Cancer insidiously spreads itself into remote corners of the body, with greedy fingers reaching out where it is most unwanted. With unmatched stealth, it manages to send pieces of itself to distant organs through avenues of lymph or blood. And strangely enough, even if the cancer originated in the lungs, any distant metastasis will always show microscopic signs of its organ of origin if a scientist or doctor cares to check. So, if a brain cancer eventually lodges itself into the femur or spine, there are cellular markers that will actually brand that metastasis as originating in the brain. It's like a postmark by the cancer post office which delivers nauseating information of its original port of entry.
As the cancer nudges its way into various body systems and organs, it chokes off blood supply lines, interrupts normal metabolic activity, and insinuates itself in places where it is wholly unwelcome. Once it invades an area, the tumor will then begin to grow its own blood vessels, co-opting a nourishing blood supply for its own devices. Deprived of adequate circulation of blood, important organs or tissues become compromised and begin to malfunction or die. Chain reactions of metabolic chaos are set off, and delicate biological balances begin to be altered. At a certain point, there is no turning back, and the body begins an inexorable decline.
If treatment is chosen, the damage done by both chemotherapy and radiation can often exacerbate previous symptoms or create new ones. Radiation can permanently damage certain tissues which happen to be in the way of the treatment, and chemotherapy is wholly nonselective in which cells it destroys. For this reason, hair and other fast-growing cells are killed, including the lining of the gastrointestinal tract. Many cancer patients will say that the effects of the treatment are worse than the disease. An ironic reality.
When a patient comes to hospice, no further treatments are planned, and the disease is left to run its natural course. Left to its own devices, cancer spreads its wings and lodges in brain, bone, liver, lung---almost anywhere. And while certain cancers have a predilection for metastasizing to certain distant lands, it will also simply begin to work its way into locally adjacent sites, pushing through tissue, breaking down walls, filling up cavities, destroying connective tissue. If the cancer is in a visceral organ like the pancreas, it will choke off vital blood vessels and take up more and more space in a crowded abdominal cavity. Back pain, nausea, and radiation of pain to the flank will only add insult to injury as the cancer slowly takes over more and more bodily real estate. Running amok, symptom management and alleviation of suffering become the only goal.
As the patient nears the end, all medications are stopped which do not directly treat specific symptoms related to the cancer or its effects. Eventually, much to a family's dismay, medications for underlying chronic disorders (like thyroid diseases or diabetes, for instance) will simply be discontinued. Just as the cancer is allowed to run its course, other underlying conditions are allowed to simply coexist with the cancer, and the management of symptoms and the alleviation of pain and suffering hold sway as the laser beam focus of care.
As a clinician or a family member, this decline of the body as it is taken over by unwanted forces is difficult to witness. Family members and friends may face denial, anger, or any number of reactions as their loved one declines before their eyes. With any luck, skilled clinicians can provide the emotional, psychological and spiritual support which is so needed at this pivotal time. Clergy and other members of the care team can also provide additional support as the situation spirals inexorably towards death.
Countless patients and families experience this series of battles and maddening losses when cancer moves to a stage beyond treatment or cure. With physical illness comes loss of independence, mental decline, spiritual questioning, and psycho-emotional changes. When hope of a cure has vanished, then hope for peace and freedom from suffering become the focus, and a thoughtful hospice team will treat the family as skilfully as it treats the dying patient.
Many of us have walked this road with a loved one or known someone who has. Cancer somehow seems to touch a majority of families, either by direct experience or at least by association. In my own family, every man on my father's and mother's side seems to have died from cancer, and my step-father succumbed to pancreatic cancer less than five months ago.
I have known cancer intimately in my personal life and my professional life, and while it is an acquaintance I don't covet, it is one which has brought me deeper knowledge of the human condition beyond anything I could ever have imagined. Without a doubt, even more learning will ensue as I work in a hospice setting, but also simply from being a human being in relation to other human beings who are facing illness and the certainty of death.
To anyone who has lived through the loss of a loved one to cancer, I offer my sincerest condolences, my prayers for your healing, my prayers for your loved one's soul, and my hopes that your life and family will be further spared unnecessary suffering. In the face of loss and death, we all must face our own mortality and spiritual pain, and I wish you, dear Reader, strength and peace in your own travels down this often turbulent and troubling path of human existence. Namaste.
Tuesday, January 29, 2008
Monday, January 28, 2008
Of Hospice and Free Agency
Life as a (per diem) hospice nurse has certainly altered what (some of) my workdays can be like. Instead of answering to the unending demands of more than eighty needy patients as a care manager, I now answer to the rather predictable needs of no more than six residential patients.
What is unusual about my hospice work is that, during any given shift, one nurse and one home health aide must not only provide direct care to six patients in varying states of illness, including medications, bathing, treatments, dressings, and toileting. We are also responsible for preparing meals, cleaning up after meals, feeding patients who need to be fed, doing laundry, answering phones, taking out trash and recycling, and doing general housekeeping. If it sounds like a lot, it is, and I often feel that I am torn in a dozen directions at once.
Just today, in the midst of tending to a patient's lacerations from an early morning fall and calling the medical director about orders, we were toileting patients, passing medications, answering call bells, preparing breakfast, and thinking about how to begin preparing for lunch as we cleaned up from the maelstrom of breakfast. Phew! With several patients who are at risk for falls, and several who may be entering the final stages of life, meal preparation can sometimes seem like the last thing one wants to think about. But it must be done, nonetheless.
Still, as a workplace wherein I come and go, it is still a relief to simply do just that---come and go. The benefits of not being full-time anywhere are still making themselves known. For now, I revel in the fact that there is nowhere I report to day in and day out. And that free agency is a blessing beyond measure.
What is unusual about my hospice work is that, during any given shift, one nurse and one home health aide must not only provide direct care to six patients in varying states of illness, including medications, bathing, treatments, dressings, and toileting. We are also responsible for preparing meals, cleaning up after meals, feeding patients who need to be fed, doing laundry, answering phones, taking out trash and recycling, and doing general housekeeping. If it sounds like a lot, it is, and I often feel that I am torn in a dozen directions at once.
Just today, in the midst of tending to a patient's lacerations from an early morning fall and calling the medical director about orders, we were toileting patients, passing medications, answering call bells, preparing breakfast, and thinking about how to begin preparing for lunch as we cleaned up from the maelstrom of breakfast. Phew! With several patients who are at risk for falls, and several who may be entering the final stages of life, meal preparation can sometimes seem like the last thing one wants to think about. But it must be done, nonetheless.
Still, as a workplace wherein I come and go, it is still a relief to simply do just that---come and go. The benefits of not being full-time anywhere are still making themselves known. For now, I revel in the fact that there is nowhere I report to day in and day out. And that free agency is a blessing beyond measure.
Saturday, January 26, 2008
Awoken by Pain
I am awoken by pain this morning. My pain is like a ball crammed into my right lower back muscles, a most unwelcome visitor. My pain is like a parasite that distracts my attention, sometimes limiting my ability to be present, or worse, shortening my fuse.
I try to not allow my pain to limit what I do, but I have to admit that it already has. Cross-country skiing? Forget it. Sitting comfortably for more than an hour? Generally not possible. Waking from sleep without discomfort? A rare occurrence. And even swimming, that form of exercise that seems the most low-impact? Aches nonetheless.
So what does one do with pain which seems to want to stick around and be a constant companion? I've tried ignoring it. I've tried catering to it. I've talked to it and rejected it. For now, it seems that I'll simply continue to try to live my life as if it weren't there.
I try to not allow my pain to limit what I do, but I have to admit that it already has. Cross-country skiing? Forget it. Sitting comfortably for more than an hour? Generally not possible. Waking from sleep without discomfort? A rare occurrence. And even swimming, that form of exercise that seems the most low-impact? Aches nonetheless.
So what does one do with pain which seems to want to stick around and be a constant companion? I've tried ignoring it. I've tried catering to it. I've talked to it and rejected it. For now, it seems that I'll simply continue to try to live my life as if it weren't there.
Wednesday, January 23, 2008
The New World
What a difference a week makes. From one week to the next, my life has shifted from a eleven-year history of full-time employment to a new paradigm of self-directed part-time employment which is still somewhat puzzling to my reeling brain and mind.
How does one arrange one's days when they aren't built around the 9 to 5 framework? What parameters does one set in order to get things done, balanced with time to not do anything at all? Does one think, "Don't just sit there, do something!" or "Don't just do something, sit there!"?
What does it mean to not have one job that defines one's place in the working world? When someone asks the ubiquitous question, "What do you do?", what becomes your new ten-second elevator speech?
"Well, you see, I'm a newly-minted under-employed nurse slacker, waxing poetic---latte in hand---at a cafe with Wifi near you!" Or perhaps, "I'm a burnt-out nurse with more per diem jobs than I can count."
However one defines it, I know this first week has seen me working a few hospice shifts, attending my new Tai Chi/Qi Gong class and my new writers' workshop, and---dammit---crying uncontrollably during a matinee showing of The Kite Runner. My slacker cup runneth over.
I embrace this new life, even as I must accept not commuting with Mary every day, letting go of my beloved work family, and allowing the uncertain fickleness of this new paradigm to overrun my life. Gaining control of these new reins, I have no doubt that a kinder, gentler work-life will emerge, seeded with challenge yet relatively free of the trappings which so efficiently burnt me to a crispy shadow of my former self.
Here's a toast to newness and all its inherent uncertainty.
How does one arrange one's days when they aren't built around the 9 to 5 framework? What parameters does one set in order to get things done, balanced with time to not do anything at all? Does one think, "Don't just sit there, do something!" or "Don't just do something, sit there!"?
What does it mean to not have one job that defines one's place in the working world? When someone asks the ubiquitous question, "What do you do?", what becomes your new ten-second elevator speech?
"Well, you see, I'm a newly-minted under-employed nurse slacker, waxing poetic---latte in hand---at a cafe with Wifi near you!" Or perhaps, "I'm a burnt-out nurse with more per diem jobs than I can count."
However one defines it, I know this first week has seen me working a few hospice shifts, attending my new Tai Chi/Qi Gong class and my new writers' workshop, and---dammit---crying uncontrollably during a matinee showing of The Kite Runner. My slacker cup runneth over.
