a letter

Today a letter was delivered to the nurses' station. It was addressed to "the nurses and aides" on our floor. The letter was a thank you note for the care we provided to a patient at the end of his life who passed away in the early morning. He had been sick for a long time and chose to be with us for his death, which he knew was coming. 
It sounds like typical end of life fare, maybe. The kind of letter you might expect from a family member or close friend of the deceased after a long hospital or hospice stay. But it wasn't. It was from another patient.  What is even more amazing is that the two men were randomly assigned roommates. But the second man immediately took to assisting the sicker patient and then at the end, keeping silent vigil at his bedside.

A third, younger homeless man had also been taking care of the man before he passed. The third man had met the older man when they were both patients. Once the younger man was discharged, he continued to call and visit daily until the end.

"It's not friendly anymore," the younger homeless man had once said to me. "It's hard on the streets. Mean. But you see the oldtimers and they're all family. Our generation doesn't have that."

But it seems like at least some of them do. And maybe, just maybe it's never too late to make a family.

End of Life Care

I spent one day with a hospice nurse at a V.N.A (visiting nurse association) in Western Mass in the fall of 2006. During that day alone I first decided to become a hospice nurse; and then I decided to not become a hospice nurse.

I drove to the V.N.A office the morning of my hospice rotation with determination and an iron will. Having avoided assignments to many dying patients throughout the first few years of school, I was nervous. I was worried that being around dying people would dredge up some personal memories I was well aware of, but not ready to deal with.
Within two hours to my surprise, I thought I had found my calling.*

Each visit I spent with any of these men and women in their homes was an honor. I felt like talking to them, hearing their stories and bringing them comfort was a chance to touch something sacred.

Death is mysterious. Most people have never seen a dead body, unless they have been to a memorial service which involves a viewing of the corpse. By then it has been injected, stuffed and made up and is more of a prop than anything else. Many people have never seen someone die, and never will.

Being with these men and women, the mystery of death didn't scare me; it beckoned me. My own losses didn't haunt me; they fueled me. ** I wanted to understand how to serve people in their final moments. I felt a surge of passion for helping every person die with dignity, and in the way of their choosing. You want Elvis records playing? You want your plants near your bed? Ok. You want me to throw all the plants away? I will. You want a Rabbi? A priest? A Popsicle? I will bring it. You will be a human being until the end.

But you already know that I changed my mind by the end of that one day, because that's how I started this piece. By 2pm I became intimidated and afraid. And what ended up scaring me was one thing and one thing only:

As we were driving away from our last house my preceptor said to me, "In the end we use the morphine more and more frequently. It allows them to be completely comfortable. Sometimes it might be that last push of morphine that slows their respiration rate down completely. That's hard. But you do it anyway."

Essentially, a measure of comfort in the very end can be the thing that hurries death.

Now, obviously, the person is dying. There is a protocol to prevent life saving measures. It's called a DNR. The person is going to die now or in ten minutes and we're not going to prevent it. Furthermore, his quality of life is dependent on the comfort measures between now and then. So does it matter if the push you give pushes him over?
If you kill him to comfort him?

Logically, no. But the idea stopped me cold in all my young nursing student zeal. I tried not to think about it for the rest of school.

Now, more and more often it seems, end of life care is a part of my job. I didn't seek it out, but I also stopped running from it. And then I started to feel the same sense of purpose and honor I had before. And sometimes the choices that fall on health care providers are very, very hard. But someone has to make them; someone has to act in accordance with the patient's wishes when the patient can no longer wish out loud.

It's important to figure out your own feelings before you're on the other end of that morphine. Although sometimes we surprise ourselves in moments of extreme trials, going into them unarmed with knowledge of self is dangerous. It can cause loss of objectivity and emotional panic, which is no place to make life or death decisions from.

I'm curious to know what other folks, both medical and non medical, think since it's a topic that came up amongst my co workers last night.
Keep in mind, although this is sure to open up the topic of assisted suicide, that's not what I'm talking about here. The patient hasn't asked for medical assistance to terminate life. He has asked to be allowed to die, comfortably.

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* To be fair, I am kind of constantly thinking I've found my calling.
** Keep in mind, this was all in one shift. In one day.