In the home they have owned for more than 40 years, they live their lives as they always have. The same trees are visible through the kitchen window. The grass is still green. The grandfather clock given to them by her parents for their tenth wedding anniversary still chimes in the foyer. The curtains and the sofas haven't changed in years, and the silver flatware in the breakfront drawer still evokes memories of Thanksgiving dinners, birthdays, and family gatherings galore. From the kitchen linoleum to the wood paneling in the family room, little has changed in this cozy suburban home.
While the outward appearances are relatively static, it is her dementia that has permanently changed the calculus of their relationship. It began with mild, transitory forgetfulness, only to slowly escalate into full-blown dementia as the months went by without a formal diagnosis. She would walk into a room and stand there, utterly stumped as to why she was there. He would leave her in the frozen food aisle to look for light bulbs in another part of the grocery store, and when he would return to find her, she would still be there, staring blankly at the ice cream display, apparently lost in thought but actually lost in the absence of cohesive thought.
At a certain point, it was apparent that she could not be alone. She could no longer bathe herself, toilet herself, dress herself, or make even the most rudimentary decisions. Luckily, if a plate of food is placed before her, she will still reflexively use her fork or spoon to scoop up food and bring it to her mouth. Sometimes, the fork spears nothing but air and she must be redirected to bring it down to the plate again. At other times, the food will fall back to the plate or into her lap, but she won't notice. She will bring an empty spoon to her mouth with the same motion and intention as a spoon laden with mashed potatoes. She doesn't recognize the difference, and he monitors her intake with the eyes of a loving, doting husband of 55 years.
He has refused all assistance other than skilled nursing and physical therapy. A home health aide? Never. Meals on wheels? Not a chance. Day care? Unthinkable. She is his project, his object of devotion, the love of his life and the mother of their children. His days revolve around her, and he revolves around her like a moon around a planet with a strong gravitational pull.
Her eyes seem aware, yet it is not clear what they register. She responds to some questions but not others, and it is uncertain how much of her response is reflexive rather than real. Her shuffling gait, her blank gaze, her apparent lack of interest in anything happening around her---these are hallmarks of her state of mind, and he must long for the days of lively conversation and verbal interplay. How lonely he must be, prematurely bereft of his friend, his lover, his bride.
"You see how her hair is set?" he asks. "Friday is Hair Day," he explains. "I wash it, set it, dry it, and then brush it out and spray it. Just like she used to do. We make her beautiful for the weekend when the kids and grandkids come to visit." He smiles proudly.
Sitting in the chair, her hands passively resting in her lap, she stares at me, smiles, and almost looks through me. I hold her hand, tell her I would like to take her blood pressure, and she raises her arm and places it on the table. I thank her for her assistance. She smiles again.
Placing the tools of my trade in my bag after making some final notes, I shake her hand and get up to leave. Her husband walks me to the door and we shake hands warmly.
"You're the model husband, and I can see that she's receiving the best possible care here at home," I say as we shake hands.
"Thank you," he replies. "I try my best. She's all I have, and I want her here with me."
"Let us know if you need more help," I say as I enter the breezeway between the kitchen and the garage. "You're doing a wonderful job and she looks so well-cared for. Take care, and her primary nurse will be back on Tuesday to check that elbow."
"Bye bye, and thanks for coming over." He waves and closes the door.
What other slow and silent human dramas are occurring in the other well-kept homes on this quiet street? How many other spouses are devoting their every minute to the care of a beloved who is no longer quite as healthy and vibrant as they used to be?
Devotion and love are the engines that drive relationships and lead us to selflessly focus our energies on the human objects of that love. Here was a stellar example of how that type of deep, lifelong connection manifests in real life. Despite the sadness and loss that underlie such a situation, the human manifestation of that devotion and love is truly an inspiring sight to behold and an honor to witness.
Showing posts with label visiting nursing. Show all posts
Showing posts with label visiting nursing. Show all posts
Saturday, October 18, 2008
Sunday, August 31, 2008
Cell-Phone Ring Tones: A Cautionary Tale
Just this past week I was doing some home visits for my local visiting nurse agency. Three out of four visits were for psychiatric patients who live on their own and need daily visits to monitor their medication compliance. I've been doing this sort of thing for years, so I always know what to expect, more or less.
While I was visiting my second patient, we sat at his kitchen table as I prefilled his medication box for the upcoming four days. We chatted about the weather, his apartment, his general health, and his family. It was a normal visit with a paranoid schizophrenic, and our rapport was comfortable despite the fact that we had never met before.
Halfway through filling his medication box, my cell phone rang. Unfortunately, I had not set my phone on silent and the sound of the phone's ringing filled the air. Now, I am not one to download a new ring tone from the Internet every week like some people seem to do. In fact, when I received this phone earlier this year, the pre-programmed ring tones were so annoying, I searched for something in earnest that I could embrace as my own. Eschewing all mechanical sounds, I opted at the time for the sound of a galloping horse (paying $1.99 for the privilege of its use) and have had that ring tone ever since.
Enter the psychiatric home visit. Perhaps you see what's coming.....
As my phone rang a third time, my patient----who suffers from paranoid schizophrenia with auditory and visual hallucinations---began looking around the room in order to identify the origin of the sounds of the galloping horse. Seeing that he was not answering my most recent question due to this new distraction, I realized that he was likely experiencing my phone ringing as a psychological phenomenon, his eyes darting around the room nervously as the ringing continued. Struggling to extract the phone from my pocket, I hurriedly opened it, turned it to silent, and apologized profusely for the rude interruption. He looked at me perplexed.
"That sound of the horses you just heard----I heard it too," I said. "It's actually my phone. I downloaded that ring-tone. I'm so sorry if it frightened or confused you."
He looked at me blankly for a moment and then a look of realization came across his face. "It was your phone? I was hearing your phone?"
"Yeah, it was just my phone. Sorry, again." I smiled weakly.
"OK, OK, no problem." He looked dazed.
"Well, let's finish this med box and I can get out of your hair this morning." I returned to the task at hand with a silent sigh of relief.
He seemed to come around back to his originally clear-eyed self after several minutes, and as I left, I apologized again and closed the door behind me, all the while chastising myself for my negligence in not silencing my phone when my home visits began an hour earlier.