I embrace this new life, even as I must accept not commuting with Mary every day, letting go of my beloved work family, and allowing the uncertain fickleness of this new paradigm to overrun my life. Gaining control of these new reins, I have no doubt that a kinder, gentler work-life will emerge, seeded with challenge yet relatively free of the trappings which so efficiently burnt me to a crispy shadow of my former self.
Here's a toast to newness and all its inherent uncertainty.
Monday, January 21, 2008
Happy Birthday, MLK!
Happy Birthday to a man who changed the world by walking his talk, and by empowering others by his example of selfless sacrifice and devotion to justice. Martin Luther King graced this earth briefly, but he left a legacy which is, and always will be, larger than life.
Last year, I had the privilege to visit the burial place of Mr. King in Atlanta, as well as his childhood home and the excellent and moving museum dedicated to his memory. It was a great day for me to visit those hallowed places, and I look forward to visiting again and again.
It is a profound day for our country---and the world---and I pause in thought in memory of one of the greatest leaders in history.
Last year, I had the privilege to visit the burial place of Mr. King in Atlanta, as well as his childhood home and the excellent and moving museum dedicated to his memory. It was a great day for me to visit those hallowed places, and I look forward to visiting again and again.
It is a profound day for our country---and the world---and I pause in thought in memory of one of the greatest leaders in history.
Sunday, January 20, 2008
Three Years
Amidst the excitement of leaving my full-time job after seven years, the 3rd birthday of Digital Doorway slipped right by me on the 18th of January. It's hard to believe that three years have elapsed since I posted my first missive on this blog (thanks to a suggestion from my brother). It has been a satisfying ride, and blogging has opened doors of friendship, camaraderie, creativity, community, and, lo and behold, some paid work as a writer. (Stay tuned as Nurse LinkUp---a new online networking community for nurses---is relaunched, wherein I will be a main contributor of content.)
Thank you to everyone who visits this site, for those who choose to comment occasionally, and for my fellow bloggers who send traffic my way. I am happy to say that blogging comes as naturally as walking these days, and I look forward to three more years of the digital journey.
Thank you to everyone who visits this site, for those who choose to comment occasionally, and for my fellow bloggers who send traffic my way. I am happy to say that blogging comes as naturally as walking these days, and I look forward to three more years of the digital journey.
Saturday, January 19, 2008
A Chapter Closes, a Chapter Opens
As of today, I am no longer employed as a full-time worker. After eleven years of working 9 to 5 as a nurse, I am now a free agent, able to pick and choose when and where I work, on my own terms. With per diem status at four separate agencies, my weeks are mine to orchestrate and conduct. Of course, this means that I must now keep track of a much more complicated personal and professional schedule, and I must hope that I never show up at the wrong workplace on the wrong day. Still, the sense of freedom is incredible, and it will take some time to actually get my head around this new reality.
Of note, one of my greatest losses is the fact that my wife Mary and I will no longer be commuting together every day, and we will no longer be only 200 yards apart during our long workdays, meeting in the park for walks and sitting down for lunch in the midst of our harried days. As director of an inner city senior center just minutes from my former office, we have shared a place in this community for more than a year, and we both feel this palpable loss. I will be visiting weekly, able to actually be more present when I am indeed there, but there is still a loss incurred, and we are both processing its impact.
Yesterday, I was overwhelmed by my colleagues' generosity as a surprise luncheon was held in my honor. According to my wishes, money was collected for a donation to Save Darfur, but my thoughtful colleagues still had to throw in a gift certificate to a local spa and a very personal photo album with a photo of each person accompanied by a personal message. It was a bittersweet day, and some tears were shed (by myself and others). I was, and am, deeply touched by such an outpouring of good will and camaraderie. I will miss my work family deeply. Even though I will help out at the office on a per diem basis from time to time, it will never be the same, and that is clearer and clearer to me even now.
As sad as it has been to say goodbye to so many patients, it is truly a great relief to know that my responsibility for the management of more than eighty individuals' healthcare is over, and I can look forward to new types of therapeutic relationships with patients in varied clinical settings. Change is difficult and inevitable, and I embrace it willingly, even as moments of doubt and grief wash through me like waves.
For better or worse, I have shifts planned for both tomorrow and Monday at my new hospice job, short-circuiting any immediate sense of breathing room. However, there is plenty of time for breathing, and I plan to do a great deal of that each and every day.
For the moment, an inner sigh of relief, and a sense of peace that a chapter has been closed, a new one being written moment by moment, and day by day. I welcome the new, and will certainly cherish the old in a special place in my heart.
Of note, one of my greatest losses is the fact that my wife Mary and I will no longer be commuting together every day, and we will no longer be only 200 yards apart during our long workdays, meeting in the park for walks and sitting down for lunch in the midst of our harried days. As director of an inner city senior center just minutes from my former office, we have shared a place in this community for more than a year, and we both feel this palpable loss. I will be visiting weekly, able to actually be more present when I am indeed there, but there is still a loss incurred, and we are both processing its impact.
Yesterday, I was overwhelmed by my colleagues' generosity as a surprise luncheon was held in my honor. According to my wishes, money was collected for a donation to Save Darfur, but my thoughtful colleagues still had to throw in a gift certificate to a local spa and a very personal photo album with a photo of each person accompanied by a personal message. It was a bittersweet day, and some tears were shed (by myself and others). I was, and am, deeply touched by such an outpouring of good will and camaraderie. I will miss my work family deeply. Even though I will help out at the office on a per diem basis from time to time, it will never be the same, and that is clearer and clearer to me even now.
As sad as it has been to say goodbye to so many patients, it is truly a great relief to know that my responsibility for the management of more than eighty individuals' healthcare is over, and I can look forward to new types of therapeutic relationships with patients in varied clinical settings. Change is difficult and inevitable, and I embrace it willingly, even as moments of doubt and grief wash through me like waves.
For better or worse, I have shifts planned for both tomorrow and Monday at my new hospice job, short-circuiting any immediate sense of breathing room. However, there is plenty of time for breathing, and I plan to do a great deal of that each and every day.
For the moment, an inner sigh of relief, and a sense of peace that a chapter has been closed, a new one being written moment by moment, and day by day. I welcome the new, and will certainly cherish the old in a special place in my heart.
Thursday, January 17, 2008
The Long Goodbye
Well, it's the eve of my final day of full-time work and I can't sleep. Is there really any wonder why? Plus, my stomach has been acting up all week, my appetite is off, my back hurts more the last 48 hours, and my Restless Legs Syndrome is back with a vengeance, meds be damned.
Still, amidst it all, I am maintaining a relatively sunny outlook, and feel enormously good about my decision to leave.
Still, amidst it all, I am maintaining a relatively sunny outlook, and feel enormously good about my decision to leave.
On the phone with a patient this afternoon after having already said our official goodbyes yesterday, my patient said: "OK, I'm not going to say goodbye, because yesterday after we hung up, I burst into tears. So, see you later!" Gulp.
Another patient said, "Man, I'm gonna miss you so much. What am I gonna do without you?"
I also had four no-show's for appointments over the last two days. Avoidance, or just par for the course?
One of the hardest things is having already said goodbye to a patient, and then they call again and again with additional questions, and we have to go through the whole thing all over. Harder still is simply not being able to see everyone face to face, or wanting to make yet another visit to have further closure and simply not being able to do so due to time constraints.
These last three days have been simply hellish in terms of work load, and I have spent the majority of the week feeling under assault, a term my wife used to characterize what my job seems like most of the time.
I am always coming up with new metaphors for what our office is like, and this week it seems like a beach-head where an army has entrenched, digging bunkers and setting up strategic positions. Calls from patients are like shells lobbed into our midst, and the resultant shrapnel is the fallout of each call, sending us scurrying to put out the fires caused by each barrage. As each new call comes in, the administrative staff yell "INCOMING!" at the top of their lungs as we clinicians duck, hoping not to be hit with a bombshell of unmet need.
I am always coming up with new metaphors for what our office is like, and this week it seems like a beach-head where an army has entrenched, digging bunkers and setting up strategic positions. Calls from patients are like shells lobbed into our midst, and the resultant shrapnel is the fallout of each call, sending us scurrying to put out the fires caused by each barrage. As each new call comes in, the administrative staff yell "INCOMING!" at the top of their lungs as we clinicians duck, hoping not to be hit with a bombshell of unmet need.
After seven years of such constant hammering away at my psyche, I'm ready for a rest from case management. I welcome the opportunity to simply go to work, be present for a shift, to give my all, to serve those in need in the moment, and then retire to my home with no further worries or concerns. While I am certain to eventually miss the long-term relationships which do indeed offer such richness, I welcome this change like manna from heaven.
Tuesday, January 15, 2008
A Wall of Need and Shared Humanity
Following a snow-day on Monday which elongated the weekend into a luxurious three days, I was hit straight on today by a wall of need which simply plowed down everything in its path. Like a fly waiting for a windshield on the freeway (a nod to Peter Gabriel for that imagery), I was like a sitting duck as the calls came pouring in throughout the day. Narcotic prescriptions, sick calls, complaints, missed appointments, more sick calls, prescriptions, transportation problems, more missed appointments, electrciity cut off for non-payment, even more narcotics---the day wore on uncomfortably, like wearing a suit that's too tight.
Towards the end of the day, I realized that my days of being responsible for all of these patients and their care are coming to a close. With just three days of full-time employment remaining, this is essentially my "field goal" for the week (note the highly rare sports metaphor). I kept saying to myself: "This is my final Tuesday. This is my final Tuesday." Waves of relief were juxtaposed with alternate (albeit smaller) waves of grief and/or loss.
One patient and I came to some semblance of closure on the phone this afternoon, although since she is the one person who I have actually given my phone number to, the closure had to do with our professional relationship rather than our new friendship. Our boundaries are clear, and I have no doubt that she would never abuse her personal access to me.
Conversely, other patients seem to be extending their needy tentacles towards me as I attempt to extricate myself, and I give non-committal answers when they ask me to "keep in touch", and I generally respond by saying that I'll hopefully see them around the clinic from time to time.
Sitting at the computer in the doctors' area, I print out narcotic prescription after narcotic presciption, and I give thanks that these days will soon come to pass. This narcotic merry-go-round of which I have so recently written really seems to often put me over the proverbial edge. And with 5:00 pm Friday on the not-so-distant horizon, I feel excited at the prospect of so many odious and redundant tasks falling by the wayside.
