospital, as she wanted. They were at the park, watching children play. Mom wanted to be in charge of that, too. We sent a photo to Dad from the previous shift, circumventing the computer rule. We uploaded a photo we took of his little family with the wound care digital camera. His one and only family photo for his little football fan. Being a nurse is hard. We can't always find the moral of the story, or the benefit of every situation, but we try.
  3. Palliative wound care is much more than exudate and odor management. Maintaining optimal function and mobility is an important part of symptom control and supportive care as well. Optimize Function and Mobility To optimize function and mobility in persons with nonhealing wounds, interventions should be tailored to the needs, comfort level, and desires of the individual patient. The overarching goal is to maintain as much function and independence for as long as possible to improve quality of life. Pain management should be adjusted to the amount and level of activity. Pain causes limited motion, restricted social interaction, and reduced capacity to conduct normal activities of daily living, such as dressing, bathing, and using the toilet. Pressure Redistribution Palliative care patients who are bedridden need pressure redistribution beds with support surfaces to help eliminate pressure, shear friction, and maceration. These devices reduce pressure by conforming to the contours of the body to redistribute the pressure over a larger surface. Group 1 pressure redistribution devices include pressure pads and mattress overlays composed of foam, gel, or water products, and the least expensive air mattresses. Group 2 devices include powered pressure reducing mattresses and mattress overlays, therapy beds, and low air loss mattresses to manage the heat and humidity of the skin. The only group 3 device is the clinitron air fluidized bed, where warm filtered air is circulated through silicone coated ceramic beads in the mattress, to evenly distribute an individual's body weight over a large surface. Infection Prophylaxis Infection prophylaxis is another important approach to palliative care of non-healing wounds, as it helps to control symptoms and prevent complications. Non-healing wounds, especially open ones, have a potential for serious wound infections that can extend to the underlying tissue and bone, where infectious organisms can enter the bloodstream with spread of infection throughout the body. Infection can make the wound, as well as the distressing symptoms associated with the wound, much worse. Signs of Infection Classic signs of wound infection are redness, swelling, warmth, extreme tenderness, increased exudate, purulent drainage, contact bleeding, odor, and fever or chills. A variety of different management strategies may be employed, since the development of a wound infection in a debilitated patient depends on the complex interplay of many factors. Treatment options include diagnostic testing to guide the choice of antimicrobials, antimicrobial topical products, antibiotics, wound bed cleansing, and surgical debridement of necrotic tissue. Pain Pain is a characteristic feature of nonhealing wounds and advanced life-limiting conditions. The constant pain can take a toll on quality of life, transforming the time that remains into a miserable existence. Effective pain management, therefore, is paramount for patients with nonhealing wounds at end-of-life. Ways to alleviate wound-associated pain include medicating the patient before dressing changes, moistening dry dressings prior to removal, the liberal use of opioid medications and topical anesthetics such as lidocaine, refrigerating dressings before application, avoiding the use or overuse of tape, and the use of wound gel products such as collagen hydrogel to lessen trauma to the wound bed. Palliative wound care places great emphasis on symptom management. Maintaining optimal function and mobility, managing wound infections, and controlling pain are all important approaches to help patients with nonhealing wounds and terminal conditions achieve the highest possible quality of life.
  4. I recently spent 45 minutes talking about death, and hospice, with my husband's sister in Maryland. Her mother -a delightfully quirky 91-year-old activist who still spends her days faxing her congressmen-just signed on with the local hospice. I'm a hospice nurse, by far the most rewarding work I've done in 35 years in the profession. I'm doing my best to help them navigate these new waters. Why is hospice nursing challenging? I understand so well what she's going through-teetering on that invisible line between wanting to cheer someone on to keep trying, and allowing them to decide that it's OK to stop fighting what is inevitable for all of us. Esther has, by my estimation, months, maybe a year left in her increasingly frail body. Although she's still very sharp, mentally, she forgets things more, has to stop more often to catch her breath, and can't really muster any enthusiasm for exercising with her walker. She spends more time in bed or on the couch, wakes up later, goes to bed earlier. I see the familiar signs of someone looking beyond this mortal coil. Considering the quality of those months is, to my mind, far more important than wringing out more of them by pushing her to eat more and take more walks. There comes a time with an aging parent when you have to stop trying to make things better, and decide to just love them, respect their wishes, and be present. I think that time has come with Esther. At this stage, it's important to distinguish between what COULD be done and what SHOULD be done. Still, it's hard. Damned hard. As I remember well with my own Dad, it's easy to decide in an abstract way that you don't want to prolong life unnaturally, to trade quality for quantity. Yet, when my rapidly declining father broke his hip, I was heartbroken to hear that he decided not to have surgery (in retrospect, this would have been a miserable experience he might not have survived). I wanted to let him go peacefully, without a lot of high-tech, dehumanizing interventions. I just didn't want to do it YET. No matter how clear we are, in a theoretical way, about wanting a peaceful, dignified end for our loved ones, we're never ready for this moment to be the last we have with them. That pain is something we sign on for when we let ourselves love someone or something impermanent. Which is, alas, everyone and everything. Loving the impermanent is one of the necessary pains included in this beautiful, untidy package we call life; I've decided to learn to live with it. The alternative, to harden ourselves and not get "too attached" (a concept that has taken much of the heart out of medicine, in my opinion) is not one I care for. This is what I love most about working for Hospice-we get attached to, and often fall in love with, our patients; it's a given. And although I'm aware of how much we bring to patients and families we care for-comfort, supplies, clarification of what's important, understanding of what they're going through and what's ahead-I always feel I've received more than I give. It's an honor to be with people who are facing their own mortality. Somehow frivolous concerns seem ... frivolous; the specter of death has a way of distilling what's important in life. And being reminded of our universal mortality reminds me not to squander this life I have on resentments, or worries, or acquiring more things. I'm more aware of the beauty, and the fragility, of the world and our relationships. So, I answered the questions I hear so often. Joining hospice does not generally cause people to give up and die-often the support we give causes them to rally and live longer and more comfortably; sometimes they even "graduate." Pain medicines, used appropriately, do not cause addiction or hasten death, but the need for them often coincides with a decline that has already begun to accelerate; ideally medications relieve pain and air hunger in patients' last months, even sometimes increasing activity. And yes, there are always gray areas: How long is it safe to leave her alone? How much should we push her to eat and exercise? As always, I suggested she answer these questions from her best understanding of, and respect for, Esther's wishes, and by exploring them with the hospice staff. We'll fly out over winter break; I look forward to spending some bittersweet, heart-ful time with my beloved mother-in-law. And I hope to make sure she's comfortable, and help love her out of this life. That's the best any of us can do, and what we all hope for in our last days.
  5. VickyRN

    Skin Changes At Life's End (SCALE)

    The skin is the largest organ of the body and can become dysfunctional at life's end, with loss of integrity, just like any other vital body system, with reduced ability to utilize nutrients and other factors necessary to sustain normal skin function. The manifestations of this dysfunctional state are called skin changes at life's end (scale). These end-of-life skin changes stem from ineffective skin and underlying soft tissue perfusion, increased vulnerability to external insults (such as minimal pressure), build up of metabolic wastes, and local tissue factors. At end-of-life, a person may develop skin breakdown, despite multiple appropriate interventions and optimal care, as it may be impossible to shield the skin from insult and injury in its compromised state. The acronym scale describes clinical phenomena in skin and soft tissues that occur when the dying process compromises homeostasis, resulting in skin failure. Skin failure is defined as the localized death of skin and its underlying tissues due to decreased blood flow secondary to dysfunction of other body systems, often multiple system organ failure. This failure of the largest organ can be classified as acute, chronic, or end-stage. Clinicians need to have a realistic understanding of what can be achieved, in terms of prevention and treatment of wounds, due to the declining health status of individuals with multiple comorbid conditions and/or terminal illness, as they approach end of life. As stated earlier, not all pressure ulcers at end-of-life are avoidable. A common manifestation of scale is a phenomenon known as the kennedy terminal ulcer (ktu), which is a special type of pressure ulcer that forms suddenly in dying individuals. A pressure ulcer, also termed a bedsore or a decubitis ulcer, is a lesion that develops as a result of unrelieved pressure, shearing force, or friction or a combination of these factors. It usually develops over bony prominences. The damage consists of areas of tissue ischemic hypoxia, necrosis and ulceration. Pressure ulcers are most often seen in elderly, immobilized, or emaciated patients. The sores are graded by stages of severity, from stage i through stage iv. Research is limited, but the ktu is an unavoidable pressure ulcer that develops in some individuals as they are dying, usually within 2 weeks of death and in conjunction with impaired skin perfusion. This unique type of skin failure or skin breakdown is typically found on the sacrum or coccyx, occurs suddenly (usually within hours), and is shaped like a pear, butterfly, or horseshoe. The ulcers may be red, yellow, black, or purple in color, and tend to progress rapidly to stage iii/ iv. The treatment for the ktu is the same as for any other pressure ulcer of the same stage. This has been an overview of scale, a topic that is just beginning to be researched. Not all pressure ulcers are avoidable at end-of-life, especially the kennedy terminal ulcer.
  6. aging1

