After eleven years of providing direct nursing care---all in ambulatory settings, mind you---I wonder when it will be time to take a break and approach my work in the healthcare field from another vantage point. While I, like many nurses, thrive on the interpersonal relationships which nursing engenders, I also long for a rest from the emotional tugging which is part and parcel of my work.
But what is it about that "emotional tugging" that is so exhausting, you ask? The answer, to a large extent, is vicarious traumatization, wherein the act of bearing witness to the trauma of others can lead to internalization of trauma and psychic distress by the clinician. Several studies cited on the American Psychological Association website conclude that clinicians with their own personal trauma histories are more likely to experience deleterious effects when working closely with patients experiencing trauma.
Taking into consideration that the majority of my patients have suffered multiple traumas and live chaotic and difficult lives, I am consistently in a place of feeling unable to fully relieve the suffering of those around me. Confronted day after day by individuals whose suffering continues largely unabated, I surmise that my own level of suffering appears to have concurrently elevated, perhaps in response to those for whom my efforts seem to have little effect.
Many of my patients experience depression, anxiety, PTSD, and other forms of mental illness and psychic distress, not to mention chronic pain. Interestingly, my own depression, distress and physical pain symptoms have become significantly exacerbated in the last few years, leading me to more fully appreciate and understand my patients' suffering based on my own experience. Having been diagnosed myself with PTSD six years ago following a friend's murder, I appreciate the long-lasting effects of such experiences and the immeasurable difficulty of recovery.
The concept of vicarious traumatization is one which we all---clinicians and non-clinicians alike---might understand, but it is only now, as my own physical and psychic suffering has become augmented, that I more fully comprehend the insidiousness of its impact on the unwary clinician.
Luckily, this Thursday, I will attend a "Behavioral Health Grand Rounds" at a local hospital, where several experts on vicarious traumatization will present their research, their findings, and their recommendations to those of us interested to know more. As my leave of absence approaches at the end of this week, this particular presentation could not be more timely. I welcome this information, and also welcome the self-realization that it may engender.
Monday, October 29, 2007
Thursday, October 25, 2007
What Lunch Hour?
As I begin to plan for a five-week unpaid leave from the rat race, I feel particularly sensitive to messages, both implicit and explicit, that communicate that overworking is a culturally accepted practice.
In the last few days, I have begun to notice an ad campaign by Dunkin' Donuts (I refuse to link to their website, just to spite them) that truly speaks to what drives me to take a break from work altogether. This ubiquitous American purveyor of non-organic, non-free-trade coffee and fatty, sugary treats is now propagating billboards which promote a lifestyle unfriendly to slowness and thoughtfulness. "Eat on the Run!" screams one billboard, while another colorfully suggests that I "Work Through Lunch!". What have we come to? How did I become another victim of American workforce culture?
A recent study in the UK cites data showing that fewer and fewer Brits stop working in order to eat the midday meal. An article on Monster.com urges workers to take lunch breaks, and article after article cites the shrinking lunch hour and lengthening workday. In my own office, the majority of us eat lunch at our desks as we finish notes, check emails, and answer calls. And when five o'clock rolls around, so many of us seem to simply keep working since there seems to be no end to the work we need to do. No wonder we're all exhausted. The Japanese even have a word for death from overwork: Karoshi. At least it's not a purely American phenomenon.
So, those billboards that cajole us to work through lunch and eat on the run? Why not boycott Dunkin' Donuts, instead?
In the last few days, I have begun to notice an ad campaign by Dunkin' Donuts (I refuse to link to their website, just to spite them) that truly speaks to what drives me to take a break from work altogether. This ubiquitous American purveyor of non-organic, non-free-trade coffee and fatty, sugary treats is now propagating billboards which promote a lifestyle unfriendly to slowness and thoughtfulness. "Eat on the Run!" screams one billboard, while another colorfully suggests that I "Work Through Lunch!". What have we come to? How did I become another victim of American workforce culture?
A recent study in the UK cites data showing that fewer and fewer Brits stop working in order to eat the midday meal. An article on Monster.com urges workers to take lunch breaks, and article after article cites the shrinking lunch hour and lengthening workday. In my own office, the majority of us eat lunch at our desks as we finish notes, check emails, and answer calls. And when five o'clock rolls around, so many of us seem to simply keep working since there seems to be no end to the work we need to do. No wonder we're all exhausted. The Japanese even have a word for death from overwork: Karoshi. At least it's not a purely American phenomenon.
So, those billboards that cajole us to work through lunch and eat on the run? Why not boycott Dunkin' Donuts, instead?
Tuesday, October 23, 2007
Moments of Sadness, Moments of Warmth
Today I had a moment of sadness as I told a patient that I would be going on leave for five weeks. As I began to tell her my plans, her face fell and she said, "I'll miss you so much, but at least I'll see you in December." This woman and I have a close relationship bordering on what seems like a friendship, and the genuine warmth between us is a gift, as it is with a number of my patients. I also assumed that she could read between the lines, and that this leave of absence may be more than I was saying.
Why was I sad? Because this temporary goodbye is, by extension, practice for a larger, more permanent goodbye in the future. Whether I will take permanent leave of my job by the end of the year, or whether I tough it out for a few months in hopes of seeing some programmatic changes, this leave of absence which begins in ten days will be a taste of what it might feel like to really say goodbye.
There are patients who tell me they love me. There are patients, like the one mentioned above, with whom I have a great deal of warmth and positive mutual regard after more than five years of getting to know one another. Granted, the relationships are one way in most respects, but that does not decrease their true humanity and genuine quality.
Just this afternoon, I was visiting a patient who has not filled several of her prescriptions for more than a week---including her morphine---because she has absolutely no money left, not even enough for a $1 copayment. What could I say? How could I react? I dropped a twenty-dollar bill on the table as I left her mobile home. She took my hand and thanked me so graciously, her eyes sparkling with tears. How does one say goodbye to someone with whom one has been so connected?
Confusion, sadness and anticipation all coexist. Whether that coexistence is peacable remains to be seen.
Why was I sad? Because this temporary goodbye is, by extension, practice for a larger, more permanent goodbye in the future. Whether I will take permanent leave of my job by the end of the year, or whether I tough it out for a few months in hopes of seeing some programmatic changes, this leave of absence which begins in ten days will be a taste of what it might feel like to really say goodbye.
There are patients who tell me they love me. There are patients, like the one mentioned above, with whom I have a great deal of warmth and positive mutual regard after more than five years of getting to know one another. Granted, the relationships are one way in most respects, but that does not decrease their true humanity and genuine quality.
Just this afternoon, I was visiting a patient who has not filled several of her prescriptions for more than a week---including her morphine---because she has absolutely no money left, not even enough for a $1 copayment. What could I say? How could I react? I dropped a twenty-dollar bill on the table as I left her mobile home. She took my hand and thanked me so graciously, her eyes sparkling with tears. How does one say goodbye to someone with whom one has been so connected?
Confusion, sadness and anticipation all coexist. Whether that coexistence is peacable remains to be seen.
Monday, October 22, 2007
Compassion Fatigue, Monday Style
Today was the first Monday since I made the decision that a leave of absence is in the cards and coming soon. That said, my morning behaved in a way which underscored my need for a break and the "compassion fatigue" that has settled into my bones.
My first patient of the day was a 10am home visit to someone who lives in the subsidized housing near the clinic. I strolled through the lovely autumn morning and rang the bell, riding the rickety elevator to the third floor. My patient hangs out at a local community center, drinks what I fear is far too many beers on the weekends, and has personal hygiene which leaves much to be desired. Just last month, I visited and checked through her medications, noting that most of the prescriptions were dated from June of this year and had not been refilled since. Just to be sure, I called her pharmacy, and lo and behold, she has not filled a prescription in five months. With asthma, hypertension, high cholesterol, and a host of other chronic conditions, some of these medications are crucial to her well-being and survival.
"So," I began, "I see you haven't been taking your medications."
"Oh yes," she responded. "I take them every day like you taught me."
I shake my head. "Now, how can that be?" I ask, "when all of these prescriptions were filled in June and you haven't been back to the pharmacy since?"
She was speechless, stammered an excuse, and looked away.
"Look," I said. "These medications are not for my health, they're for yours. Either take them or not, but don't tell me what you think I want to hear. Tell me the truth."
"I'll start taking them all tomorrow, I promise," she said, putting out her hand for me to shake.
"We can shake," I said, "but I don't believe you today. We've done this before. See you next month."
"I love you," she said as I left her apartment, one of the few English phrases she knows.
I returned to the office, feeling angry that my months of work with her had done so little to effect her consciousness vis-a-vis her health. I drank a cup of coffee and went out to the waiting room to assess a patient who came in to see me without an appointment.
"I'm so anxious and depressed," she said with tears in her eyes. "I have chest pain, neck pain, back pain, a rash on my face, and my eyes feel hot. Also, I'm constipated, I'm nauseous, and I'm losing weight because I have no appetite. And the veins in my hands feel hot." She grabbed my hand as if to demonstrate the feverish heat of her fingers, which actually felt cool to the touch. Her husband sat on the exam table watching our interaction gravely as she enumerated her myriad symptoms.
Leaving the exam room, I went back to the office briefly, sat down, and literally lay my head on the desk, despairing over the fact that I had nothing to say to this tearful woman amidst her calamity of medical symptoms. Gathering my wits, I returned to the exam room, offered some supportive counseling, secured her an afternoon appointment with her doctor, and sent her home to rest for a few hours.