Still, the human side of nursing is the sweetest, and the blessings and compassion which I receive from the majority of patients warms my heart and lightens my soul. When I choose to share with certain patients that I have been struggling with chronic stress-related illness and pain, the compassion that I feel reflected back to me means more than I can ever communicate in return. Shared humanity is truly the beautiful core of a healthy therapeutic relationship, and I am moved that that beauty is reflected in the eyes of many patients as I bid a heartfelt adieu.
Towards the end of the day, I realized that my days of being responsible for all of these patients and their care are coming to a close. With just three days of full-time employment remaining, this is essentially my "field goal" for the week (note the highly rare sports metaphor). I kept saying to myself: "This is my final Tuesday. This is my final Tuesday." Waves of relief were juxtaposed with alternate (albeit smaller) waves of grief and/or loss.
One patient and I came to some semblance of closure on the phone this afternoon, although since she is the one person who I have actually given my phone number to, the closure had to do with our professional relationship rather than our new friendship. Our boundaries are clear, and I have no doubt that she would never abuse her personal access to me.
Conversely, other patients seem to be extending their needy tentacles towards me as I attempt to extricate myself, and I give non-committal answers when they ask me to "keep in touch", and I generally respond by saying that I'll hopefully see them around the clinic from time to time.
Sitting at the computer in the doctors' area, I print out narcotic prescription after narcotic presciption, and I give thanks that these days will soon come to pass. This narcotic merry-go-round of which I have so recently written really seems to often put me over the proverbial edge. And with 5:00 pm Friday on the not-so-distant horizon, I feel excited at the prospect of so many odious and redundant tasks falling by the wayside.
Still, the human side of nursing is the sweetest, and the blessings and compassion which I receive from the majority of patients warms my heart and lightens my soul. When I choose to share with certain patients that I have been struggling with chronic stress-related illness and pain, the compassion that I feel reflected back to me means more than I can ever communicate in return. Shared humanity is truly the beautiful core of a healthy therapeutic relationship, and I am moved that that beauty is reflected in the eyes of many patients as I bid a heartfelt adieu.
Saturday, January 12, 2008
The Long and Short of Therapeutic Relationships
For the last seven years, I have had the privileged opportunity to build solid therapeutic relationships with patients over the long term. Despite the frustrations and stressors therein, having the time and space to truly get to know patients over such a span of years has many benefits, both for the patient and for me, the provider of care. Long-term therapeutic relationships allow for trust to be built in such a way that I have been able to become, as it were, a part of people's lives.
Making periodic home visits to a considerable number of my patients has also engendered a considerable sense of intimacy and shared experience. Getting to know spouses, children, grandchildren and others during my visits, the web of human contact is strengthened and enlarged. Becoming somewhat of a fixture in someone's home---albeit a fixture who appears and disappears at will---creates a dynamic that simply cannot be equaled during any number of office visits. In terms of getting to know a patient and their life, there is nothing like sitting in their living room and directly experiencing their world by smelling the food cooking on the stove, seeing the room where they sleep, and getting a visceral sense of what this family's lifestyle is truly like. In my opinion, doctors should make house-calls to each of their patients at least once, if only to get a sense of how that person lives, information which is therapeutically priceless.
For myself personally, I have given my all to many of the relationships that I have nurtured with my patients over the years. Over time, that investment has paid dividends which cannot be measured, and I know that my presence has been beneficial to many. Now, as I prepare to take my leave, I can see the repercussions which the severing of those ties can have. For myself, I must process the guilt of leaving, of "abandoning" my patients (as several have described it to me as they react to the news of my departure). For them, they must accept my departure from their lives, and be receptive to a new provider and a new relationship which will have different dynamics and a entirely different feeling. For some, hopefully, that relationship will be equally or even more fulfilling for them. For others, things will just never be the same. But I remind myself that the only constant in the universe is change, and we are all experiencing that constant in this moment, whether we like it or not.
As I move into a new paradigm of work as a nurse, I will embrace the opportunity for more short-term relationships with patients. As a per diem visiting nurse, I may walk into a home for a brief interaction with a patient who I may never see again. With no history, no biases, and no preconceived notions, that moment is wide open for creative and compassionate interaction. As a per diem nurse in a small residential hospice, I may come to work one day and have a deeply emotional connection with a patient, only to return the following week to learn that that person has died. Thus, while a long-term investment is not an option in these relationships, it presents a golden opportunity to make each interaction count, holding nothing back and letting that moment be all that it can be.
While I am grieving the loss of many of the connections which I have nurtured over the years, I am simultaneously celebrating the relief that I feel as I relinquish the enormous responsibility that those long-terms relationships have brought to bear. Human interaction allows for depth and intimacy in many ways, and I plan to use my interpersonal skills in such a manner as to continue to satisfy my need for emotional intimacy with patients, even if those relationships are short-lived.
In this moment, as I write this missive, I feel a pain in my heart as the faces of patients I love pass over my mental movie screen. As I release my guilt and sense of responsibility, I shower each individual with compassion and understanding for their suffering, and wishes for healing and satisfaction with their lives, their health, and the relationships which they have with their medical providers. Even if I am no longer present in their daily lives, what we have shared is something which cannot be erased, and the value of those interactions---and the emotional and spiritual reverberations therein---can still be carried in our hearts.
Making periodic home visits to a considerable number of my patients has also engendered a considerable sense of intimacy and shared experience. Getting to know spouses, children, grandchildren and others during my visits, the web of human contact is strengthened and enlarged. Becoming somewhat of a fixture in someone's home---albeit a fixture who appears and disappears at will---creates a dynamic that simply cannot be equaled during any number of office visits. In terms of getting to know a patient and their life, there is nothing like sitting in their living room and directly experiencing their world by smelling the food cooking on the stove, seeing the room where they sleep, and getting a visceral sense of what this family's lifestyle is truly like. In my opinion, doctors should make house-calls to each of their patients at least once, if only to get a sense of how that person lives, information which is therapeutically priceless.
For myself personally, I have given my all to many of the relationships that I have nurtured with my patients over the years. Over time, that investment has paid dividends which cannot be measured, and I know that my presence has been beneficial to many. Now, as I prepare to take my leave, I can see the repercussions which the severing of those ties can have. For myself, I must process the guilt of leaving, of "abandoning" my patients (as several have described it to me as they react to the news of my departure). For them, they must accept my departure from their lives, and be receptive to a new provider and a new relationship which will have different dynamics and a entirely different feeling. For some, hopefully, that relationship will be equally or even more fulfilling for them. For others, things will just never be the same. But I remind myself that the only constant in the universe is change, and we are all experiencing that constant in this moment, whether we like it or not.
As I move into a new paradigm of work as a nurse, I will embrace the opportunity for more short-term relationships with patients. As a per diem visiting nurse, I may walk into a home for a brief interaction with a patient who I may never see again. With no history, no biases, and no preconceived notions, that moment is wide open for creative and compassionate interaction. As a per diem nurse in a small residential hospice, I may come to work one day and have a deeply emotional connection with a patient, only to return the following week to learn that that person has died. Thus, while a long-term investment is not an option in these relationships, it presents a golden opportunity to make each interaction count, holding nothing back and letting that moment be all that it can be.
While I am grieving the loss of many of the connections which I have nurtured over the years, I am simultaneously celebrating the relief that I feel as I relinquish the enormous responsibility that those long-terms relationships have brought to bear. Human interaction allows for depth and intimacy in many ways, and I plan to use my interpersonal skills in such a manner as to continue to satisfy my need for emotional intimacy with patients, even if those relationships are short-lived.
In this moment, as I write this missive, I feel a pain in my heart as the faces of patients I love pass over my mental movie screen. As I release my guilt and sense of responsibility, I shower each individual with compassion and understanding for their suffering, and wishes for healing and satisfaction with their lives, their health, and the relationships which they have with their medical providers. Even if I am no longer present in their daily lives, what we have shared is something which cannot be erased, and the value of those interactions---and the emotional and spiritual reverberations therein---can still be carried in our hearts.
Friday, January 11, 2008
Broken Hearts and More Goodbyes
The next to last week is over, and I am now looking my final week at work straight in the eye. I had a few tough moments as I said my goodbyes to a few people, and several patients were teary-eyed as we bade our farewells. Even though there's a chance that we may cross paths when I'm covering a shift at the clinic here and there, the relationships we have known over time will never return.
One couple of whom I am exceedingly fond are simply held in a dear, dear place in my heart. I felt choked up as we shook hands the other day, and even though I promised to keep tabs on them, our days sharing laughs together are essentially over.
Another patient with whom I have been through a great deal turned away from me as she began to cry yesterday, and she said "it will just never be the same with anyone else."
Still another patient said, "I've been feeling really bad about it, but I know you have to take care of yourself. Thanks for going the extra mile for me."
Coming out of an exam room this afternoon, the medical director of the clinic looked at me and informed me without a shred of irony or sentimentality that I am breaking many patients' hearts this week.
Gulp.
It is a tough burden to bear when one provides the care that others so depend on. It's even more of a burden when one realizes that leaving those individuals behind is yet another loss in their compendium of loss and grief. Still, these relationships have a value which will carry us all forward, and new relationships will yield even more gifts and learning for each of us. Saying goodbye is a practice and an art, and for better or worse, I'm getting a whole lot of practice these days.
One couple of whom I am exceedingly fond are simply held in a dear, dear place in my heart. I felt choked up as we shook hands the other day, and even though I promised to keep tabs on them, our days sharing laughs together are essentially over.
Another patient with whom I have been through a great deal turned away from me as she began to cry yesterday, and she said "it will just never be the same with anyone else."
Still another patient said, "I've been feeling really bad about it, but I know you have to take care of yourself. Thanks for going the extra mile for me."
Coming out of an exam room this afternoon, the medical director of the clinic looked at me and informed me without a shred of irony or sentimentality that I am breaking many patients' hearts this week.
Gulp.
It is a tough burden to bear when one provides the care that others so depend on. It's even more of a burden when one realizes that leaving those individuals behind is yet another loss in their compendium of loss and grief. Still, these relationships have a value which will carry us all forward, and new relationships will yield even more gifts and learning for each of us. Saying goodbye is a practice and an art, and for better or worse, I'm getting a whole lot of practice these days.
Thursday, January 10, 2008
CPR, STAT!