So, nurses and other concerned citizens, movies and cafes are not the only places where the ubiquity of ringing cell phones can alter the trajectory of one's day (and annoy others in the process). I learned an interesting lesson that day, one that can potentially be translated to other professions and life situations. Cell phones may be useful for staying connected with one's friends and family, but they are often intrusive, ill-timed, and in this case, downright disturbing. A cautionary tale, indeed.
While I was visiting my second patient, we sat at his kitchen table as I prefilled his medication box for the upcoming four days. We chatted about the weather, his apartment, his general health, and his family. It was a normal visit with a paranoid schizophrenic, and our rapport was comfortable despite the fact that we had never met before.
Halfway through filling his medication box, my cell phone rang. Unfortunately, I had not set my phone on silent and the sound of the phone's ringing filled the air. Now, I am not one to download a new ring tone from the Internet every week like some people seem to do. In fact, when I received this phone earlier this year, the pre-programmed ring tones were so annoying, I searched for something in earnest that I could embrace as my own. Eschewing all mechanical sounds, I opted at the time for the sound of a galloping horse (paying $1.99 for the privilege of its use) and have had that ring tone ever since.
Enter the psychiatric home visit. Perhaps you see what's coming.....
As my phone rang a third time, my patient----who suffers from paranoid schizophrenia with auditory and visual hallucinations---began looking around the room in order to identify the origin of the sounds of the galloping horse. Seeing that he was not answering my most recent question due to this new distraction, I realized that he was likely experiencing my phone ringing as a psychological phenomenon, his eyes darting around the room nervously as the ringing continued. Struggling to extract the phone from my pocket, I hurriedly opened it, turned it to silent, and apologized profusely for the rude interruption. He looked at me perplexed.
"That sound of the horses you just heard----I heard it too," I said. "It's actually my phone. I downloaded that ring-tone. I'm so sorry if it frightened or confused you."
He looked at me blankly for a moment and then a look of realization came across his face. "It was your phone? I was hearing your phone?"
"Yeah, it was just my phone. Sorry, again." I smiled weakly.
"OK, OK, no problem." He looked dazed.
"Well, let's finish this med box and I can get out of your hair this morning." I returned to the task at hand with a silent sigh of relief.
He seemed to come around back to his originally clear-eyed self after several minutes, and as I left, I apologized again and closed the door behind me, all the while chastising myself for my negligence in not silencing my phone when my home visits began an hour earlier.
So, nurses and other concerned citizens, movies and cafes are not the only places where the ubiquity of ringing cell phones can alter the trajectory of one's day (and annoy others in the process). I learned an interesting lesson that day, one that can potentially be translated to other professions and life situations. Cell phones may be useful for staying connected with one's friends and family, but they are often intrusive, ill-timed, and in this case, downright disturbing. A cautionary tale, indeed.
Thursday, August 14, 2008
A Visiting Nurse and the Puzzle of Humanity
Last night, I was doing some visits for the visiting nurse agency who recently employed me. On my fourth and final visit, I had a revelation of sorts.
I drove about twenty minutes to reach this patient's home, winding through lovely country roads, past old farm houses and pastures. Reaching his neighborhood of middle- and upper middle-class homes, I was struck by how out of the ordinary this situation seemed to me. For the last eight years, almost all of my home visits have been to poor, inner-city neighborhoods, trailer parks, or lower income neighborhoods with modest single family homes. Not since I was a visiting nurse back in the late 90's had I actually visited a patient whose home reminded me, perhaps, of my own parents' home back in the day.
The home smelled of garlic, tomato sauce and stewing summer squash from a large garden in the back yard. An above-ground pool bubbled outside, and we sat on a relatively new overstuffed sofa, our feet on plush carpet, a rambunctious four-month-old yellow lab entering and exiting the room every few minutes. My patient's wife buzzed around the kitchen and dining room, setting the table and trying to usher the dog away from my bag of bandages and supplies.
My patient and I talked about his work with a medium-sized company, his recent surgery, and how his wound had been healing. Like sitting with a benign uncle in a comfortable living room (with the exception that I was actually dressing a surgical wound), we chatted about dogs, our adult children, and a few other random subjects.
At the end of the visit, I put away my supplies and washed my hands, readying to take my leave as dinner was reaching the well-laid table. It was such a familiar scene---familiar in a visceral way, but unfamiliar in terms of the home environments into which I've been accustomed to walking in the course of my nursing career.
I felt no judgment of my patient and his lifestyle. In some ways, it smacked of American middle-class privilege, but I had no idea of knowing from this brief encounter what this man and his family might think about the poor. Perhaps they give money regularly to progressive social causes and volunteer at the local food bank. Maybe one of his children works for a left-wing NGO or humanitarian organization. Maybe they support the Republican National Committee. Who knows?
Before, during and after this visit, the main focus of my awareness was on class, privilege, and the fact that I have so rarely had the opportunity to visit patients in such comfortable and middle-American surroundings.
I'm not sure how I feel about this demographic shift, although I still do visits to rooming houses and low-income buildings in our area. Having mostly eschewed my work in the nearby inner city, I am now evaluating this new manifestation in my professional life and how it effects me on an emotional, spiritual and psychological level.
Choosing currently to work as a visiting nurse in our much less ethnically diverse collegiate area (which in turn is surrounded by middle- and upper-middle class neighborhoods, small towns and semi-rural suburbs), I am acknowledging my certain sense of "compassion fatigue" and burnout that I experienced working with the poorest of the poor in the city for the better part of a decade, and my slow adjustment to a new class paradigm.
For almost ten years, my professional identity (and to some extent my personal identity, as well), was wed to the notion that I worked in service to the poor, advocating and fighting for them to receive the best quality health care that I could coerce and squeeze from the system. Stepping out of that environment---at least temporarily---I'm struck by the stark differences of class and privilege that I witness, and I simply acknowledge to myself that yes, this is assuredly different.
So, patients come and patients go. They are all of one class or another, all born into some situation or another, their class, race and social status beyond their control. I am simply noting the differences, evaluating my response, and cultivating an awareness that allows me to sit with each person, look them in the eye, and meet them face to face, hopefully without judgment or preconceptions.