Did someone say compassion fatigue? This Monday morning onslaught of unresolvable circumstances in the face of multiple chronic illnesses and exhausted apathy seemed to wear on my soul like a grindstone. It was a day when my ability to be annoyed or have my patience worn thin was as raw as I could imagine it to be. (How may days until that leave of absence?)
Patience worn thin
compassion meter maladjusted,
crispy nurse lurches
towards rest
for the weary caregiver's soul.
My first patient of the day was a 10am home visit to someone who lives in the subsidized housing near the clinic. I strolled through the lovely autumn morning and rang the bell, riding the rickety elevator to the third floor. My patient hangs out at a local community center, drinks what I fear is far too many beers on the weekends, and has personal hygiene which leaves much to be desired. Just last month, I visited and checked through her medications, noting that most of the prescriptions were dated from June of this year and had not been refilled since. Just to be sure, I called her pharmacy, and lo and behold, she has not filled a prescription in five months. With asthma, hypertension, high cholesterol, and a host of other chronic conditions, some of these medications are crucial to her well-being and survival.
"So," I began, "I see you haven't been taking your medications."
"Oh yes," she responded. "I take them every day like you taught me."
I shake my head. "Now, how can that be?" I ask, "when all of these prescriptions were filled in June and you haven't been back to the pharmacy since?"
She was speechless, stammered an excuse, and looked away.
"Look," I said. "These medications are not for my health, they're for yours. Either take them or not, but don't tell me what you think I want to hear. Tell me the truth."
"I'll start taking them all tomorrow, I promise," she said, putting out her hand for me to shake.
"We can shake," I said, "but I don't believe you today. We've done this before. See you next month."
"I love you," she said as I left her apartment, one of the few English phrases she knows.
I returned to the office, feeling angry that my months of work with her had done so little to effect her consciousness vis-a-vis her health. I drank a cup of coffee and went out to the waiting room to assess a patient who came in to see me without an appointment.
"I'm so anxious and depressed," she said with tears in her eyes. "I have chest pain, neck pain, back pain, a rash on my face, and my eyes feel hot. Also, I'm constipated, I'm nauseous, and I'm losing weight because I have no appetite. And the veins in my hands feel hot." She grabbed my hand as if to demonstrate the feverish heat of her fingers, which actually felt cool to the touch. Her husband sat on the exam table watching our interaction gravely as she enumerated her myriad symptoms.
Leaving the exam room, I went back to the office briefly, sat down, and literally lay my head on the desk, despairing over the fact that I had nothing to say to this tearful woman amidst her calamity of medical symptoms. Gathering my wits, I returned to the exam room, offered some supportive counseling, secured her an afternoon appointment with her doctor, and sent her home to rest for a few hours.
Did someone say compassion fatigue? This Monday morning onslaught of unresolvable circumstances in the face of multiple chronic illnesses and exhausted apathy seemed to wear on my soul like a grindstone. It was a day when my ability to be annoyed or have my patience worn thin was as raw as I could imagine it to be. (How may days until that leave of absence?)
Patience worn thin
compassion meter maladjusted,
crispy nurse lurches
towards rest
for the weary caregiver's soul.
Sunday, October 21, 2007
Time for a Break, Damn the Torpedos
Quite recently, I wrote that burnout had come to visit, and I was uncertain of what to do. That despair of not knowing has given away to the simple realization that something had to be done, and that has led me to make the decision to take a unpaid leave of absence in the interest of my mental, spiritual, emotional, and physical health. For a hard-working, dedicated, and relatively codependent nurse, the decision to do something so dedicated to pure self-care is nothing short of a miracle (and I think my wife would agree wholeheartedly). But a leave of absence is something whose time has come, even if the bank account may feel quite differently.
Nurses are reknown for working until they drop, giving their all for patient care, and going down with the proverbial ship, damn the torpedos. Well, I have realized that the multiple torpedos of chronic pain, depression, grief, and reactivated PTSD are enough to warrant some serious self-care, and I'm the only one who can make it happen (with a little prodding from "The Missus").
When unfathomable stress couples with an untenable workload, no accrued time off, and personal issues crying out for succor, a decision to abandon self-care at such a crucial time is tantamount to suicide. As I have felt myself slip into a coma of denial and stress-induced despair, there has been a simulataneous realization that if I do not intervene on my own behalf, more debilitating chronic illness---beyond my current health challenges---may force a permanent leave of absence in the future, complete with permanent disability and loss of function. Therefore, in the interest of self-preservation and my own well-being, something has got to give, and work seems like the best candidate to be jettisoned.
In terms of my own attachments and aforementioned codependence, concerns over the well-being of my patients and my colleagues abound. I worry over how my colleagues will cope in my absence. I experience anticipatory guilt over the burdens they will bear. I worry about my patients, their feelings of abandonment, as well as the fact that after a five-week break, I just may not be able to face the rigors of my challenging job anew. All that taken into consideration, there is no denying that I have no choice but to choose my own health over any mechanism of denial which I can fabricate. The time has come, and I have to take a stand for myself.
There is a huge leap of faith involved in taking a step towards healing. There is also an enormous well of self-preservation that begs me to act before it's too late. Luckily, I have the support and wherewithal to be able to relinquish a month's pay in pursuit of personal healing, and I am grateful for that luxury which many others could never achieve. I hope to use my time wisely, and make some decisions from a place of calm.
I intend to use this forum to process my experience, describe my struggles, and elucidate the path upon which I'm embarking. Please come along for the ride---I could use the company.
Nurses are reknown for working until they drop, giving their all for patient care, and going down with the proverbial ship, damn the torpedos. Well, I have realized that the multiple torpedos of chronic pain, depression, grief, and reactivated PTSD are enough to warrant some serious self-care, and I'm the only one who can make it happen (with a little prodding from "The Missus").
When unfathomable stress couples with an untenable workload, no accrued time off, and personal issues crying out for succor, a decision to abandon self-care at such a crucial time is tantamount to suicide. As I have felt myself slip into a coma of denial and stress-induced despair, there has been a simulataneous realization that if I do not intervene on my own behalf, more debilitating chronic illness---beyond my current health challenges---may force a permanent leave of absence in the future, complete with permanent disability and loss of function. Therefore, in the interest of self-preservation and my own well-being, something has got to give, and work seems like the best candidate to be jettisoned.
In terms of my own attachments and aforementioned codependence, concerns over the well-being of my patients and my colleagues abound. I worry over how my colleagues will cope in my absence. I experience anticipatory guilt over the burdens they will bear. I worry about my patients, their feelings of abandonment, as well as the fact that after a five-week break, I just may not be able to face the rigors of my challenging job anew. All that taken into consideration, there is no denying that I have no choice but to choose my own health over any mechanism of denial which I can fabricate. The time has come, and I have to take a stand for myself.
There is a huge leap of faith involved in taking a step towards healing. There is also an enormous well of self-preservation that begs me to act before it's too late. Luckily, I have the support and wherewithal to be able to relinquish a month's pay in pursuit of personal healing, and I am grateful for that luxury which many others could never achieve. I hope to use my time wisely, and make some decisions from a place of calm.
I intend to use this forum to process my experience, describe my struggles, and elucidate the path upon which I'm embarking. Please come along for the ride---I could use the company.
Monday, October 15, 2007
The Calculus of Burn-Out
It's time to face the facts. Burn-out and compassion fatigue are taking hold. Work is taking it's toll. The days are feeling heavy and the burdens of the day even heavier. Caring is hard work, and the burden of such caring can further weigh on one's soul. Subjected to the trauma and suffering of others on a daily basis, the emotional cost of such work is considerable. Calculate into the equation the physical effects of stress and its ramifications, and one crispy nurse results.
What to do under such circumstances? How to assuage the deep soul fatigue that plagues the earnest nurse? When no vacation time or sick time is available and the additional stress of the holidays approaches, where does one turn? When chronic pain, diminishing health, and depression bite at one's heels, what decisions can be made to turn the proverbial table?
These are the questions I ask myself today. Answers will, no doubt, be forthcoming.
What to do under such circumstances? How to assuage the deep soul fatigue that plagues the earnest nurse? When no vacation time or sick time is available and the additional stress of the holidays approaches, where does one turn? When chronic pain, diminishing health, and depression bite at one's heels, what decisions can be made to turn the proverbial table?
These are the questions I ask myself today. Answers will, no doubt, be forthcoming.
Thursday, October 11, 2007
Clinical Conundrum
The scenario is not easy: a hearing-impaired, cognitively-impaired patient with a history of undocumented head injury is newly diagnosed with diabetes. He now has no local family, the last family member having moved out of state three months ago. Due to the lack of documentation and the fact that the patient has only been in the U.S. for several years, I have no access to any medical records which will allow him eligibility for the Department of Mental Health, the Department of Mental Retardation, or the state head injury program. He is able to basically care for himself and does not need personal care. The only services I have been able to cobble together is a homemaker for three hours per week. He has no car, no friend with a car, and lives relatively far from the nearest supermarket. He also has a very limited income.
How do I teach someone with such a low educational level and cognitive deficits how to change his diet and lifestyle in the face of a new diagnosis of diabetes? How do I educate an individual who is functionally illiterate to read ingredient and nutrition labels on groceries before purchasing them? Like many inner-city residents, he generally shops at small, local grocery stores which carry a limited selection of foods at considerably higher prices. The nearest supermarket is a significant distance, and my patient cannot carry two heavy bags of groceries very far. As food costs rise with the price of fuel, his limited resources are squeezed, and his food stamp benefit has not risen---and will not rise---to accommodate the increased prices at the supermarket. Unfortunately, food pantries generally distribute canned and packaged foods high in sodium, added sugar and carbohydrates---just what a new diabetic does not need in his diet as he tries to make new choices.