This morning, I attended a CPR recertification for healthcare professionals, and was surprised at the significant changes therein. The very gung-ho presenter gave us an impassioned speech about the importance of CPR, and drive home the very salient point that most of us professionals who ever use CPR will most likely do so out in the community---at a shopping mall, grocery store, or even at home---rather than at work. Aside from those who work in the ICU or other critical care area, CPR is generally performed when one is off-duty, and we should be determined to get as many civilians certified as possible. Even more urgent is the need for more automatic electronic defibrillators out in the community, and unfortunately there are just not enough of those golden little machines around.
An interesting piece of information that I learned today was that, contrary to what has been taught for decades up until now, we were concentrating way too much on mouth-to-mouth resuscitation and performing woefully too few chest compressions. Statistics clearly demonstrate that the old CPR paradigm was falling far short of the mark, and of the people who actually survived following CPR, less than 40% actually experienced good quality of life. Due to the relative lack of chest compressions performed in traditional CPR, brain perfusion was a mere shadow of what it could have been, thus many survivors were suffering unnecessary cognitive deficits from lack of cerebral oxygen flow.
The new and improved CPR instructions drill home the fact that it is compressions which save a life, not mouth-to-mouth. While keeping an open airway and providing periodic rescue breaths is still an intrinsic aspect of the entire procedure of CPR, it is the act of compressing the heart against the chest wall which perfuses the brain, coronary muscle and kidneys with the oxygenated blood needed to prevent negative sequelae. "Compressions, compressions, compressions" was the mantra that we heard all morning, and by the time we left, the new ratio of 30 compressions to 2 breaths was cemented in our brains, along with the strict instructions that compressions must be "deeper, harder, and faster" than ever before. No more fumbling around, re-checking the pulse and giving two breaths every 15 compressions. Get that heart pumping, and get a defibrillator on that chest stat!
Apropos of the notion of automatic electronic defibrillators (AEDs) we also learned about commotio cortis, a condition in which an otherwise healthy heart stops due to blunt trauma to the chest. Sadly, young athletes---school-age children, teens, and college students---die from this condition every year, which generally occurs when a young athlete is struck in the area of the heart by a ball, limb, or other implement at precisely the moment when the heart is at a specific point in the cardiac cycle. Of note, the use of AEDs by coaches and others involved in youth sports has shown dramatically increased survival rates for young people experiencing commotio cortis. Thus, it is in everyone's interest to lobby schools and youth athletic programs to obtain AEDs and train adults and young people in their correct use.
CPR is a crucial skill which can indeed save lives if used correctly, and especially if enough individuals in the society are properly certified. I encourage everyone to become certified, recertify every two years, and urge family members and friends to do the same. Someday the life that's saved may very well be your own---or that of someone you love.
An interesting piece of information that I learned today was that, contrary to what has been taught for decades up until now, we were concentrating way too much on mouth-to-mouth resuscitation and performing woefully too few chest compressions. Statistics clearly demonstrate that the old CPR paradigm was falling far short of the mark, and of the people who actually survived following CPR, less than 40% actually experienced good quality of life. Due to the relative lack of chest compressions performed in traditional CPR, brain perfusion was a mere shadow of what it could have been, thus many survivors were suffering unnecessary cognitive deficits from lack of cerebral oxygen flow.
The new and improved CPR instructions drill home the fact that it is compressions which save a life, not mouth-to-mouth. While keeping an open airway and providing periodic rescue breaths is still an intrinsic aspect of the entire procedure of CPR, it is the act of compressing the heart against the chest wall which perfuses the brain, coronary muscle and kidneys with the oxygenated blood needed to prevent negative sequelae. "Compressions, compressions, compressions" was the mantra that we heard all morning, and by the time we left, the new ratio of 30 compressions to 2 breaths was cemented in our brains, along with the strict instructions that compressions must be "deeper, harder, and faster" than ever before. No more fumbling around, re-checking the pulse and giving two breaths every 15 compressions. Get that heart pumping, and get a defibrillator on that chest stat!
Apropos of the notion of automatic electronic defibrillators (AEDs) we also learned about commotio cortis, a condition in which an otherwise healthy heart stops due to blunt trauma to the chest. Sadly, young athletes---school-age children, teens, and college students---die from this condition every year, which generally occurs when a young athlete is struck in the area of the heart by a ball, limb, or other implement at precisely the moment when the heart is at a specific point in the cardiac cycle. Of note, the use of AEDs by coaches and others involved in youth sports has shown dramatically increased survival rates for young people experiencing commotio cortis. Thus, it is in everyone's interest to lobby schools and youth athletic programs to obtain AEDs and train adults and young people in their correct use.
CPR is a crucial skill which can indeed save lives if used correctly, and especially if enough individuals in the society are properly certified. I encourage everyone to become certified, recertify every two years, and urge family members and friends to do the same. Someday the life that's saved may very well be your own---or that of someone you love.
Wednesday, January 09, 2008
The Narcotic Merry-Go-Round
The number of patients that I see who are prescribed chronic narcotic medications is astronomically high. Of course, there are many people who have pain worthy of taking narcotics on a daily basis---for cancer-related pain, post-surgical pain, etc---yet so many people abdicate their pain management all too easily to the drugs that will cause them physical dependence, constipation, and somnolence with no end in sight. As a person with chronic pain with an unknown etiology, I fully understand that strong drive to eradicate pain from one's life. Pain overtakes one's psyche, pushes other concerns out of the way, and leaves one desperate for relief.
While it is well-documented that pain is woefully and poorly managed throughout the United States, leaving countless patients suffering unnecessarily, I still find myself having mixed feelings about the ease with which so many providers seem to write those scripts for Oxycontin, morphine, and Percocet. At our local ER, it seems like there's a gum-ball machine near the revolving door, and patients simply have to say they're in pain and a prescription is produced in a knee-jerk reaction of instant gratification.
One of the questions we ask ourselves and each other about these patients on chronic narcotics is how long they will be on these meds? For the patients with failed back surgeries and other serious conditions, we consider that they may very well be on narcotics for life, and that is often the lesser of many evils. For others whose pain has no visible or discernible cause, we often question the intelligence of long-term narcotic use, understanding that tolerance will increase with time, and dependence only continue to deepen, both physically and psychologically. Now, often that dependence (which is different than addiction, mind you) is wholly warranted and acceptable, yet I feel that there is sometimes a lack of judiciousness on the part of the prescribers as they acquiesce to the pressure to write those scripts for controlled substances.
I do not question that narcotics are often needed for patients whose pain is not touched by non-steroidal anti-inflammatories and other non-pharmacological interventions, but sometimes I feel that those prescriptions move just a little too freely, especially when one considers that diversion (the selling of such medications to others for profit) happens on downtown street corners on a daily basis. Word has it, I hear, that our clinic is considered a great place to score some narcotics to sell at the bus station. A nice reputation to have.
Perhaps I feel uncomfortable with the amount of narcotics that fly off the shelves these days because a significant portion of my job these last few years has been fielding calls from my patients who are on chronic narcotics as they seek a new refill of their meds. Since many of my patients are former substance abusers and our level of trust in them is relatively low, some of them need to come to the office every seven days for a one-week supply of morphine or Percocet. While having to come in to see me weekly is inconvenient for them, it is equally a hassle for me in terms of printing up scripts, hunting down docs for signatures, and having all of this ready in a timely manner for frequently impatient patients. As I ready to leave my job of seven years, I quietly revel in the notion that I will soon enough finally escape from this narcotic merry-go-round.
Percocet, anyone?
While it is well-documented that pain is woefully and poorly managed throughout the United States, leaving countless patients suffering unnecessarily, I still find myself having mixed feelings about the ease with which so many providers seem to write those scripts for Oxycontin, morphine, and Percocet. At our local ER, it seems like there's a gum-ball machine near the revolving door, and patients simply have to say they're in pain and a prescription is produced in a knee-jerk reaction of instant gratification.
One of the questions we ask ourselves and each other about these patients on chronic narcotics is how long they will be on these meds? For the patients with failed back surgeries and other serious conditions, we consider that they may very well be on narcotics for life, and that is often the lesser of many evils. For others whose pain has no visible or discernible cause, we often question the intelligence of long-term narcotic use, understanding that tolerance will increase with time, and dependence only continue to deepen, both physically and psychologically. Now, often that dependence (which is different than addiction, mind you) is wholly warranted and acceptable, yet I feel that there is sometimes a lack of judiciousness on the part of the prescribers as they acquiesce to the pressure to write those scripts for controlled substances.
I do not question that narcotics are often needed for patients whose pain is not touched by non-steroidal anti-inflammatories and other non-pharmacological interventions, but sometimes I feel that those prescriptions move just a little too freely, especially when one considers that diversion (the selling of such medications to others for profit) happens on downtown street corners on a daily basis. Word has it, I hear, that our clinic is considered a great place to score some narcotics to sell at the bus station. A nice reputation to have.
Perhaps I feel uncomfortable with the amount of narcotics that fly off the shelves these days because a significant portion of my job these last few years has been fielding calls from my patients who are on chronic narcotics as they seek a new refill of their meds. Since many of my patients are former substance abusers and our level of trust in them is relatively low, some of them need to come to the office every seven days for a one-week supply of morphine or Percocet. While having to come in to see me weekly is inconvenient for them, it is equally a hassle for me in terms of printing up scripts, hunting down docs for signatures, and having all of this ready in a timely manner for frequently impatient patients. As I ready to leave my job of seven years, I quietly revel in the notion that I will soon enough finally escape from this narcotic merry-go-round.
Percocet, anyone?
Tuesday, January 08, 2008
Dangerous Messages
Standing in line at the pharmacy the other day, I was struck by the headlines I saw on several magazines on display near the register. The headlines screamed, and I paraphrase: "Young Starlets Reveal How They Lose Weight Fast!" and "Tired of Winter Fat? Lose 20 Pounds in One Week!"
Living in a college town, I wondered how many young impressionable female college, high school, junior high (and elementary!) students stood in line at this and other stores, reading those headlines, fervently ruing the few pounds they may have gained over the holidays. How do they compare themselves to those starlets and models? What messages are sinking in, especially into the brains of those school-age girls? What are we doing to girls and women in this culture?
As the media proclaim the dangers of obesity (some calling it an epidemic), we also run the risk of running too far in the other direction, sending our young girls (and some boys) into crazed tailspins of body image dysmorphia. As someone who was a chubby youngster, I myself was frequently on the receiving end of jokes and innuendos about my weight from relatives, family, and strangers alike. The resultant misguided self-talk about my body still reverberates in my mind to this day, and I still suffer the psychic consequences of the frequently cruel statements which so often came my way.