Nursing brings one into contact with the diversity of humanity. This diversity of humanity is a wonder to behold, and in one's relationship to that wonder, one can also find a many puzzles to ponder.
I drove about twenty minutes to reach this patient's home, winding through lovely country roads, past old farm houses and pastures. Reaching his neighborhood of middle- and upper middle-class homes, I was struck by how out of the ordinary this situation seemed to me. For the last eight years, almost all of my home visits have been to poor, inner-city neighborhoods, trailer parks, or lower income neighborhoods with modest single family homes. Not since I was a visiting nurse back in the late 90's had I actually visited a patient whose home reminded me, perhaps, of my own parents' home back in the day.
The home smelled of garlic, tomato sauce and stewing summer squash from a large garden in the back yard. An above-ground pool bubbled outside, and we sat on a relatively new overstuffed sofa, our feet on plush carpet, a rambunctious four-month-old yellow lab entering and exiting the room every few minutes. My patient's wife buzzed around the kitchen and dining room, setting the table and trying to usher the dog away from my bag of bandages and supplies.
My patient and I talked about his work with a medium-sized company, his recent surgery, and how his wound had been healing. Like sitting with a benign uncle in a comfortable living room (with the exception that I was actually dressing a surgical wound), we chatted about dogs, our adult children, and a few other random subjects.
At the end of the visit, I put away my supplies and washed my hands, readying to take my leave as dinner was reaching the well-laid table. It was such a familiar scene---familiar in a visceral way, but unfamiliar in terms of the home environments into which I've been accustomed to walking in the course of my nursing career.
I felt no judgment of my patient and his lifestyle. In some ways, it smacked of American middle-class privilege, but I had no idea of knowing from this brief encounter what this man and his family might think about the poor. Perhaps they give money regularly to progressive social causes and volunteer at the local food bank. Maybe one of his children works for a left-wing NGO or humanitarian organization. Maybe they support the Republican National Committee. Who knows?
Before, during and after this visit, the main focus of my awareness was on class, privilege, and the fact that I have so rarely had the opportunity to visit patients in such comfortable and middle-American surroundings.
I'm not sure how I feel about this demographic shift, although I still do visits to rooming houses and low-income buildings in our area. Having mostly eschewed my work in the nearby inner city, I am now evaluating this new manifestation in my professional life and how it effects me on an emotional, spiritual and psychological level.
Choosing currently to work as a visiting nurse in our much less ethnically diverse collegiate area (which in turn is surrounded by middle- and upper-middle class neighborhoods, small towns and semi-rural suburbs), I am acknowledging my certain sense of "compassion fatigue" and burnout that I experienced working with the poorest of the poor in the city for the better part of a decade, and my slow adjustment to a new class paradigm.
For almost ten years, my professional identity (and to some extent my personal identity, as well), was wed to the notion that I worked in service to the poor, advocating and fighting for them to receive the best quality health care that I could coerce and squeeze from the system. Stepping out of that environment---at least temporarily---I'm struck by the stark differences of class and privilege that I witness, and I simply acknowledge to myself that yes, this is assuredly different.
So, patients come and patients go. They are all of one class or another, all born into some situation or another, their class, race and social status beyond their control. I am simply noting the differences, evaluating my response, and cultivating an awareness that allows me to sit with each person, look them in the eye, and meet them face to face, hopefully without judgment or preconceptions.
Nursing brings one into contact with the diversity of humanity. This diversity of humanity is a wonder to behold, and in one's relationship to that wonder, one can also find a many puzzles to ponder.
Friday, August 01, 2008
Be Silent and Listen
The apartment is stiflingly hot. The carpets are worn and stained, and the kitchen floor is ghastly in its filthiness. Cigarette butts litter the tables, and it's difficult to tell how many were put out in the overflowing ash tray and how many were simply snuffed out on the scarred wooden coffee table.
I am shadowing a psychiatric visiting nurse, learning the ropes so that I can help out with mental health visiting nurse visits on a per diem basis. She knows this patient well and seems able to easily understand his mumbling answers to her questions.
The next apartment we visit is relatively neat and clean. The patient is engaging and much more talkative. He likes to write, has a Master's degree, and uses a Smith-Corona typewriter that sits on the kitchen table. His psychosis has prevented him from working or otherwise engaging in a more active life for a number of years. I peak at the page still held in the typewriter's grip, and the first line says: "I like that the anagram for the word 'listen' is 'silent'."
I had never considered the relationship between those two words before, and sat contemplating the multiple levels of meaning inherent in that relationship as the nurse continued her assessment.
Listening does indeed involve a commitment to momentary silence, and any listening done without allowance for silence is not necessarily true listening. Sure, I can question a patient and pretend I listen to her answer as I filter her response through my own preconceived notions of what she might say (or what I want her to say). I can also listen to her response, already wondering how I can use it in my next blog post, essentially robbing her of my complete attention as I consider how to turn this visit into a story.
With patients---whether they be psychiatric patients or hospice patients---listening is a gift that we can give, and if we are able to listen---truly listen---we are wrapping that gift in the shiny material of our own humanity.
In my work as a hospice nurse and visiting nurse, I want to bring the gift of truly listening to the care I provide. I can check blood pressures, dress wounds, take temperatures and irrigate catheters, but when all is said and done, open-hearted listening without a personal agenda can be more telling than the most comprehensive physical exam.
"Silent" is the anagram of "listen" for a reason.
I am shadowing a psychiatric visiting nurse, learning the ropes so that I can help out with mental health visiting nurse visits on a per diem basis. She knows this patient well and seems able to easily understand his mumbling answers to her questions.
The next apartment we visit is relatively neat and clean. The patient is engaging and much more talkative. He likes to write, has a Master's degree, and uses a Smith-Corona typewriter that sits on the kitchen table. His psychosis has prevented him from working or otherwise engaging in a more active life for a number of years. I peak at the page still held in the typewriter's grip, and the first line says: "I like that the anagram for the word 'listen' is 'silent'."
I had never considered the relationship between those two words before, and sat contemplating the multiple levels of meaning inherent in that relationship as the nurse continued her assessment.
