Rapport, Rock, Hard Place, and the NFL playoffs.

–noun

relation; connection, esp. harmonious or sympathetic relation: a teacher trying to establish close rapport with students.

from dictionary.reference.com.

i had a patient who was gonna die. in a sense, all of my patients are going to die, but with a terminal illness, sometimes you know someone is going to die sooner rather than later. the patient was in a bad way. young (40's) and terminal. they had a form of cancer that had spread throughout the body, and the only treatment was one that would be really, really bad for certain organs. said organs belonging to my patient were not working, and had not been working for some time.

i had an instructor in nursing skool tell me that all medicines were poison. i still think of them that way. i mean, look at all the commercials for meds on TV. the majority of the time, they have time to state the name of the drug, what it might help with, then the remainder of the time left, they pay those used car sales guys to go thru, like, 50 bazillion side effects.

'depressed? try abilify! side effects may include, increasedriskofsuicidedepressionanxietydecreasedlibidosexualfunctioningdeathorworse.

so my patient had this cancer, and these crappy organs, and had apparently been using home/herbal remedies to try and fix said organs. the ROCK; the patient had cancer. a treatable cancer, but the treatment wrecks havoc on certain organs which THE HARD PLACE were in failure, necessitating a transplant. the patient really needed an organ transplant, but with the cancer, there was no way.

you get the picture? terminal.

so, i'm work a buncha days in a row, then i have a buncha days off. so i had there patient for a long time at night, while during the days, there were different nurses that came and went. most of the day nurses would report to me that the patient was in a sooper funk, and either depressed or in denial or inappropriately processing, if at all, the fact that DEATH was in the room.

however, the patient was totally 'with it.' for me.

why?

well, for one thing, i didn't talk to the patient about dying. didn't mention it. instead, i talked about stuff like college and pro football, favorite books i read/was reading. i spoke about my family. i asked about my patient's family. and really got to know about my patient and the life that was BEFORE.

where dayshift got one-word answers or no answers at all, i got life stories. i didn't walk into the room with a sympathetic look on my face and encourage my patient to 'just let it all out,' or 'give a good cry.' i refused to look in the corner of the room where DEATH was sitting, reading his copy of People magazine.

lest you think i'm some sort of genius or something for my approach, let me tell you why i did what i did. i am not good with emotions. i'm not a fan of how my emotions make me feel. plus, the mechanism that enables most humans to cry broke on me a long time ago and i never took it back in to get it fixed. when i cry, it sounds like hell and looks worse. snot, redness, weird noises and the works. NOT. PRETTY.

so i do not allow my self to get emotional. not for my self or for my patients. i don't want to cry, and i don't want my patients to cry either. that is not to say that i don't feel for my patients, i feel very deeply for them, just not while i'm at work. i save that feeling crap for my days off the occasional bottle of Blue Moon.

so DEATH is in the room. sitting at the bedside, in his dark rotting robes, playing 'angry birds' on his ipad, like everybody else. he's probably pissed that i'm ignoring him, or maybe not. i figure he's seen everything at this point. point is, i ignore him. and for twelve hours that is my shift, my patient can ignore him too. because i am babbling about Malcolm Gladwell and Brett Fav-ruh, and the Miracle at Qwest field. and my wife'd boob-feeding and how max drives me crazy.

and it is just what my patient needed. (disclaimer; i do offer to hold my patients hands, if needed and appropriate. i do practice appropriate therapeutic touch. and i touch my patients without gloves. at least a couple times per shift.)

Fine Line, Three Things

how comfortable are you with . . . . . . being an agent of death? with being the one to push that last bit of morphine and ativan to send someone onwards from this life?

i'm still working on that issue.

one of the nurses i work with was telling me about a time that he, as we say, 'pushed' the death dose, and it has stuck with him ever since. even years later it hard for him to administer the big 'comfort care' doses that are usually prescribed for end-of-life situations.

there are three things that we do at the 'ospital.

thing one that we do; everything we can. if your heart starts to go, we can hit you with drugs, drips, and electricity. and cardiologists, cardiology hospitalists, or heart surgeons/thoracic surgeons. we can give you meds to keep your heart steady, increase its contractility, keep your blood pressure low or high. if your kidneys fail, we gots nephrologists, we can give you meds for high potassium, clean your blood with dialysis machines, and replace your electrolytes. we try to prevent clots. if your throw a clot anyways, we can pull it out or try to dissolve it with TPA. if you have infection we have some pretty big-time antibiotics. if you are bleeding we can stick tubes with video cameras and grabbers down your throat or up your pooper pipe. we can make you swallow a 'pill-camera' that will take pictures of your whole GI system, transmit it to a receptor on your belt. wow. there are LOTS of things that we can do to prevent death, turn back illness.

and unless you tell us otherwise, we do all this and more. to and for everybody. that's the baseline.

thing two that we do, is almost the same as the above, except for DNR/DNI. those letters stand for 'do not resuscitate,' and 'do not intubate.' which means, like i said, we do all of the things above (and more, by no means was that an exhaustive list of all the things we can do), EXCEPT FOR breathing for you (DNI) and doing chest compressions (DNR) on you, should your heart/lungs just up and quit.

the last thing that we do is comfort care. it's pretty simple-we just do stuff to make you comfortable. this is reserved for people who have reached the end of the medical rope, so to speak. people who have no chance of recovery, or who are too frail/weak/broken/old to survive whatever procedures we have left that might 'prolong life.' for some people, that means withdrawing support. if you are already on a ventilator and can no longer breathe on your own, removing ventilator support will send you on your merry way very quickly. those decisions are not mine to make or to carry out. first of all, i work nights. decisions like that are for day-time awake doctors and social workers and family members. occasionally, support will be withdrawn and the patient will last a little while, like into night shift. my turf.