Speaking of choices, what are mine? Let him flounder in a food desert? Commit to taking him to the grocery store each month when his check arrives? Push for further neuropsychological and cognitive testing with the bleak hope of increasing his chances for admission to a head injury program? The options are limited and the task is Herculean.
These are the types of scenarios over which the earnest nurse loses sleep.
How do I teach someone with such a low educational level and cognitive deficits how to change his diet and lifestyle in the face of a new diagnosis of diabetes? How do I educate an individual who is functionally illiterate to read ingredient and nutrition labels on groceries before purchasing them? Like many inner-city residents, he generally shops at small, local grocery stores which carry a limited selection of foods at considerably higher prices. The nearest supermarket is a significant distance, and my patient cannot carry two heavy bags of groceries very far. As food costs rise with the price of fuel, his limited resources are squeezed, and his food stamp benefit has not risen---and will not rise---to accommodate the increased prices at the supermarket. Unfortunately, food pantries generally distribute canned and packaged foods high in sodium, added sugar and carbohydrates---just what a new diabetic does not need in his diet as he tries to make new choices.
Speaking of choices, what are mine? Let him flounder in a food desert? Commit to taking him to the grocery store each month when his check arrives? Push for further neuropsychological and cognitive testing with the bleak hope of increasing his chances for admission to a head injury program? The options are limited and the task is Herculean.
These are the types of scenarios over which the earnest nurse loses sleep.
Tuesday, October 09, 2007
Post-Traumatic Workday Syndrome
It was in many ways a typical day following a three-day weekend. My voicemail was teeming with messages by the time I sat down at my desk at 9:15am. Emails were summarily ignored until the afternoon. The phone rang as if it had a mind of its own, and patients---whether scheduled to see me or not---seemed to be in the waiting room of the clinic every time I passed through. At one point, as I walked through the waiting room to find a patient for a scheduled visit, I was literally accosted by three other patients who "just happened" to be lying in wait nearby. I was like a zebra trying to skirt around the edges of the oasis and not be seen by the predators in the grass. But, like the zebra, I am all too noticeable in my environment, and surreptitiousness is next to impossible.
By noon, my head was swimming, and I heard a small voice in my head calling for nutrition---anything to keep the engine going. Buried in paperwork and charts and partially completed tasks, I skipped the microwave and ate my leftovers at room temperature (a common practice, and probably healthier, if you believe the rumors about the dangers of microwaved food). Luckily, a patient scheduled to see me in the clinic at noon was a no-show, since I had double-booked myself for a home visit to another patient at the same time. As I force-fed myself my lunch, I called patient #2 and said I'd be 30 minutes late. (He may be unemployed and disabled, but his time is valuable, too.)
Three o'clock, and the pace slackened only briefly before starting up again just before 4, and it was all I could do to get out the door to pick up Mary down the street at the Senior Center by 5:15, knowing I had a meeting at home for the Medical Reserve Corps of my town for which I volunteer my services. Leaving the office, I knew full well that there were more than fifteen unfinished visit notes in my bag, a number which will only be further increased as soon as I hit the tarmac tomorrow. Will I finish those notes tonight before bed or tomorrow at breakfast? It's possible, but the trauma of the day may only lend itself to a swim, a snack, and retirement to the oh-so-needed bed. (Did someone say "retirement"?)
That said, the remaining business of the day will need to simply fade to the background, or my unfinished work will only interrupt and short-circuit my need for restful sleep. How to turn it off? That is a life's work in and of itself, and tonight is a good opportunity to practice letting go.
By noon, my head was swimming, and I heard a small voice in my head calling for nutrition---anything to keep the engine going. Buried in paperwork and charts and partially completed tasks, I skipped the microwave and ate my leftovers at room temperature (a common practice, and probably healthier, if you believe the rumors about the dangers of microwaved food). Luckily, a patient scheduled to see me in the clinic at noon was a no-show, since I had double-booked myself for a home visit to another patient at the same time. As I force-fed myself my lunch, I called patient #2 and said I'd be 30 minutes late. (He may be unemployed and disabled, but his time is valuable, too.)
Three o'clock, and the pace slackened only briefly before starting up again just before 4, and it was all I could do to get out the door to pick up Mary down the street at the Senior Center by 5:15, knowing I had a meeting at home for the Medical Reserve Corps of my town for which I volunteer my services. Leaving the office, I knew full well that there were more than fifteen unfinished visit notes in my bag, a number which will only be further increased as soon as I hit the tarmac tomorrow. Will I finish those notes tonight before bed or tomorrow at breakfast? It's possible, but the trauma of the day may only lend itself to a swim, a snack, and retirement to the oh-so-needed bed. (Did someone say "retirement"?)
That said, the remaining business of the day will need to simply fade to the background, or my unfinished work will only interrupt and short-circuit my need for restful sleep. How to turn it off? That is a life's work in and of itself, and tonight is a good opportunity to practice letting go.
Thursday, October 04, 2007
A Sweet Epidemic
I looked at the test results and knew immediately what it illustrated---my patient is diabetic. Not only is this patient newly diagnosed, I have been directly involved in diagnosing four new diabetics this year alone. Diabetes, along with morbid obesity, is truly an American epidemic, and the Latino community is most likely the hardest hit.
According to the New York Times, public health officials are expecting "a huge wave of new cases (that) could overwhelm the public health system and engulf growing numbers of the young, creating a city where hospitals are swamped by the disease's handiwork, (and) schools scramble for resources as they accommodate diabetic children." And just imagine the effect on the workforce, productivity, and the cost of healthcare.
With a food supply imbued with fats and sugars, a growing population of obese, poorly educated and poverty-stricken citizens, and a society which thrives on convenience, speed, and a sedentary life on remote control, the stage is set for an epidemic of proportions never before imagined. As Americans become sicker and more disabled, and a larger portion of the society reaches old age, healthcare premiums and the cost of healthcare in general could very well outstrip the ability to properly care for those aging with chronic illness.
Disparities in how healthcare dollars are spent play a large role in the tactics used to improve public health and educate the populace. According to the same New York Times article mentioned above, 1,000 New Yorkers were infected with TB last year in the face of a $27 million expenditure on TB prevention and treatment. Meanwhile, with diabetes expected to engulf more than 1 million New Yorkers in short order, New York allots less than $1 million for diabetes education and outreach each year. There is a calculus of scale when dealing with disease, and we seem to be failing the class miserably.
The American Diabetes Association estimates that the cost to the nation for the care of individuals with diabetes in 2002 amounted to approximately $132 billion. For the treatment of all cancers combined, the country spent approximately $171 billion that same yeat. Simple math will tell anyone paying close enough attention that the epidemic of obesity and diabetes in America must be brought under control, or we will have a public health nightmare beyond our wildest dreams within a generation.
So, when I educate my patient about his new diagnosis of diabetes, I am not just doing it for him. Of course, I share with my patient the goal of a long and healthy life free from the ravages of an insidious and potentially fatal chronic disease. More broadly, I strive to also keep him healthy for the good of the society, the healthcare system, the economy, and the future care of others who will some day need to benefit from high quality healthcare just as he does now. The sugar coursing through his blood does its damage quite silently, and it is my job to partner with my patient so that he does not become just one more statistic related to the development of avoidable kidney damage and preventable blindness.
When it comes to this new 21st-century epidemic of diabetes and obesity, the current news---and the predictions for the future of American health and healthcare---is anything but sweet.
According to the New York Times, public health officials are expecting "a huge wave of new cases (that) could overwhelm the public health system and engulf growing numbers of the young, creating a city where hospitals are swamped by the disease's handiwork, (and) schools scramble for resources as they accommodate diabetic children." And just imagine the effect on the workforce, productivity, and the cost of healthcare.
With a food supply imbued with fats and sugars, a growing population of obese, poorly educated and poverty-stricken citizens, and a society which thrives on convenience, speed, and a sedentary life on remote control, the stage is set for an epidemic of proportions never before imagined. As Americans become sicker and more disabled, and a larger portion of the society reaches old age, healthcare premiums and the cost of healthcare in general could very well outstrip the ability to properly care for those aging with chronic illness.
Disparities in how healthcare dollars are spent play a large role in the tactics used to improve public health and educate the populace. According to the same New York Times article mentioned above, 1,000 New Yorkers were infected with TB last year in the face of a $27 million expenditure on TB prevention and treatment. Meanwhile, with diabetes expected to engulf more than 1 million New Yorkers in short order, New York allots less than $1 million for diabetes education and outreach each year. There is a calculus of scale when dealing with disease, and we seem to be failing the class miserably.
The American Diabetes Association estimates that the cost to the nation for the care of individuals with diabetes in 2002 amounted to approximately $132 billion. For the treatment of all cancers combined, the country spent approximately $171 billion that same yeat. Simple math will tell anyone paying close enough attention that the epidemic of obesity and diabetes in America must be brought under control, or we will have a public health nightmare beyond our wildest dreams within a generation.