Listening does indeed involve a commitment to momentary silence, and any listening done without allowance for silence is not necessarily true listening. Sure, I can question a patient and pretend I listen to her answer as I filter her response through my own preconceived notions of what she might say (or what I want her to say). I can also listen to her response, already wondering how I can use it in my next blog post, essentially robbing her of my complete attention as I consider how to turn this visit into a story.
With patients---whether they be psychiatric patients or hospice patients---listening is a gift that we can give, and if we are able to listen---truly listen---we are wrapping that gift in the shiny material of our own humanity.
In my work as a hospice nurse and visiting nurse, I want to bring the gift of truly listening to the care I provide. I can check blood pressures, dress wounds, take temperatures and irrigate catheters, but when all is said and done, open-hearted listening without a personal agenda can be more telling than the most comprehensive physical exam.
"Silent" is the anagram of "listen" for a reason.
Friday, June 20, 2008
Unions and Confusion
My new per diem position as a hospice nurse with a local visiting nurse agency entails mandatory membership in a union, the first time I have ever needed to join a union. I am woefully unprepared (and ignorant) when it comes to union issues, and I imagine that my education in this area may provide some fodder for writing as time goes on.
Interestingly, the union in my new workplace has been in contract negotiations with my employer for ten months, the last contract expiring in August of 2007. Just yesterday, after a less than a half day of orientation, I was allowed to go home 90 minutes early, and only today I learned that a picket line formed in front of the office not one hour after I had left for home. Was I purposefully sent home so that I wouldn't see the picket line? Did my boss want me to avoid the uncomfortable experience of not knowing whether to join the picket or not? Was it all simply unrelated?
I plan to post about my experiences vis-a-vis working in a "union shop" from time to time, and will probably find this experience quite enlightening. Stay tuned to this labor channel for further contract negotiation updates!
Interestingly, the union in my new workplace has been in contract negotiations with my employer for ten months, the last contract expiring in August of 2007. Just yesterday, after a less than a half day of orientation, I was allowed to go home 90 minutes early, and only today I learned that a picket line formed in front of the office not one hour after I had left for home. Was I purposefully sent home so that I wouldn't see the picket line? Did my boss want me to avoid the uncomfortable experience of not knowing whether to join the picket or not? Was it all simply unrelated?
I plan to post about my experiences vis-a-vis working in a "union shop" from time to time, and will probably find this experience quite enlightening. Stay tuned to this labor channel for further contract negotiation updates!
Wednesday, May 28, 2008
The Wheat and the Chaff
Driving from patient to patient today in the admittedly not-so-big city, I found myself wondering how much longer I can do this. From pot-holes to one-way streets and buildings close to being condemned, I realized today that this job's days may be numbered. Actually, having just signed on to begin providing per diem hospice and palliative care closer to home, I realized that I very well could be seeing my final days of urban visiting nursing.
Now, of course there is excellent fodder for writing while seeing patients in the city: drug abuse, litter, homelessness, squalor and the like. However, those things exist everywhere, and every interaction, every moment can be fodder for writing if one sees things through that incisive lens.
As far as being professionally challenged, quick visits to the mentally ill in the city do not necessarily provide much in the way of clinical learning, and after quitting my full-time job in January where learning was de rigeur, hospice and palliative care are the place where I feel my clinical skills can truly grow.
So, as The Part-Time-Nurse-With-Five-Jobs, I am seeing that the time to separate the occupational wheat from the chaff is upon us. Has anyone seen my thresher?
Now, of course there is excellent fodder for writing while seeing patients in the city: drug abuse, litter, homelessness, squalor and the like. However, those things exist everywhere, and every interaction, every moment can be fodder for writing if one sees things through that incisive lens.
As far as being professionally challenged, quick visits to the mentally ill in the city do not necessarily provide much in the way of clinical learning, and after quitting my full-time job in January where learning was de rigeur, hospice and palliative care are the place where I feel my clinical skills can truly grow.
So, as The Part-Time-Nurse-With-Five-Jobs, I am seeing that the time to separate the occupational wheat from the chaff is upon us. Has anyone seen my thresher?
Monday, May 26, 2008
Hospice and Palliative Care: A New Opportunity
I have accepted a per diem position with a local visiting nurse agency which provides both palliative care and hospice care to people in our region. Since I became a nurse in 1996, I have worked in the urban areas which are located just under an hour from our home. I have always commuted elsewhere to work, and subsequently have never provided nursing care here in my own county.
For several reasons, I am quite excited about this position. For one, I will actually be able to see patients in and around the town where we live, as well as in neighboring towns and counties, some of which are quite lovely and bucolic. Making home visits in our area---rather than in the down-and-out city---will be a novel and welcome experience, and I look forward to not necessarily having to deal so much with drug dealers, litter, urine-soaked hallways, and other hallmarks of urban visiting nursing (although I will keep my other home care job in the city, as well).
More importantly, I am professionally excited to be embarking on the learning curve of officially becoming a hospice nurse, mentoring with seasoned hospice nurses who can teach me the nuances of a very important nursing specialty. While I did indeed have a short-lived position at a local residential hospice from which I was forced to resign for health reasons earlier this year, I was not there long enough to fully appreciate the breadth and depth of all there is to learn about providing hospice care. In previous positions, I have had the opportunity of supporting patients and families through the dying process, and have even had the honor of pronouncing the death of several beloved patients, but there is still so much more to learn.
Last summer, my wife and I were integral in providing care to my step-father who died surrounded by family in early September from complications of pancreatic cancer. That experience---and my previous experiences as a visiting nurse with terminally ill patients---cemented my desire to become more of an expert in end-of-life care, and I feel that I now may have an opportunity to accumulate the knowledge that I have longed for.
As part of my new position, I will also begin working with this particular agency's palliative care team, which offers symptom management and support to patients living with terminal illness who are still receiving treatment and are not yet eligible for hospice services. This is another area of specialty which intrigues and excites me, and I look forward to the knowledge that will also come from that specific professional experience.
Four months after quitting my full-time job, things are beginning to come together, and I give thanks that I am able to find satisfying and relatively well-paid work in my chosen profession. May other be so blessed.
