Monday, December 31, 2007

Year's End

The last day of the year brought with it patients in every manner of crisis. A patient called in tears, certain that she has brain cancer, her head feeling like it is splitting in two.

"I want one of those things where they put a hat or something on your head. Oh, what is it?"

"An EEG?" I ask, grasping at straws.

"Yes, that's it! I want that!" she yells, dissolving into more tears. "And I think I have throat cancer, too."

The next call revolves around---what else? Narcotics.

"Why does the doctor want to decrease my oxycodone? I only did heroin once and it was just to celebrate. I won't do it again."

Again and again the calls come in, like everyone just seems to need to put their crises in my lap before the year is over. Maybe it's just pay-back for planning to leave altogether. Several patients manage to suck me in today, and I feel emotionally triggered by the ferocity of their trauma, my mind working with my psyche to mitigate the damage.

The highlight of my day is delivering bottles of sparkling cider to some of my favorite patients, leaving behind a smidgen of New Year's (non-alcoholic) cheer. A few shared laughs and blessings bestowed upon me round out the day, keeping me from sinking beneath the onslaught of unquenchable need.

Home embraces my weary bones like a treasured balm. Thoughts of what has proven to be a quite difficult and trying year lead to wishes and desires for a kindler, gentler year in 2008. Personal loss, worsening illness, and the physical manifestations of stress and burnout have all come home to roost this year. Through it all, I have tried to maintain a healthy "witness self" who watches the wheels without going under---a frequently Sisyphean task.

In 2008, I will leave my full-time job of seven years, piecing together a new way of earning a living, manifesting improved health, shrugging off the ills of undue stress, and re-embracing creativity and spontaneity. No resolutions, no promises, no enjoinders. Just a healthy desire for change, for health, and for a new chance to do it better.

Happy New Year, many happy returns, and may all beings everywhere be free from suffering.

Sunday, December 30, 2007

The Countdown

The countdown continues as I face only 14 more work days before my full-time employment ends. As I connect with patients and inform them that I am leaving the practice, the reality of the change sets in. I also realize that some of my patients' lives will indeed change radically as they negotiate new clinical relationships that may or may not serve them as well as their relationship with me has done.

In terms of what I have done for patients, frequently going the extra mile---both literally and figuratively---I wonder if my going that extra mile has truly served them well. Having done so, their expectations may be that subsequent clinicians will do what I have done for them, and in this assumption they may indeed be sorely mistaken. If that is the case, did my going that extra mile only foster dependence and disempower them from a more proactive approach to their own care?

Enabling behavior among clinicians does occur, and in my (current) line of work---care coordination for the disabled and vulnerable---we are all guilty. However, if enabling does go so far as to disempower, then what has truly been served, the patient's needs or the clinician's own guilt?

For myself, this is the end of an era. It is the end of being in long-term therapeutic relationship with patients. It is the end of being a fixture in patients' lives year after year, through births, deaths, tragedies, and the inescapable comedies of error. It is the end of that feeling of responsibility of carrying the details of the care of so many on my own shoulders. I have gained much from that responsibility, and it has certainly fed my own need to be so needed. But is being so needed really all that it's cracked up to be?

As for my patients, they will survive, and they will navigate the new world without my presence however they can. Some will latch onto a new provider, some will simply fade into the healthcare woodwork. Abandonment issues will surface for some, and the more functional of these individuals will work through those issues and come out on the other side. For a few, I will just be one more well-meaning and earnest clinician who danced in their life for a while before spinning out of orbit like so many others before me.

In one exchange with a patient to whom I was breaking the news of my imminent departure, my patient said something about the fact that we had "done so much good work together" as if it was now all lost. My response was to counter that statement by framing it in the light of forward movement, of her new ability to build upon that foundation and realize more of her innate potential for self-directed advocacy. She agreed, but maintained her assertion that it was a loss of large proportions.

