Saturday, December 15, 2007

Death in the Afternoon

This afternoon, I worked my second orientation shift at a residential hospice where I have been hired as a per diem hospice nurse. Situated not far from where I live, working in such a small and homey environment with no more than six patients at a time is a far cry from my usual work as a Nurse Care Manager for the poorest of the poor in the inner city. (More on that upcoming career transition in subsequent posts.)

As a nursing student, hospice work was my stated career goal, and although I have not actually worked for a hospice organization per se, I have coordinated and taken part in hospice care for a number of my patients over the years. As a visiting nurse, terminal patients would often remain on our service, with family members or an automatic pump administering morphine around the clock. I was honored to pronounce a number of patients dead, signing provisional death certificates and facilitating post-mortem arrangements.

Now, with my new official position as a nurse in a free-standing hospice, the opportunity to provide focused and specialized care to the dying has become a reality, and I'm happy to assume this new role, at least on a per diem basis for the moment.

Over the course of the day, my preceptor (a 30-year practical nurse veteran) and I monitored and cared for five patients with the diligent assistance of an equally experienced home health aide and one volunteer. Two patients in particular received the lions' share of our attention based upon their deteriorating health, non-verbal and semi-comatose condition, and apparent closeness to death.

Around 2:30 we entered the room of the one patient who we deemed to be closest to his life's denouement, checking his pulses and respiratory status every few minutes. His peripheral pulses became weak and thready, eventually becoming undetectable altogether as his body shunted all available circulatory volume towards his brain and heart and lungs. It was at this time that we also became aware that his hands and feet---previously painfully contracted with neurologically-based deformities---were now relaxed, the skin mottled and gray. Feeling his weakening and slowing carotid pulses, we marked the slow decrease in the force of circulation to the brain as his respiratory rate decreased, with quick gasping breaths marked by long periods of apnea (cessation of breathing). By now his rapid decline was obvious.

At 2:58 pm, I placed my stethoscope on his chest, detected absolute lack of movement of air in the lungs and completely absent carotid pulse. It was then that we pronounced him dead, signed the death certificate, and began the long list of phone-calls and documentation which follows a death in a facility such as ours.

Orientation or not, this death appeared to welcome me with open arms into the fold of hospice care. My comfort level with the dying process and the many clinical and interpersonal processes involved, all confirmed for me that this is a place where I would like to be. Bringing all of my training, clinical skills, compassion, and desire to serve to bear, I can now see that hospice and the shepherding of the dying towards their ultimate goal---a noble and comfortable death---is truly a place which I would like to call home.

As this gentleman's soul enters what the Buddhists call the Bardo stage, I wish him well on his journey, and I thank him deeply for the honor of attending his death. May he be free of his suffering, may he be at peace, and may we all be so blessed to die with such grace and nobility.
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