Friday, September 23, 2005

Death Pays a Call

Yesterday morning, we were able to smoothly transfer my dying patient to his home for his final hours with family. The hospice nurses met me at the home, and we spent 90 minutes teaching the caregivers different techniques: how to move and reposition him to maintain comfort and decrease pressure on bony areas; how to administer extra IV morphine and Ativan for pain and agitation; how to provide oral, skin, and catheter care; what to do when his breathing changes and he slides into unconsciousness; what to do when he dies. The nuts and bolts of midwifing a death.

A call came late yesterday afternoon that the family was beginning to implode, verbally attacking the main non-family caregiver, creating a very stressful atmosphere. Although the dying gentleman was almost in a coma, hearing is always the last sense to be lost, and he reacted with grimacing and great agitation to the interpersonal melee unfolding around him. I was able to calm the situation somewhat over the phone, and hoped that all would be well enough for my dear patient to have a peaceful night, which would later prove to be his last night on earth.

I arrived to the home at noon today, and all was well and tranquil. My patient's respiratory rate had been decreasing and becoming more irregular, with longer and longer pauses between breaths, a sure sign of his steady decline toward death. His urine output was becoming darker and more scant, signaling that his kidneys were actively conserving fluids, producing as little urine as possible, trying their best to keep the body's fluid and blood volume at an acceptable capacity for the cancer-ravaged body. He was now completely unresponsive, the room's ambient sound being that of the pneumatic bed and oxygen tank whirring as white noise above the sounds of traffic through the window and voices from the kitchen and living room.

Saying that I knew this would be my last time with him, the family allowed me a few moments alone at the bedside. I communicated in Spanish that he was now free to leave, the family was together, friends gathered, everything in readiness for his departure. There was nothing more for him to be concerned about, all business had been taken care of, and nothing now stood in the way of him leaving his body. I encouraged him to thank his body for its service, and prepare to leave it behind for good. I kissed his forehead and left the room.

In the living room, I was generously offered a huge plate of traditional food which was impossible to turn down. We ate and chatted, and I shared with several people that the dying will often wait until all is quiet and no one is at the bedside to take their leave. It is a common phenomenon, perhaps because the dying person wishes to spare his or her loved ones from witnessing their departure, preferring to do it alone. After all, we are born alone and die alone, and no one can travel those passages for us. It is a singular event in life and one to be faced with aplomb and tranquility if at all possible, not to mention great courage and humility.

Not fifteen minutes had transpired between my goodbye soliloquy in the bedroom and finishing our meal in the living room when someone went to check on the dying man who was the central focus of everyone's attention for so many days now. I was abruptly called into the bedroom, and I immediately confirmed what was vividly apparent--he had died quietly after I left the room, leaving his body while we all ate our lunch together in the living room. Perhaps he really took to heart what I had said and realized it was time to go. Perhaps he would have died at that time whether I had been there or not, but being given permission to go, being blessed on one's way is a gift that can always be given to the dying, and I felt honored that I was given the gift of being present during this death, both for the dying and the living.

The scene that followed was classic: tears, hugs, weeping sons arriving afar receiving urgent cell-phone calls, neighbors coming to pay their respects. I, the professional, wandered from room to room, offering helpful words, concrete advice, fielding questions, and preparing the body. Not being a visiting nurse, per se, I am not licensed to pronounce a patient dead and sign the death certificate in Massachusetts, although I have been priviledged to perform this service in the past when I did have that legal right and responsibility. I called the hospice nurse and reported the time of death, requesting a nurse be dispatched as soon as convenient.

Exiting the building after warm goodbyes filled with kind words, a certain fullness pervaded my spirit, and a level of emotional exhaustion that cannot be described, along with a feeling of elation and freedom as well. Unfortunately, three more very busy hours of work would then ensue, robbing me of the opportunity to further explore this state of being. I was instead ruthlessly flung back into the maelstrom of the day, removed from the timelessness that seemed to pervade that apartment as we contemplated the death of a very noble man.

But now I can reflect on the experience, bless this soul on its journey, and enjoy the knowledge that my guidance played a small part in this soul's ultimate transition from the physical world to the spiritual realm.

Yes, Death paid a call, and I would say that the call was a sweet one.


Anvilcloud said...

I don't know what else to say but to offer my thanks for this post.

Anonymous said...

absolutely beautiful. would it be too much to suggest that we aren't really born alone? our mothers are there with us, to hold us and comfort us in our traumatic journey...just as the dying have their family and friends there to guide them. and...some of us were twins, and have always felt that "other" with us along the way.

your writing is poetry, keith. i'm in awe.

Cuppa said...

A beautiful post. Thank you.

Keith "Nurse Keith" Carlson, RN, BSN, NC-BC said...

Thanks to all.

Christian, what I meant was this: when we are born, that journey through the birth canal from the warmth and safety of the womb is done alone--no one can do it for you. You make that journey alone, and your first breath of air, the fluid being squeezed out of your lungs as you emerge, is, to me, a singular experience of one individual undergoing a transformation that is theirs alone.

Similarly, when one crosses the threshold from life to death, no one can assist you. The hands on your body, the voices of loved ones might soothe your body, but in that moment of ultimate transition, you are utterly alone as you transform from a being of corporeality to a being of light and energy.

Of course we are never truly alone---others are nearby in both of these monumental circumstances, but the actual act of transformation and journey--that is something that I deeply feel we must face ourselves.

Anonymous said...

I understand. Perhaps I was mixing up "alone" with "lonely." Thank you for your wonderful words.

Anonymous said...

Thanks, Keith. That was beautiful.

Melaina RN, PHN, MS, CNS, ACHPN said...

What a privilege and an honor to have made such a strong connection with this patient and his family. Beautifully-written post. My favorite line: "the timelessness that seemed to pervade that apartment as we contemplated the death of a very noble man"

Anonymous said...

I still remember the first patient I had of whom was in hospice care and was sent home to die. After we got her comfortable one abternoon, we retired to the kitchen, people were stressed, so we took everyone to the bedroom and closed the door to just sit and relax, it was then my patient took her leave, we tried to minimize the rest of the family of having to watch this happen. What you wrote made me mindful of the gift of service we offer to others. I myself work in hospice care/religious counseling here in Montreal.

thank you for this piece.

OldCottonPicker said...

Life and death both can be wonderful and a blessing, depending on the choices one has made.

Thanks be to Christ, death is not our enemy.
May God Bless,