So, when I educate my patient about his new diagnosis of diabetes, I am not just doing it for him. Of course, I share with my patient the goal of a long and healthy life free from the ravages of an insidious and potentially fatal chronic disease. More broadly, I strive to also keep him healthy for the good of the society, the healthcare system, the economy, and the future care of others who will some day need to benefit from high quality healthcare just as he does now. The sugar coursing through his blood does its damage quite silently, and it is my job to partner with my patient so that he does not become just one more statistic related to the development of avoidable kidney damage and preventable blindness.
When it comes to this new 21st-century epidemic of diabetes and obesity, the current news---and the predictions for the future of American health and healthcare---is anything but sweet.
Thursday, September 27, 2007
In The Little City That Couldn't
In my city of employment---which I like to call "The Little City That Couldn't"---child poverty and infant mortality run rampant, as do drug abuse, violence, domestic violence, and crime. When measured against other small and medium-sized American cities, our little fiefdom is almost always ranked on the wrong end of the scale. Social service agencies abound, but is this little society truly being served?
Take mental health, for example. For our Medicaid patients, there is a small handful of behavioral health agencies which accept new patients. Most of these agencies have long waiting lists, and our patients in crisis often go without mental health services at the time that they truly need them. Due to the backlog of needy individuals, the local psychiatric emergency service is reknowned for turning away even the most blatantly suicidal patients. In a broken system, broken clients are served by broken clinicians employed by broken agencies which limp along on poor funding and frequent mismanagement. Sometimes, the streets seem to be teeming with the Walking Wounded, and we well-meaning clinicians who truly want to make a difference wring our hands in desperate impotence.
One of my patients desperately needs mental health treatment. This person would like to undergo treatment with Interferon and Ribavarin for chronic Hepatitis C, but the Interferon can cause debilitating depression and suicidality, thus, before beginning Interferon, the client must establish a relationship with a mental health professional. Unfortunately, there is at least a three-month wait for a mental health intake appointment. Following the intake, it could be another month or two before the client finally sits down with a new therapist. When it comes to seeing a psychiatrist or Clinical Nurse Specialist who can prescribe psychotropic medications, it may be another four months for that appointment. Sadly, due to our patients' frequently chaotic lives, missed appointments are all to common. If one too many appointments is missed, the client is put back on a waiting list and left to their own (often suboptimal) devices.
A broken city simply cannot provide a strong enough safety net for its neediest citizens, and our little city often falls flat on its face vis-a-vis this ultimate responsibility. Be it mental health, environmental safety, public safety, transportation, substance abuse treatment or housing, many American cities fall far short of what they should be able to provide. With billions spent to support a seemingly pointless (and endless) War on Terror, where even returning veterans with PTSD are left out in the cold, our cities struggle to meet even the most minimal of their responsibilities.
Here in the trenches of human service, we cling to whatever lifeboats we can find, as do our clients. At times, we succeed in saving those in our care. At other times, we watch as our unfortunate charges slip away on the currents of social problems too large for us to tackle alone. Occasionally, the vicious undertoe will obliterate a client, and we face our failures alone on the shore. In this Little City That Couldn't, each day is another opportunity for success or failure, and we simply accept that both potential outcomes are part and parcel of the day to day struggle.
Take mental health, for example. For our Medicaid patients, there is a small handful of behavioral health agencies which accept new patients. Most of these agencies have long waiting lists, and our patients in crisis often go without mental health services at the time that they truly need them. Due to the backlog of needy individuals, the local psychiatric emergency service is reknowned for turning away even the most blatantly suicidal patients. In a broken system, broken clients are served by broken clinicians employed by broken agencies which limp along on poor funding and frequent mismanagement. Sometimes, the streets seem to be teeming with the Walking Wounded, and we well-meaning clinicians who truly want to make a difference wring our hands in desperate impotence.
One of my patients desperately needs mental health treatment. This person would like to undergo treatment with Interferon and Ribavarin for chronic Hepatitis C, but the Interferon can cause debilitating depression and suicidality, thus, before beginning Interferon, the client must establish a relationship with a mental health professional. Unfortunately, there is at least a three-month wait for a mental health intake appointment. Following the intake, it could be another month or two before the client finally sits down with a new therapist. When it comes to seeing a psychiatrist or Clinical Nurse Specialist who can prescribe psychotropic medications, it may be another four months for that appointment. Sadly, due to our patients' frequently chaotic lives, missed appointments are all to common. If one too many appointments is missed, the client is put back on a waiting list and left to their own (often suboptimal) devices.
A broken city simply cannot provide a strong enough safety net for its neediest citizens, and our little city often falls flat on its face vis-a-vis this ultimate responsibility. Be it mental health, environmental safety, public safety, transportation, substance abuse treatment or housing, many American cities fall far short of what they should be able to provide. With billions spent to support a seemingly pointless (and endless) War on Terror, where even returning veterans with PTSD are left out in the cold, our cities struggle to meet even the most minimal of their responsibilities.
Here in the trenches of human service, we cling to whatever lifeboats we can find, as do our clients. At times, we succeed in saving those in our care. At other times, we watch as our unfortunate charges slip away on the currents of social problems too large for us to tackle alone. Occasionally, the vicious undertoe will obliterate a client, and we face our failures alone on the shore. In this Little City That Couldn't, each day is another opportunity for success or failure, and we simply accept that both potential outcomes are part and parcel of the day to day struggle.
Monday, September 24, 2007
Time (and Urine) Will Tell
"So," I say into the phone. "You were in the ER last night."
"Yeah," he replies. "I felt so sick. They sent me home after a while, though."
"Do you know that your urine came out positive for cocaine and alcohol?"
"Well, yeah. Let me be truthful," he replied. "I was in New York with my cousin, I was stressed out, and I did some cocaine. No lies, OK? Urine tests don't lie, and if I lie to you, I'm really just lying to myself, right?"
I took a deep breath. "Yes, that's right. Now, the other problem is that your urine came back negative for opiates. We've been prescribing you morphine for pain, and your urine should be positive for morphine. What happened there?"
"OK, OK. Like I said, I was in New York and forgot to bring my morphine. That led to me stressing out and doing the coke and alcohol. I know you're not gonna trust me now. I'll do any urine test you want, any day you want. I want to earn your trust back." He was pleading now.
"You just have to understand," I explained. "When we prescribe you morphine, we expect to see it in your urine. When your urine comes back negative for morphine and positive for cocaine, what do you think we suspect that you're doing with the morphine?"
"Selling it on the street to buy cocaine?" he answered faintly.
"Exactly! And that's a big no-no in our book, I'm afraid." I pause for effect. "The last thing a doctor wants is the medication he prescribes to end up being sold at the bus station, and believe me, alot of what we prescribe IS sold at the bus station."
He was worried now. "Look, I'm so sorry. I'll do whatever you want, but you can't cut my morphine off. My pain is still so bad. Tell Dr. ___________ that he can order any tests he wants. Please."
"Don't worry, we're not cutting you off yet. That would be cruel. But you've got work to do." I continued my diatribe. "There will certainly be urine tests, but they'll be random. And you can't say you can't make it when we call you to come down to the clinic. You signed a pain contract, so now you have to honor it."
"OK, OK. I'll do it. Tell the doctor I'll do it. I'll show you that this was a one-time thing."
"OK, just relax, and we'll talk to you soon. And stay out of trouble, y'hear?"
"Yeah. I'll talk to you soon." He hung up first.
I hung up the phone and took a deep breath. I hate these conversations. I also hate dealing with narcotics. I hate the whole system. Pain management is a total drag for the tired Nurse Care Manager, and narcotic diversion onto the streets haunts us daily. These are the times I play Good Cop/Bad Cop, and it's no fun for anyone, including me.
Was he telling the truth? Can I trust him? Will his subsequent toxicology screens be negative? My sense of hope and faith say yes, but only time (and urine) will tell.
"Yeah," he replies. "I felt so sick. They sent me home after a while, though."
"Do you know that your urine came out positive for cocaine and alcohol?"
"Well, yeah. Let me be truthful," he replied. "I was in New York with my cousin, I was stressed out, and I did some cocaine. No lies, OK? Urine tests don't lie, and if I lie to you, I'm really just lying to myself, right?"
I took a deep breath. "Yes, that's right. Now, the other problem is that your urine came back negative for opiates. We've been prescribing you morphine for pain, and your urine should be positive for morphine. What happened there?"
"OK, OK. Like I said, I was in New York and forgot to bring my morphine. That led to me stressing out and doing the coke and alcohol. I know you're not gonna trust me now. I'll do any urine test you want, any day you want. I want to earn your trust back." He was pleading now.
"You just have to understand," I explained. "When we prescribe you morphine, we expect to see it in your urine. When your urine comes back negative for morphine and positive for cocaine, what do you think we suspect that you're doing with the morphine?"
"Selling it on the street to buy cocaine?" he answered faintly.
"Exactly! And that's a big no-no in our book, I'm afraid." I pause for effect. "The last thing a doctor wants is the medication he prescribes to end up being sold at the bus station, and believe me, alot of what we prescribe IS sold at the bus station."
He was worried now. "Look, I'm so sorry. I'll do whatever you want, but you can't cut my morphine off. My pain is still so bad. Tell Dr. ___________ that he can order any tests he wants. Please."
"Don't worry, we're not cutting you off yet. That would be cruel. But you've got work to do." I continued my diatribe. "There will certainly be urine tests, but they'll be random. And you can't say you can't make it when we call you to come down to the clinic. You signed a pain contract, so now you have to honor it."
