Wine and Roses

A week lapse in blogging due to extenuating circumstances, caring for a dying parent. Stranded in suburban purgatory without internet connection or any of my usual anchors.

Death comes slowly and inexorably. We all die in increments. From the day we are born we are moment by moment closer to the time of our death.

And what does this proximity to death mean? What does it portend?

I feel that it portends our deeply held need to live even more fully and to forgive those who have trespassed against us, for those days of wine and roses are altogether too fleeting.

Death Circles the Wagons

When Death begins to circle its wagons
drawing ever tighter spaces
around our dying loved one
we circle our wagons as well
drawing on previously untapped emotional and physical reserves
in order to do what we felt was beyond our ken.

Never did we think
that we could do what we are now doing.
Never could we picture the compromises, the sacrifices,
the emotional stretching that we would need to endure.
Never did we consider how Death---so patient----
would slowly and inexorably remove our loved one
from our midst,
allowing us an intimate view
of how Death begins to take our loved one
even while he is still breathing before our very eyes.

Wait, watch
Listen and breathe.
Death may be cruel, Death may be kind
but Death is eventually our final friend in life;
removing our physical presence from this mortal coil
when our personal Sun has set.

Even as Death causes our loved one to wither
and unequivocally disappear
before our very eyes,
God(dess) is there,
holding the hands of all, the dying and the bereaved alike,
guiding us to a place
where Grace, Wisdom, and Beauty make their home.

We watch the wagons circle, helpless, yet
poised for the future,
but still clinging to a present
that must eventually give way
to a new world for our loved one,
a world to which they must travel alone.
Alone, yes, they must take their leave of us alone,
to release themselves from a body ready to return to Source.

We cannot accompany our loved one on that final road,
yet they are released by us with blessings
and hopes
for a sweet, sweet hereafter.

A Roundup at Change of Shift

The newest version of Change of Shift---that venerable carnival of nurse bloggers---is now up and running at Nurse Ratched's Place, with a Western theme. Yours truly is even included this time, relaxing in a crowded tavern. So grab your lasso and enjoy the roundup!

Try, Try Again

"So, how come you didn't come in for your blood test last week?" I punch at the computer keyboard, checking his lab results.

"Oh, I forgot. You see, there're these Mexicans I'm helping out---they're farmworkers, they needed a ride." His eyes dart around the room.

"Uh huh." I poke at the keyboard a little more. I let him squirm a little.

"So, when you're due for your narcotic prescription, I hear from you like clockwork." Our eyes meet.

"Well, if I don't have the oxycodone, I know I'll be in pain. But the blood test? It doesn't seem to matter that much." He smiles sheepishly.

"Yeah," I respond. "Then you end up in the hospital with a huge clot in your leg, and if we don't catch it in time you throw a clot to your heart and you die a sudden death. Not much of a consequence, huh?"

"I'll be better about it now, I promise. I know the blood test is important."

"Y'know, I've heard that from you before, but I always wanna believe you and give you another chance." We both smile and I put my hand on his shoulder as we walk up the hall towards the waiting room.

"Why do you keep giving me another chance if I keep fucking up?"

"Because I like you and I care about you. That's why."

"Oh."

"See you next week?"

"Sure. Next Wednesday at ten."

Will he come next week for his blood test? Probably not. But when that oxycodone prescription comes due, you know he'll be calling. Will he get another chance after that? Absolutely. And why not?

A Plethora of Patients' Excuses

"I forgot your phone number."

"My phone is disconnected."

"I didn't come to see the doctor because I didn't feel well."

"I stopped taking my diabetes medications because I was mad that my blood sugar was high."

"I didn't take my medication because I was mad at the doctor."

"I was in New York/Puerto Rico/Florida/New Jersey for two months."

"Someone stole my phone."

"Someone stole my car."

"My __________ died."

"I had to take ____________ to ______________."

"My daughter wanted to go shopping."

"My dog ate the mail."

"My son/daughter/father/husband/wife/mother was sick."

"I had to go to court."

"The doctor doesn't care, so why should I?"

"You didn't remind me."

"You never call."

"You don't care about me anymore."

"I hate myself."