For several reasons, I am quite excited about this position. For one, I will actually be able to see patients in and around the town where we live, as well as in neighboring towns and counties, some of which are quite lovely and bucolic. Making home visits in our area---rather than in the down-and-out city---will be a novel and welcome experience, and I look forward to not necessarily having to deal so much with drug dealers, litter, urine-soaked hallways, and other hallmarks of urban visiting nursing (although I will keep my other home care job in the city, as well).
More importantly, I am professionally excited to be embarking on the learning curve of officially becoming a hospice nurse, mentoring with seasoned hospice nurses who can teach me the nuances of a very important nursing specialty. While I did indeed have a short-lived position at a local residential hospice from which I was forced to resign for health reasons earlier this year, I was not there long enough to fully appreciate the breadth and depth of all there is to learn about providing hospice care. In previous positions, I have had the opportunity of supporting patients and families through the dying process, and have even had the honor of pronouncing the death of several beloved patients, but there is still so much more to learn.
Last summer, my wife and I were integral in providing care to my step-father who died surrounded by family in early September from complications of pancreatic cancer. That experience---and my previous experiences as a visiting nurse with terminally ill patients---cemented my desire to become more of an expert in end-of-life care, and I feel that I now may have an opportunity to accumulate the knowledge that I have longed for.
As part of my new position, I will also begin working with this particular agency's palliative care team, which offers symptom management and support to patients living with terminal illness who are still receiving treatment and are not yet eligible for hospice services. This is another area of specialty which intrigues and excites me, and I look forward to the knowledge that will also come from that specific professional experience.
Four months after quitting my full-time job, things are beginning to come together, and I give thanks that I am able to find satisfying and relatively well-paid work in my chosen profession. May other be so blessed.
Sunday, May 18, 2008
Alone
"What a lovely home you have here," I say as I walk in the front door.
"Thanks. People always say that when they come here." He seems like any other suburban middle-aged man. We sit in the living room.
"So, what's happening today?" I ask as I open his lock box and arrange his morning and evening medications.
"I don't know. Maybe I'll make some calls. Maybe I won't. I don't have a car right now so I don't know what to do today."
"Well, it's a beautiful day out there. Would you consider getting some sun, checking out the flowers and the trees, and getting some fresh air? I see on your care plan that you're supposed to try to go outside every day."
"Yeah, I could do that, I guess. I hadn't thought of that. I'm pretty lonely, too. I've been depressed."
"I think I know what you mean," I reply. (What I want to say is that I've been very depressed myself, but "therapeutic use of self" does not seem appropriate in this situation. There are times like these when I want to explain how depression also frequently has its grip on me, and reaching out---both to people and to Nature---is often my greatest survival strategy.)
"How about this?" I begin. "Make some calls to at least one friend and one member of your family this morning. Then make sure you get outside for a walk once this morning and once this afternoon. Getting out of the house can be really helpful, even if only for a few minutes. The sun feels so good."
"OK. I can do that. Thanks for the suggestion. Should I take these meds now?" He seems confused.
"Yeah. Take these now and take the evening meds with dinner. And I'll leave your meds for Sunday on the table since there won't be a nurse coming tomorrow."
"Oh, that's right," he replies. "Sundays are hard because nobody comes over. It can seem like a long day, especially when I don't have a car and it's so far to town."
"Well, remember we talked about making those calls today? Maybe there's someone who can come see you tomorrow, especially if they know your car is broken down."
"Hey, that's right. Why didn't I think of that? I'll make those calls as soon as you leave." A smile passes across his face, then disappears. By the time we reach the door, he's smiling again.
"Thanks so much for the visit," he says, shaking my hand warmly. "I feel a little better now."
"So, you'll do some good things for yourself today?" I ask in parting.
"Oh, yes. Absolutely. You can bet on it."
I get in the car and put the key in the ignition. Looking in the rear-view mirror, I see that he has walked over to the garden and is leaning on the fence, looking out towards the hills. The sun is bright and there are a few horses in the fields beyond his house.
My prescription for him was no different than what I tell myself, and in the face of depression and the sense of isolation that often accompanies it, there's no telling how effective those interventions will be. When it comes to the mystery of our minds and the solitude we each experience within our minds, no one can offer an explanation that will wholly satisfy us.
Some of us are blessed with an inner equanimity free of depression and isolation from others. Some of us---myself included---struggle with the demons of depression and other mental afflictions that bog us down and cloud our thinking. Depression can short-circuit decision-making and cause us to pull away from those we love just when we need them most.
And what about my admonition to my patient to call friends and family and get outside in the sun? It was like I was talking to myself.
"Thanks. People always say that when they come here." He seems like any other suburban middle-aged man. We sit in the living room.
"So, what's happening today?" I ask as I open his lock box and arrange his morning and evening medications.
"I don't know. Maybe I'll make some calls. Maybe I won't. I don't have a car right now so I don't know what to do today."
"Well, it's a beautiful day out there. Would you consider getting some sun, checking out the flowers and the trees, and getting some fresh air? I see on your care plan that you're supposed to try to go outside every day."
"Yeah, I could do that, I guess. I hadn't thought of that. I'm pretty lonely, too. I've been depressed."
"I think I know what you mean," I reply. (What I want to say is that I've been very depressed myself, but "therapeutic use of self" does not seem appropriate in this situation. There are times like these when I want to explain how depression also frequently has its grip on me, and reaching out---both to people and to Nature---is often my greatest survival strategy.)
"How about this?" I begin. "Make some calls to at least one friend and one member of your family this morning. Then make sure you get outside for a walk once this morning and once this afternoon. Getting out of the house can be really helpful, even if only for a few minutes. The sun feels so good."
"OK. I can do that. Thanks for the suggestion. Should I take these meds now?" He seems confused.
"Yeah. Take these now and take the evening meds with dinner. And I'll leave your meds for Sunday on the table since there won't be a nurse coming tomorrow."
"Oh, that's right," he replies. "Sundays are hard because nobody comes over. It can seem like a long day, especially when I don't have a car and it's so far to town."
"Well, remember we talked about making those calls today? Maybe there's someone who can come see you tomorrow, especially if they know your car is broken down."