That day of finally closing the door on my seven-year sojourn---January 18th---is close on the horizon. What happens between now and then is only one part of the story. After that, a new chapter begins, and I will write that chapter with great interest and care. Perhaps it is already written and I only need to find it within myself.....

Wednesday, December 26, 2007

Pity vs. Compassion

"When your fear touches someone's pain it becomes pity; when your love touches someone's pain, it becomes compassion."

---Stephen Levine

Facing a return to work today after a long weekend, this quote speaks to me. It speaks of one of the touchstones of being in a helping profession, and of a life-long journey centered around developing, nurturing, and propagating compassion.

In the face of professional burnout, one can easily turn away from compassion, lose sight of it, and move into less therapeutic and unhelpful territory. This is what one might call compassion fatigue. Pity is an ugly cousin of compassion, but burnout can lead into much uglier territory still, like resentment and anger. Leveled against clients and patients, these emotions whittle away at the therapeutic relationship, leaving nothing but the starkest of connection. These manifestations essentially poison the well of compassion, but hopefully not beyond repair.

For myself, I am extricating myself before the damage is done, to me or others. I am exiting stage left with my compassion fatigued, but still intact and heartfelt. While I may feel badly for those patients whose abandonment issues will be stirred up by my leaving, better for them to face their issues than to face my loss of compassion.

Transitions are never easy. As the year comes to a close, change is inevitable, and I ready myself for the shifting sands and the equally inevitable challenges that change will bring. I will also endeavor to help my patients to do the same.

Thursday, December 20, 2007

Phone Conversation: An Exercise in Boundaries

The phone rings at my desk.

"So," a voice says through the receiver. "Can I get my oxycodone prescription today?"

"Your oxycodone prescription?" I respond. "Is this __________ calling?"

"Yes, it's me. I need my prescription now! You've kept me waiting!"

"Now wait a second. You spent the whole weekend snorting heroin and I sent you to the ER in an ambulance because you were wandering your building naked and hearing voices," I say. "You also had a machete on the kitchen counter. I thought you were in danger. And now you want your oxycodone just like that?"

"Yes. I'm in pain and I need it and now you won't give it to me. Jesus Christ!"

"Listen." I try to be patient. "You were out of control this weekend. Even your son said so."

"But I was celebrating! Can't I celebrate like anyone else?"

"Well," I say. "You could have taken a friend out to a nice restaurant to celebrate. Or maybe gone to a movie and bought yourself something nice at the mall. Instead, you chose to go out on the street, buy some heroin, and then spent most of the weekend psychotic. How can we trust you with a bottle of oxycodone?"

"C'mon! I need my meds! You can't refuse to give me my meds!"

"Well, this is the story. I have decided that I will give the bottle of meds to your visiting nurse. She will keep the meds in the lock box and give you four pills every morning for you to take throughout the day. Then the next morning you'll get four more. That's the deal. Either you accept what I'm offering or you get no narcotics at all. No arguments. No bargains. Period."

"No, no, no. You can't do that. I need my fucking meds now!"

I sigh. "Look, _________. This is it. Take it or leave it. I have your prescription in my hand and I'm about to go find the doctor to have her sign it. I can just as easily shred the prescription and we'll talk after Christmas."

"OK. But I'd better get my meds!"

"I'll have the doctor sign your script now, as long as she agrees to my plan. But if you use any more heroin, take any street drugs, or do anything like that again, I guarantee you she'll stop writing those prescriptions right away."

"OK, OK," she grumbles.

"Merry Christmas, my dear."

"Yeah, yeah. Bye." She hangs up.

I hang up my phone and my colleagues applaud. An exercise in boundaries? Sure. And patience. And compassion. And insanity. Was I really on a leave of absence just five days ago? It seems like an eternity.

Tuesday, December 18, 2007

Running for My Money

Today was one of those days where this line of work can give an earnest Nurse Care Manager a run for his money. (And I do certainly feel like I'm running for my money today.)