"OK, OK. I'll do it. Tell the doctor I'll do it. I'll show you that this was a one-time thing."
"OK, just relax, and we'll talk to you soon. And stay out of trouble, y'hear?"
"Yeah. I'll talk to you soon." He hung up first.
I hung up the phone and took a deep breath. I hate these conversations. I also hate dealing with narcotics. I hate the whole system. Pain management is a total drag for the tired Nurse Care Manager, and narcotic diversion onto the streets haunts us daily. These are the times I play Good Cop/Bad Cop, and it's no fun for anyone, including me.
Was he telling the truth? Can I trust him? Will his subsequent toxicology screens be negative? My sense of hope and faith say yes, but only time (and urine) will tell.
Friday, September 21, 2007
Violation
We arrived to this scenario yesterday morning. After months of partially smashed windows, we finally had our first office break-in. The intruders made off with a computer. They didn't have much time once they tripped the alarm.
Last year, a colleague at a neighboring agency was shot in the shoulder when she was caught in gang-related crossfire.
As one of my Latina colleagues quipped, "That's life in The Ghetto, people. Get over it."
Saturday, September 15, 2007
The Pain of Reentry
How does one reenter daily life following a life-changing event like a death? Beyond that, reentering the workplace is perhaps the most challenging of all. Woe to the grieving worker who has not neatly sown up the grieving process before the following Monday at 9am!
Returning to work after a three-week absence to tend to my step-father's dying process and death, I gingerly returned to work and was immediately dizzied by the frantic comings and goings of my colleagues. Standing in the office on my first day back to work, it seemed as if I was a reluctant swimmer poised on the edge of a raging river, considering touching my toe to the water yet highly aware that the undertow would drag me under at my first sign of surrender to its horizontal power.
Of course, my compassionate colleagues welcomed me with hugs and kisses and offers of assistance. Several individuals went out of their way by offering concrete tasks which they could shoulder: filling med boxes for my more dependent patients, making phone calls I was reluctant to place. Still, as I sat at my desk, the cobwebs of absence began to clear, and the onrush of details needing attention quickly filled my brain which until that moment had been busy with other processes of a more personal nature.
Stepping (however reluctantly) into the rapids of the workplace, I realized quite readily that my colleagues' stress and my patients' neediness neither lessened nor took a break while I was otherwise engaged with family. Our "disability care management" office is without a doubt a rushing rapid of information and nursing care which has a laudable goal of keeping the most disabled and chronically ill inner-city patients aligned with the overarching pursuit of preventive health, self-care, and crisis management. In pursuit of that goal, we nurses, nurse practitioners, and medical assistants bend over backwards, often pulling out our hair in order to deliver the quality care which we see as necessary to the well-being of our patients. That said, in order to accomplish this goal, it seems widely accepted that our workplace must function like a battleship at full bore, the ammunition (of health) at the ready, and the crew in a constant state of hypervigilant combat against disability, addiction, disease, and poverty. In delivering such care, the caregivers wear themselves pretty thin.
So, in walks the bereaved nurse, fresh from a parent's illness and ultimate death, still reeling with emotion and saturated with stories of my own family's newest evolution. At 9:00 on Monday morning, I again took on the yoke of the needs of more than eighty people, fifty of whom consider me their first line of defense for most any situation related to their health and well-being. And a yoke it seems.
For more than two weeks, the travails of my patients (and my colleagues who cared for them in my absence) were shadows which would flit across my consciousness, yet danced on the periphery of my mind. With the care of my step-father and coordination of his own care team as a top priority, the worries of the workplace slowly sank to the bottom of my cognitive well. However, even as my enfeebled brain again made attempts to grasp the enormity of the task before me, this first week back was an enormous challenge, and the journey from Monday to Friday seemed at first Herculean, but ultimately felt most Sisyphean.
The boulder is now at rest during this blessed weekend, balanced delicately on my desk some twenty-one miles from our home, patiently awaiting my return. Come Monday, it will again be time to shoulder that burden, and also to continue to seek ways which will decrease said burden's impact on my physical health, grieving process, and emotional well-being.
Yes, the reentry is difficult. When the Space Shuttle is reentering the earth's orbit, the fires of the atmosphere will put the Shuttle's outer layer of protective skin to the ultimate test. That skin is all that protects the astronauts within from the searing and destructive heat of the earth's gaseous envelope. And so for me, my emotional "skin" is what similarly protects me from the vicissitudes of nursing practice, the double (and at times paradoxical) challenge of embodying the noble goal of self-care while I deliver care to others in need.
This Saturday evening, I am grateful for the weekend, for the winds of late summer, for the fickle September weather, for the peace that home affords, for the love that buoys me in times of trouble. I also give thanks for the skin which protects me from the elements, be they emotional or physical in nature.
Dying is hard work, but the dying person is eventually (and thankfully) released from that process, moving beyond all notions of corporeal suffering. But here on earth, the grieving must release themselves from their suffering, all the while maintaining the activities which keep home and hearth upright and functional. And here is the challenge: grieve, move beyond the loss, enter a new relationship with the dead, and embrace life anew.
Returning to work after a three-week absence to tend to my step-father's dying process and death, I gingerly returned to work and was immediately dizzied by the frantic comings and goings of my colleagues. Standing in the office on my first day back to work, it seemed as if I was a reluctant swimmer poised on the edge of a raging river, considering touching my toe to the water yet highly aware that the undertow would drag me under at my first sign of surrender to its horizontal power.
Of course, my compassionate colleagues welcomed me with hugs and kisses and offers of assistance. Several individuals went out of their way by offering concrete tasks which they could shoulder: filling med boxes for my more dependent patients, making phone calls I was reluctant to place. Still, as I sat at my desk, the cobwebs of absence began to clear, and the onrush of details needing attention quickly filled my brain which until that moment had been busy with other processes of a more personal nature.
Stepping (however reluctantly) into the rapids of the workplace, I realized quite readily that my colleagues' stress and my patients' neediness neither lessened nor took a break while I was otherwise engaged with family. Our "disability care management" office is without a doubt a rushing rapid of information and nursing care which has a laudable goal of keeping the most disabled and chronically ill inner-city patients aligned with the overarching pursuit of preventive health, self-care, and crisis management. In pursuit of that goal, we nurses, nurse practitioners, and medical assistants bend over backwards, often pulling out our hair in order to deliver the quality care which we see as necessary to the well-being of our patients. That said, in order to accomplish this goal, it seems widely accepted that our workplace must function like a battleship at full bore, the ammunition (of health) at the ready, and the crew in a constant state of hypervigilant combat against disability, addiction, disease, and poverty. In delivering such care, the caregivers wear themselves pretty thin.
So, in walks the bereaved nurse, fresh from a parent's illness and ultimate death, still reeling with emotion and saturated with stories of my own family's newest evolution. At 9:00 on Monday morning, I again took on the yoke of the needs of more than eighty people, fifty of whom consider me their first line of defense for most any situation related to their health and well-being. And a yoke it seems.
For more than two weeks, the travails of my patients (and my colleagues who cared for them in my absence) were shadows which would flit across my consciousness, yet danced on the periphery of my mind. With the care of my step-father and coordination of his own care team as a top priority, the worries of the workplace slowly sank to the bottom of my cognitive well. However, even as my enfeebled brain again made attempts to grasp the enormity of the task before me, this first week back was an enormous challenge, and the journey from Monday to Friday seemed at first Herculean, but ultimately felt most Sisyphean.
The boulder is now at rest during this blessed weekend, balanced delicately on my desk some twenty-one miles from our home, patiently awaiting my return. Come Monday, it will again be time to shoulder that burden, and also to continue to seek ways which will decrease said burden's impact on my physical health, grieving process, and emotional well-being.
Yes, the reentry is difficult. When the Space Shuttle is reentering the earth's orbit, the fires of the atmosphere will put the Shuttle's outer layer of protective skin to the ultimate test. That skin is all that protects the astronauts within from the searing and destructive heat of the earth's gaseous envelope. And so for me, my emotional "skin" is what similarly protects me from the vicissitudes of nursing practice, the double (and at times paradoxical) challenge of embodying the noble goal of self-care while I deliver care to others in need.
This Saturday evening, I am grateful for the weekend, for the winds of late summer, for the fickle September weather, for the peace that home affords, for the love that buoys me in times of trouble. I also give thanks for the skin which protects me from the elements, be they emotional or physical in nature.
Dying is hard work, but the dying person is eventually (and thankfully) released from that process, moving beyond all notions of corporeal suffering. But here on earth, the grieving must release themselves from their suffering, all the while maintaining the activities which keep home and hearth upright and functional. And here is the challenge: grieve, move beyond the loss, enter a new relationship with the dead, and embrace life anew.
Thursday, September 13, 2007
Good News Always Welcome
In the midst of my personal struggles, I am very pleased to announce that the Nursing Online Education Database (NOEDb) has named the top 25 nursing blogs on the Internet, and Digital Doorway was rated #15. NOEDb apparently used third-party ratings from sites like Google and Technorati to rate the sites and gather objective data.
I am honored and humbled by being included in this list of excellent nurse bloggers, and it is moments like these that remind me that there are actually real people out there reading blogs, feeding this technological revolution in communication and connectivity. Blogging can often feel like a lonely venture, with few comments to bolster the blogger who sends missives out into the ethers in hopes of connection and readership. Thanks to all who read Digital Doorway, and please continue to support bloggers by visiting their sites and letting them know you're out there. And thanks again for visiting. After all, without readers, blogs are just more digital noise.