"Hey, that's right. Why didn't I think of that? I'll make those calls as soon as you leave." A smile passes across his face, then disappears. By the time we reach the door, he's smiling again.
"Thanks so much for the visit," he says, shaking my hand warmly. "I feel a little better now."
"So, you'll do some good things for yourself today?" I ask in parting.
"Oh, yes. Absolutely. You can bet on it."
I get in the car and put the key in the ignition. Looking in the rear-view mirror, I see that he has walked over to the garden and is leaning on the fence, looking out towards the hills. The sun is bright and there are a few horses in the fields beyond his house.
My prescription for him was no different than what I tell myself, and in the face of depression and the sense of isolation that often accompanies it, there's no telling how effective those interventions will be. When it comes to the mystery of our minds and the solitude we each experience within our minds, no one can offer an explanation that will wholly satisfy us.
Some of us are blessed with an inner equanimity free of depression and isolation from others. Some of us---myself included---struggle with the demons of depression and other mental afflictions that bog us down and cloud our thinking. Depression can short-circuit decision-making and cause us to pull away from those we love just when we need them most.
And what about my admonition to my patient to call friends and family and get outside in the sun? It was like I was talking to myself.
Thursday, April 03, 2008
Of Order and Chaos
I enter the apartment building and stop at the security desk.
“Who are you here to see?” asks the surprisingly pleasant security guard. She is a large African American woman, and she regards me with a friendly and curious expression.
“I’m here to see Mr. A,” I reply, fingering the ID badge that's clipped to my jacket. “Visiting nurses.”
“Oh, God bless you,” she says. “Good luck. Tenth floor, turn right out of the elevator."
I travel the ten floors in the briefest of upward journeys, and make my way down the hall, looking at the numbers on the apartment doors. His door at the end of the hall is wide open. I stand on the threshold and peer in. I knock and a voice responds, welcoming me in.
“Mr. A? I’m from the visiting nurses. May I come in?”
“Sure, sure, come in, come in,” says a disembodied voice from inside.
I step inside the studio apartment. To my left is the kitchen, or what once was a kitchen and is now more of a storage closet which only pretends to be a kitchen. Every surface is covered with papers, pens, and trash. Even the counters are covered, and the sink is full of dishes as well as a sheaf of papers and a telephone book.
Mr. A pokes his head around the wall that separates the kitchen from the living room.
“Come in here, please, please,” he says invitingly.
The fax that I received on this patient said that he could be combative, distant, or uncooperative. This gentleman seems so much the opposite, at least at first glance, anyway.
“How are you this morning?” I ask, as I attempt with some difficulty to clear a place on the table to put my bag.
“Oh, not so good, not so bad, but I’m going to visit my sister later today.”
His accent could be Indian, or maybe Pakistani, but I don’t want to ask. His diagnosis is paranoid schizophrenia, after all, and as a nurse who is visiting him for the first time, I don’t want to potentially alienate him from the start.
I take in the rest of his living space. The twin bed in the corner is covered with papers, envelopes, and a few plates of partially eaten food. A rowing machine takes up most of the center of the small apartment, and I marvel at the flotsam and jetsam that covers every surface.
“Did you take your meds last night, Mr. A?” I ask.
“Oh yes, here you are,” he says as he hands me the pill container which yesterday’s nurse prefilled for him yesterday morning. It’s empty.
“How did you sleep last night?”
“Very well, thanks,” he replies. His eye contact is good, although he seems to be uncomfortable sitting still at the table with me.
“Oh, before I forget, could you sign this for me?” I hand him my visit note, which has a place for patients to sign as proof that the nurse was actually there for the visit.
“That’s for them to know you were here, right?”
“Yes sir, you have that right, “ I reply.
He is so conversant, so positive and forthright. He is like the opposite of what I was told to expect.
I survey the remainder of his living space and see piles of papers everywhere. There is trash on the floor, chicken bones, milk cartons, a few cardboard boxes. I wonder what trauma or experience caused him to live like this. Although his eye contact is good, there is a wariness that I am now picking up on, a sense that he is uncomfortable in his own skin. Still, I feel completely comfortable with him, and we smile at one another.
I busy myself filling his med box with his morning and evening pills, reading the list carefully and putting my initials in each little box after I place that particular pill in its rightful place. He watches me closely. Once I‘m finished with the meds, I double-check the list and feel satisfied that I did it correctly. I hand him his morning meds.
“Thanks,” he says as he pops them all in his mouth and raises a large mug of water to his lips.
I check his blood pressure and pulse, listen to his lungs, and questions him briefly about his bowels, his urinary status, his appetite, his sleep quality, all the while looking in his eyes, assessing his skin and getting a general intuitive “read” on his overall health.
“Thanks for coming,” he says, as he walks me to the door.
The floor, covered with trash and papers, is like the elephant in the room that I dare not mention. Were he my patient, I would slowly address these issues over time. But in my position as just one more nurse passing through, I leave the elephant for someone else.
We shake hands and I leave his apartment. Even though I have been to so many homes like this in the past, I am stunned by how this man lives, and by the quiet desperation that I saw in his eyes.
“And how was our friend today?” asks the security guard who blessed me just thirty minutes prior.
“Just fine today, just fine,” I reply. “Thanks for your help.”
“God bless you” is her reply, delivered with a wave and a smile.
The outside air is fresh and cold, and I welcome my reentry into the clean orderliness of the wider world.
“Who are you here to see?” asks the surprisingly pleasant security guard. She is a large African American woman, and she regards me with a friendly and curious expression.
“I’m here to see Mr. A,” I reply, fingering the ID badge that's clipped to my jacket. “Visiting nurses.”
“Oh, God bless you,” she says. “Good luck. Tenth floor, turn right out of the elevator."
I travel the ten floors in the briefest of upward journeys, and make my way down the hall, looking at the numbers on the apartment doors. His door at the end of the hall is wide open. I stand on the threshold and peer in. I knock and a voice responds, welcoming me in.
“Mr. A? I’m from the visiting nurses. May I come in?”
“Sure, sure, come in, come in,” says a disembodied voice from inside.
