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?

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.

Monday, May 19, 2008

Sunday, May 18, 2008


"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.

Saturday, May 17, 2008

Desire and Happiness

Whatever joy there is in this world
All comes from desiring others to be happy,
And whatever suffering there is in this world
All comes from desiring myself to be happy.


Friday, May 16, 2008

Rural Health Care: A Few Thoughts

Having just interviewed for a position with a home health agency whose territory covers a large swath of rural countryside, I am appreciating the challenges and difficulties of delivering care in such a setting. Whereas the city---where I currently provide home health care---finds patients in an area of high population density and relatively close geographic proximity, serving patients who live in mostly single family homes in far-flung sections of the countryside is an entirely different story.

When considering such matters, I recall how Dr. Paul Farmer, the founder of Partners in Health (recently featured on "60 Minutes"), created teams of trained lay outreach workers to bring care to patients living in rural isolation.

Native American reservations face great challenges when it comes to the delivery of home health care. The Center for Rural Health at the University of North Dakota School of Medicine use their resources to drive policy and develop care models vis-a-vis rural health and the delivery of medical care in rural areas.

Even the Health Resources and Services Administration of the U.S. Department of Health and Human Services has an Office of Rural Health Policy that strives to improve rural health care around the country.

It is now an accepted fact that physicians are leaving primary care and family practice in droves as specialization becomes the ultimate goal. More and more medical students choose specialties other than primary care as the cost of medical school skyrockets and the subsequent debt after graduation becomes even more astronomical.

While much is written about a nursing shortage which is feared to be worsening by the day, a physician shortage--especially of primary care physicians---is also taking hold, and one can easily extrapolate that any nurse or physician shortage is bound to have a devastating effect on rural health around the country. Many articles recount how doctors are in high demand, and strategies to lure health care workers to rural areas are discussed in stories and reports from Australia, Norway, and elsewhere.

Rural health is a subject which has never captured my imagination, yet today's interview and a few clicks of the mouse were enough to make me dig just a little deeper. While strategies and policies to offset the growing national shortage of nurses and doctors are developed and implemented, those living in rural areas are sure to be hoping that they don't get left in the proverbial dust.

Wednesday, May 14, 2008

Definition and Redefinition

Working a few hours at the community health center in the city yesterday was a good reminder of the things I do and don't like about my current career trajectory. Spending a half-day helping out in my old office also solidified those stark reminders of why I eschewed full-time work four months ago.

Quietly observing my colleagues, I watched as everyone seemed to be running around in circles of frustration and habituated action. Paperwork flew as harried notes were written and typed, prescriptions proffered and recommendations made. Med refills, telephone calls, follow-ups, appointments and prescriptions devour the minutes of everyone's day, and I certainly did not see many happy faces in the course of my work day.

Driving home, I remarked to my wife Mary how I do indeed miss intellectually stimulating interactions with my favorite doctors, and I also do sincerely miss some of the personal connections that I had with a few very special patients. Still, that life now seems to be fading further, and I practice letting go over and over again when I pass through the office or the health center as a per diem nurse. It is a deeply personal process, and my own self-definition is still very much in flux.

As I try to define who I am professionally in the world---nurse, healer, writer, blogger, consultant---I'm struck by how those definitions themselves feel limiting. My identity as a nurse is still quite firmly front and center, and "writer" now feels more real than ever. But there is more to me than those two words, and this mid-life period of redefinition (but not "crisis", mind you!) is a rich time of seeking and asking. As for the answers, they are slow in coming, and the more I grasp for them, the further away they seem to recede.

Sunday, May 11, 2008

During the Dream.....

Always recognize the dreamlike qualities of life and reduce attachment and aversion. Practice good-heartedness toward all beings. Be loving and compassionate, no matter what others do to you. What they will do will not matter so much when you see it as a dream. The trick is to have positive intention during the dream. This is the essential point. This is true spirituality.