    A Time to Die

    I recently spent 45 minutes talking about death, and hospice, with my husband's sister across the country. Her mother (my mother-in-law)-a delightfully quirky 91-year-old activist who still spends her days faxing her congressmen-just signed on with the local hospice. I'm a hospice nurse, by far the most rewarding work I've done in 35 years in the profession. I'm doing my best to help them navigate these new waters. I understand so well what she's going through-teetering on that invisible line between wanting to cheer someone on to keep trying and allowing them to decide that it's OK to stop fighting what is inevitable for all of us. Esther has, by my estimation, months, maybe a year left in her increasingly frail body. Although she's still very sharp, mentally, she forgets things more, has to stop more often to catch her breath, and can't really muster any enthusiasm for exercising with her walker. She spends more time in bed or on the couch, wakes up later, goes to bed earlier. I see the familiar signs of someone looking beyond this mortal coil. Considering the quality of those months is, to my mind, far more important than wringing out more of them by pushing her to eat more and take more walks. There comes a time with an aging parent when you have to stop trying to make things better, and decide to just love them, respect their wishes, and be present. I think that time has come with Esther. At this stage, it's important to distinguish between what COULD be done and what SHOULD be done. Still, it's hard. Damned hard. As I remember well with my own Dad, it's easy to decide in an abstract way that you don't want to prolong life unnaturally, to trade quality for quantity. Yet, when my rapidly declining father broke his hip, I was heartbroken to hear that he decided not to have surgery (in retrospect, this would have been a miserable experience he might not have survived). I wanted to let him go peacefully, without a lot of high-tech, dehumanizing interventions. I just didn't want to do it YET. No matter how clear we are, in a theoretical way, about wanting a peaceful, dignified end for our loved ones, we're never ready for this moment to be the last we have with them. That pain is something we sign on for when we let ourselves love someone or something impermanent. Which is, alas, everyone and everything. Loving the impermanent is one of the necessary pains included in this beautiful, untidy package we call life; I've decided to learn to live with it. The alternative, to harden ourselves and not get "too attached" (a concept that has taken much of the heart out of medicine, in my opinion) is not one I care for. This is what I love most about working for Hospice-we get attached to, and often fall in love with, our patients; it's a given. And although I'm aware of how much we bring to patients and families we care for-comfort, supplies, clarification of what's important, understanding of what they're going through and what's ahead-I always feel I've received more than I give. It's an honor to be with people who are facing their own mortality. Somehow frivolous concerns seem ... frivolous; the specter of death has a way of distilling what's important in life. And being reminded of our universal mortality reminds me not to squander this life I have on resentments, or worries, or acquiring more things. I'm more aware of the beauty, and the fragility, of the world and our relationships. So, I answered the questions I hear so often. Joining hospice does not generally cause people to give up and die-often the support we give causes them to rally and live longer and more comfortably; sometimes they even "graduate." Pain medicines, used appropriately, do not cause addiction or hasten death, but the need for them often coincides with a decline that has already begun to accelerate; ideally, medications relieve pain and air hunger in patients' last months, even sometimes increasing activity. And yes, there are always gray areas: How long is it safe to leave her alone? How much should we push her to eat and exercise? As always, I suggested she answer these questions from her best understanding of, and respect for, Esther's wishes, and by exploring them with the hospice staff. We'll fly out over winter break; I look forward to spending some bittersweet, heart-full time with my beloved mother-in-law. And, I hope to make sure she's comfortable, and help love her out of this life. That's the best any of us can do, and what we all hope for in our last days.
  7. Palliative care services are a very important resource for those patients who have been recently diagnosed with a terminal illness. Care needs fluctuate throughout the course of any life-limiting disease. No longer are patients required to terminate aggressive treatment, and possibly give up all hope in order to receive much needed services. These Palliative care services may include: Help navigating the healthcare system. Multiple symptom and pain management. Guidance with difficult and complex treatment choices. Emotional and spiritual supportive counseling. Patient and family open communication. Unfortunately, there continues to be a lack of knowledge and understanding among many Physicians, who are resistant to the idea of Palliative care. They continue to have the idea that if their patient considers Palliative care services, that the patient is actually giving up and is ready to die. But that is simply not the case. According to the American Nurses Association, Palliative Care is recommended for: Any stage of illness. Used in conjunction with treatment. Helps with the transition from curative care to Hospice. These patients can continue with their aggressive disease- oriented treatment, as ordered by their Physician, while receiving much needed services. The network of support from the entire Palliative care team, may even aid the patient in continuing with their treatment. Palliative Care is beneficial, not only for the seriously ill patient, but their families as well. This also makes for a much smoother transition or "bridge" to elective Hospice services at a later time. This bridge provides for the movement of the pre-hospice patient, on to full hospice services, without an actual crisis. This new Hospice patient admission can now be a direct result of a tranquil, peaceful, and an elected personal choice. It is important that all healthcare team members have an understanding of the aspects of Palliative care services. Detailed information and a referral about these important services should be initiated at the actual diagnosis point with the Physician. The Journal of Hospice and Palliative Nursing explains, that although the Physician makes the initial diagnosis, it is the important universal communicative role of the Nurse, which takes on special importance during such intense times such as serious illness and end-of-life care. It is the Nurse who provides accurate information so that individuals can make informed decisions following the shock of such a diagnosis. As our vastly educated population ages, the planning of our own personal end of life journey will become increasingly important. No longer will patients be faced with the "treat or not to treat" decision following a diagnosis of a life-limiting disease. As Physicians become more informed, and learn the importance of Palliative care services for their patients, this transition will become a peaceful and tranquil experience. There are so many advantages to the patient as they receive Palliative Care services and then bridge peacefully on the Hospice Services. End of Life should be respected, and all resources should be offered and provided to the patient and their families at the point of diagnosis. All treatment options as well as a referral to Palliative care services should be initiated in order to assist the individual with the most beneficial and personally detailed plan of care.
  8. NurseAlwaysNForever