I am honored and humbled by being included in this list of excellent nurse bloggers, and it is moments like these that remind me that there are actually real people out there reading blogs, feeding this technological revolution in communication and connectivity. Blogging can often feel like a lonely venture, with few comments to bolster the blogger who sends missives out into the ethers in hopes of connection and readership. Thanks to all who read Digital Doorway, and please continue to support bloggers by visiting their sites and letting them know you're out there. And thanks again for visiting. After all, without readers, blogs are just more digital noise.
Wednesday, September 12, 2007
The Tool-Box
Following a life-altering experience, how does one reintegrate back into one's former life? When one has been living in an altered state, with "normal" daily life in suspended animation, how does one comfortably fit back into that daily routine? Superimpose the grieving process on that reintegration, and all bets are off.
Many of us are aware of the five classic "stages" of the grieving process: denial, anger, depression, bargaining, acceptance. But nothing is ever so cut and dry, and our emotional lives are varied and complex. For me, in this moment, there are various layers of exhaustion coloring my experience, my body slowly coming into some semblance of equilibrium. Powers of concentration and focus remain relatively unreliable, but hints of the balanced self peek through the haze. Patience is a virtue at this stage, both with others and one's self.
Grief comes in many guises, and it manifests in so many ways throughout the day. Circumspect self-care and self-awareness seem to be the best tools at my disposal. But the first step in using those tools is at least opening the tool-box. As Sogyal Rinpoche has said, "Our present condition, if we use it skillfully and with wisdom, can be an inspiration to free ourselves from the bondage of suffering."
Many of us are aware of the five classic "stages" of the grieving process: denial, anger, depression, bargaining, acceptance. But nothing is ever so cut and dry, and our emotional lives are varied and complex. For me, in this moment, there are various layers of exhaustion coloring my experience, my body slowly coming into some semblance of equilibrium. Powers of concentration and focus remain relatively unreliable, but hints of the balanced self peek through the haze. Patience is a virtue at this stage, both with others and one's self.
Grief comes in many guises, and it manifests in so many ways throughout the day. Circumspect self-care and self-awareness seem to be the best tools at my disposal. But the first step in using those tools is at least opening the tool-box. As Sogyal Rinpoche has said, "Our present condition, if we use it skillfully and with wisdom, can be an inspiration to free ourselves from the bondage of suffering."
Monday, September 10, 2007
The Dividends of Grieving
A brief quote from a line written in an email to my beloved siblings with whom I share the bittersweet burden of mourning:
So, now for the work of grieving. The hourly pay is poor, but the dividends will be worth every moment invested. Remember, "unshed tears will make other organs weep."
So, now for the work of grieving. The hourly pay is poor, but the dividends will be worth every moment invested. Remember, "unshed tears will make other organs weep."
Sunday, September 09, 2007
The Universe of the Grieving
And now the grief settles into our bones. Mary and I have been complaining today of profound aches and pains, an experience which my sister shares. Our muscles are like stones which have lost the long-ago suppleness of soil. Our joints ache and creak like wintry tree limbs. We move through a syrup of feeling, even as we unpack the car, wash clothes, and attempt to resume "normal" life following the experience of a death.
Today we avoided a neighborhood picnic, lacking all motivation for superficial conversation and pleasantries. At the supermarket, we ducked in order to not encounter someone who we knew would only drain us with her narcissism. Tomorrow, I work from home, and Mary enjoys one more day of bereavement leave. Tuesday, we re-enter the proverbial rat-race, even as we continue to feel like we're still in a parallel universe, the Universe of the Grieving.
This special universe is inhabited by many, and even as some of us lose sight of it as we become enshrouded in the everyday world once more, a part of our heart remains in the Universe of the Grieving, holding the memories of our departed loved one in a special and tender place.
Pieces of my soul dwell permanently in the Universe of the Grieving, holding a spirit candle for my beloveds who have since left this earthly plane. The candle I burn for my step-dad glows most brightly, having only recently been lit. Some day another beloved's candle will be the newest one to grace my spirit altar, but for now his soul occupies the center of that most sacred space, and I send love and light to him as he claims his most righteous prize.
Today we avoided a neighborhood picnic, lacking all motivation for superficial conversation and pleasantries. At the supermarket, we ducked in order to not encounter someone who we knew would only drain us with her narcissism. Tomorrow, I work from home, and Mary enjoys one more day of bereavement leave. Tuesday, we re-enter the proverbial rat-race, even as we continue to feel like we're still in a parallel universe, the Universe of the Grieving.
This special universe is inhabited by many, and even as some of us lose sight of it as we become enshrouded in the everyday world once more, a part of our heart remains in the Universe of the Grieving, holding the memories of our departed loved one in a special and tender place.
Pieces of my soul dwell permanently in the Universe of the Grieving, holding a spirit candle for my beloveds who have since left this earthly plane. The candle I burn for my step-dad glows most brightly, having only recently been lit. Some day another beloved's candle will be the newest one to grace my spirit altar, but for now his soul occupies the center of that most sacred space, and I send love and light to him as he claims his most righteous prize.
Friday, September 07, 2007
Ashes to Ashes
This afternoon, I went to the funeral home and picked up my step-father's ashes. A small, compact container wrapped tightly in cardboard and sealed with official notification of its contents weighed heavily in my arms as I carried it down the steps.
Once in my car, I sat in the driver's seat and hugged that box to my chest, breathing quietly, feeling its weight in my lap. When I was ready, I placed the box gingerly on the passenger seat, and began to drive back towards my mother's house, where I would deliver her beloved husband's remains into her trembling hands. During that ride, I rested my right hand on top of the little box, just as I might rest my hand on my son's shoulder.
About half-way home, I realized that I was carefully avoiding bumps and pot-holes, gingerly taking turns, as if a fragile and easily damaged cargo sat beside me. Perhaps that fragile cargo was actually my own heart, heavy with grief, relieved that his suffering was over, and worried for my mother's future and well-being. Carrying those ashes was like being a solitary pall-bearer, shouldering a container whose contents were undeniably heavy, but whose ultimate goal was lightness and the shedding of the physical body's weight.
Resting that box on the piano in the living room after everyone had a chance to feel its weight, it was so very apparent that he is not actually in that box. What is in that box is simply the remains of a body, a vessel, a vehicle that propelled that soul through this life for eighty years. That soul, that spirit, is now free, roaming a world of which we can only dream. Blessings on that soul, even as the ashes and dust and bone fragments which remain with us are scattered to the winds of the earth.
Tomorrow, we celebrate that soul's accomplishments and that body's life on earth. And then we move on without him at our side, but with him always in our hearts.
Once in my car, I sat in the driver's seat and hugged that box to my chest, breathing quietly, feeling its weight in my lap. When I was ready, I placed the box gingerly on the passenger seat, and began to drive back towards my mother's house, where I would deliver her beloved husband's remains into her trembling hands. During that ride, I rested my right hand on top of the little box, just as I might rest my hand on my son's shoulder.
About half-way home, I realized that I was carefully avoiding bumps and pot-holes, gingerly taking turns, as if a fragile and easily damaged cargo sat beside me. Perhaps that fragile cargo was actually my own heart, heavy with grief, relieved that his suffering was over, and worried for my mother's future and well-being. Carrying those ashes was like being a solitary pall-bearer, shouldering a container whose contents were undeniably heavy, but whose ultimate goal was lightness and the shedding of the physical body's weight.
Resting that box on the piano in the living room after everyone had a chance to feel its weight, it was so very apparent that he is not actually in that box. What is in that box is simply the remains of a body, a vessel, a vehicle that propelled that soul through this life for eighty years. That soul, that spirit, is now free, roaming a world of which we can only dream. Blessings on that soul, even as the ashes and dust and bone fragments which remain with us are scattered to the winds of the earth.
Tomorrow, we celebrate that soul's accomplishments and that body's life on earth. And then we move on without him at our side, but with him always in our hearts.
Tuesday, September 04, 2007
Unfolding the Days of Mourning
When someone dies, we take a breath and realize that a new chapter has begun. Where before we cleaned the commode and wiped a sweaty brow, now we sift through memories and personal effects. Where before we concerned ourselves with medications and symptoms, now we examine legal necessities and paperwork. While our loved one was living while dying, we were also living through their dying process, slowly letting go of the old earthly relationship as we opened to a less corporeal connection which loomed large in our future. As our loved one's eyes began to focus beyond us in their softening gaze, we looked more and more closely for the subtle changes that might portend the end being near.
Once the body has been removed from the home and the hospital bed and other equipment as well, one must take stock of the space where the loved one lived and died, and accept that their physical presence in that space is now a thing of the past.
Next come the personal effects. A watch. A money clip. A ring. A necklace. The trousers hang in the closet, pockets still filled with the normal flotsam and jetsam of a life: wallet, keys, change, mints, candies usually carried for bank tellers and cashiers in stores, a handkerchief.
And then there are the clothes that hang in the closet, bereft of the body which once filled them. The shirts pine for a beating heart. The pants wish for legs to crease and bend them. The socks sit alone alongside the underwear and undershirts. The ties and belts dangle sadly like plants in a hanging garden. But a new life awaits them.
Food begins to arrive from caring friends and family. The phone is rarely at rest. Arrangements are made, and plans created. Activity is a welcome relief from the heaviness of mourning, yet too much activity can also preclude one's feelings being actively felt.