In this media-saturated world where there simply seems to be no escape---especially for the young---it is the responsibility of the society at large to monitor its language and the messages which it feeds to its most vulnerable members. From my point of view, we are failing miserably, and the resulting eating disorders and unrealistic body image suffered by young women across this country are the natural result of our stark collective failure. How can we right this wrong?
Our collective failure is, of course, our collective responsibility to rectify. But how can we do so when the powers of the media---and the very culture itself---thwart us at every turn? God help young women as they face this constant onslaught to which they can never measure up, and if we can't stem the tide, we will have no one to blame but ourselves.
Living in a college town, I wondered how many young impressionable female college, high school, junior high (and elementary!) students stood in line at this and other stores, reading those headlines, fervently ruing the few pounds they may have gained over the holidays. How do they compare themselves to those starlets and models? What messages are sinking in, especially into the brains of those school-age girls? What are we doing to girls and women in this culture?
As the media proclaim the dangers of obesity (some calling it an epidemic), we also run the risk of running too far in the other direction, sending our young girls (and some boys) into crazed tailspins of body image dysmorphia. As someone who was a chubby youngster, I myself was frequently on the receiving end of jokes and innuendos about my weight from relatives, family, and strangers alike. The resultant misguided self-talk about my body still reverberates in my mind to this day, and I still suffer the psychic consequences of the frequently cruel statements which so often came my way.
In this media-saturated world where there simply seems to be no escape---especially for the young---it is the responsibility of the society at large to monitor its language and the messages which it feeds to its most vulnerable members. From my point of view, we are failing miserably, and the resulting eating disorders and unrealistic body image suffered by young women across this country are the natural result of our stark collective failure. How can we right this wrong?
Our collective failure is, of course, our collective responsibility to rectify. But how can we do so when the powers of the media---and the very culture itself---thwart us at every turn? God help young women as they face this constant onslaught to which they can never measure up, and if we can't stem the tide, we will have no one to blame but ourselves.
Sunday, January 06, 2008
Second Chance to Live: An Inspiring Blog
Hi Keith,
My name is Craig J. Phillips. I am a traumatic brain injury survivor and a master’s level rehabilitation counselor. I sustained an open skull fracture with right frontal lobe damage and remained in a coma for 3 weeks at the age of 10 in August of 1967. I underwent brain and skull surgery after waking from the coma. Follow-up cognitive and psyche / social testing revealed that I would not be able to succeed beyond high school. In 1967 Neurological Rehabilitation was not available to me, so I had to teach myself how to walk, talk, read, write and speak in complete sentences. I completed high school on time and went on to obtain both my undergraduate and graduate degrees. For an in depth view of my process please read my post,
http://secondchancetoliveThroughout my lifetime I developed strategies to overcome many obstacles and in so doing I have achieved far beyond all reasonable expectations. On February 6, 2007 at the encouragement of a friend I created Second Chance to Live.
Second Chance to Live presents topics in such a way to encourage, motivate and empower the reader to live life on life’s terms. I believe our circumstances are not meant to keep us down, but to build us up. As a traumatic brain injury survivor, I speak from my experience, strength and hope. As a professional, I provide information to encourage, motivate and empower both disabled and non-disabled individuals to not give up on their process. Please read my post, http://secondchancetoliveThank you for your time and your kindness. Have a simply phenomenal day!
Craig R. Phillips, MRC, BA
Saturday, January 05, 2008
Letting Go Again and Again
Letting go is getting easier with each passing day. With only ten work days remaining (not that I'm counting!), the approaching new reality is quickly becoming less of a distant idea and more of a concrete certainty. Change seems to truly be the only constant in the universe in which we can have complete faith and trust.
Patients' reactions are still varied. "But why?" is a common refrain, followed by worries about the future.
Yesterday, I was traipsing through the health center waiting room, hoping not to be noticed by any patients lurking in the corners. Suddenly, I heard my name being called and I turned. There sat a patient whom I have not seen for some time, and as I informed her of my imminent departure, her face fell, although she quickly smiled and wished me the best. "You'll continue to be in my prayers every day," she said, reaching out to give me a hug and a kiss. A sweet goodbye.
So far, I have chosen to give my home telephone number to only one patient who I trust implicitly not to abuse that information. She is an educated and self-sufficient woman who understands that our therapeutic relationship is coming to an end and any subsequent contact will be solely as friends. Additionally, I have told a few of my favorite patients that I may call them from time to time, but not to have any specific expectations. For the majority, it is a final goodbye, with the caveat that I will be working per diem shifts in the clinic and they may run into me now and then.
There are still three patients I have not told for whom I fear my departure will be difficult at best. Taking my fears into account, I am attempting to arrange joint visits with their therapists or case managers so that the news can be broken in a safe and supportive environment with another trusted professional on hand. These are the most tender goodbyes that could actually have clinical repercussions.
Overall, this process is going smoothly, and I am somewhat impatient to begin my new work lifestyle. Still, there is much work to be done---a plethora of t's to be crossed and i's to be dotted---before I can truly close that door behind me. I am processing my guilt at leaving my colleagues in the lurch, and I am also processing the fact that my professional identity---of working with the poorest and sickest of the poor and the sick---will need to change in the coming weeks and months. This does not diminish my self-chosen position as an advocate for the disenfranchised and vulnerable, but it does underscore the fact that I will not be slogging away in the trenches forty hours a week after the 18th of January. Can one leave the trenches and still be a fierce advocate for those in need of advocacy? I believe so, and I plan to figure out how to do just that.
Now for a weekend of R & R, and psychic preparation for the continued process of letting go.
Patients' reactions are still varied. "But why?" is a common refrain, followed by worries about the future.
Yesterday, I was traipsing through the health center waiting room, hoping not to be noticed by any patients lurking in the corners. Suddenly, I heard my name being called and I turned. There sat a patient whom I have not seen for some time, and as I informed her of my imminent departure, her face fell, although she quickly smiled and wished me the best. "You'll continue to be in my prayers every day," she said, reaching out to give me a hug and a kiss. A sweet goodbye.
So far, I have chosen to give my home telephone number to only one patient who I trust implicitly not to abuse that information. She is an educated and self-sufficient woman who understands that our therapeutic relationship is coming to an end and any subsequent contact will be solely as friends. Additionally, I have told a few of my favorite patients that I may call them from time to time, but not to have any specific expectations. For the majority, it is a final goodbye, with the caveat that I will be working per diem shifts in the clinic and they may run into me now and then.
There are still three patients I have not told for whom I fear my departure will be difficult at best. Taking my fears into account, I am attempting to arrange joint visits with their therapists or case managers so that the news can be broken in a safe and supportive environment with another trusted professional on hand. These are the most tender goodbyes that could actually have clinical repercussions.
Overall, this process is going smoothly, and I am somewhat impatient to begin my new work lifestyle. Still, there is much work to be done---a plethora of t's to be crossed and i's to be dotted---before I can truly close that door behind me. I am processing my guilt at leaving my colleagues in the lurch, and I am also processing the fact that my professional identity---of working with the poorest and sickest of the poor and the sick---will need to change in the coming weeks and months. This does not diminish my self-chosen position as an advocate for the disenfranchised and vulnerable, but it does underscore the fact that I will not be slogging away in the trenches forty hours a week after the 18th of January. Can one leave the trenches and still be a fierce advocate for those in need of advocacy? I believe so, and I plan to figure out how to do just that.
Now for a weekend of R & R, and psychic preparation for the continued process of letting go.
Tuesday, January 01, 2008
Resolution or Revolution?
Well, Bono may have sung that "nothing changes on New Year's Day", but we can choose to make small personal changes with the force of our will and a determination for growth and self-improvement, no matter the outer circumstances of the world. Even as genocide, hunger, poverty and war rage around us, we can champion incremental changes within our own small sphere of influence, and those changes can ripple outward and effect others in positive ways for days to come.
Personally, this New Year is about self-care and optimal health, and rather than make resolutions to exercise more, eat better, and sleep eight hours a day, I will simply make a commitment to self-care in whatever form that that may take. Mind you, I am planning to make a list of self-care activities and choices that I can make, but rather than serve as a list of resolutions that I must follow without question, this list will be a reference point, a place to look for hints when I feel that I've lost the thread.
I see resolutions as dangerous for one good reason---they are inevitably broken. If I resolve to swim no less than 60 laps per week, I'll most likely fail half the time. If I resolve to write a blog entry every day, having that verbalized expectation will probably thwart me in my writing process. If I decide to eat absolutely no sugar for the next two months (something that I have done for many months at a time in the past), I also will probably fall on my face (with a mouth full of chocolate to cushion the blow).
My simple solution is to revolutionize my personal resolution process. Today I will generate that list of self-care options, and it will serve as a reminder of what I can do when my wheels are spinning. It is an ongoing process of discovery, and I see the New Year as a perfect time to recharge those self-care batteries.
Many happy returns to you and yours, dear Reader, and may the New Year open its heart to you in gentle and compassionate ways.
Personally, this New Year is about self-care and optimal health, and rather than make resolutions to exercise more, eat better, and sleep eight hours a day, I will simply make a commitment to self-care in whatever form that that may take. Mind you, I am planning to make a list of self-care activities and choices that I can make, but rather than serve as a list of resolutions that I must follow without question, this list will be a reference point, a place to look for hints when I feel that I've lost the thread.
I see resolutions as dangerous for one good reason---they are inevitably broken. If I resolve to swim no less than 60 laps per week, I'll most likely fail half the time. If I resolve to write a blog entry every day, having that verbalized expectation will probably thwart me in my writing process. If I decide to eat absolutely no sugar for the next two months (something that I have done for many months at a time in the past), I also will probably fall on my face (with a mouth full of chocolate to cushion the blow).
My simple solution is to revolutionize my personal resolution process. Today I will generate that list of self-care options, and it will serve as a reminder of what I can do when my wheels are spinning. It is an ongoing process of discovery, and I see the New Year as a perfect time to recharge those self-care batteries.
Many happy returns to you and yours, dear Reader, and may the New Year open its heart to you in gentle and compassionate ways.
Monday, December 31, 2007
Year's End
The last day of the year brought with it patients in every manner of crisis. A patient called in tears, certain that she has brain cancer, her head feeling like it is splitting in two.
"I want one of those things where they put a hat or something on your head. Oh, what is it?"