    Brave Little Soldier Boy

    That I wasn't sure I would be able to, that I really didn't want to ever be in that situation. I got the job and was told that if we got any kids I probably wouldn't have to take care of them. We don't get many children on our services. It wasn't long before we did get a 13-year-old little boy. I'll call him Robbie. Robbie had been diagnosed with brain cancer at the age of ten during a routine eye exam. He had undergone chemo and radiation and was in remission for a little over a year. During his one year follow up they found that he now had spinal cancer and there was no treatment for him. Robbie came on service with us. He was nearing the end of his 7th-grade year and was determined to go to school daily. He was able to walk at first, however, before the end of the school year he was w/c bound and had a foley cath in place. He was steadily getting weaker and declining more and more every day. He never asked for any special treatment or for anyone to take care of him. He was loved by everyone at his school. On the last day of school, we got a call and I made a trip out. He was so very sick. He hadn't even woken up for most of the day. I told him we were going to take him home early, but he refused. Robbie finished his 7th-grade year out. Even as his health was failing him he remained full of life. He wanted to go out on a date before he passed. He did and even had a limo ride. He wanted to go to Sea World, and did, in his w/c. Make a wish sent him to meet the Orange county chopper people and he got to ride on a Harley. By the 3rd week of summer vacation, Robbie was starting to lose feeling to his feet. I seemed to be finding reasons to "stop by" almost daily. By the start of his 5th week, I was his nurse and still found reasons to stop by daily. I came in one day and Robbie was writing furiously in a spiderman notebook. I said "Whatcha writing soldier?" He looked up and said, " My will. Do you think you could help me? I keep forgetting to remember stuff." We wrote his will out, him dictating, me transcribing. Baseball cards - My big brother. One day he might be on one. Fishing stuff - My dad. He'll be sure to catch a big one. Clothes - Goodwill. They won't fit anybody at home. Important stuff/papers/awards - Mom. She won't lose 'em. Room - My little brother. He shouldn't have to keep sharing with my sister. Stuffed animals - My little sister. She'll love 'em to pieces. The list went on and on. These were the ones that stuck with me the most. We had his will notarized and he was so proud that he had done it. He said, I gotta plan my funeral next you know. I hafta get ready to go to Heaven with Jesus. I hugged him and held him tight. Told him everything would be okay, all the while begging God not to take him from me. Not to put his family through this. Constantly asking why? In time, I realized that even though Robbie was only 13 he was much more prepared to pass than most of the adults I knew. He had no anger or fear. He accepted his fate. He spent days planning his funeral. The music, the color of his casket piece, his casket, his clothes. He had to have a casket with an angel on all four corners so they could "Carry him to Heaven". By the middle of summer, Robbie was paralyzed from the chest down. He itched fiercely and began to have severe pain. We put him on Atarax and Duragesic patches. He never complained, never got angry. He was such a soldier. He passed away in his sleep a week before school started back up. We had started continuous care, and he was lying in my arms as he took his last breath. His funeral was the most beautiful funeral I had ever been to. Maybe it was knowing that he planned it, every last little detail, almost like one would plan a party. It was beautifully choreographed..... He was buried in a Harley T-shirt and jeans. He had a guitar pick in his hand. They played when I get where I am going, Who you'd be today, I will always love you, You raise me up, and many more. His flowers were all red, orange and black. Several of them had motorcycles in them. He even was buried in the spot he picked out under a weeping willow. He told his momma that he wanted to be buried there so that when he went to be with Jesus she wouldn't have to cry because the tree was doing it for her. What did I learn? That God knows what he is doing and takes us when the time is right. Robbie was so much more prepared and ready for his death and it couldn't have come at a better time for him. And guess what... I love pedis now. Somehow it is the most fulfilling thing you can do, even if it is helping them have a comfortable passing. My little soldier boy, I salute you and will never forget how brave you were as you set out on your journey.
  9. In a 10 minute period, she would go from hot to cold and back to hot again, requiring multiple trips to her room to adjust the a/c or add/subtract blankets, etc. To add to the fact that her call bell was so consistent that it was the cadence to which we all set our pace, if it was not answered within the first 10 seconds of its activation, she would begin calling random names of nurses and aids that may or may not be on duty at the time. Yes, Mrs. Jones was a handful and I am ashamed now to say that I dreaded dealing with her on a daily basis. I had a million other things to do and 25 other patients who needed my attention! Didn't she understand??? Mrs. Jones was a Hospice patient for what seemed like forever. She frequently called the name of the Hospice nurse too. Mrs. Jones was alert and oriented and just seemed to need an unusual amount of attention which I was really hard pressed to provide and I was resentful of that. I came to work one early fall day to find that Mrs. Jones, who had been her usual self the day before had taken a turn for the worse. She was hallucinating, and her general condition had greatly deteriorated. She was still, however, aware of her call light! I tended to her all evening and into the night. I turned and changed her many time myself because the aides were busy with others and she needed such frequent attention. This also gave me the opportunity to keep up with her condition. At one point around 1 AM, I walked into her room and heard her talking in a sweet, grandmotherly voice that was unfamiliar to me too... well, no one that I could see. She was saying, "Don't go near that bush now. There are wasps in there." I asked, "Mrs. Jones, who are you talking to?" "Why, these children, of course. I don't want them to get stung. You stay away from it too." "OK." I agreed and started to leave the room. "Have you seen my daughter?", she asked me. In fact, her daughter hadn't been in to see her mom for months. I have no idea what had happened but the instruction in her chart stated that her daughter should only be called upon Mrs. Jones death. I told her that I had not. She then made the statement that changed my life. "I wanted her here because I am going to die tonight and I don't want to be alone.", she said. At first, I thought this was a melodramatic way of demanding yet MORE attention. As I turned to leave the room, I was overwhelmed by the feeling that I needed to stay. I went to the nurses' station and gathered some paperwork, well aware that I had plenty to do. I told the aids where I would be and carried my paperwork into Mrs. Jones room pushing a bedside table on which to work. "I'll be here with you, Mrs. Jones.", I told her. She smiled. She wanted to tell me about her family and her problems with her daughter and needless to say, not much paperwork got done. I realized through her stories that she needed attention because she really didn't have anyone but the staff of the nursing home. She talked for two solid hours as I listened and held her hand. When she had covered all the information she wanted me to know about her personally, she said, "You know I love you, Stacey." She had never called me by name before always referring to me as "nurse". With a new and heartfelt understanding of Mrs. Jones "neediness" and tears now welling in my eyes, I said, "I love you too, Mrs. Jones." And I meant it. Shortly after this exchange, her breathing became labored and eventually stopped. I was holding her hand as she passed peacefully. I called the supervisor and Hospice and her daughter. The aids came in prepared to handle the routine post-mortem care. I asked them to let me do it. I washed Mrs. Jones, changed her gown and her bed and brushed her beautiful white hair. Mrs. Jones was gone and I realized that I had too long been annoyed by her constant need for attention and never took the time to find out the reason for it. She was a lonely little lady who really looked at the staff who was "bothered" by her as her family. Shame on all of us. I gained a new perspective on my chosen career. I am a nurse to serve my patients/residents in more ways than I knew. I thank Mrs. Jones every day for teaching me that. I was very late getting out of work that morning but it was OK. It was my honor to see that Mrs. Jones didn't have to be alone on her journey. Now I remember why I became a nurse. Mrs. Jones changed my life...and in an indirect way, the lives of every patient for whom I have cared since.
  10. kaylie1

