A day of living and dying

If I live to be 100 years old, I will never forget the events of today. Never.

Perhaps it was because it was the first death I’ve witnessed during my just-starting nursing career. Perhaps it was because it was such a sad retelling of the darkest chapter of my own life thus far. Maybe it was the deep compassion and professionalism I saw demonstrated today. Or because it was the first time I had seen that it is possible to die in comfort free from all the tubes and machinery of acute care settings.

Although I’m not sure of all the reasons, I do know this: I left a hospice facility today a different person than when I arrived.

I’d been looking forward to this experience since I’d first learned that we’d each be spending a day in the hospice setting. A group of hospice workers who spoke to our class last semester had piqued my interest in care for the terminally ill, and they had spoken so highly of their facility that I was eager to see it for myself.

The hospice home proved to be everything they had described and more. Immediately upon entering, I sensed that this was indeed a home, not a hospital. The beautiful wood floors, elegant furnishings, and smoldering fireplaces welcomed me, and I noticed immediately that there were no hospital smells at all. Rather, the fragrance of bacon and eggs made me feel as if I were entering my grandmother’s kitchen, and I felt at home even before a single person spoke to me.

I was assigned to Susan, an RN who has worked at the hospice home for six years. She was just about to check in on Ms. P, a 78-year-old white female with lung cancer who was about to get her next dose of morphine. “She’s actively dying,” Susan mentioned as we prepared to enter the room. And, indeed, she was. At first glance, it appeared that the patient had stopped breathing, but after a long pause, her chest rose and fell ever so slightly. Her son sat in a chair beside the bed, expressionless, holding her hand and waiting.

Without warning, I was taken back to that night three years ago when my brother and I held an all-night vigil at our mother’s bedside, waiting … and hoping … for her to take another breath, yet at the same time waiting … and hoping … that the nightmare would end soon for us all.

Susan administered the morphine, instructed the son to let her know if he needed anything, and we quietly left the room.

Next door was a middle-aged Hispanic gentleman with continuous bladder irrigation whose pain was difficult to control that morning. Susan had already given him his regular dose of morphine, but judging by his facial expressions, the patient was still hurting.

We went back to the med room, and Susan explained that rules pertaining to narcotic administration are a little more relaxed in a hospice setting than in acute care. The patients’ comfort is paramount, so they are given whatever they need to control their pain. Mr. G was eventually given two more injections before his symptoms abated and he felt like eating breakfast.

From there, we saw Mr. K, a new admit who could not communicate except for grunts and head movements and Mrs. S., an elderly woman who was able to be moved to a chair and wanted to tell us about growing up in Iowa.

Back in the med room, Susan noted that it was time for Mrs. P. to get her eye drops. “I don’t know if her son will want her to have them or not, but I’ll take them anyway,” she said.

We went back to Ms. P's room, and the patient’s family members sensed by the look on Susan's face that the end was very near for their mother. All conversation ceased, and the adult daughters gathered around the bed, holding hands while Susan felt the patient’s pulse. After awhile, she put her stethoscope to the woman’s chest and listened for a full minute.

Finally, she uttered the words they had known were coming. “She’s gone.”

In those moments, I felt an awkwardness that is strange to even write about. Being present at the death of someone else’s beloved family member seemed intrusive and far too personal a moment to witness. Like butting in on someone else’s wedding night, it felt like an experience to which I should not be privy.

But I was. And no one there seemed to have a problem with my presence.

When we left the room after expressing our condolences to the family, Susan didn’t stop for a moment before entering Mr. G’s room to make sure his last dose of morphine had done the trick and that he was able to eat.

I was a little surprised at the “business as usual” attitude surrounding Ms. P’s passing. Susan made the necessary phone calls to the coroner and funeral home and arranged for the body to be picked up when the family was ready. But really, this is a place where people come to die, I had to remind myself. When you witness death on a recurring basis, it probably ceases at some point to lose the mystery it has for the rest of us. It’s just another part of the circle of life.

At some point in the morning, I was summoned to another part of the building where Becky, a field nurse, was preparing to visit a patient in an outlying community. I helped her gather an armful of supplies to take with us, and she told me a little bit about the patient along the way.

Mrs. R. was in her early 60s and was being cared for in the home of her daughter. Over the weekend, the daughter had noticed a decline in her mother and had requested a visit from the on-call nurse. When Becky and I arrived, the daughter seemed anxious and eager to discuss her mother’s condition. They spent nearly half an hour in the kitchen going over Mrs. R’s medications and discussing which ones could be withheld in light of the patient’s ongoing problems with nausea and vomiting and which ones the daughter should keep trying to get her mother to take. Becky had several suggestions for foods to try that the patient might tolerate.

When we went back to see Mrs. R, I was surprised that she looked so young. Seeing what COPD had done to this woman made me thank God all over again that I had never put a cigarette to my lips. Even on oxygen, her breathing was labored. The ominous rattle of fluid in her lungs was audible even without a stethoscope.

“She really needs a hospital bed,” Becky told the daughter back in the kitchen after we’d had to perform great feats of strength to pull the twin-sized bed away from the wall and reposition the patient on a mound of pillows. “Do you think I could bring it up to her again?” she asked.

The daughter agreed that a hospital bed would make caring for her mother easier, and within the next several minutes, Becky graciously broached the subject once again with Mrs. R, received permission from the lady once adamantly opposed to sleeping on a hospital bed, and arranged for delivery later that day.

A phone call was made to the hospice physician after Becky and I left. Based on Becky's findings, Dr. Miller determined that Mrs. R’s death was probably not too far away and ordered atropine drops to manage the patient’s respiratory secretions. He agreed to phone in the prescription to an area pharmacy, and we headed that way to pick it up.

Within a few minutes, we were back on our way to deliver the atropine and have a very difficult conversation with Mrs. R’s daughter.

“I talked to Dr. Miller,” Becky began. “He feels like your mother is nearing the end of her life.” She reached across the kitchen table to take the daughter’s hands in her own. Looking her squarely in the eye, Becky very carefully recounted the details of her conversation with the hospice physician, told the daughter what she could expect to see as her mother’s organ systems shut down, and answered her questions as thoroughly and as sensitively as she could.

Once again, I had the feeling that I was some place I shouldn’t be. A peeping Tom into a holy, painful moment of truth. Someone else’s moment of truth.

But in that moment, I also realized that hospice nursing could very well be my calling in life. Years ago, while struggling to “find myself”, I waffled between three very different career paths: health care, education, or family counseling. And here, right in front of me, was a nurse filling all three of those roles.

“You have the best job in the world,” I told Becky later as we left the little mobile home once again. “You know that, don’t you?”

She agreed without hesitation. “I feel like I make a difference,” she said. “I can’t make everything all right for my patients and their families, but I can walk alongside them through some of the most difficult days of their lives and help support them, help educate them, and help them make decisions that they can feel good about.”

That’s a difference I sincerely hope I can make someday.

All names have been changed in the above post.