On my way home from work today, I stopped by the home of a patient who has been slowly withering away from invasive and incurable cancer for many months now. With care by the local VNA/Hospice organization in place, he receives excellent care which allows him to stay at home rather than to die in a nursing home. As I have mentioned in previous posts, this gentleman's wife works six days per week, and her tenacity and courage in the face of her husband's slow death has been nothing less than heroic. Her friends and family have all pulled together, taking shifts at the bedside, learning to suction his tracheostomy, administer medications through a gastric tube, and do all of the things required for the home-based care of a dying human being.
Usually, when I make my unannounced visits, one of the wonderful personal care attendants who the family has hired with funds from our organization is at the home, tending to my patient, or quietly watching TV in the living room, always attentive for the slightest hint that there is a need for suctioning or other assistance in the bedroom down the hall. Long gone are the days when he would ring a bell for help and then mouth the words he wished to communicate, always refusing to write down his requests, relying instead on his caregivers to read his lips, or failing that, his mind.
Today, I was very surprised to find his wife at home at 4pm, and we had a heartfelt hug and a long tete-a-tete on the living room couch. We discussed the funeral arrangements, the wake, the obituary, the high cost of funerals, and her sense of peace that all of these details are arranged and ready to be put into action at a moment's notice. I praised her for her courage and strength, and reaffirmed for the umpteenth time that she has given her husband a priceless gift: the chance to die at home, surrounded by the sounds, smells, and feelings of a house where he feels comfortable, safe, and at peace. I encouraged her to talk to him up until the final moments, since hearing is said to be the last sense to fail, and that her encouraging words and expressions of love will do wonders for him as these final hours go by.
Moving into the room where her husband has lay for months, I followed this steady and surprisingly peaceful woman into the room. I've been visiting weekly for months, the hospice nurse doing all the work, my role being more to sit back and observe, getting involved in decisions that need my input, as well as keeping the primary doctor apprised of the situation. He lay there on his back, as always, the trach bubbling with secretions, his chest rattling, all of his accessory muscles of respiration working away. As his body tries harder to capture as much air as possible, it has recruited the shoulder, neck, and abdominal muscles to expand the lungs as far as they can go, and this type of breathing pattern is very common at this stage of the dying process. Eventually, long periods of breathlessness---apnea---will begin, marking yet another transition as he heads towards respiratory arrest. The morphine has been administered every three hours up until now, and I quickly call the hospice nurse to inquire if we can increase the frequency to every hour in order to lessen any discomfort and air hunger which our mutual patient might be experiencing. We all know that narcotic analgesics depress the respiratory center in the brain and can ostensibly hasten death, but when weighed against the potential for unnecessary suffering as the patient begins to possibly feel like he's drowning inside his own lungs, it's a worthwhile endeavor. Her affirmative answer gives us the green light and I instruct the attendant and wife to start giving morphine hourly.
With each of my visits over the last month or so, I've always spent a few minutes telling this lovely gentleman that his wife will be OK, that he is loved and safe, and that he is free to go at the time of his choosing. I have consistently given him a kiss on the forehead and told him I loved him before taking my leave, and I do not take that ritual lightly. My love for him is genuine, as is my admiration for him and his family, especially his wife and sister-in-law. They are truly special in my eyes.
Being a creature of habit, I again took time to talk with him while his wife looked on. I kissed him on the forehead, telling him with certainty that this would be the last time that I would see him in this body, this vehicle of learning and loving. I told his wife that I could not see him lasting through the weekend, and that I would hazard a guess that he'd be gone within twenty-four hours. As always, she promised to call me when he dies---no matter the hour of day or night---so that I can light a candle for his spirit as soon after his passing as possible.
Not being a hospice nurse or visiting nurse, I cannot currently have the honor of pronouncing a patient dead, something which I did a number of times as a visiting nurse. Doing a pronouncement is a solemn yet beautiful mission: one arrives at the home after that long anticipated telephone call and does what one must do. I remember receiving that call one evening about six years ago. I had requested that I be the nurse to pronounce my patient, and the call came on my cell-phone when I was at the creek nearby my house with my dogs, having a late afternoon swim. I told the daughter who placed the call to simply keep everyone calm, that there was no rush to call the funeral director, and that they could have several hours to simply be in the presence of their loved one before we did anything at all. I reiterated that the death was not an emergency, and that I would be there within the hour. I ran home with the dogs, showered, and drove the thirty minutes to their home, arriving as the driveway was filling with the cars of friends and relatives who had received similar calls with the news. This scene is, I think, quite typical:
The family and friends are gathered. The deceased person lays quietly in bed. There is often low lighting and candles, hushed voices in the home. Sometimes children are playing and laughing, life naturally continuing even in the presence of its denouement. A thoughtful family member or friend washes dishes or prepares food, people chat, cry, laugh, tell stories. It's an unoffical wake for those in the closest circle. The hospice nurse or visiting nurse arrives. People gather around, the nurse going into the room to see the patient, check for vitals, and determine official lifelessness. The nurse checks the time, fills out the death certificate (at least in my state, anyway) and decides with the family how long to wait to call the funeral home and allow the body to be taken. That last time I did a pronouncement which I remembered in the preceding paragraph, we had some food, sat at the table, chatted about the patient/loved one, and called the funeral home about an hour after I'd arrived. The funeral directors were quite nice and efficient, and when the body of my patient was safely stowed in the hearse, I took my leave and went home.
Back in the present, I will not have the opportunity to render that service this time. That's for someone else to do. My work for this family as of late has been one of background support, and I'm fine with that role. Knowing he's in good hands, well medicated, relatively comfortable and held in the hearts of his friends and family, my stewardship of this scenario is basically at a close. I release this soul, send him lovingly on his way, and bless his family as they begin the process of walking the earth without him physically at their side.
May all beings be free from suffering. May all beings find peace in life, and in death.