Whirlwind Weekends and Weathering Storms

A string of whirlwind weekends---and the impending death of my step-father---have been generally impeding my ability to blog as consistently as I would like. Regular readers will also notice that death, dying and the grieving process have also made themselves quite visible in recent writings. When faced with the mortality of a loved one, one's own mortality also indeed comes to the fore.

Gyalse Rinpoche has said: "Planning for the future is like going fishing in a dry gulch; nothing ever works out as you wanted, so give up all your schemes and ambitions. If you have got to think about something—make it the uncertainty of the hour of your death."

The above is interesting advice at such a transitional time in life, when the stability, well-being and future of family structure is in question. How can one plan when the future is so uncertain? One can only ask for guidance and peace of mind to weather the storms of the unfolding days.

Birthday Ruminations: Life, Death and in Between

Today is my 43rd birthday, and I am working from home, spending some quiet time with Tina the Dog and a hammock. Calls and emails come in from time to time. Lawnmowers and other daytime neighborhood comings and goings fill the air.

Even as life continues on its usual trajectory, death lurks in the shadows. We really do spend a great deal of our time ignoring death, avoiding death, trying to beat Death at his own game. Movies portray death in many guises: as the demise of a self-destructive addict, the heroic death of a firefighter, the needless accidental death of a child, the tragic death of hundreds due to natural disasters, wars, famine, and genocide. The media bring us news of death daily as famous celebrities die, dozens of people are slaughtered by car bombs in Baghdad, or bridges and mines collapse in our cities and towns. Eventually, news of death becomes so routine, so ubiquitous, we are almost immune to its import, its very impact diminished through repetition, our eyes glazed over in disbelief.

As a medical provider, my desire, of course, is to assist my patients in postponing death, improving their health and quality of life, as well as trying to ensure that chronic diseases are treated, prevented, or stabilized. Colonoscopies, mammograms, testicular exams, blood tests---these are all means to the end of thwarting illness and death. But even these scientific machinations cannot save us all, and cancer grows in parts not scoped, or disease manifests when some aberrant gene decides to turn itself on. We are all works in progress, and as the saying goes, nothing is more certain in life than death and taxes.

When terminal illness strikes a family member, the other members of that family are forced into an intimate conversation with mortality. Through the processes of denial and ignorance, we can potentially shield ourselves from some aspect of this reality, but when push comes to shove, Death will force himself through the door one way or another.

In Ingmar Bergman's film The Seventh Seal, the protagonist---a knight journeying through a a Europe gripped by the Black Plague---challenges Death to a game of chess, buying time while still knowing what the eventual endgame will be. This is a lesson for us all---we can buy time, we can stall, we can challenge Death at every turn, but even on a day which celebrates our birth, death must also be a part of the inner conversation.

I often want to ask a dying person what it feels like to know that one's life is so very close to its end. Is there a breathless panic that not enough has been done? Are there regrets of relationships still unhealed? Is there a kind of relief that one feels? Is there lamenting of places not visited, photos not taken, pictures not painted, songs not written? And what of acceptance and peace? How does one face one's imminent death knowing full well that there was so much more to be done, so much more living to enjoy? How does one reconcile that in one's mind and heart?

Obviously to me, one of the most effective ways to beat Death at his own game is to embrace life in all of its challenges and curve-balls, throwing oneself into each day with abandon and determination. Unfortunately, we all occasionally lose sight of our mortality, putting off until tomorrow what we could do today, knowing full well somewhere in the back of our minds that tomorrow may never come. As for cleaning the bathroom or mowing the lawn, I see no problem with putting that off 'til the 'morrow. But telling someone how much you love them, looking into the eyes of a child, smelling a rose in full bloom, or writing that long-dreamed of novel---these are the things that simply cannot wait. A dirty bathroom is one thing. An unhealed relationship is quite another.

So, as a birthday present to myself, I take this moment to reflect on life and death, and make a pact to continue to remind myself of the importance of each day and my ability to embrace it for all it's worth. Doing any less is only inviting Death to eventually rob me of something I treasure through the mechanisms of regret and remorse. We should all strive to deny Death that opportunity, and allow Life its share of victory and everyday bliss.

My Other Blogs

This is just a brief note to remind new (and seasoned) readers that I have two other blogs which you are invited to peruse at your leisure.