First, there's the patient with acute psychosis who apparently went on an inhaled heroin binge this weekend to celebrate finishing a very important multiple-month medical treatment. She told me that a friend had suggested going out to a fancy dinner instead of blowing her money on heroin. "It was actually a pretty good idea," she said with a laugh. After discussing the voices in her head and her non-compliance with taking her medications, she agreed to go by ambulance to the ER for an evaluation.

Another patient just seems to be having a hard time getting his life on track (a familiar complaint and observation here at "Train Wrecks 'r' Us". I feel deep compassion for his suffering, but sometimes it seems we just have to sit and let them work it out themselves.

The next patient complains about my long leave-of-absence, and says over the phone, "You mean, you've been back since yesterday and you haven't called me yet? I missed you so much!" How will I break the news to her that, in five weeks, I'll be permanently gone from her life?

Still another patient hears the news of my imminent departure and says, "Oh no! Another doctor leaving me behind? What next?" (She always refers to me as her doctor.)

These and other reactions are enough to make me feel guilty for leaving, but then I simply remind myself of the reasons why I'm leaving, the multiple stressors, the fast pace, the overwhelming feeling that I am running a race with no end in sight. I've been running like this for seven years, and working full-time for eleven.

We all run for our money in many ways, and any line of work will generally keep one running. This particular line has simply worn out the treads of my old Nurse Care Manager tires. I'm just due for a tune-up, some new treads, and a new place to run. In old-fashioned terminology, I'm "plum worn out" and have opened myself up to a new way to make my living in the world. The hardest part of that process is saying goodbye, and that is without a doubt par for the course.

Monday, December 17, 2007

Hello and Goodbye

I returned to work today following my six-week leave of absence, and while it was nice to say hello to friends, colleagues and patients once again, the reality is that I also have to begin saying goodbye as soon as I say hello. With my exit (stage left) planned for January 18th, time is of the essence to begin the disengagement process. It's an interesting exercise, and long-disused emotional muscles are being flexed as we speak. And when new muscles are flexed, we all know there's some growing pains.

It's easier than I thought to get started. I have to try to say goodbye to more than 80 patients, many of whom I have worked with for seven years, sharing numerous ups and downs and the challenges of poverty and chronic illness. Having begun, saying goodbye is not as difficult as I imagined. Then again, I have yet to speak with the patients with whom I have shared the most closeness and emotional intimacy. That is where the emotional rubber meets the road.

I was on the phone with one particular patient today. I told her I would be leaving the practice on January 18th. She seemed to take it in stride, said she loved me and would miss me, and agreed to get together next week for what would probably be our final visit. Another patient simply said, "Why are you leaving? Is it for more money?". Well, not exactly. Just more time at home.

One of my favorite patients, a vulnerable twenty-three year old young woman---a year younger than my son---was the most wrenching goodbye to date. When I broke the news to her over the phone today, I felt myself wince, and I could hear the strain in her voice. We agreed to meet at her home on Wednesday to check in. That therapeutic relationship will be one of the most difficult to terminate. That is the first small pain of this process.

So, five weeks of goodbyes, explanations, the transfer of crucial information, and the formulation of a new work life. An interesting way to end a year-----and to start anew.

Sunday, December 16, 2007

It's the End of My Leave as I Know It (and I feel fine)

Well, dear Reader, tonight marks the end of my six-week medical leave of absence from my full-time job, with Monday morning's return to my Nurse Care Manager's desk in approximately 14 hours from the time of this writing. So, what did I accomplish on this leave of absence, you ask? For posterity and my own edification, allow me to enumerate:

Resignation: first and foremost, during this period of time for reflection and self-care I came to the earth-shattering conclusion that I can no longer sustain the pace of my position, and I submitted my letter of resignation. While I return to the fray tomorrow at 9am, I enter only briefly, knowing full well that, come January 18th, my tenure at that position will have come to a timely end. Saying goodbye to beloved and respected colleagues will be difficult, but most challenging will be terminating my relationships with dozens of patients, many with whom I have shared a great deal over seven years. Be that as it may, the decision feels right, and I'm sure I'll process some aspects of it here on Digital Doorway. It's like giving up a part of my identity, both as a person and as a nurse, and the letting go (and grieving) process has already begun.