I step inside the studio apartment. To my left is the kitchen, or what once was a kitchen and is now more of a storage closet which only pretends to be a kitchen. Every surface is covered with papers, pens, and trash. Even the counters are covered, and the sink is full of dishes as well as a sheaf of papers and a telephone book.
Mr. A pokes his head around the wall that separates the kitchen from the living room.
“Come in here, please, please,” he says invitingly.
The fax that I received on this patient said that he could be combative, distant, or uncooperative. This gentleman seems so much the opposite, at least at first glance, anyway.
“How are you this morning?” I ask, as I attempt with some difficulty to clear a place on the table to put my bag.
“Oh, not so good, not so bad, but I’m going to visit my sister later today.”
His accent could be Indian, or maybe Pakistani, but I don’t want to ask. His diagnosis is paranoid schizophrenia, after all, and as a nurse who is visiting him for the first time, I don’t want to potentially alienate him from the start.
I take in the rest of his living space. The twin bed in the corner is covered with papers, envelopes, and a few plates of partially eaten food. A rowing machine takes up most of the center of the small apartment, and I marvel at the flotsam and jetsam that covers every surface.
“Did you take your meds last night, Mr. A?” I ask.
“Oh yes, here you are,” he says as he hands me the pill container which yesterday’s nurse prefilled for him yesterday morning. It’s empty.
“How did you sleep last night?”
“Very well, thanks,” he replies. His eye contact is good, although he seems to be uncomfortable sitting still at the table with me.
“Oh, before I forget, could you sign this for me?” I hand him my visit note, which has a place for patients to sign as proof that the nurse was actually there for the visit.
“That’s for them to know you were here, right?”
“Yes sir, you have that right, “ I reply.
He is so conversant, so positive and forthright. He is like the opposite of what I was told to expect.
I survey the remainder of his living space and see piles of papers everywhere. There is trash on the floor, chicken bones, milk cartons, a few cardboard boxes. I wonder what trauma or experience caused him to live like this. Although his eye contact is good, there is a wariness that I am now picking up on, a sense that he is uncomfortable in his own skin. Still, I feel completely comfortable with him, and we smile at one another.
I busy myself filling his med box with his morning and evening pills, reading the list carefully and putting my initials in each little box after I place that particular pill in its rightful place. He watches me closely. Once I‘m finished with the meds, I double-check the list and feel satisfied that I did it correctly. I hand him his morning meds.
“Thanks,” he says as he pops them all in his mouth and raises a large mug of water to his lips.
I check his blood pressure and pulse, listen to his lungs, and questions him briefly about his bowels, his urinary status, his appetite, his sleep quality, all the while looking in his eyes, assessing his skin and getting a general intuitive “read” on his overall health.
“Thanks for coming,” he says, as he walks me to the door.
The floor, covered with trash and papers, is like the elephant in the room that I dare not mention. Were he my patient, I would slowly address these issues over time. But in my position as just one more nurse passing through, I leave the elephant for someone else.
We shake hands and I leave his apartment. Even though I have been to so many homes like this in the past, I am stunned by how this man lives, and by the quiet desperation that I saw in his eyes.
“And how was our friend today?” asks the security guard who blessed me just thirty minutes prior.
“Just fine today, just fine,” I reply. “Thanks for your help.”
“God bless you” is her reply, delivered with a wave and a smile.
The outside air is fresh and cold, and I welcome my reentry into the clean orderliness of the wider world.
Sunday, March 30, 2008
Here With the Lord Beside Me
She sits on the double bed in her studio apartment with great dignity, the early morning light streaming in the window. Gospel music plays on a small CD player on a table by the kitchen door. This is our first meeting since I'm just covering for her usual nurse.
"How are you this morning, _________?"
"Oh, I'm OK. I'm here with the Lord beside me," she says with a nod of her head towards the CD player. The music plays on.
"Did you sleep well last night?" I ask.
"Well, I only slept a few hours. I can't sleep much since the doctors killed my daughter last year."
I look her in the eye, and she stares back. Her gaze makes me slightly uneasy, but I hold it.
"I am so sorry for the loss of your daughter. That must be so hard."
"Yes, but He sees me through."
We listen to the gospel music for a moment.
"The music is really beautiful," I say sincerely.
"Can I give you your meds now?"
"Sure, honey," she replies.
I put her morning meds together, prefill her evening meds to take with dinner, and ask if she needs anything else.
"No, I'll be alright. My PCA will be here in a few hours."
"OK. I hope to see you again some time, my dear."
"God bless you, and thanks for coming."
She stares at me with that unsettling gaze again. Sometimes the chronically mentally ill can be socially awkward or unaware of how they look at people or how they speak. But in this case, I just feel like she's looking at me very deeply, and I simply try to meet her gaze.
"God bless you, too, and I'm very sorry about your daughter."
"Thanks you. Bye bye, dear," she says as I close the door.
Walking to my car, the ubiquitousness of loss and grief hits me, and I take a deep breath as I open the car door.
Just another day on earth.
"How are you this morning, _________?"
"Oh, I'm OK. I'm here with the Lord beside me," she says with a nod of her head towards the CD player. The music plays on.
"Did you sleep well last night?" I ask.
"Well, I only slept a few hours. I can't sleep much since the doctors killed my daughter last year."
I look her in the eye, and she stares back. Her gaze makes me slightly uneasy, but I hold it.
"I am so sorry for the loss of your daughter. That must be so hard."
"Yes, but He sees me through."
We listen to the gospel music for a moment.
"The music is really beautiful," I say sincerely.
"Can I give you your meds now?"
"Sure, honey," she replies.
I put her morning meds together, prefill her evening meds to take with dinner, and ask if she needs anything else.
"No, I'll be alright. My PCA will be here in a few hours."
"OK. I hope to see you again some time, my dear."
"God bless you, and thanks for coming."
She stares at me with that unsettling gaze again. Sometimes the chronically mentally ill can be socially awkward or unaware of how they look at people or how they speak. But in this case, I just feel like she's looking at me very deeply, and I simply try to meet her gaze.
"God bless you, too, and I'm very sorry about your daughter."
"Thanks you. Bye bye, dear," she says as I close the door.