    Through the back door

    We had just finished our Monday morning hospice report. As a group, we routinely meet for 30 minutes on Monday morning to share admissions and deaths over the weekend. I was preparing my schedule for the day, still thinking of a patient that had just passed away over the weekend. I thought to myself, its pretty cool to be able to help others make the transition through death. It is often nursing care at its most basic-comfort care. This is when the call came into the office to my supervisor-"Sue." She was a bit distraught saying that the caller was the daughter of a patient screaming in the background with pain. Sue had assured me that as soon as the order for the morphine was signed off by the attending, that I would be able to pick it, and the rest of the comfort kit, up from the pharmacy. Quickly, I hurried out the door and into my car. I was on my way. I entered the address on the GPS and wasn't really sure how far away it was. I knew that the patient was to be admitted for Cancer, although I wasn't sure what type of Cancer or about the source of pain. I assumed she was dying as any other patient on hospice, but for the pain to be this severe, maybe it was more terminal. I just didn't know how I would be able to help, especially without the comfort kit and/or the morphine. About 10 minutes down the road, I received a call from Sue. She wanted to know if I was almost there. She said if the Dr. could hear the patient screaming on the phone, then he would be more likely to sign the order. The Dr. was still working on it. Sue was getting ready to follow up once again with him. Arriving at the home, the daughter "Lisa" met me in the driveway. "Did you bring the morphine?" I responded, "No ..I'm sorry, we are still working on that. Is it OK if I go ahead and see her?" She said, " Sure go up these stairs into the back door." So I ran up the stairs and entered the room of a screaming woman lying in bed. Looking directly into her eyes, I said, "where is your pain?" The patient motioned with her eyes and said in a weak voice, "down there," only to start screaming again. I asked the daughter if she was constipated to which she said "maybe." I replied, "Would you mind if I just check, I mean I know we just met?" With the daughter's assistance, I turned the patient to the side and with rectal check started disimpacting the patient. After a few balls of hard stool, the patient stopped screaming. The daughter's response was, "You really came in the back door more than once, didn't you?" Not sure she ever used the morphine or comfort kit, but I had later picked it up at the pharmacy and brought it back to her in case she needed it. I phoned the office to speak directly with Sue and said, "The pain is gone. It turned out she was impacted, and I just disimpacted her." Sue's response was, "Thank God!" The patient died the next morning. She just needed to be comfortable. As a nurse I had the unique opportunity to relieve the suffering of another person that I had just met. Entering the back door in more ways than one says something pretty special about their confidence in me as a nurse. I am proud to say that I directly relieved her suffering and helped her make it along her journey.
  11. "People brought all their sick to him and begged him to let the sick just touch the edge of his cloak, and all who touched him were healed." Matt. 14:35-56 I arrived at the house ahead of the ambulance that was bringing the patient home, and noticed the gathering clouds of a summer storm sweeping its arms around towers of humid air, ready to release the tension of the hot day. The family met me at the door and I went around the room, shaking hands with the patient's daughter and granddaughter. The elderly husband, came in last, shuffling a bit, but smiling and extending his hand in greeting. The granddaughter bent over conspiratorially to whisper, "He has dementia." I asked a few questions about medical history and explained some of the process of admission to hospice care. We heard the ambulance pull up, it's loud back-up "beep, beep" bringing our conversation to a stop. We all looked beyond the hospital bed that stood parked by the front window, to see the ambulance driver rush around to the rear just as the first raindrops fell. When they brought her in, she clutched her sheet over her face and wiped the rain out of her eyes but then kept wiping as more water sprung out in tears. Her face crumpled as she wept and her family rushed over, trying to determine if she was in pain. She smiled through her tears and said, "I thought I would never see this place again." I walked around to the other side of the bed, took her hand gently in mine and introduced myself. While I helped her finish wiping the rain from her face, I noticed her bright blue eyes, set in pale skin, framed by soft white hair. She was quite lovely for a woman her age, and her smiling eyes added to her beauty. Just then, he husband came over from the corner where he had been trying to get out of the way. He reached down and took her other hand and sat down beside her. He caressed her fingers and then leaned over to kiss her. The tears came again, this time to the eyes of those of us watching the scene unfold. As I continued my assessment, I touched her forearm gently while taking her blood pressure and asked questions about the pain. Before inspecting her abdomen where an erosive cancer had left a draining wound, I donned gloves and asked permission with eye contact. Then with the help of family, we turned her over gently so I could inspect her skin, noting several red places on her back and coccyx. Her mobility was impaired by the of pain of a recently fractured vertebra. That together with significant weight loss and poor intake, contributed to many skin integrity issues. After a careful assessment and lots more questions about bowel and bladder function, pain, and respiratory status, I worked with her granddaughter to get her positioned with pillows and one of her own quilts so that she could rest from her transfer. Through all this, her sweet husband stood nearby holding her hand gently in his. While I offered the touch of compassionate care, he offered her the comfort of a well-worn and enduring love. After we finished signing the requisite paperwork, I gathered my things and stood. Then I waited to take a cue from the granddaughter and daughter, reading their non-verbal communication to see if they would welcome a gentle hug or if a handshake would again be more appropriate. Sensing their need for a comforting touch, I offered a sideways hug to the daughter and reciprocated the granddaughter's approach for a full hug, then moved over to squeeze the patient's shoulder gently. Her husband, now seated beside her on the bed, simply nodded his goodbyes. As I walked down the front steps, papers in one arm and computer bag in the other, I thought again about the beauty of the touch between the patient and her husband. I wondered about how touch plays a part in healing. Although the patient had a terminal diagnosis, and was weak and frail, the husband's touch was clearly healing, bringing her comfort and peace at a difficult time. I wondered about my role as a professional nurse and my use of touch during this interaction and in others. I asked myself questions about touch: when is it therapeutic and when is it invasive? How do I know where the fine line is that separates those two? How can I be a better listener so that I see and interpret non-verbal communication? I wondered, too, about how our necessary protective barriers separate us from our patients. With gowns, gloves, face shields, how do we continue to convey warmth and provide for a healing touch? In the home, it is admittedly easier, as family members and nurses sit side-by-side on a couch, signing papers, a natural closeness happens. But what about in other settings? I have been blessed to be a person with relative good health and only a few opportunities to pass through the medical system during times of crisis. But those times touch and posture stand out, in stark relief: the doctor who crouched down to eye level in the ED to tell my beloved sister, "This is the end of the road;" the nurse-midwife who recited the Lord's prayer in the delivery room while holding my hand; the nurse who held my forearm gently to steady me as she told us our teenage son's CT scan was okay after he had a serious bike wreck. The touches were all brief, but the healing they brought continues to warm my heart. A touch can make all the difference. As nurses, we learn from experience and also from modeling what is appropriate touch and how to employ touch with compassion and respect. That evening, as the setting sun peaked out again from the spent clouds, I stepped over puddles and looked back over my shoulder, to see the warm glow of light coming through the patient's picture window, framing the family members as they moved about the room, holding onto the love that held them together. Joy Eastridge, RN, BSN, CHPN
  12. I work PRN at a hospice house. I was taking care of a patient that had been with us for 2 months and was very well known to the full-time staff, yet I had only taken care of her on 3 occasions. There had been several issues with the family due to cultural differences but the times I had taken care of her she was alone and resting. Until Thanksgiving. One of her sons called me into her room and very politely asked to have her transferred to the hospital to pursue life-saving measures. I was a bit taken aback as this was not a situation I had encountered yet. I maintained composure and professionally educated the son on his mother's condition (poorly responsive, no PO intake for days, weak pulses) and the limited resources the hospital would be able to provide, only delaying the inevitable. He relayed this to another family member on the phone who was adamant this was what they wanted. I spoke with the HCPOA who also confirmed this request, and followed policy by making the medical director and clinical supervisor aware and then calling EMS. The son signed the revocation form. When EMS came to transport the patient, they tried to educate the son as well to no avail. Her failing body was transferred to a stretcher and taken out of the hospice house. The entire interaction from beginning to end lasted only an hour. I know that my direct interaction with the family was professional and without judgment, but afterwards with my co-workers, I was angry and judgmental. And I carried that mindset with me home and for the rest of the night. I judged their decisions. I assumed they were uneducated on their mother's condition and prognosis. That they were being selfish and causing their loved one to suffer more. As a nurse, I assumed I knew best. I've seen countless people pass away at the hospice house. I've educated and re-educated family members who are grieving too badly to understand. Some are more accepting than others. Some just can't let go. But when they are too distracted, too tired, and too afraid to face reality, it is not my place to judge. The next morning as I was driving to my full-time job I prayed and reflected on my thoughts and actions. I felt ashamed of my lack of compassion and empathy. Why didn't I place myself in their shoes? Why did I feel the need to speak my bitterness and judgment on a situation I had no real knowledge about? Why was I carrying a burden that had nothing to do with me? As healthcare workers sometimes all we can do is educate. Patients most of the time actually won't do as they are instructed. They are often noncompliant with their treatments. It can be frustrating for us. But it is not our disease. Ultimately it is not our decision and it is not our life. It is easy for us to vent to our co-workers (and sometimes necessary) but it is not our place to judge. We end up carrying that negativity with us whether we realize it or not. The next time you are involved in a situation that is ethically controversial, that goes against your knowledge, that is testing your patience and that you may disagree with, take a deep breath. Try and take an understanding approach from the patient's or family member's point of view. We do not know their entire life story, their family dynamics, or their thought process. It is our job to educate, listen, advocate, and support. It is not our place to judge.
  13. Currently, I am a nursing student. But, between experiences in a clinical setting as well as my own personal life, I feel like I want to be a hospice nurse. Does anybody have any advice for me regarding this? How does one go about becoming a certified Palliative care nurse? I currently work as a CNA, and I experienced my first death a few days ago. It was really hard for me, as people insisted on drawing blood and other diagnostic tests on a man who was DNR. For the most part, he was incoherent. But, there were a few times when he was clear as day. He didn't want to be poked and prodded anymore. He just wanted to be left alone. He knew he was dying, and he wanted to go on his own terms. I am not normally a hyper-sensitive person. ( in that way) I don't cry over lost patients. But, this guy...I did cry. Nobody was there for him, other than me. I was there when he took his last breath...and I was the one who saw the lone tear in his eye. I was the person who had to tell his nurse that I thought he was dead. I took it upon myself to perform his post-mortem care. I felt it was my responsibility to do so. I was the person who he spent the last hours of his life with. I was the last person he laid eyes on, the last person he talked to, the last person to talk to him. I had to be the one to get him cleaned up and ready. Unfortunately, as the lone CA on shift, that meant neglecting vitals on some other patients. God forbid the nurses take a couple of readings. ......... Not to mention that they told me not to bother. Somebody had to sit with this poor soul. God knows they weren't going to bother. This guy died in pain. He spent hours bleeding out. He was in so much pain. I was NOT going to leave him alone. I knew he was dying, he knew he was dying. I could not, in good conscience, leave him alone to die by himself. My heart made me sit beside him and hold his hand. My heart made me clean him up to the best of my ability. It wasn't easy. I work on a psych floor for elderly patients. Deaths are not a normal occurrence on our floor. This experience has been a profound wake up call for me. He should not have been in so much pain. No one should have been drawing blood. That man should have been allowed to die with dignity, on his own terms. I wish I could tell his kids that he was not alone when he passed. I was there with him. I was holding his hand. I know I am just a lowly CA, but I think his kids would take comfort knowing that someone was there with him when he took his last breath. That he wasn't alone. That someone who cared about him was there with him to the end. I know it's not my place to say such things.
  14. NurseAlwaysNForever