"An EEG?" I ask, grasping at straws.
"Yes, that's it! I want that!" she yells, dissolving into more tears. "And I think I have throat cancer, too."
The next call revolves around---what else? Narcotics.
"Why does the doctor want to decrease my oxycodone? I only did heroin once and it was just to celebrate. I won't do it again."
Again and again the calls come in, like everyone just seems to need to put their crises in my lap before the year is over. Maybe it's just pay-back for planning to leave altogether. Several patients manage to suck me in today, and I feel emotionally triggered by the ferocity of their trauma, my mind working with my psyche to mitigate the damage.
The highlight of my day is delivering bottles of sparkling cider to some of my favorite patients, leaving behind a smidgen of New Year's (non-alcoholic) cheer. A few shared laughs and blessings bestowed upon me round out the day, keeping me from sinking beneath the onslaught of unquenchable need.
Home embraces my weary bones like a treasured balm. Thoughts of what has proven to be a quite difficult and trying year lead to wishes and desires for a kindler, gentler year in 2008. Personal loss, worsening illness, and the physical manifestations of stress and burnout have all come home to roost this year. Through it all, I have tried to maintain a healthy "witness self" who watches the wheels without going under---a frequently Sisyphean task.
In 2008, I will leave my full-time job of seven years, piecing together a new way of earning a living, manifesting improved health, shrugging off the ills of undue stress, and re-embracing creativity and spontaneity. No resolutions, no promises, no enjoinders. Just a healthy desire for change, for health, and for a new chance to do it better.
Happy New Year, many happy returns, and may all beings everywhere be free from suffering.
"I want one of those things where they put a hat or something on your head. Oh, what is it?"
"An EEG?" I ask, grasping at straws.
"Yes, that's it! I want that!" she yells, dissolving into more tears. "And I think I have throat cancer, too."
The next call revolves around---what else? Narcotics.
"Why does the doctor want to decrease my oxycodone? I only did heroin once and it was just to celebrate. I won't do it again."
Again and again the calls come in, like everyone just seems to need to put their crises in my lap before the year is over. Maybe it's just pay-back for planning to leave altogether. Several patients manage to suck me in today, and I feel emotionally triggered by the ferocity of their trauma, my mind working with my psyche to mitigate the damage.
The highlight of my day is delivering bottles of sparkling cider to some of my favorite patients, leaving behind a smidgen of New Year's (non-alcoholic) cheer. A few shared laughs and blessings bestowed upon me round out the day, keeping me from sinking beneath the onslaught of unquenchable need.
Home embraces my weary bones like a treasured balm. Thoughts of what has proven to be a quite difficult and trying year lead to wishes and desires for a kindler, gentler year in 2008. Personal loss, worsening illness, and the physical manifestations of stress and burnout have all come home to roost this year. Through it all, I have tried to maintain a healthy "witness self" who watches the wheels without going under---a frequently Sisyphean task.
In 2008, I will leave my full-time job of seven years, piecing together a new way of earning a living, manifesting improved health, shrugging off the ills of undue stress, and re-embracing creativity and spontaneity. No resolutions, no promises, no enjoinders. Just a healthy desire for change, for health, and for a new chance to do it better.
Happy New Year, many happy returns, and may all beings everywhere be free from suffering.
Sunday, December 30, 2007
The Countdown
The countdown continues as I face only 14 more work days before my full-time employment ends. As I connect with patients and inform them that I am leaving the practice, the reality of the change sets in. I also realize that some of my patients' lives will indeed change radically as they negotiate new clinical relationships that may or may not serve them as well as their relationship with me has done.
In terms of what I have done for patients, frequently going the extra mile---both literally and figuratively---I wonder if my going that extra mile has truly served them well. Having done so, their expectations may be that subsequent clinicians will do what I have done for them, and in this assumption they may indeed be sorely mistaken. If that is the case, did my going that extra mile only foster dependence and disempower them from a more proactive approach to their own care?
Enabling behavior among clinicians does occur, and in my (current) line of work---care coordination for the disabled and vulnerable---we are all guilty. However, if enabling does go so far as to disempower, then what has truly been served, the patient's needs or the clinician's own guilt?
For myself, this is the end of an era. It is the end of being in long-term therapeutic relationship with patients. It is the end of being a fixture in patients' lives year after year, through births, deaths, tragedies, and the inescapable comedies of error. It is the end of that feeling of responsibility of carrying the details of the care of so many on my own shoulders. I have gained much from that responsibility, and it has certainly fed my own need to be so needed. But is being so needed really all that it's cracked up to be?
As for my patients, they will survive, and they will navigate the new world without my presence however they can. Some will latch onto a new provider, some will simply fade into the healthcare woodwork. Abandonment issues will surface for some, and the more functional of these individuals will work through those issues and come out on the other side. For a few, I will just be one more well-meaning and earnest clinician who danced in their life for a while before spinning out of orbit like so many others before me.
In one exchange with a patient to whom I was breaking the news of my imminent departure, my patient said something about the fact that we had "done so much good work together" as if it was now all lost. My response was to counter that statement by framing it in the light of forward movement, of her new ability to build upon that foundation and realize more of her innate potential for self-directed advocacy. She agreed, but maintained her assertion that it was a loss of large proportions.
That day of finally closing the door on my seven-year sojourn---January 18th---is close on the horizon. What happens between now and then is only one part of the story. After that, a new chapter begins, and I will write that chapter with great interest and care. Perhaps it is already written and I only need to find it within myself.....
In terms of what I have done for patients, frequently going the extra mile---both literally and figuratively---I wonder if my going that extra mile has truly served them well. Having done so, their expectations may be that subsequent clinicians will do what I have done for them, and in this assumption they may indeed be sorely mistaken. If that is the case, did my going that extra mile only foster dependence and disempower them from a more proactive approach to their own care?
Enabling behavior among clinicians does occur, and in my (current) line of work---care coordination for the disabled and vulnerable---we are all guilty. However, if enabling does go so far as to disempower, then what has truly been served, the patient's needs or the clinician's own guilt?
For myself, this is the end of an era. It is the end of being in long-term therapeutic relationship with patients. It is the end of being a fixture in patients' lives year after year, through births, deaths, tragedies, and the inescapable comedies of error. It is the end of that feeling of responsibility of carrying the details of the care of so many on my own shoulders. I have gained much from that responsibility, and it has certainly fed my own need to be so needed. But is being so needed really all that it's cracked up to be?
As for my patients, they will survive, and they will navigate the new world without my presence however they can. Some will latch onto a new provider, some will simply fade into the healthcare woodwork. Abandonment issues will surface for some, and the more functional of these individuals will work through those issues and come out on the other side. For a few, I will just be one more well-meaning and earnest clinician who danced in their life for a while before spinning out of orbit like so many others before me.
In one exchange with a patient to whom I was breaking the news of my imminent departure, my patient said something about the fact that we had "done so much good work together" as if it was now all lost. My response was to counter that statement by framing it in the light of forward movement, of her new ability to build upon that foundation and realize more of her innate potential for self-directed advocacy. She agreed, but maintained her assertion that it was a loss of large proportions.
That day of finally closing the door on my seven-year sojourn---January 18th---is close on the horizon. What happens between now and then is only one part of the story. After that, a new chapter begins, and I will write that chapter with great interest and care. Perhaps it is already written and I only need to find it within myself.....
Wednesday, December 26, 2007
Pity vs. Compassion
"When your fear touches someone's pain it becomes pity; when your love touches someone's pain, it becomes compassion."
---Stephen Levine
Facing a return to work today after a long weekend, this quote speaks to me. It speaks of one of the touchstones of being in a helping profession, and of a life-long journey centered around developing, nurturing, and propagating compassion.
In the face of professional burnout, one can easily turn away from compassion, lose sight of it, and move into less therapeutic and unhelpful territory. This is what one might call compassion fatigue. Pity is an ugly cousin of compassion, but burnout can lead into much uglier territory still, like resentment and anger. Leveled against clients and patients, these emotions whittle away at the therapeutic relationship, leaving nothing but the starkest of connection. These manifestations essentially poison the well of compassion, but hopefully not beyond repair.
For myself, I am extricating myself before the damage is done, to me or others. I am exiting stage left with my compassion fatigued, but still intact and heartfelt. While I may feel badly for those patients whose abandonment issues will be stirred up by my leaving, better for them to face their issues than to face my loss of compassion.
Transitions are never easy. As the year comes to a close, change is inevitable, and I ready myself for the shifting sands and the equally inevitable challenges that change will bring. I will also endeavor to help my patients to do the same.
---Stephen Levine
Facing a return to work today after a long weekend, this quote speaks to me. It speaks of one of the touchstones of being in a helping profession, and of a life-long journey centered around developing, nurturing, and propagating compassion.
In the face of professional burnout, one can easily turn away from compassion, lose sight of it, and move into less therapeutic and unhelpful territory. This is what one might call compassion fatigue. Pity is an ugly cousin of compassion, but burnout can lead into much uglier territory still, like resentment and anger. Leveled against clients and patients, these emotions whittle away at the therapeutic relationship, leaving nothing but the starkest of connection. These manifestations essentially poison the well of compassion, but hopefully not beyond repair.
For myself, I am extricating myself before the damage is done, to me or others. I am exiting stage left with my compassion fatigued, but still intact and heartfelt. While I may feel badly for those patients whose abandonment issues will be stirred up by my leaving, better for them to face their issues than to face my loss of compassion.
Transitions are never easy. As the year comes to a close, change is inevitable, and I ready myself for the shifting sands and the equally inevitable challenges that change will bring. I will also endeavor to help my patients to do the same.
Thursday, December 20, 2007
Phone Conversation: An Exercise in Boundaries
The phone rings at my desk.
"So," a voice says through the receiver. "Can I get my oxycodone prescription today?"
"Your oxycodone prescription?" I respond. "Is this __________ calling?"
"Yes, it's me. I need my prescription now! You've kept me waiting!"
"Now wait a second. You spent the whole weekend snorting heroin and I sent you to the ER in an ambulance because you were wandering your building naked and hearing voices," I say. "You also had a machete on the kitchen counter. I thought you were in danger. And now you want your oxycodone just like that?"
"Yes. I'm in pain and I need it and now you won't give it to me. Jesus Christ!"
"Listen." I try to be patient. "You were out of control this weekend. Even your son said so."
"But I was celebrating! Can't I celebrate like anyone else?"