On the physical side, one must ask simple questions. Are you eating? Are you hydrating? Can you sleep? Would exercise be a benefit to you now? A fine balance must be struck, whether it be emotionally, physically or spiritually. You walk a tightrope of emotional balance, and living friends and family offer guiding hands along the way.
Laughter, smiles, moments alone, moments in motion, the awareness of loss---they are all part and parcel of the unfolding of the days of mourning.
Once the body has been removed from the home and the hospital bed and other equipment as well, one must take stock of the space where the loved one lived and died, and accept that their physical presence in that space is now a thing of the past.
Next come the personal effects. A watch. A money clip. A ring. A necklace. The trousers hang in the closet, pockets still filled with the normal flotsam and jetsam of a life: wallet, keys, change, mints, candies usually carried for bank tellers and cashiers in stores, a handkerchief.
And then there are the clothes that hang in the closet, bereft of the body which once filled them. The shirts pine for a beating heart. The pants wish for legs to crease and bend them. The socks sit alone alongside the underwear and undershirts. The ties and belts dangle sadly like plants in a hanging garden. But a new life awaits them.
Food begins to arrive from caring friends and family. The phone is rarely at rest. Arrangements are made, and plans created. Activity is a welcome relief from the heaviness of mourning, yet too much activity can also preclude one's feelings being actively felt.
On the physical side, one must ask simple questions. Are you eating? Are you hydrating? Can you sleep? Would exercise be a benefit to you now? A fine balance must be struck, whether it be emotionally, physically or spiritually. You walk a tightrope of emotional balance, and living friends and family offer guiding hands along the way.
Laughter, smiles, moments alone, moments in motion, the awareness of loss---they are all part and parcel of the unfolding of the days of mourning.
Monday, September 03, 2007
Death's Labor Pains on Labor Day
Today at 4:10pm, my beloved step-father left this world as we surrounded his bed to witness his final breaths. As he moved through the stages of the dying process over the last 48 hours, I became more and more certain that the end was drawing ever closer, perhaps more rapidly than I originally surmised it might. His struggle to allow his spirit to leave his body was truly like labor, and we were the midwives and cheerleaders along his triumphant road to freedom.
Just as it happens around the world at every hour under the sun, people came and went from my parents' home over these last days, and we all played our parts in the unfolding drama according to our individual roles and skills. My step-father's lovely daughters, sons-in-law, granddaughter, and great-grandchildren all added to the quality of the times shared under this roof, and his final days were filled with loving visits and calming energy. One visitor, a Stephen Minister by vocation, remarked that Spirit was "just pouring through the house", and he praised our little home hospice with words of benediction.
Losing myself in the minutiae of my step-dad's hourly care, I realized that my grieving process was being (somewhat necessarily) truncated by my self-imposed duties of conductor, coordinator, choreographer, and caregiver. Even as others found moments to cry, my reservoir was seemingly dry. But when the moment came and he took his final breath, we all huddled around the bed, and the tears and sobs came in torrents, releasing days of unexpressed stress and grief. It is said that "unshed tears will make other organs weep". I wrung some organs dry today, so to speak, and now I can sleep the rest of the exhausted along with the rest of our family.
His death was a fine one, navigated with grace, dignity, and a collective benevolence of spirit. Now we can be certain that our dear loved one is winging his way to a place of deserved beauty and peace, and our efforts here on Earth sent him with enormous love to fuel his journey.
Just as it happens around the world at every hour under the sun, people came and went from my parents' home over these last days, and we all played our parts in the unfolding drama according to our individual roles and skills. My step-father's lovely daughters, sons-in-law, granddaughter, and great-grandchildren all added to the quality of the times shared under this roof, and his final days were filled with loving visits and calming energy. One visitor, a Stephen Minister by vocation, remarked that Spirit was "just pouring through the house", and he praised our little home hospice with words of benediction.
Losing myself in the minutiae of my step-dad's hourly care, I realized that my grieving process was being (somewhat necessarily) truncated by my self-imposed duties of conductor, coordinator, choreographer, and caregiver. Even as others found moments to cry, my reservoir was seemingly dry. But when the moment came and he took his final breath, we all huddled around the bed, and the tears and sobs came in torrents, releasing days of unexpressed stress and grief. It is said that "unshed tears will make other organs weep". I wrung some organs dry today, so to speak, and now I can sleep the rest of the exhausted along with the rest of our family.
His death was a fine one, navigated with grace, dignity, and a collective benevolence of spirit. Now we can be certain that our dear loved one is winging his way to a place of deserved beauty and peace, and our efforts here on Earth sent him with enormous love to fuel his journey.
Sunday, September 02, 2007
One Year: Of Endings and Beginnings
I just posted this on Latter Day Sparks and decided to also post it here. Thanks for stopping by.
Today, September 2nd, 2007, at approximately 1pm, Sparkey will be dead one year. His body still rests in the earth just beside our house, but his spirit body moves in an entirely different dimension.
Even as we celebrate his life and honor the 12-month anniversary of his passing, we sit vigil here in New Jersey, comforting my beloved step-father as he moves into the final stages of the dying process himself. The details of Sparkey's passage are fresh in my mind, and at this time (10am) on September 2nd of last year, we were enjoying what we knew would be our final morning and afternoon on earth with our wonderful canine companion. It was a day of final events: the last walk, the last meal, the final treats from the mail carrier, loving visits from the neighbors, Sparkey bestowing a final kiss to a small child's face (our neighbors' newborn). And then, before we could catch our breath, the vet came, we administered the medications, and he died, crying a final tear from his left eye as we kissed him and told him how loved and lovely he truly was.
Now, on this very day, we watch as my step-father's breathing becomes erratic, with 5-second periods of apnea (the absence of breathing), followed by a succession of rapid breaths once again. Hints of a minimal rattle in the throat make themselves known from time to time, yet he then breathes normally again. There will be no doctor visiting today to administer a dose of medicine to end his struggle, to assuage his suffering. In our culture, our dogs' and cats' suffering is painlessly ended when it is seen to be the most humane act we can perform; yet our suffering human loved ones, whose quality of life has long since diminished to less than a shadow of its former self, must struggle and gasp until the end. Morphine assists the process and depresses respiration, but Tulane will not experience the sudden and painless release that Sparkey was so blessed to receive.
Speaking of Sparkey and Tulane, Sparkey has now visited Tulane twice over the last few months, the most recent visit being only several days ago. When my mother and my wife and I were finishing a conversation around Tulane's bed early last week, Tulane said, "I didn't want to interrupt your conversation, but Sparkey was just here. He came through the window and stood by my bed, looking at me, smiling and panting, and wagging his tail furiously." (We all noted that there was a chocolate-chip cookie on the bedside table and Sparkey may have been eying it from across the veil.) Tulane seemed very pleased by this visit, as he did by a similar visit several months ago when Sparkey entered through the closed front door and curled around Tulane's legs under the kitchen table. With each visit, Tulane describes being able to smell Sparkey in the air, and to smell him on his hand after petting his head, long after our favorite golden dog had left the scene.
So, we await Tulane's death, midwifing him through the process, even as we recognize and celebrate Sparkey's anniversary. It is a significant day in our lives, and its importance informs our every waking (and sleeping) moment.
Happy un-Birthday Sparkey! May you run and play and rest in a peaceful and wonderful world, and may you welcome Tulane when he is ready to join you there. We love you, Sparkey!
Today, September 2nd, 2007, at approximately 1pm, Sparkey will be dead one year. His body still rests in the earth just beside our house, but his spirit body moves in an entirely different dimension.
Even as we celebrate his life and honor the 12-month anniversary of his passing, we sit vigil here in New Jersey, comforting my beloved step-father as he moves into the final stages of the dying process himself. The details of Sparkey's passage are fresh in my mind, and at this time (10am) on September 2nd of last year, we were enjoying what we knew would be our final morning and afternoon on earth with our wonderful canine companion. It was a day of final events: the last walk, the last meal, the final treats from the mail carrier, loving visits from the neighbors, Sparkey bestowing a final kiss to a small child's face (our neighbors' newborn). And then, before we could catch our breath, the vet came, we administered the medications, and he died, crying a final tear from his left eye as we kissed him and told him how loved and lovely he truly was.
Now, on this very day, we watch as my step-father's breathing becomes erratic, with 5-second periods of apnea (the absence of breathing), followed by a succession of rapid breaths once again. Hints of a minimal rattle in the throat make themselves known from time to time, yet he then breathes normally again. There will be no doctor visiting today to administer a dose of medicine to end his struggle, to assuage his suffering. In our culture, our dogs' and cats' suffering is painlessly ended when it is seen to be the most humane act we can perform; yet our suffering human loved ones, whose quality of life has long since diminished to less than a shadow of its former self, must struggle and gasp until the end. Morphine assists the process and depresses respiration, but Tulane will not experience the sudden and painless release that Sparkey was so blessed to receive.
Speaking of Sparkey and Tulane, Sparkey has now visited Tulane twice over the last few months, the most recent visit being only several days ago. When my mother and my wife and I were finishing a conversation around Tulane's bed early last week, Tulane said, "I didn't want to interrupt your conversation, but Sparkey was just here. He came through the window and stood by my bed, looking at me, smiling and panting, and wagging his tail furiously." (We all noted that there was a chocolate-chip cookie on the bedside table and Sparkey may have been eying it from across the veil.) Tulane seemed very pleased by this visit, as he did by a similar visit several months ago when Sparkey entered through the closed front door and curled around Tulane's legs under the kitchen table. With each visit, Tulane describes being able to smell Sparkey in the air, and to smell him on his hand after petting his head, long after our favorite golden dog had left the scene.