    I'm Leaving You Here

    I had never intended on becoming a nurse, however, that is the direction that God sent me in and I have not regretted it ever since. I loved the nursing home and getting to know all of the patients and their families. I never had grandparents and they all just kind of filled the gap for me. Each of my patients was like an extension to my family. Every time I had a pt that got put on hospice I would get so angry at the MD and would feel that they were giving up on my pt. I didn't want to "let" them just die. How dare they? I just didn't understand the benefit of hospice at that time. After working at the nursing home for a year I had an ethical conflict with the current DON and decided at that time to quit. I submitted my two-week notice and she politely told me that they would not need for me to finish working it out. I went home and balled my eyes out. I felt like I had lost a large portion of my family. I had no idea what I was going to do, where I was going to work, or how I was going to pay my bills. I prayed day in and day out for God to send me in the right direction and vowed to not even apply for a job until I felt that it was the one he wanted me to apply for. After church one Sunday I received a call from a friend of mine who's father was a supervisor at a local hospice and she informed me that he was very interested in hiring me. I told her I would think about it, and I did. I felt a very strong urge to do it, but couldn't help but think that God must be laughing at the time. Me, do hospice? Was he crazy? I couldn't fight the urge and did apply for the job. They gave me a lengthy test full of questions that I had no clue how to answer. Miraculously, I only missed a few. I was hired and went through the 3 days of orientation before I was assigned my caseload. My first hospice pt was a Lutheran minister in his 50's with Brain CA and the only warning I got was that he would try to convert me. I arrived at his home, rang the doorbell and waited patiently for an answer. I was so nervous. What did I say to this man who was dying? How did I talk to him? Do people realize how often they use the words die or kill me in a conversation.? "Oh, I could just die" or "That kills me." What if I slipped up and said it and he got offended. What if I made him sad? At that moment the door was answered by a middle-aged man with wire-rimmed glasses. I introduced myself and he invited me in. I will call him Joe. Joe offered me a seat on his sectional and he sat down as well. He didn't even look sick really. I explained I had to get his vital signs and ask him a few questions. He allowed this and everything was in normal range. We shook hands and I started to leave. Joe touched me on the shoulder and said, "You know I'm dying and I know I'm dying. It's okay if we talk about it." I apologized and explained that I just didn't really know what to say and that I was sorry that he and his family were having to go through this. His only reply was a hug and then with a grin, he said, " Don't feel sorry for me I feel sorry for you. I'm leaving you here." In that moment I realized that he was right. Mr. Joe lived for six months. During that time he declined very slowly at first. It started with mild confusion and forgetfulness, to not even being able to recall his wife's name, even when she sat right in front of him. Mr. Joe never lost his faith though. I told him happy Easter before the holiday. He explained he would be having the real Easter in Heaven with God when he passed. How could a man have such strong faith to not remember his wife's name who sat beside him, but still remember such strong things about the Lord, who he'd never laid eyes upon? A month before Joe died he became bedridden and was unable to speak. We would talk to him at length. He even got to where he could barely open his mouth and swallow his food. He was transported to the local hospital for his last few days. His family was more comfortable with the thought of him passing there. His wife never left his side. When we were waiting for him to be moved to his floor I bent down and said "Joe, when you get up there you put in a good word with the man upstairs for me. I need all the help I can get." He smiled and spoke for the first time in over a month and told me he would. Mr. Joe died the next day with a smile on his face and all I could think was, "You lucky son of a gun." Talk about a change of heart. I know Joe was put in my life for a reason and Hospice is my passion!
  15. jeastridge

    Palliative Care + Hospice = A+

    November is National Palliative Care and Hospice Month I scrolled down through the EMR and found what I was looking for: Palliative Care Consult. As a hospice nurse, we often get referrals from Palliative Care and their consult is a great place to start reading to get a picture of where this patient has been and what their current situation is. As I read, I discovered the 72 year old patient had extensive lung cancer and had been treated with radiation. During treatment, he began to have severe bone pain as the disease progressed. His oncologist called in Palliative Care to assess the current situation and to begin discussions with the patient about possibly transitioning into hospice care. After reading through the consult, I felt more comfortable about beginning a conversation with the family, knowing that the door to end of life conversation was already open and that hospice was not a completely foreign term to them. I gathered up the referral, the patient's history and physical, and general information about our particular hospice agency before I headed down the hall and knocked on the door, ready to do the Hospice Evaluation to determine if the patient was ready for and qualified for hospice care. After knocking, I heard a soft, "Come in," on the other side and pushed the door on open. In the small hospital room I saw the patient in the bed, his white hair blending into the pillow, oxygen in place, hands on either side of the tucked in sheet, palm down, as if holding the bed in place by the force of his will. He smiled, a kindly smile and said a weak hello. Beside him sat his wife, eyes lined with worry and circled with dark shadows that betrayed long hours of vigil. I introduced myself as the hospice nurse and saw his wife's mouth make a small "oh" as she exhaled long and deep. After pulling up a chair, I sat down and started by asking him how he was feeling and how the pain was at this time. After we got to know each other a bit, I began to gently explain what hospice is and does. While hospice partners with palliative care, the two serve distinct and different purposes in the health care arena. Palliative care joins the patient's health care team when there is a need for symptom management during the treatment phase of long term illness. They help respond to a variety of troubling symptoms including pain. They are experts in identifying and foreseeing potential problems that complicate the patient's ability to continue to find enjoyment in life. Palliative care also plays a strong role is helping families begin discussions about Advance Care Directives. Because of their specialized training, they have the ability to approach the topic of the patient's end of life wishes with sensitivity and finesse. Hospice care comes into the picture when the physician team feels that there is a shortened life expectancy of six months or less. While this time frame is difficult to pinpoint, in practical terms it can mean that the patient has extensive disease that continues to advance with limited therapeutic value to be found in any available treatment modalities. Whether it is cancer, or end stage lung disease, or end stage heart disease or end stage renal disease, or some other life-limiting condition, the hospice team's role begins when all options are weighed and in the balance the potential success of treatment is overcome by the potential difficulties of complications. So why would you pick hospice instead of palliative care? Palliative care is office and hospital based and still in the realm of focusing on potential treatments and possible rehab. It is centered on alleviating symptoms while the physician, patient and/or the family are continuing to pursue live-extending treatments. Hospice, on the other hand, is defined by the expected shorter term lifespan of six months or less. Clearly, many patients live longer than the six months since none of us has the ability to fully forecast disease progression, but it is the most educated assessment possible. By Medicare guidelines, hospice patients must meet the six month life expectancy estimate and also be ready to no longer continue in the treatment phase of disease management. In other words, no more chemo, radiation or interventional testing. "Yes, but I have heard of patients in hospice who continue to get blood transfusions or other care." So true. On a case by case basis, hospice does, at times, administer transfusions -for comfort. Or schedule a paracentesis, or do some palliative radiation for pain management. But in a general sense, when a patient enters hospice, they are weary of the treatment phase and mostly want to be at home to receive care from the team that includes a nurse, nurses' aides, spiritual care and social workers. Some hospices have a Hospice House and all have agreements with long term care facilities where their patients can go for more complicated symptom management or for respite care when family members becomes exhausted. Roughly 75% of hospice patients receive their care exclusively at home-whatever that "home" definition is-but from time to time it is important that they be transported to a more specialized facility when home-based care can no longer meet their symptom management needs related to pain, dyspnea, agitation, restlessness, etc. As we finished our conversation, I could see the patient and his wife relax a bit. While hospice is never a welcomed development in the course of treatment, it can bring some peace and resolution to the turmoil of months of difficult decisions. I shook hands with the patient and his wife, and we made an appointment to meet the next day to do the hospice admission at their home. With a smile and a wave, I pulled the door closed behind me.
  16. TheCommuter

    The Ultimate Bravery Of Dying Patients

    Funny how you'll plan every aspect of every trip except the most important one you'll ever take (NHPCO, n.d.). The process of dying is a deeply personal, inevitable, and unique journey that every individual will make at some point in the circle of life. I have always held the deepest admiration for patients who are approaching the end of their lives in an accepting manner, for they are facing their vulnerabilities, fears, and questions about their own mortality with great courage and dignity. These dying patients can bestow profound lessons and teachable moments upon those who are willing to listen. And all of us should take the time to listen. Material possessions and careers have mostly lost their importance when one is dying. Think about it. Patients who are resting on their deathbeds do not obsess over the custom granite counter tops in the kitchen. They do not worry about the fate of the big screen television. They do not seek comfort in the luxury car that might be parked in the driveway. They do not want to embrace the expensive artwork that is affixed to the walls of the mini-mansion. They do not wish to surround themselves with shiny jewelry. They do not beg to return to the workplace for another shift. Money is transient; it comes and goes. Material things eventually lose their luster. Jobs and careers come and go. The things that were so significant during one's youth suddenly become so insignificant when one is dying. On the other hand, the accumulation of experiences, relationships, bonds, and memories will be what truly holds meaning to the patient who has reached the end of life. The most basic of all human needs is the need to love and be loved (Schuler, 2010). In summary, here are some lessons I have learned from these astoundingly brave patients who are confronting their own mortality. The consumerist lifestyle will leave a person with an emotional void without any deeper human connections. The person who works many hours or multiple jobs to accumulate nice possessions is really depriving himself of the time and opportunity to pursue the things that truly count, such as relationships with family and friends. Living comfortably means placing less emphasis on money, career, and material things and assigning more importance to the joy of human contact, memories, and pursuits. People should amass more experiences and less things. Alas, the best things in life really are free. work-cited.txt
  17. jeastridge