"Well," I say. "You could have taken a friend out to a nice restaurant to celebrate. Or maybe gone to a movie and bought yourself something nice at the mall. Instead, you chose to go out on the street, buy some heroin, and then spent most of the weekend psychotic. How can we trust you with a bottle of oxycodone?"
"C'mon! I need my meds! You can't refuse to give me my meds!"
"Well, this is the story. I have decided that I will give the bottle of meds to your visiting nurse. She will keep the meds in the lock box and give you four pills every morning for you to take throughout the day. Then the next morning you'll get four more. That's the deal. Either you accept what I'm offering or you get no narcotics at all. No arguments. No bargains. Period."
"No, no, no. You can't do that. I need my fucking meds now!"
I sigh. "Look, _________. This is it. Take it or leave it. I have your prescription in my hand and I'm about to go find the doctor to have her sign it. I can just as easily shred the prescription and we'll talk after Christmas."
"OK. But I'd better get my meds!"
"I'll have the doctor sign your script now, as long as she agrees to my plan. But if you use any more heroin, take any street drugs, or do anything like that again, I guarantee you she'll stop writing those prescriptions right away."
"OK, OK," she grumbles.
"Merry Christmas, my dear."
"Yeah, yeah. Bye." She hangs up.
I hang up my phone and my colleagues applaud. An exercise in boundaries? Sure. And patience. And compassion. And insanity. Was I really on a leave of absence just five days ago? It seems like an eternity.
"So," a voice says through the receiver. "Can I get my oxycodone prescription today?"
"Your oxycodone prescription?" I respond. "Is this __________ calling?"
"Yes, it's me. I need my prescription now! You've kept me waiting!"
"Now wait a second. You spent the whole weekend snorting heroin and I sent you to the ER in an ambulance because you were wandering your building naked and hearing voices," I say. "You also had a machete on the kitchen counter. I thought you were in danger. And now you want your oxycodone just like that?"
"Yes. I'm in pain and I need it and now you won't give it to me. Jesus Christ!"
"Listen." I try to be patient. "You were out of control this weekend. Even your son said so."
"But I was celebrating! Can't I celebrate like anyone else?"
"Well," I say. "You could have taken a friend out to a nice restaurant to celebrate. Or maybe gone to a movie and bought yourself something nice at the mall. Instead, you chose to go out on the street, buy some heroin, and then spent most of the weekend psychotic. How can we trust you with a bottle of oxycodone?"
"C'mon! I need my meds! You can't refuse to give me my meds!"
"Well, this is the story. I have decided that I will give the bottle of meds to your visiting nurse. She will keep the meds in the lock box and give you four pills every morning for you to take throughout the day. Then the next morning you'll get four more. That's the deal. Either you accept what I'm offering or you get no narcotics at all. No arguments. No bargains. Period."
"No, no, no. You can't do that. I need my fucking meds now!"
I sigh. "Look, _________. This is it. Take it or leave it. I have your prescription in my hand and I'm about to go find the doctor to have her sign it. I can just as easily shred the prescription and we'll talk after Christmas."
"OK. But I'd better get my meds!"
"I'll have the doctor sign your script now, as long as she agrees to my plan. But if you use any more heroin, take any street drugs, or do anything like that again, I guarantee you she'll stop writing those prescriptions right away."
"OK, OK," she grumbles.
"Merry Christmas, my dear."
"Yeah, yeah. Bye." She hangs up.
I hang up my phone and my colleagues applaud. An exercise in boundaries? Sure. And patience. And compassion. And insanity. Was I really on a leave of absence just five days ago? It seems like an eternity.
Tuesday, December 18, 2007
Running for My Money
Today was one of those days where this line of work can give an earnest Nurse Care Manager a run for his money. (And I do certainly feel like I'm running for my money today.)
First, there's the patient with acute psychosis who apparently went on an inhaled heroin binge this weekend to celebrate finishing a very important multiple-month medical treatment. She told me that a friend had suggested going out to a fancy dinner instead of blowing her money on heroin. "It was actually a pretty good idea," she said with a laugh. After discussing the voices in her head and her non-compliance with taking her medications, she agreed to go by ambulance to the ER for an evaluation.
Another patient just seems to be having a hard time getting his life on track (a familiar complaint and observation here at "Train Wrecks 'r' Us". I feel deep compassion for his suffering, but sometimes it seems we just have to sit and let them work it out themselves.
The next patient complains about my long leave-of-absence, and says over the phone, "You mean, you've been back since yesterday and you haven't called me yet? I missed you so much!" How will I break the news to her that, in five weeks, I'll be permanently gone from her life?
Still another patient hears the news of my imminent departure and says, "Oh no! Another doctor leaving me behind? What next?" (She always refers to me as her doctor.)
These and other reactions are enough to make me feel guilty for leaving, but then I simply remind myself of the reasons why I'm leaving, the multiple stressors, the fast pace, the overwhelming feeling that I am running a race with no end in sight. I've been running like this for seven years, and working full-time for eleven.
We all run for our money in many ways, and any line of work will generally keep one running. This particular line has simply worn out the treads of my old Nurse Care Manager tires. I'm just due for a tune-up, some new treads, and a new place to run. In old-fashioned terminology, I'm "plum worn out" and have opened myself up to a new way to make my living in the world. The hardest part of that process is saying goodbye, and that is without a doubt par for the course.
First, there's the patient with acute psychosis who apparently went on an inhaled heroin binge this weekend to celebrate finishing a very important multiple-month medical treatment. She told me that a friend had suggested going out to a fancy dinner instead of blowing her money on heroin. "It was actually a pretty good idea," she said with a laugh. After discussing the voices in her head and her non-compliance with taking her medications, she agreed to go by ambulance to the ER for an evaluation.
Another patient just seems to be having a hard time getting his life on track (a familiar complaint and observation here at "Train Wrecks 'r' Us". I feel deep compassion for his suffering, but sometimes it seems we just have to sit and let them work it out themselves.
The next patient complains about my long leave-of-absence, and says over the phone, "You mean, you've been back since yesterday and you haven't called me yet? I missed you so much!" How will I break the news to her that, in five weeks, I'll be permanently gone from her life?
Still another patient hears the news of my imminent departure and says, "Oh no! Another doctor leaving me behind? What next?" (She always refers to me as her doctor.)
These and other reactions are enough to make me feel guilty for leaving, but then I simply remind myself of the reasons why I'm leaving, the multiple stressors, the fast pace, the overwhelming feeling that I am running a race with no end in sight. I've been running like this for seven years, and working full-time for eleven.
We all run for our money in many ways, and any line of work will generally keep one running. This particular line has simply worn out the treads of my old Nurse Care Manager tires. I'm just due for a tune-up, some new treads, and a new place to run. In old-fashioned terminology, I'm "plum worn out" and have opened myself up to a new way to make my living in the world. The hardest part of that process is saying goodbye, and that is without a doubt par for the course.
Monday, December 17, 2007
Hello and Goodbye
I returned to work today following my six-week leave of absence, and while it was nice to say hello to friends, colleagues and patients once again, the reality is that I also have to begin saying goodbye as soon as I say hello. With my exit (stage left) planned for January 18th, time is of the essence to begin the disengagement process. It's an interesting exercise, and long-disused emotional muscles are being flexed as we speak. And when new muscles are flexed, we all know there's some growing pains.
It's easier than I thought to get started. I have to try to say goodbye to more than 80 patients, many of whom I have worked with for seven years, sharing numerous ups and downs and the challenges of poverty and chronic illness. Having begun, saying goodbye is not as difficult as I imagined. Then again, I have yet to speak with the patients with whom I have shared the most closeness and emotional intimacy. That is where the emotional rubber meets the road.
I was on the phone with one particular patient today. I told her I would be leaving the practice on January 18th. She seemed to take it in stride, said she loved me and would miss me, and agreed to get together next week for what would probably be our final visit. Another patient simply said, "Why are you leaving? Is it for more money?". Well, not exactly. Just more time at home.
One of my favorite patients, a vulnerable twenty-three year old young woman---a year younger than my son---was the most wrenching goodbye to date. When I broke the news to her over the phone today, I felt myself wince, and I could hear the strain in her voice. We agreed to meet at her home on Wednesday to check in. That therapeutic relationship will be one of the most difficult to terminate. That is the first small pain of this process.
So, five weeks of goodbyes, explanations, the transfer of crucial information, and the formulation of a new work life. An interesting way to end a year-----and to start anew.
It's easier than I thought to get started. I have to try to say goodbye to more than 80 patients, many of whom I have worked with for seven years, sharing numerous ups and downs and the challenges of poverty and chronic illness. Having begun, saying goodbye is not as difficult as I imagined. Then again, I have yet to speak with the patients with whom I have shared the most closeness and emotional intimacy. That is where the emotional rubber meets the road.
I was on the phone with one particular patient today. I told her I would be leaving the practice on January 18th. She seemed to take it in stride, said she loved me and would miss me, and agreed to get together next week for what would probably be our final visit. Another patient simply said, "Why are you leaving? Is it for more money?". Well, not exactly. Just more time at home.
One of my favorite patients, a vulnerable twenty-three year old young woman---a year younger than my son---was the most wrenching goodbye to date. When I broke the news to her over the phone today, I felt myself wince, and I could hear the strain in her voice. We agreed to meet at her home on Wednesday to check in. That therapeutic relationship will be one of the most difficult to terminate. That is the first small pain of this process.
So, five weeks of goodbyes, explanations, the transfer of crucial information, and the formulation of a new work life. An interesting way to end a year-----and to start anew.
Sunday, December 16, 2007
It's the End of My Leave as I Know It (and I feel fine)
Well, dear Reader, tonight marks the end of my six-week medical leave of absence from my full-time job, with Monday morning's return to my Nurse Care Manager's desk in approximately 14 hours from the time of this writing. So, what did I accomplish on this leave of absence, you ask? For posterity and my own edification, allow me to enumerate:
Resignation: first and foremost, during this period of time for reflection and self-care I came to the earth-shattering conclusion that I can no longer sustain the pace of my position, and I submitted my letter of resignation. While I return to the fray tomorrow at 9am, I enter only briefly, knowing full well that, come January 18th, my tenure at that position will have come to a timely end. Saying goodbye to beloved and respected colleagues will be difficult, but most challenging will be terminating my relationships with dozens of patients, many with whom I have shared a great deal over seven years. Be that as it may, the decision feels right, and I'm sure I'll process some aspects of it here on Digital Doorway. It's like giving up a part of my identity, both as a person and as a nurse, and the letting go (and grieving) process has already begun.