The first is Latter Day Sparks, an homage to our dog Sparkey who died September 2nd, 2006 of kidney failure. I tend to post a memory or photo on the 2nd of each month, and Mary posts a missive intermittently.

Next is A Nurse and His Treo, wherein I post a daily photo taken with my trusty little smart-phone.

Thanks for visiting, and y'all come back now, y'hear?

Caring for the Dying and the Self

When a loved one is in the (relatively slow) process of dying from a terminal illness, we can often lose ourselves in the minutiae of care-giving, ignoring our own needs vis-a-vis the grieving process. When someone is living at home and facing death with family at their side, those family members providing emotional and physical support can be consumed by the needs of the dying person, consequently being potentially cut off from their own feelings and the need to grieve and mourn an imminent loss.

Finessing the end of a life is a subtle emotional process for all involved. Elizabeth Kubler-Ross had very specific ideas about the "stages" of grieving and loss which radically changed the global conversation about death and dying. Stephen and Ondrea Levine also offer a unique spiritual perspective of this most intimate and ubiquitous human experience. Sogyal Rinpoche, often quoted on this blog, shares his own views of death and dying through his own spiritual lens in his seminal book, The Tibetan Book of Living and Dying, one chapter being entitled Heart Advice on Helping the Dying.

I have found myself lost in the pragmatics of supporting my parents as my step-father faces death from metastatic pancreatic cancer. With no treatment options remaining, home hospice care is now the key to comfort, symptom management, and emotional and spiritual support for my parents. In this way, I hope to make room for my own grieving which has been sidelined by the need for practical problem-solving and advocacy. Those needs will not disappear, but when one enlists the assistance of professionals who are highly skilled in this delicate process, one can begin to let one's guard down and open to the winds of grief.

I now welcome those winds to blow through me, allowing myself to begin the process of letting go even as constant presence and compassion is needed. For if the caregiver goes uncared for, the caregiver's ability to serve will only suffer. To paraphrase an ancient physician whose name is unknown to me: "Unshed tears will make other organs weep".

Addiction: The Unending Struggle

This morning I watched HBO's 90-minute special documentary "Addiction" with my colleagues in lieu of our usual multidisciplinary team meeting. Frequent readers of Digital Doorway may remember that I was asked by HBO's public relations team last year to post a review of the film in advance of its original broadcast on the cable network. While I did point out some minor shortcomings in that review, I felt at the time that the film offered the general public and healthcare providers alike a succinct yet moving overview of the most current science vis-a-vis addiction and its treatment, illustrated with real-life stories which drive home the basic thesis of the entire HBO undertaking---that addiction, for all intents and purposes, is a disease of the brain which is chronic and treatable. However, the film never fails to also underscore the fact that addiction destroys relationships, wrecks families, often kills its sufferers, and costs the taxpayer millions of dollars per year in treatment, legal ramifications, lost productivity, and societal costs.

On my third viewing of the film, I was surprised that I still cried at the most touching moments, despite the fact that I have seen those segments a number of times and know exactly what's coming. Thinking that I might be slightly bored seeing the same film yet again, I brought along some paperwork to do in case the experience became tedious for me at any point. However, in that dimly lit room, shades drawn, my twenty-some-odd colleagues transfixed, watching the screen with rapt attention and nary a murmur of comment or side conversation, I was completely engrossed in the film, emotionally hooked into each story and finding my heart and mind opening yet again to the message with which I am by now very familiar.

I'm not sure how the HBO project has fared vis-a-vis its ultimate and overarching goal of energizing a national conversation about addiction, the need for adequate treatment, the stigma which labels it as a moral failing or character flaw, and the science that shows its physiological basis. Still, this film---a series of discrete vignettes which each stand on their own yet work as a comprehensive whole---has had an effect on me well beyond the initial viewing. The thirteen additional short films in the series can all be streamed on HBO.com for free or seen on HBO on- demand, along with the 90-minute documentary which is the subject of the preceding paragraphs.