Friday, May 09, 2008

National Nurse's Week

In recognition of National Nurses' Week (officially May 6th to May 12th), I want to take a moment to honor the approximately 2.9 million registered nurses who provide skilled and compassionate care to millions of Americans day in and day out. Nurses are an essential component of the healthcare system, and this week is simply an opportunity for recognition of a body of individuals whose work is essential to the health and well-being of so many.

Expanding that notion, I would also like to recognize nurses worldwide, my professional brethren with whom I am connected through our mutual dedication to service and nursing care. All too often, we focus too keenly on our own community or country, losing sight of those in lands beyond our borders. Nurses and other healthcare workers labor each day in refugee camps, on battlefields, at the site of natural disasters, and on the streets of cities the world over.

Many blessings to my fellow nurses, and to anyone and everyone who has ever taken a moment to help another sentient being. May we all be free from suffering.

Sunday, May 04, 2008

Pain and the Seeds of Compassion

There comes a time in life when one decides to surrender to what is, to acknowledge that one has hit a wall. I have arrived at just such an impasse, and while it's not an easy thing to do, I finally have to admit that I feel powerless over my pain.

Having worked with patients with chronic illness----including chronic pain---for years, I never saw myself as someone with chronic illness. People with intractable pain and multiple diagnoses were always separate from me, living in a world which I did not inhabit.

Now, having quit my job due to the ravages of stress and chronic illness, I admit that I am---at least for the moment---struggling with chronic illness, and that its effect on my life is global and overwhelming.

Up until now, I have consistently said that pain would not limit what I do, that I would not allow the pain to intrude upon my daily activities. However, I am moved to report that I have indeed surrendered some aspects of my life to the cruel fingers of pain, and I no longer do many of the things that I used to. Pain has insidiously begun a campaign of contraction aimed at my life, and I have weakened under the onslaught.

Despite the fact that I have not found a single modality or treatment that assuages my symptoms enough to remark about, I do hold out hope that somewhere, somehow, there will be an answer. Whether it is complete cessation of pain or just better control, I have to feel that there is still possibility and potential.

Nursing brings one into contact with people in all stages of health and illness. I have seen people ravaged by cancer and AIDS. I have dressed enormous physical wounds that would not heal, and I've witnessed the torture of psychological wounds that fester for a lifetime.

I myself now long for cessation of my own suffering, and in my role as a nurse I want my personal experience of suffering to inform and empower my interactions with patients and others who hurt. Shared experience breeds compassion and understanding. May my own experience further nurture the seeds of compassion in me.

Thursday, May 01, 2008

Patient Contact: Missing in Action

My new work life has significantly decreased regular contact with patients, the one-on-one interactions that are part and parcel of most nurses' lives. In a recent post, I mentioned how I'm personally missing some of my former patients and the place that they inhabited in my life. I also find that I am simply missing the types of interactions that can remind me of why I became a nurse in the first place.

My current per diem visiting nurse gig is just not panning out, with several weeks going by without my being needed whatsoever. In my other per diem work, actual patient interactions are few and far between, and when I find myself with a patient in their home, I relish those brief moments of connection.

Due to my health, I am fiercely resisting the psychologically subterranean urge to take a 15- or 20-hour part-time position, but I am applying for two more per diem visiting nurse positions (one with a hospice component) in the hopes that I can have more experiences of face-to-face therapeutic interaction without the nightmare of case management.

So why did I leave my previous job, you may ask, if I miss patient care so much? The fact was that case managing 83 chronically ill people was no picnic, and the detailed coordination of those individuals' medical care---while gratifying and challenging---had such a negative impact on my health that it simply had to end. While I enjoy the interaction, it's the case management and detail coordination that almost killed me.

So, this nurse aches for patient contact but eschews the trap of full-time or part-time work which previously proved so burdensome. Now the secret is to fulfill my yearning while still avoiding burnout........