Hospice: I have applied and been hired for a position as a per diem hospice nurse at a small residential hospice not far from my home. I hope to complete my orientation there quite soon, and begin to pick up shifts as they become available. A goal long postponed.

New opportunity: I have contracted to serve as a Nurse Consultant for Nurse LinkUp, an online nurse networking community for which I previously provided occasional articles. When the site is re-launched, I will be providing original content, recruiting members and advertisers, and using my experience as a nurse to influence the development of the site.

Self-care: acupuncture, a sleep study, psychotherapy, rest, exercise, rejuvenation, solitude, writing, reading----I have had almost as much of these as I wanted (though a few more naps would have been nice......)

Home-care: laundry, organization, an enema for the basement, cleaning, winterizing---good medicine for the nurse with OCD.

Business idea: the development of stress management and burnout prevention workshops for nurses and other healthcare professionals.

Technological upgrade: we did it---we switched to Mac from Windows, and I am reveling in the change! Eat your heart out, Bill Gates!

The importance of decreased stress: the most crucial accomplishment and realization of these six precious weeks has been the need for decreased stress in my life. How else could I have cultivated the needed distance to realize that my stress level was leading me on a path of chronic stress-related illness and dysphoria? Without such a radical decision (with thanks to my wife Mary for pushing me), there may not have been a renewed commitment to self-care, and a realization that working full-time, 9-5, was just not working for me anymore. Not working? Nay, it was not working, and I was not fully living. I was caught in the maelstrom of stress compounded by a workplace wherein there was relentless demand with too few mitigating factors. A release was needed, and six weeks was only a taste of what that release might look like.

Granted, a professional life which is a patchwork of per diem positions, consulting, and self-employment may seem to some to be a self-made purgatory (and perhaps I'll feel similarly in a year or so), but for now, such freedom of movement and broader parameters are just what the, I mean the nurse....ordered. Prescription received, and the co-payment? Priceless!

Good-byes: and now the goodbyes begin, and this long-awaited and dreaded separation can get underway. I realize that there is much to grieve, much letting go to do, and sadness and doubt are inevitable. Still, in my heart of hearts, I know that it's for the best, and I consistently remind myself of the line by Michelle Shocked which I have mentioned here before: "The secret of a long life is knowing when it's time to go."

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.

Sunday, December 09, 2007

Psychiatric Units: The Next Extreme Makeover?

Making a visit to a friend in a psychiatric ward reminds me of everything a psych unit should be and generally is not. Ostensibly places where individuals in need of respite and psychological support are sent for “healing”, all of the units which I have visited generally lack every amenity which I would consider necessary for the creation of a truly healing environment. From the institutional colors of the walls to the utter lack of homey touches denoting any notion of soul, most psychiatric units still seem to lack the humanistic qualities that readily foster recovery, wellness, and normalcy. Hospitals---whether they be psychiatric or otherwise---sorely lack the amenities and cutting edge philosophies which could actually create truly healing environments.

In the unit which I recently visited, there is the poorly named “Relaxation Room”. Here, I was not surprised to find institutional furniture (what else could there be?), one bright fluorescent light fixture in the ceiling, and a maddeningly lame collection of plastic bins desultorily littered with colored beads, dry white rice (for “tactile stimulation”), an empty bottle of bubbles, and other detritus perhaps thought to have therapeutic and “crafty” benefits. In said relaxation room, there was no source of music. In an effort to create a sense of relaxation, one entire wall was covered with an enormous piece of wallpaper showing a life-size beach scene in a useless attempt to give the individual “relaxing” in the room a sense of being at the seaside. Two deflated bean-bag chairs sat lazily collapsed against the wall. The room is anything but relaxing. It feels more like a glorified closet, a dubious afterthought of pretend holism.