    The Unpredictable Work of Dying

    "How long will it be?" my patient asked at the end of the admission process to hospice. She whispered the question as I leaned over to say good-bye. Hoarse because of recent radiation to her throat cancer, she struggled to gasp out the question. I squeezed her hand and told her the honest truth, "I don't know, but I do know this: we will be honest with you and let you know when we see changes that could indicate that the time is closer." Emma seemed satisfied with the words I offered and by the honesty they conveyed. After all, being straightforward with compassion is a gift that hospice can offer their patients, a gift that is muffled in layers of treatment and uncertainty through much of the diagnosis and illness stage of terminal disease. I came back to see Emma about 10 days later for a prn visit. I found her much changed and only semi-conscious. Unable to speak, she looked pleadingly at me and her eyes voiced the anguish that we could only dimly perceive. Answering her unspoken question, I whispered into her ear, "It won't be very long now. We are with you. Your family is here. How can I help you now?" She almost imperceptibly shook her head and looked toward the wall, closing her eyes. But things did not proceed smoothly for Emma. Her primary nurse shared with me that she lingered on much longer than expected, barely breathing, not eating or drinking for 10 more days. The family, exhausted, kept asking us why it was taking so long? "What can we do to help her?" We continued to medicate her on a regular basis and we walked down that road with her, so we felt fairly confident that she wasn't suffering a lot of pain, but there is no denying, however much we wish it weren't so, that lingering for a long time at the point of death involves suffering for everyone involved-the patient, the family and yes, even the nurses. If you take a poll of the people around you and ask them about their "ideal" way to die, you will likely get a variety of answers but probably one main theme: almost everyone wants to "die in their sleep" or "just not wake up one morning." While these visions are understandable and probably consistent with the normal human desire to evade suffering and pain, they do not often mesh with the reality that we find as nurses. Dying can be hard. It can take time and work. The process can be painful for everyone involved, leaving the survivors with at least extreme fatigue and often with burdens of guilt, sometimes akin to PTSD. How can we help people the dying and their families survive an unpredictable process with a certain outcome? Honesty As nurses dealing with the dying, compassionate honesty is key. Notice that "the blunt truth" is not the same thing as "compassionate honesty." Telling someone the potentially difficult details of what lies ahead is more akin to punishment than help. But telling someone what we do know, as it becomes evident, can be helpful. Some patients don't want to talk about any of the process and we must respect and honor that. Some want more certainty than we can honestly offer and we have to tell them that, too. But hospice does have the great benefit of helping all involved to be on the same page with what is happening, especially as the patient transitions into active dying. Offer hope As long as there is life, there is hope. Talking about hope is not the same thing as proposing "false hope" which can be defined at "pie in the sky" mentality. Hope can mean a lot of different things: hope that today will be a good day; hope that a loved one will call; hope that the pain will be less on the new schedule. There is always something to look at with a hopeful attitude. Educate (as desired by patient and family) As hospice nurses, provide general info about the dying process. Some hospice agencies have booklets that they give patients, to be read as desired, if desired. The booklets talk about specifics related to the dying process and also about potentially helpful interventions to promote comfort. Education involves planning ahead as much a possible. Asking the patient and family about their goals at the end of life is essential in helping everyone involved face the impending change. Having the POST forms signed, the designated medical power of attorney-all of this can add peace and a more settled atmosphere. Monitor word choice carefully Author K. Ann Smith writes in her blog post, "Didn't they understand that I was tortured by the word "fighting"? They said "your mom is fighting" and I heard "Your mom is fighting to live while you've agreed to withhold food and water so she'll die." They said "fighting" and I translated that one word into, "Your mom is fighting, but you're furious because she isn't dying fast enough." They said "fighting" and I felt they were asking me "why aren't you helping your mother?" [KevinMD.com 8/8/16] As we accompany the dying and their families, we have a sacred responsibility to be empathetic and compassionate, especially in our word choices. When death does not come on our pre-determined personal schedule or as expected by the law of averages, we have to hold our feelings very carefully in check, not allowing any sense of failure to leak out onto the situation. Part of that is not being too specific about what to expect, as patients and families may put more stock in our specific words than we recognize. Instead we err on the side of pulling back the long train of words that threaten to erupt from our mouths, words born of long hours of experience. Yes, we do know a lot, but we don't know everything. Only God knows how long it will be for sure. Acknowledge that dying can be hard work The image of our loved one saying their final words and gently closing their eyes to pass on is appealing but rarely matches reality. While premature death can be much too sudden-here one breath and gone the next-the more common transition to death involves days and sometimes even months of gradual decline. Death can be hard work.The final accomplishment of our lives-the process of dying-is rarely effortless and seems to have times when the mystery of the beyond speaks loudly into a space that we wish we could control. In the end, mystery prevails and we submit to it and do our best to work with what we know, in the here and now, helping our patients ease on in their time and in their way.
  18. Care for terminal patients is becoming a booming business as the Boomers come of age. Being one myself, I can tell you that Nursing care for these patients will only become more critical as shortages continue in the nursing field, even as new nursing schools ramp forward for the next big boom in our industry! I have a Pet Peeve though which really irks me. It's nurses who do not truly care for their patients. It's Nurses who perform their jobs with reckless abandonment. It is nurses who entered the field for the money and not for providing true Nursing care to patients. When we look back at Florence Nightingale and the inspiration which sprang forth from her and the drive to help others the Modern nursing method began to take hold and develop as she created and started the first school of Nursing. What is it hospice Nurses do? A Primary function is support! Familial support, patient support, physician support, facility support, logistics and planning, record keeping and followup and follow through with orders and basic nursing functions as we go about our Jobs taking care of patients. If there is one revolving theme among hospice organizations it is turnover! Not only patient turn over which is expected, but care giver turnover. There are of course many reasons for such turnover. Burnout is a key factor in this specific and very frustrating segment of the health care field. Lets face it our patients are going to die and there is nothing we can do to stop it! That is a hard thing to get use to for a Nurse I think. We spend a few years to a number of years in school to learn to care for people and to help facilitate the healing process and the real blunt truth is Non of our Patience will heal or get better save a miracle from God and they likely will die. I think some nurses enter this field because it is one of the fastest growing fields in health care along with the Money which is often the best in the industry for such a specific field as far as nurses go. One should be a well rounded nurse. Having cut their teeth in Med surge to gain basic skills and often many other specific fields within Nursing. Experience is a key factor in ones ability. I see such dynamic changes nowadays. I see nurses coming straight out of school with basic skill set entering this field because of the money and not because of the ability to effect change for the patience. Call me old fashion but patient care is an all encompassing field and requires a skill set with many different areas and is a dynamic field. Dealing with Terminal patience takes a certain type of person, male or female it takes what I like to call a caring soul. One who with empathy for the patient and with a self propelling drive to make their situation as comfortable and as easy as possible. Dying is not an easy process and some deal with it very differently. I believe in my heart the Nurse has to be an Jack of all trades. An advocate for the patient, the ability to stand up to the physician when they wish to do things which the patient does not want to have done. The ability to hold a hand, share a hug, hand out a kiss or two and to be a support to the patient, family and friends and also help them to gain knowledge of their rights and to help them do the things they can do and to be at ease as one can be with their impending death. In reality everyone wants to be cared for and to feel that they are in control of their situation as much as possible and our job is to facilitate that in every way possible. To make sure that they are as informed as they wish to be about their condition and to help them navigate the health care system and to receive the best possible care and to provide the best options possible giving their conditions and situations which may dictate. Nurses need to be careful that they do not simply walk and perform basic skills with out including their patients into the mix which a number do not. I have seen nurses walk in a room never say hello, never acknowledge the patient, simply sit read the chart begin to do things to the patient and never tell them what they are doing and forget that they are dealing with a Live person and not some Log. Nurses need to stop take a deep breath and to bring the patient into the conversation where possible and include them in everything they do. They need to seek the patients assistance and to help the patient to navigate the dying process if possible and to help them in every way possible. nursing is a well respected field going through many changes and growing so dramatically and as nurses, health care professionals we have got to get back to the basics of Florence Nightingale and to help our New nurses to gain critical knowledge of patient dynamics and teach them skills in communication which seem to be seriously lacking. To be fair there are a great Many nurses who care deeply about their patients and do everything in their power to help their patients in every way possible and are very deliberate in their actions on the patients behalf and to those nurses I give them a pat on the back. Hospice is a difficult field as are many such specific nitch nursing fields and require a well rounded and capable nurse able to navigate the entire process for their patients. I intend to create a course for Hospice nurses and to get it approved for CEU's on dealing with Hospice patients and I pray that the next wave of nurses out of school before they jump straight into hospice go and gain some well needed knowledge and practicle work experience in a hospital so that their skills are well rounded it is so critical to have some basic knowledge and Nursing school only gives us a very small snap shot of skills. Lets face it if you get to do more than one procedure twice while in nursing school it is a Minor miricle given the time constraints in the hospital settings in which we train while doing clinical settings. I love this field so much and worry that without the kinds of skills and basic understandings and knowledge its the patients who ultimately suffer...
  19. VickyRN