Walking to my car, the ubiquitousness of loss and grief hits me, and I take a deep breath as I open the car door.
Just another day on earth.
Tuesday, February 19, 2008
A Visit
As a part-time visiting nurse, one often enters a home blind, without a notion of what will wait behind the door. Often, the outside will tell a story one tries to quickly decipher before even entering the home. And then the story unfolds.
As I approach the stoop, I notice a shopping cart filled with returnable bottles and cans to the left of the crumbling steps. I climb those steps and look into the yard to the left. Detritus of urban life litters what could have been a yard at one time: hub-caps, an eviscerated washing machine, the fenders of several cars, rotting lumber, moldy carpets. What looks like it may have been a cage for a few dogs now holds bag upon bag of trash. I hate to think how this will all smell in the summer heat.
I knock. I knock again. And again. I'd rather this person answer the door so she can get her meds and I can get paid for this visit. I knock yet again.
The door opens following a short period of undecipherable noise from inside. The room smells of stale cigarette smoke. I put my bag down on the table in what seems to be the cleanest spot. The young woman who sleepily opened the door says, "She'll be right there." I put my paperwork down on the table and I notice that it sticks to the wood. Hmmm.
There is yelling from the bedroom around the corner. "Why do these nurses come so early? I'm so tired!" I note that it's almost 9am and I should have been here at least 30 minutes ago.
"Is she OK? I ask. "I thought her regular nurse usually comes at 8."
"Oh, she just likes to complain." The young woman goes back up the stairs and I'm left to wait. A few minutes go by, and there is rustling and complaining from the other room as I ruminate on the other visits I still need to make.
"I'm coming, I'm coming," she yells, and enters the room in a bustle.
She smells of urine and maybe a hint of sweat and feces. I greet her warmly in both English and Spanish.
"Buenos dias, hello, how are you?" I smile. "Where's your med box and the paperwork?"
She opens a cabinet and produces the box and the all-important folder which any nurse who comes to the home can use to guide him or her as to what to accomplish during the visit. I have a secret piece of paper with the combination to her med box. She can't be trusted with her meds---like so many of our patients---so a locked box is kept in the home.
"Thanks." She smiles wanly and sticks her finger out so I can check her blood sugar with the glucometer on the table.
The machine beeps. "105. Muy bien," I say as I hand her some gauze to staunch the blood from her finger that I just pricked.
The visit is inconsequential as visits go. I am one more face, one more nurse who has come to check her sugar and blood pressure, administer her meds, and then be on my way. The fact that I speak Spanish seems not to impress her. She answers in English no matter what language I use. How tiring it must be to have a virtual stranger in her home each morning. What an imposition when one wishes only to sleep one's depression away. Her blank stare and flat affect belie her underlying mental illness, and I feel compassion for her even as I reel from the smell of urine that surrounds her. I wonder when the home health aide will visit her next, or if her family will make sure she bathes.
Not being a case manager has its rewards, and having relinquished the management of the intricacies of more than eighty people's lives, this momentary glimpse into a life on the edge of chaos reminds me why I so recently quit my full-time job. In my current position---covering for absent nurses and stopping in on patients who need a visit---there is no management, no follow-through. It is simply a visit and nothing more. It is a fleeting clinical glimpse, a hello and a goodbye, and I move on to the next.
As I approach the stoop, I notice a shopping cart filled with returnable bottles and cans to the left of the crumbling steps. I climb those steps and look into the yard to the left. Detritus of urban life litters what could have been a yard at one time: hub-caps, an eviscerated washing machine, the fenders of several cars, rotting lumber, moldy carpets. What looks like it may have been a cage for a few dogs now holds bag upon bag of trash. I hate to think how this will all smell in the summer heat.
I knock. I knock again. And again. I'd rather this person answer the door so she can get her meds and I can get paid for this visit. I knock yet again.
The door opens following a short period of undecipherable noise from inside. The room smells of stale cigarette smoke. I put my bag down on the table in what seems to be the cleanest spot. The young woman who sleepily opened the door says, "She'll be right there." I put my paperwork down on the table and I notice that it sticks to the wood. Hmmm.
There is yelling from the bedroom around the corner. "Why do these nurses come so early? I'm so tired!" I note that it's almost 9am and I should have been here at least 30 minutes ago.
"Is she OK? I ask. "I thought her regular nurse usually comes at 8."
"Oh, she just likes to complain." The young woman goes back up the stairs and I'm left to wait. A few minutes go by, and there is rustling and complaining from the other room as I ruminate on the other visits I still need to make.
"I'm coming, I'm coming," she yells, and enters the room in a bustle.
She smells of urine and maybe a hint of sweat and feces. I greet her warmly in both English and Spanish.
"Buenos dias, hello, how are you?" I smile. "Where's your med box and the paperwork?"
She opens a cabinet and produces the box and the all-important folder which any nurse who comes to the home can use to guide him or her as to what to accomplish during the visit. I have a secret piece of paper with the combination to her med box. She can't be trusted with her meds---like so many of our patients---so a locked box is kept in the home.
"Thanks." She smiles wanly and sticks her finger out so I can check her blood sugar with the glucometer on the table.
The machine beeps. "105. Muy bien," I say as I hand her some gauze to staunch the blood from her finger that I just pricked.
The visit is inconsequential as visits go. I am one more face, one more nurse who has come to check her sugar and blood pressure, administer her meds, and then be on my way. The fact that I speak Spanish seems not to impress her. She answers in English no matter what language I use. How tiring it must be to have a virtual stranger in her home each morning. What an imposition when one wishes only to sleep one's depression away. Her blank stare and flat affect belie her underlying mental illness, and I feel compassion for her even as I reel from the smell of urine that surrounds her. I wonder when the home health aide will visit her next, or if her family will make sure she bathes.
Not being a case manager has its rewards, and having relinquished the management of the intricacies of more than eighty people's lives, this momentary glimpse into a life on the edge of chaos reminds me why I so recently quit my full-time job. In my current position---covering for absent nurses and stopping in on patients who need a visit---there is no management, no follow-through. It is simply a visit and nothing more. It is a fleeting clinical glimpse, a hello and a goodbye, and I move on to the next.
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