What might there be in a true “Relaxation Room”? A fountain. A selection of ambient, classical, and other calming music. A video monitor on the wall from which the patient can choose various nature scenes to watch and meditate on. Full-spectrum lighting and/or therapeutic lighting. Inspirational books written by spiritual leaders and others who offer words of comfort, solace, and empowerment. Meditation cushions. Clean and soft carpeting for doing yoga or stretching.

On a psychiatric unit, where can patients spend time? In the tiny “Relaxation Room”? A non-descript and highly uncomfortable “dining room” with hard wooden chairs and tables? Where is the exercise room, complete with yoga mats, exercise balls, and other non-threatening materials without sharp edges or other risk factors. Where can a patient really work off some steam? Where does one go to run, or to roll on the floor and stretch? How can physical health and fitness be so utterly overlooked when restoration of health is so paramount?

As for food, why can’t it be served “family style” at a long table, where patients sit together and pass food back and forth from serving dishes, fostering community, interaction, and socialization? Why must everyone receive their individualized institutional tray and sit---isolated and disconnected---as they “nourish” themselves?

Where is the garden? Where are the full-spectrum lights which studies have shown can counteract the ravages of Seasonal Affective Disorder? Where are the inspiring books, DVDs, and magazines? Where are the “healing clowns”, visiting musicians, poets and artists? Where are the plants and the stuffed animals? Where, dammit, is the comfort?

The “kitchen”, open for “nourishment” and snacks, sports Salada tea, tepid water, coffee, and crackers. Where is the fresh fruit? What nutritional choices are there other than sugar, caffeine and white flour? Where are the foods that truly nourish the soul, appease the appetite, and provide some modicum of sensual stimulation and satisfaction?

The most notable evolution vis-a-vis providing radically different environments within a hospital setting is the birthing room. Expecting parents have demanded that birthing suites and maternity wards within hospitals be designed in a way which provides the comforts of home within a hospital setting. This vocal and relatively affluent group has brought about enormous and revolutionary change vis-a-vis the nature of the birthing environment. Families in labor now ensconce themselves in wood-paneled suites with king-size, four-poster beds, birthing tubs, and numerous amenities meant to provide the laboring mother and her spouse and family a comfortable and home-like environment in which to undergo the process of birth. This is revolutionary, yet this revolution has not moved beyond the walls of maternity centers, and perhaps the psychiatric units are the next frontier in need of an “extreme makeover”.

I am sure that somewhere in this country (but more likely in Europe), there exist psychiatric institutions wherein humanism and holism are paid more than just lip service. For now, the majority of psychiatric institutions in this country are most likely similarly sterile and devoid of simple yet effective changes which could lend themselves to providing a much more pleasant, healing, and effective therapeutic environment.

In the end, money talks. Birthing is big business, and hospitals compete for families and continually try to outdo one another with their “birthing packages”, offering home-like experiences for deserving and demanding (and affluent) families who want a special birthing experience within the safety of a hospital.

As for the psychiatric patients, who will advocate for their experience of improved therapeutic environments? Will the families of those who need in-patient psychiatric treatment band together and flex their economic muscle, demanding change and improvement? Or perhaps there is a Victorian-era austerity or Dickensian horror which we collectively feel is still appropriate for those experiencing “madness”. Do we still negatively label those struggling with mental illness or extreme states of mind? Do we judge those who have attempted suicide as undeserving of a beautiful, calming, and truly healing environment?

Recovery from attempted suicide, mania, major depression, affective disorders, thought disorders or personality disorders can be a life-long process. Some never fully recover and must utilize psychiatric units as if they were equipped with revolving doors. If many of our most vulnerable citizens need to visit such places, why do we hesitate to offer them the most healing and supportive environments that we can? This is not just a medical question. It is moral question. And if this question was part of a pass or fail test, we would long ago have failed quite miserably.