Hospice: I have applied and been hired for a position as a per diem hospice nurse at a small residential hospice not far from my home. I hope to complete my orientation there quite soon, and begin to pick up shifts as they become available. A goal long postponed.
New opportunity: I have contracted to serve as a Nurse Consultant for Nurse LinkUp, an online nurse networking community for which I previously provided occasional articles. When the site is re-launched, I will be providing original content, recruiting members and advertisers, and using my experience as a nurse to influence the development of the site.
Self-care: acupuncture, a sleep study, psychotherapy, rest, exercise, rejuvenation, solitude, writing, reading----I have had almost as much of these as I wanted (though a few more naps would have been nice......)
Home-care: laundry, organization, an enema for the basement, cleaning, winterizing---good medicine for the nurse with OCD.
Business idea: the development of stress management and burnout prevention workshops for nurses and other healthcare professionals.
Technological upgrade: we did it---we switched to Mac from Windows, and I am reveling in the change! Eat your heart out, Bill Gates!
The importance of decreased stress: the most crucial accomplishment and realization of these six precious weeks has been the need for decreased stress in my life. How else could I have cultivated the needed distance to realize that my stress level was leading me on a path of chronic stress-related illness and dysphoria? Without such a radical decision (with thanks to my wife Mary for pushing me), there may not have been a renewed commitment to self-care, and a realization that working full-time, 9-5, was just not working for me anymore. Not working? Nay, it was not working, and I was not fully living. I was caught in the maelstrom of stress compounded by a workplace wherein there was relentless demand with too few mitigating factors. A release was needed, and six weeks was only a taste of what that release might look like.
Granted, a professional life which is a patchwork of per diem positions, consulting, and self-employment may seem to some to be a self-made purgatory (and perhaps I'll feel similarly in a year or so), but for now, such freedom of movement and broader parameters are just what the doctor....er, I mean the nurse....ordered. Prescription received, and the co-payment? Priceless!
Good-byes: and now the goodbyes begin, and this long-awaited and dreaded separation can get underway. I realize that there is much to grieve, much letting go to do, and sadness and doubt are inevitable. Still, in my heart of hearts, I know that it's for the best, and I consistently remind myself of the line by Michelle Shocked which I have mentioned here before: "The secret of a long life is knowing when it's time to go."
Resignation: first and foremost, during this period of time for reflection and self-care I came to the earth-shattering conclusion that I can no longer sustain the pace of my position, and I submitted my letter of resignation. While I return to the fray tomorrow at 9am, I enter only briefly, knowing full well that, come January 18th, my tenure at that position will have come to a timely end. Saying goodbye to beloved and respected colleagues will be difficult, but most challenging will be terminating my relationships with dozens of patients, many with whom I have shared a great deal over seven years. Be that as it may, the decision feels right, and I'm sure I'll process some aspects of it here on Digital Doorway. It's like giving up a part of my identity, both as a person and as a nurse, and the letting go (and grieving) process has already begun.
Hospice: I have applied and been hired for a position as a per diem hospice nurse at a small residential hospice not far from my home. I hope to complete my orientation there quite soon, and begin to pick up shifts as they become available. A goal long postponed.
New opportunity: I have contracted to serve as a Nurse Consultant for Nurse LinkUp, an online nurse networking community for which I previously provided occasional articles. When the site is re-launched, I will be providing original content, recruiting members and advertisers, and using my experience as a nurse to influence the development of the site.
Self-care: acupuncture, a sleep study, psychotherapy, rest, exercise, rejuvenation, solitude, writing, reading----I have had almost as much of these as I wanted (though a few more naps would have been nice......)
Home-care: laundry, organization, an enema for the basement, cleaning, winterizing---good medicine for the nurse with OCD.
Business idea: the development of stress management and burnout prevention workshops for nurses and other healthcare professionals.
Technological upgrade: we did it---we switched to Mac from Windows, and I am reveling in the change! Eat your heart out, Bill Gates!
The importance of decreased stress: the most crucial accomplishment and realization of these six precious weeks has been the need for decreased stress in my life. How else could I have cultivated the needed distance to realize that my stress level was leading me on a path of chronic stress-related illness and dysphoria? Without such a radical decision (with thanks to my wife Mary for pushing me), there may not have been a renewed commitment to self-care, and a realization that working full-time, 9-5, was just not working for me anymore. Not working? Nay, it was not working, and I was not fully living. I was caught in the maelstrom of stress compounded by a workplace wherein there was relentless demand with too few mitigating factors. A release was needed, and six weeks was only a taste of what that release might look like.
Granted, a professional life which is a patchwork of per diem positions, consulting, and self-employment may seem to some to be a self-made purgatory (and perhaps I'll feel similarly in a year or so), but for now, such freedom of movement and broader parameters are just what the doctor....er, I mean the nurse....ordered. Prescription received, and the co-payment? Priceless!
Good-byes: and now the goodbyes begin, and this long-awaited and dreaded separation can get underway. I realize that there is much to grieve, much letting go to do, and sadness and doubt are inevitable. Still, in my heart of hearts, I know that it's for the best, and I consistently remind myself of the line by Michelle Shocked which I have mentioned here before: "The secret of a long life is knowing when it's time to go."
Saturday, December 15, 2007
Death in the Afternoon
This afternoon, I worked my second orientation shift at a residential hospice where I have been hired as a per diem hospice nurse. Situated not far from where I live, working in such a small and homey environment with no more than six patients at a time is a far cry from my usual work as a Nurse Care Manager for the poorest of the poor in the inner city. (More on that upcoming career transition in subsequent posts.)
As a nursing student, hospice work was my stated career goal, and although I have not actually worked for a hospice organization per se, I have coordinated and taken part in hospice care for a number of my patients over the years. As a visiting nurse, terminal patients would often remain on our service, with family members or an automatic pump administering morphine around the clock. I was honored to pronounce a number of patients dead, signing provisional death certificates and facilitating post-mortem arrangements.
Now, with my new official position as a nurse in a free-standing hospice, the opportunity to provide focused and specialized care to the dying has become a reality, and I'm happy to assume this new role, at least on a per diem basis for the moment.
Over the course of the day, my preceptor (a 30-year practical nurse veteran) and I monitored and cared for five patients with the diligent assistance of an equally experienced home health aide and one volunteer. Two patients in particular received the lions' share of our attention based upon their deteriorating health, non-verbal and semi-comatose condition, and apparent closeness to death.
Around 2:30 we entered the room of the one patient who we deemed to be closest to his life's denouement, checking his pulses and respiratory status every few minutes. His peripheral pulses became weak and thready, eventually becoming undetectable altogether as his body shunted all available circulatory volume towards his brain and heart and lungs. It was at this time that we also became aware that his hands and feet---previously painfully contracted with neurologically-based deformities---were now relaxed, the skin mottled and gray. Feeling his weakening and slowing carotid pulses, we marked the slow decrease in the force of circulation to the brain as his respiratory rate decreased, with quick gasping breaths marked by long periods of apnea (cessation of breathing). By now his rapid decline was obvious.
At 2:58 pm, I placed my stethoscope on his chest, detected absolute lack of movement of air in the lungs and completely absent carotid pulse. It was then that we pronounced him dead, signed the death certificate, and began the long list of phone-calls and documentation which follows a death in a facility such as ours.
Orientation or not, this death appeared to welcome me with open arms into the fold of hospice care. My comfort level with the dying process and the many clinical and interpersonal processes involved, all confirmed for me that this is a place where I would like to be. Bringing all of my training, clinical skills, compassion, and desire to serve to bear, I can now see that hospice and the shepherding of the dying towards their ultimate goal---a noble and comfortable death---is truly a place which I would like to call home.
As this gentleman's soul enters what the Buddhists call the Bardo stage, I wish him well on his journey, and I thank him deeply for the honor of attending his death. May he be free of his suffering, may he be at peace, and may we all be so blessed to die with such grace and nobility.
As a nursing student, hospice work was my stated career goal, and although I have not actually worked for a hospice organization per se, I have coordinated and taken part in hospice care for a number of my patients over the years. As a visiting nurse, terminal patients would often remain on our service, with family members or an automatic pump administering morphine around the clock. I was honored to pronounce a number of patients dead, signing provisional death certificates and facilitating post-mortem arrangements.
Now, with my new official position as a nurse in a free-standing hospice, the opportunity to provide focused and specialized care to the dying has become a reality, and I'm happy to assume this new role, at least on a per diem basis for the moment.
Over the course of the day, my preceptor (a 30-year practical nurse veteran) and I monitored and cared for five patients with the diligent assistance of an equally experienced home health aide and one volunteer. Two patients in particular received the lions' share of our attention based upon their deteriorating health, non-verbal and semi-comatose condition, and apparent closeness to death.
Around 2:30 we entered the room of the one patient who we deemed to be closest to his life's denouement, checking his pulses and respiratory status every few minutes. His peripheral pulses became weak and thready, eventually becoming undetectable altogether as his body shunted all available circulatory volume towards his brain and heart and lungs. It was at this time that we also became aware that his hands and feet---previously painfully contracted with neurologically-based deformities---were now relaxed, the skin mottled and gray. Feeling his weakening and slowing carotid pulses, we marked the slow decrease in the force of circulation to the brain as his respiratory rate decreased, with quick gasping breaths marked by long periods of apnea (cessation of breathing). By now his rapid decline was obvious.
At 2:58 pm, I placed my stethoscope on his chest, detected absolute lack of movement of air in the lungs and completely absent carotid pulse. It was then that we pronounced him dead, signed the death certificate, and began the long list of phone-calls and documentation which follows a death in a facility such as ours.
Orientation or not, this death appeared to welcome me with open arms into the fold of hospice care. My comfort level with the dying process and the many clinical and interpersonal processes involved, all confirmed for me that this is a place where I would like to be. Bringing all of my training, clinical skills, compassion, and desire to serve to bear, I can now see that hospice and the shepherding of the dying towards their ultimate goal---a noble and comfortable death---is truly a place which I would like to call home.
As this gentleman's soul enters what the Buddhists call the Bardo stage, I wish him well on his journey, and I thank him deeply for the honor of attending his death. May he be free of his suffering, may he be at peace, and may we all be so blessed to die with such grace and nobility.
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