it happened to me one night. the room was full of family, and the patient had no chance for a recovery. the patient had ackshully been undergoing some kind of treatment and not tolerated it well. it was then discovered that instead of being checked, the disease process had advanced considerably past the point of expectation for a reasonable recovery. by the time the patient got to us, he was in pretty bad shape. losing pressures, heart arrythmias, things we recognized as Circling the Drain. the family recognized this and, in accordance with the patients' previously expressed wishes, it was decided to withdraw the care we were ready to provide.

one family member did have a special request. he sat at the patients bedside, held his hand and told him that he just had to hang on for a little bit longer, because the family needed to gather to say a proper good-bye. now, this was a patient that was so far gone, he had not responded to painful stimuli of any kind for a while. we weren't sure he was even still 'in there,' if you know what i mean. however, when his nephew made his request, a funny thing happened......

the patient's blood pressures stabilized. his heart quit doin' funny things. and his breathing settled down.

it was amazing.

he stayed that way, too, until the next night shift. when he did die, he was in the room surrounded by tons of loving, grieving family members.

here's where it gets tricky. before he died he started to breathe funny. not unexpected, but disturbing for sure to the family in the room. and struggling for air. and rattling in his throat.

comfort care means making the patient comfortable. in this case, we had large doses of morphine and ativan ordered. morphine is a narcotic, and ativan is a benzo. together, they have a synergistic effect, increasing the others power. morphine, by itself, depresses your drive to breath. combined with ativan........it is very effective. basically it stops you from breathing. you s-l-o-w-l-y breathe slower, and then, you don't breathe at all.

the patient had some family members in the room that were in the medical profession, and i felt doubly awkward walking in to the room with enough morphine and ativan to, essentially, stop this man's breathing. worse, the patients spouse asked me what i was giving the patient as i was giving it.

well, this is to make the patient more comfortable.........

sure enough, the patient slowly, quietly died a few minutes later. stopped breathing funny first, though.

now, cause of death was not listed as 'Nurse J.'

i didn't kill him, the cancer did.

at least that's what i keep telling myself.................

*************************************************************************************

our hospital has tons of crap on the walls about 'mission statements' and catchphrases to remind us to be better nurses.

it is all a bunch of crap.

i don't have any of the cute sayings mesmerized, nor could i repeat any of them to you. i'm a good nurse (or trying to be) because i want to be. i come to work everyday with the expectation that my patients deserve the best care possible, as if they were my family. if that was my uncle/brother/sister/wife/aunt what have you, how would i want them treated? keeps it real simple for me. it works too, because everybody has difficult family members. have a patient that's a lying sneaking thieving drug addict? hey, so's my dear old Uncle Bobby, i'll just pretend that's my patient and care for him like family. have a fat, outta shape patient that poorly manages their diabetes and is in the hospital every other month in DKA? hello Cousin Jodi! and so on and so forth.

plus, i am invested. this is a career, not merely a job. i care about my success, and the success and well being of my co-workers and my hospital in general. that is how i operate. i smile because i'm a smiley happy guy dammit, and if smiling is appropriate, i'll smile because i want to, not because i saw it on some silly poster of five things to do every shift in all my 'patient interactions.'

which brings me back to my original question. how do i feel about being the one to push those last deadly doses? if that really was my mother/brother/aunt, would i want this same care?

now, cause of death was not listed as 'Nurse J.

i didn't kill him, the cancer did.

at least that's what i keep telling myself.................................

Death with Dignity

there are worse things than death. like living after a stroke that takes away the complete function of one side of your body. seriously, what would that be like, to go from being active, healthy, going on cruises, going to football games, teaching piano lessons then-boom, next day. half of your body is gone. GONE. HALF.

wouldn't you want to stop breathing, too?

the next hardest thing would be being the spouse. i know that i married my best friend, how do you go from full speed to full stop on that progression? i hate seeing the spouses suffer, and can't imagine what it is that they go through. part of the reason that i started this web log, besides to hone my writing (not that it's really great or anything), is to give me a chance to reflect on what it is that i see on a daily basis in my work and give myself a chance to see things from the patient's side of the rabbit hole.

my shifts are so busy that i can't always stop and think about less emergent issues like loss of self or loss of partner when i'm (rightly) too concerned with loss of capture or shortness of breath. also, i'm a crier, and as much as crying with my patients might help them, it wouldn't help me. i hate it when my mascara runs.

okay, you're the spouse. your loved one went from fully functioning hooman being to not being able to track things to the left, not being able to feel when they had pooped, and being unable to breath on thier own. beloved also is in pain and discomfort, and obviously hating the breathing thingy. teaching kids doe-ray-me to having strangers clean you, poke you and prod you, shine lights in your eyes, ask you stoopid questions like, what's your name, sweetheart? when is your birthday? what is today? oh, close, yeah, it's january alright. great, oh you pooped again, great, let me get that for you.

how much time is enough time to wrap your head around this? how long before you can accept that when beloved says, 'i wanna die,' they mean it and in that moment, are ready to go?

1 day?

2 days?

never?

can you ever wrap your head around that? how do you prepare for that?

what can i, shiny new murse (male-nurse) do differently in my practice to be sensitive to the needs of my patients?

what do i do if the patient is telling me they want to die, but the husband or the kids keep asking me how long before beloved pulls through?

honey child, there's no pulling through this one.