    Palliative Wound Care Approaches

    Sarah Jones, age 76, is a widow who lives alone. Due to a terminal condition, she is now on hospice. She has advanced breast cancer with a fungating malignant tumor. The tumor has broken through her skin and manifests as a malodorous, exuding, necrotic skin ulcer, about 3.5 cm. In diameter, on her medial left breast. These types of wounds rarely heal and often need palliative management. The pungent odor fills her small house. Sarah is embarrassed, depressed, and socially isolated. Her family is distressed and no one wants to visit her. The constant odor makes her nauseous and anorexic. She also has large volumes of uncontrolled serous exudate which stain her clothes and furniture. What can be done to help Sarah? Palliation is a broad term that focuses on the relief and prevention of suffering in patients whose diseases or conditions are no longer responsive to curative treatment, due to advanced, life-limiting illness. The goal of palliative care is to prevent, manage, and relieve unpleasant symptoms and to promote the best possible quality of life for patients as they near life's end. As the dying process progresses and the patient becomes increasingly weak, wounds can complicate care and threaten the patient's quality of life. The skin is the largest body organ. Wounds at or near end of life are often challenging to treat and may resist healing, despite meticulous skin care and frequent repositioning. Some palliative wounds are unavoidable due to an underlying disease process. Palliative skin care strategies include stabilizing the wounds that already exist, preventing new wounds, managing unpleasant symptoms, and promoting a dignified and comfortable high-quality end-of-life. Though palliative care is not curative in focus, patients nearing the end of their lives may benefit from the curative aspects of wound care. With severe illness, however, comfort may be more important than preventive or curative measures. Some wounds in dying individuals, despite the best efforts of clinicians and caregivers, defy healing. Nonhealing wounds at end-of-life are most often directly related to debilitation from advanced chronic conditions and life-threatening illness. The skin is vulnerable to breakdown, with limited ability to heal and regenerate. Factors that contribute to the skin becoming vulnerable, impaired, and dysfunctional at life's end include immobility, decreased intake of food and fluid, diminished perfusion of tissues, impaired synthesis of protein, and overall poor general physical condition. These factors can preclude complete wound healing. Nonhealing wounds cause tremendous suffering and debilitation to the patient at end-of-life. In cases where complete wound healing is not feasible, treatment involves attacking the symptoms and underlying causes, where possible. The goals should include managing wound exudate, controlling malodor, optimizing function and mobility, preventing infections, and adequately controlling pain and other distressing symptoms. Wound exudate is often associated with leakage and malodor. It can be controlled by various types of dressings, depending on its volume and viscosity. The surrounding skin also needs to be protected from maceration and excoriation. Chronic wound exudate is corrosive and can readily cause skin irritation. The ideal dressing absorbs excess exudate from the wound and surrounding skin, while keeping the natural wound bed environment adequately moist. For light to moderate exudate, moist wound dressings such as hydrogel, hydrocolloid, or transparent films are warranted. On the other hand, moderate to heavy exudate calls for more absorbent measures: alginate, hydrofiber, or foam dressings or vacuum-assisted wound therapy. Malodor can be one of the most distressing symptoms of palliative wounds. Wound odor can be ameliorated (though often not entirely eliminated) by timely dressing changes, charcoal-activated dressings, treatment for underlying infections, debridement of nonviable tissue, metronidazole, room deodorizers, and placement of a pan with kitty litter under the patient's bed. The hospice nurse, in collaboration with the entire interdisciplinary hospice team, is developing a plan of care to address the exudate and malodor problem that has caused Sarah such distress. Hopefully, in implementing some of the strategies detailed above, Sarah will find adequate relief from these horrific symptoms.
  20. VivaLasViejas

    When Hospice Goes Wrong

    "Do not go gently into that good night...Rage, rage against the dying of the light." That was my husband's philosophy after being diagnosed with pancreatic cancer in the summer of 2013. He'd fought bravely for two and a half years, and most of that time had been good. But the drugs his oncologist gave him had failed, and there were no other options than to go on strong chemotherapy, which the doctor admitted would only prolong his life for a few months and make him miserable in the meantime. Faced with these horrible circumstances, Will and I broached the subject of hospice. Having worked closely with the various agencies in our area, I was quite impressed with their services and had learned a lot about end-of-life care. It was awful to think of Will as needing hospice, but his prognosis was so grim that it seemed entirely appropriate. He agreed readily, and so began his final odyssey. It wasn't long before we discovered how wonderful our chosen hospice agency was. Will had a nurse and massage therapist, both of whom came once a week to check up on him and make sure we had adequate supplies. He also was given a comfort pack filled with drugs he might need for nausea, vomiting, pain and agitation. They didn't bring any morphine or Dilaudid because he wasn't close to dying at the time and was relatively comfortable, but promised they would when he needed it. So I never gave it a second thought. Months passed, and although it was obvious that he was failing, Will remained pain-free...until that night. It came on all of a sudden. He'd been having one of his bad days, but this was unlike anything he'd ever experienced before---a tearing, stabbing pain in his abdomen along with severe nausea and vomiting. My son, an LPN, grabbed the pain meds and antiemetics, and we gave him everything we had, to no avail. We called hospice so they could bring him the heavy-duty pain meds; unfortunately Will's nurse wasn't on call, so we ended up with another nurse who was clearly uninterested in driving the 25 miles to our home to deliver them. She warned us against calling 911 because he would be "kicked off hospice", but offered nothing of substance. Meanwhile, my husband was crying in pain. This was a man who once broke an ankle as we were moving house and continued without stopping, never complaining, so we knew he was in desperate straits. By this time he was vomiting blood in large amounts and going into shock. We called hospice again, and this time the nurse advised us to admit him to the hospice house. It would be another two hours before he was transported, all without relief from the pain. "Why do I have to suffer like this?" he cried out repeatedly, breaking my heart and making me feel helpless. I didn't have an answer. At long last, the transport van arrived and we went to the hospice facility where nurses quickly prepared Versed and Dilaudid injections. It was still another hour or so until he got adequate relief, but the compassionate care he was given there stood in stark contrast with that of the on-call nurse. He passed away in the early morning hours, and thank God he was comfortable. But what he went through because of the unnecessary delay in pain relief is something that will haunt me the rest of my days. After all was said and done, I reported these events to the grief counselor, who is still seeing me every few weeks to help me process what happened. Of course I will never know if or how that nurse was dealt with, but I felt better knowing that someone knew about it and had brought it to the attention of people who could actually do something to make sure it never happens again. I don't blame the hospice agency; I blame the individual nurse. His own nurse would never have let Will suffer like that, and when his massage therapist heard about it she was appalled. They both came to his funeral and sent sympathy cards, and they are the ones I'll remember with love forever. Yes, hospice is a wonderful thing, and I'm grateful for all the help my husband received prior to that last night of his life. But when hospice goes wrong, it goes terribly wrong, leaving survivors to deal not only with their loved one's death, but the awful feeling that they didn't do everything that could be done.
  21. There is huge support for the recent case in the news about Brittany Maynard who recently took her own life rather than letting cancer take it from her in its own time. While many people believe that what Brittany did was a good and decent thing, a question remains: If the only way to die with dignity is to take your own life, what does it mean if you don't? As a hospice nurse, I believe all of my patients die with dignity. They die with dignity because they are human persons, with the dignity and worth all human persons deserve. I certainly can speak for the fact that they suffer, that they decline, that they need help and support of others, but that does not exclude the fact that they have dignity. Nor does it diminish their honor that they choose to let nature take its course rather than letting a pharmaceutical cocktail end it for them. It is my hope that no one believes that there is nothing to live for if you have a terminal disease. I hope all my patients know that. Life isn't always about being a perfect person, without sickness or debility. Steven Hawkings is an excellent example of this, although severely debilitated, and having a terminal illness, he continues to contribute greatly to knowledge, to science, and to many people who care deeply for him as a person. Being sick or being terminal doesn't have to mean you have no quality of life. Not knowing what Brittany Maynard was told about her condition, I can only hope that she was given the choice to continue life with hospice or palliative care. Such care can give patients quality of life they did not know they could achieve with a terminal or severe illness. Further, although a person may feel they don't want to live with sickness or debility, what they really may be feeling is that there is no hope, which is never true for anyone. They also may not understand or be informed that the things they fear may not happen at all. Often, health professionals opt to be totally honest with patients and let them know "worst case scenario" and while honesty is generally the best policy, sometimes too much information does a disservice to a vulnerable person. All of us know what happens when we look up diseases or illness on the internet: we learn things we never wanted to know or we learn things that aren't even close to accurate. Someone who has just learned they are terminally ill is someone who needs information but they also need support and at the end of life, one of the best supports is knowing that there is help no matter how dismal things seem. With hospice or palliative care, many patients realize that their symptoms can be controlled and managed and they can go on living and enjoying each day. It is beyond doubt that most people given a terminal diagnosis fear not only death, but being a burden on others. With supportive care from hospice many of these concerns are ameliorated but a patient doesn't know that if no one tells them. So before we start to think that the only way to die with dignity is to end a life, let's make sure we offer our patients every option for end of life care we can. Hospice and palliative care can make so much difference and give hope to those who may feel that they have no choices left. Let's make sure that every patient dies with the dignity of end of life care, given by health workers who believe that no one death is less dignified than others.
  22. jenakjar