Despite all of our training and understanding of the disease model of addiction, we healthcare providers are always at risk of feeling disappointment, anger, resentment, and despair when our patients relapse into drug or alcohol abuse. As much as we try our best to not see it as a moral failing or character flaw, there are still moments in our days when we put our heads in our hands and sincerely question how we can go on being objective when our souls cry out "NO!" when a client picks up again. Even when our brains say "it's a disease, they are powerless over their cravings", we must, deep down, still feel disappointment and anger from time to time, wishing that they could be stronger, more circumspect, more amenable to treatment.

Just as family members struggle between unsympathetic anger and loving compassion, we providers must also wrestle with our judgments and pin our own demons to the proverbial ground. The old adage, "there but for the grace of God(dess) go I" (which I admittedly and unapologetically use ad nauseum on this blog), still holds true. Any one of us is a potential addict, however some of us are more inclined than others, just as some are more inclined to diabetes or heart disease.

Addiction takes its toll on our society in myriad ways, and we all at some point must consider what it means to us, who in our lives may be affected, what we would like to do about it, and how we feel this society should manage such a monster in our midst. Addicts---whether homeless vets or white collar executives---all deserve the same chance at treatment and a life free of addiction and its potentially catastrophic consequences. But as long as a large segment of the population---as well as those in power---see addiction as a failure of will power and personal strength, we will still have a very long way to go.

Sensory Overload

The apartment must have been at least 90 degrees. Three large cages in the living room held eight squawking birds, one of which whistles an old Latino song incessantly. My patient breaks into song along with the bird several times during the visit. Between the heat and the singing, I felt like I might pass out.

As I attempted to check orthostatic blood pressures (vital signs taken supine, seated and standing in relatively quick succession) , one of my patient's friends burst into the apartment. Yelling almost at the top of her lungs, gesticulating wildly, the new arrival pushed a double stroller into the living room which contained two screaming young children. Amidst the tumult, a third child---perhaps eight or nine---sat down on the couch in utter silence, watching me take my patient's blood pressure and pulse.

The oppressive heat seemed multiplied by the extra bodies in the room. My patient's temperature was 99.7 and she looked faint. Her friend almost violently shoved a plate of food in my patient's lap and began spoon-feeding her as my patient tried to answer my questions. Each time I tried to ask a question again, the friend would interrupt, yelling "You're not taking care of yourself! You need to go to the hospital! Let's call an ambulance!"

Meanwhile, the two children---still strapped in the stroller---began to shriek louder as the parrot again began the incessant whistling, my patient again singing along.

I packed my bags and headed for the door, feeling quite faint myself. Muttering my goodbyes and advice, I escaped to the humid city air, cars streaming by, horns honking.

"I have to get home," I thought, looking at my watch. It was 2:35 pm---disappointingly early. No rest for the weary, and no escape for the overwrought.

Sensory overload? Just one more occupational hazard.

The End of Imagination

"The only dream worth having, I told her, is to dream that you will live while you're alive and die only when you're dead... To love. To be loved. To never forget your own insignificance. To never get used to the unspeakable violence and the vulgar disparity of life around you. To seek joy in the saddest places. To pursue beauty to its lair. To never simplify what is complicated or complicate what is simple. To respect strength, never power. Above all, to watch. To try and understand. To never look away. And never, never to forget."

--Arundhati Roy, "The End of Imagination"

Relapse

"I relapsed again," she told me. "I could barely bring myself to tell you."

"Unfortunately, it happens. But what's the plan now?" I try not to show any discernible emotion when hearing the news so that she doesn't feel judged.

"Well, I haven't used in two days. I feel like shit, though." She wrings her hands as they rest in her lap.

"Two days? That's great! every day is a new chance to make a new choice. What do you think?"

"Yeah, today's a new day, but that doesn't help me feel less like shit."

"I know, but you'll feel physically better sooner if you can just forgive yourself and let go of what happened. You can learn from your mistakes without beating yourself up about it."

"That's true. I just hope I can do it."

"You have choices every day. You made a good choice to come in today and talk to us. Let's plan on some good decisions tomorrow, too, OK?"

"OK. I'll be back next week. I think I'll get some exercise." We both stand up and shake hands.

As the door closes, I take a deep breath. Addiction must be such a weight to carry. I give thanks that it doesn't have a hold on me, and feel a swelling of compassion for those for whom it is a daily---or even an hourly---struggle.