So, we await Tulane's death, midwifing him through the process, even as we recognize and celebrate Sparkey's anniversary. It is a significant day in our lives, and its importance informs our every waking (and sleeping) moment.
Happy un-Birthday Sparkey! May you run and play and rest in a peaceful and wonderful world, and may you welcome Tulane when he is ready to join you there. We love you, Sparkey!
Saturday, September 01, 2007
The Constancy of Change
There are so many things to let go of in the course of one's lifetime. Friendships grow and fade, changing and evolving---or devolving---over time. Parents or other family members grow ill and die. Jobs are lost, careers dissolve and are reconstituted, money flows like water through one's hands. At times, tragedy strikes, and the letting go is sudden, ripping through the fabric of life like a knife, or bludgeoning one over the head with its intensity. But there is one constant, and that is change.
Loss often visits us at the most inconvenient times. We lose our job just as our child is starting college. Our car breaks down the day before we leave for vacation. A new diagnosis throws us into a medical tailspin. Depression rears its challenging head and we are derailed from our usual emotional composure. A sudden and unexpected expense drains our resources and we are financially drained almost overnight. Change---when unplanned---is certainly most inconvenient---with illness and death perhaps being the most unwanted changes of all.
How do we cope with change, especially that which is inherently unwanted and unsolicited? We read books which purport to assist the reader with such transitions in life. Bookstore shelves overflow with self-help books of all stripes, and Americans purchase scores of them, myself included. The Bible offers great comfort to many in times of change and challenge, and millions look towards its wisdom for both comfort and strength of spirit. Most recently, I have turned to several books, including When Things Fall Apart: Heart Advice for Difficult Times by Pema Chodron. While it is a Buddhist text, its message is universal and digestible by seekers of any faith.
How else do we cope with change? Psychotherapy, counseling, the church, the shoulder of a friend, alcohol and drugs, food, exercise, sleep, anger, television, denial, resistance---these are all places to which we turn, some obviously healthier than others. We encourage one another to turn to that which is nurturing and healthy, that which will add positively to our personal arsenal of coping mechanisms. Some become lost in addiction, others become lost in meaningless action---"filling time" without really living it. No one ever said it would be easy, and when we are in the thick of it, we realize that this alleged lack of ease is altogether true.
For myself, as I live through perhaps the most difficult time of my life so far---the impending death of a terminally ill parent---I strive to reach for that which is healthy and nurturing. When my best friend was murdered in 2001, post-traumatic stress took its toll, and recovery was slow and painful. An unexpected loss of that magnitude shook the foundations of my world in a way that was both shocking and painful. Now, I face this slow and incremental loss, and its impact---while no less enormous than the loss of my friend---is somewhat mitigated by the ability to begin preparing, to say goodbye, to come to terms, to accept that which is inevitable and unavoidable.
Heraclitus said "everything flows, nothing stands still. Nothing endures but change." This is a lesson which I strive to keep in mind as the winds of change, loss, and death buffet our family's ship. It is all we can do to hold onto the rails and ride the waves as they toss us about. Otherwise, we are thrown into the sea of uncertainty and groundless fear, where we are more likely to lose our way and be lost. And so, we cling to one another and to the ship of family and community, riding the swells until the sea is calm once more.
Loss often visits us at the most inconvenient times. We lose our job just as our child is starting college. Our car breaks down the day before we leave for vacation. A new diagnosis throws us into a medical tailspin. Depression rears its challenging head and we are derailed from our usual emotional composure. A sudden and unexpected expense drains our resources and we are financially drained almost overnight. Change---when unplanned---is certainly most inconvenient---with illness and death perhaps being the most unwanted changes of all.
How do we cope with change, especially that which is inherently unwanted and unsolicited? We read books which purport to assist the reader with such transitions in life. Bookstore shelves overflow with self-help books of all stripes, and Americans purchase scores of them, myself included. The Bible offers great comfort to many in times of change and challenge, and millions look towards its wisdom for both comfort and strength of spirit. Most recently, I have turned to several books, including When Things Fall Apart: Heart Advice for Difficult Times by Pema Chodron. While it is a Buddhist text, its message is universal and digestible by seekers of any faith.
How else do we cope with change? Psychotherapy, counseling, the church, the shoulder of a friend, alcohol and drugs, food, exercise, sleep, anger, television, denial, resistance---these are all places to which we turn, some obviously healthier than others. We encourage one another to turn to that which is nurturing and healthy, that which will add positively to our personal arsenal of coping mechanisms. Some become lost in addiction, others become lost in meaningless action---"filling time" without really living it. No one ever said it would be easy, and when we are in the thick of it, we realize that this alleged lack of ease is altogether true.
For myself, as I live through perhaps the most difficult time of my life so far---the impending death of a terminally ill parent---I strive to reach for that which is healthy and nurturing. When my best friend was murdered in 2001, post-traumatic stress took its toll, and recovery was slow and painful. An unexpected loss of that magnitude shook the foundations of my world in a way that was both shocking and painful. Now, I face this slow and incremental loss, and its impact---while no less enormous than the loss of my friend---is somewhat mitigated by the ability to begin preparing, to say goodbye, to come to terms, to accept that which is inevitable and unavoidable.
Heraclitus said "everything flows, nothing stands still. Nothing endures but change." This is a lesson which I strive to keep in mind as the winds of change, loss, and death buffet our family's ship. It is all we can do to hold onto the rails and ride the waves as they toss us about. Otherwise, we are thrown into the sea of uncertainty and groundless fear, where we are more likely to lose our way and be lost. And so, we cling to one another and to the ship of family and community, riding the swells until the sea is calm once more.
Friday, August 31, 2007
Wine and Roses
A week lapse in blogging due to extenuating circumstances, caring for a dying parent. Stranded in suburban purgatory without internet connection or any of my usual anchors.
Death comes slowly and inexorably. We all die in increments. From the day we are born we are moment by moment closer to the time of our death.
And what does this proximity to death mean? What does it portend?
I feel that it portends our deeply held need to live even more fully and to forgive those who have trespassed against us, for those days of wine and roses are altogether too fleeting.
Death comes slowly and inexorably. We all die in increments. From the day we are born we are moment by moment closer to the time of our death.
And what does this proximity to death mean? What does it portend?
I feel that it portends our deeply held need to live even more fully and to forgive those who have trespassed against us, for those days of wine and roses are altogether too fleeting.
Friday, August 24, 2007
Death Circles the Wagons
When Death begins to circle its wagons
drawing ever tighter spaces
around our dying loved one
we circle our wagons as well
drawing on previously untapped emotional and physical reserves
in order to do what we felt was beyond our ken.
Never did we think
that we could do what we are now doing.
Never could we picture the compromises, the sacrifices,
the emotional stretching that we would need to endure.
Never did we consider how Death---so patient----
would slowly and inexorably remove our loved one
from our midst,
allowing us an intimate view
of how Death begins to take our loved one
even while he is still breathing before our very eyes.
Wait, watch
Listen and breathe.
Death may be cruel, Death may be kind
but Death is eventually our final friend in life;
removing our physical presence from this mortal coil
when our personal Sun has set.
Even as Death causes our loved one to wither
and unequivocally disappear
before our very eyes,
God(dess) is there,
holding the hands of all, the dying and the bereaved alike,
guiding us to a place
where Grace, Wisdom, and Beauty make their home.
We watch the wagons circle, helpless, yet
poised for the future,
but still clinging to a present
that must eventually give way
to a new world for our loved one,
a world to which they must travel alone.
Alone, yes, they must take their leave of us alone,
to release themselves from a body ready to return to Source.
We cannot accompany our loved one on that final road,
yet they are released by us with blessings
and hopes
for a sweet, sweet hereafter.
drawing ever tighter spaces
around our dying loved one
we circle our wagons as well
drawing on previously untapped emotional and physical reserves
in order to do what we felt was beyond our ken.
Never did we think
that we could do what we are now doing.
Never could we picture the compromises, the sacrifices,
the emotional stretching that we would need to endure.
Never did we consider how Death---so patient----
would slowly and inexorably remove our loved one
from our midst,
allowing us an intimate view
of how Death begins to take our loved one
even while he is still breathing before our very eyes.
Wait, watch
Listen and breathe.
Death may be cruel, Death may be kind
but Death is eventually our final friend in life;
removing our physical presence from this mortal coil
when our personal Sun has set.
Even as Death causes our loved one to wither
and unequivocally disappear
before our very eyes,
God(dess) is there,
holding the hands of all, the dying and the bereaved alike,
guiding us to a place
where Grace, Wisdom, and Beauty make their home.
We watch the wagons circle, helpless, yet
poised for the future,
but still clinging to a present
that must eventually give way
to a new world for our loved one,
a world to which they must travel alone.
Alone, yes, they must take their leave of us alone,
to release themselves from a body ready to return to Source.
We cannot accompany our loved one on that final road,
yet they are released by us with blessings
and hopes
for a sweet, sweet hereafter.
Thursday, August 23, 2007
A Roundup at Change of Shift
The newest version of Change of Shift---that venerable carnival of nurse bloggers---is now up and running at Nurse Ratched's Place, with a Western theme. Yours truly is even included this time, relaxing in a crowded tavern. So grab your lasso and enjoy the roundup!
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