    I Owe It To My Dad

    I remember the day it all started. It was a simple index card with steps carefully written by my mother. Chronological ordered words instructed my 79-year old father on how to start his car and put it into drive. Those simple routine steps were fading away in his mind. For over 35 years, he had hopped in his car, 6 days a week, to drive to his small retail men's clothing store for business. Once known names were slowly disappearing. Newly acquired memories were gone almost as quickly as they were experienced. I questioned the safety of my father driving to work when he needed written instructions to turn over the engine and put it into gear, but he was not willing to relinquish his keys or his freedom just yet. However, soon thereafter, my dad became very ill with intractable diarrhea. He quickly became confused and unable to function in his weakened dehydrated state. His attempt to leave the house for work ended up with a trip to the emergency department. The following days were a chaotic blur of into the emergency department, back home, back to the emergency department, diagnosis of clostridium difficile, a cholecystectomy, saddle pulmonary embolism, and ulcerative colitis. Finally, he was admitted to the hospital with a team of physicians frantically attempting to balance his precarious state of bleeding and clotting. I spent my days communicating with the clinicians about his bleeding bowel and his dropping hematocrit. I was, at that time, a weekend quarterback of nursing of sorts. I had always loved medicine but I had never pursued it educationally. Now, I was the designated medical intermediary for my father. A colonoscopy would confirm an advanced state of ulcerative colitis with purulent and necrotic tissues in need of emergency excision. Post-operatively, an ileostomy saved my father's life. As he hovered in and out of consciousness on a ventilator, I hovered up and down the hospital halls praying for his life to be extended. In those dark, bleak hours and days and weeks that followed, I grappled with the meaning not only of my father's life but the purpose of my own. As a divorced mother of a small child, I lived with my parents and became the caregiver, along with my mother, to my father. Nursing him back to health drew me further into the path I would follow going forward. Several years later I graduated in nursing and became a registered nurse. My love for my dad certainly influenced my decision to change my course in life towards nursing. Nursing was an extension from my home into the workplace. The twelve years I was blessed to care for my dad and his many varied physiological challenges were the richest nursing experiences I ever had. Whether it was caring for his ileostomy, healing a wound, stabilizing him after an epileptic episode, or reminding him at 3:00 a.m. it was not time to go to Burger King, it formed my soul as a nurse. I would never see the world the same again. I served as a hospice nurse for several years but in the final months, days, and weaning hours of my father's life, any preconceived notions I had about nursing and life were radically transformed. All the studying, all the early morning clinical rotations, all the late nights, and all the migraines came together in that moment. I sat next to him those final 48 hours as his life, as he wavered between this world and the next. I held his hand, I washed his feet, and I wiped his brow. I administered palliative medications to soothe his breathing and his terminal agitation. I cared for him as a nurse; I spoke to him and I loved him as a daughter and as a best friend. His final breath forever altered who I was as a person and as a nurse. I would never see another patient simply as a patient, but as a friend, as a person loved by so many. Nursing has taught me so many life lessons, but the greatest lesson of all, compassion, I owe it to my Dad.
  23. jeastridge

    The Last Entry

    "Therefore, we do not lose heart. Though outwardly we are wasting away, yet inwardly we are being renewed day by day." II Corinthians 4:16 Reaching over to click my seat belt into place, I took a deep breath of the mild night air and let it out slowly, in a long sigh. Weary after a busy day, I wondered what else I could do for Mrs. C, a resident of a nearby nursing home, who was experiencing agitation in the process of dying. We had already given her the medications that were available to us, and as I drove along, I thought over the process of what to do next. My cell phone buzzed beside me, lighting up the interior of the car. I reached over and held the phone to my ear only to hear the nursing home night nurse say, "She just passed." A mixture of sadness and relief washed over me as I pulled into the brightly lit parking lot and headed for the main entrance. I thought to myself, "There is a gift in every visit, but I can't imagine what the gift will be here." I spoke with the charge nurse and went to the room to begin the process of postmortem care: pronouncing her, making the necessary calls to family, removing extraneous tubes, and making her presentable for her family. The two relatives stopped by for just a few minutes to say quick good-byes to their elderly loved one and longer thank-yous to me and the staff. After finishing the chores surrounding death, I sat down in the sturdy bedside chair to wait for the funeral home to come. I thought to myself how little I knew of this woman. What had her life been like? I knew from the chart that she was into her ninth decade and came to the nursing home after breaking her neck in a fall. The residual effects of the fall left her unable to sit up or even turn her head, and I remember during interdisciplinary team meetings (IDT) conversations discussing different ways to help Mrs. C. cope with the extreme boredom of being bed bound and limited to one view. While patients are in hospice, we hold weekly IDT meetings, times when the nurses, social workers, chaplains and occasionally families, gather together to exchange ideas and information that helps us take the best care possible of the patient; sometimes we find solutions, at other times we simply open the door for solutions to find us. As I scanned the room, my eyes lingered over the bulletin board, and I stood up to get a closer look at Mrs. C with her husband, first in a copy of an old wedding picture and then in a more recent color shot of the two of them beside a decorated Christmas tree, smiling through the years at loved ones. Instinctively, I reached over to straighten out the lotions and combs on the bedside table, and as I did I saw what looked like a journal. Opening it to the first page, I read an entry by her primary nurse relating the fact that Mrs. C. repeatedly asked her to "write down my story." The nurse brought the journal and at each visit recorded some of what Mrs. C told her about her long, eventful life. As the pages went on, there were entries from social workers, chaplains, even visitors. Each one recorded their own thoughts or memories of their relationship with Mrs. C. As I neared the end of the well worn pages, I felt my weariness fall away, replaced with a warm feeling of, "I think I know this lady now!" So I pulled a pen out from where it lodged next to my computer and began my own entry, "This is the final chapter," I wrote and suddenly felt unexpected tears well up in my eyes. In the night quiet of the nursing home hall, I heard the click of the metal funeral home gurney and hurried to finish my entry, adding a few more words of comfort to a family and respect to a woman who lived a good life. I tried to get out of the way while the burly men completed their task, then gathered up my things, ready to get on home and try to rest. As I stepped out into the hall, I heard a surprisingly loud greeting. "You are here!" a lady yelled excitedly as she began running toward me, arms outstretched. As she got closer, I realized that this was an elderly lady with mental handicaps and big, wide, toothless grin. I smiled back and when she got to me, she threw her arms around me and enveloped me in a big hug. Her body was soft, almost fluffy, and I allowed my chin to rest on her shoulder, feeling the friendship and absorbing the comfort that she transmitted as a gift for the end of my day. My pace quickened as I headed out into the night, spirits lifted by the two gifts I had received: first the gift of knowing another human being just a bit better and the other an unexpected gift of a comforting hug, given freely and unexpectedly but at such a welcome time. As told to me by Joyce Peak, RN, BSN, CHPN Joy Eastridge, RN, BSN, CHPN