O Dethmama, Where Is Thy Sting?

My absence from this site has been related to a sudden, but temporary, aversion to all things "bloggy" and unusually taxing work nights. I've truly felt the need to use every moment away from my hospice duties to tend to my physical and emotional well-being. That being said, let's take a peek at just a few of the events of my last "week" or so at work...
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The Drunken Tuck-In

I went to a new patient's home to do a "tuck-in" visit. I was let into the apartment by the patient's friend who was putting away groceries that she'd bought for him and she'd also just picked him up from jail where he'd been detained on DUI charges.

My attempt to educate the man on his medications was completely thwarted due to his inability to pay attention to my learned advice. He was passed out drunk on the sofa and any attempts to rouse him were in vain. I notified the hospice of the situation, and predicted that "this new guy is gonna be a handful". For some odd reason, I feel that this is, so far, my Best Tuck-In Ever.
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I Still Hate My Hospice's Pharmacy

Had a new admission into the inpatient unit for uncontrollable pain. The morphine drip didn't arrive until three hours after the patient arrived on the unit.
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Got a call regarding a patient with intractable nausea and vomiting. The patient's caregiver has used every intervention/medication available to her and nothing's working for this poor man. I contacted our doc and called the new orders into the pharmacy. During my conversation with the pharmacist, I made it quite clear how much the patient was suffering. In spite of this, the pharmacist still asked, "Should we mail this medication to the patient?"
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The Nursie Fight

I got into a shouting match over the phone with a nurse at one of our contracted inpatient units. She refused to go look for a patient's medications that had been sent to the wrong floor and insisted that our pharmacy redeliver the meds. Yeah, they were way too busy to look for those meds. So I flipped out.

I told her that I'd be happy to drive the 25 miles to look for the meds myself since her being inconvenienced was way more important than the patient's well-being. That pretty much got her panties in a bunch and she hung up on me... and I happily drove 25 miles to the inpatient unit.
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Just Pick Up The Phone. Please.

I've tried repeatedly to contact the Administrator On-Call this week to notify her of potential shit storms and well, "nursie fights". She never answered the phone once.
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It's Crazy Time

This poor, old woman has had a psychotic break. She's going to kill her son, her hired caregiver and then kill herself. As I speak to the son on the phone, I realize that he wants me to come over to the house. Apparently, he thinks that as soon as I walk in the door, his mother will see my heavenly halo, hear the angelic chorus and all will be well. I tell him to call 911 instead. He does.
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Deth-O-Rama

I've attended nine deaths this week.
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Drunken Tuck-In Redux

This guy's now in an inpatient unit for symptom control (i.e. keeping the pink elephants at bay). We need to work a bit harder on his situation. He's stumbling about the unit and wandering into other patients' rooms. The nurses are, understandably, not happy about this.
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The Death of Michael Jackson

I found out about MJ's death from the 88 year old husband of a patient I visited on Thursday night. I was completely stunned and my arms broke out in goose flesh. The news also made me realize how "out of the loop" I've been for over a week. Okay, need to watch less BBC, more CNN.
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Free Pepper Spray With Every Tuck-In

Both the patient and his partner were very pleasant and their tidy apartment was truly a place of sanctuary in this very, dangerous neighborhood. After making sure that the patient was settled in and his partner was comfortable with administering the new medications, it was time for me to go. The patient's partner would not let me leave the apartment, however, without first making sure that I was armed with a canister of pepper spray. Okay, this is officially, so far, the Best Tuck-In Ever.

I'm Wearin' My Ranty Panties

Lately, a few things have been getting on my last, rectal nerve. So please, indulge me for a bit. I'll get this over with quickly...

The V.I.P.'s

My hospice has had a rash of "VIP's" lately. Are they current or former employees, their family members or beloved friends? No. Actually, they're very wealthy people with a massive sense of entitlement.

• They call for a bedpan at 2 AM. Although there's a 24 hr drugstore on every corner in this city.
• They call for a nurse to sit with the patient at 9 PM so they can all go out for dinner and a movie.
• They don't call for a nurse during a real emergency, but raise holy hell with hospice management because a nurse didn't call them during the crisis. (Yeah, that's one of my favorites)
  

Apartment Complexes, Trailer Parks, etc. (at night)

• The "map" at the entrance for the complex has no "You Are Here".
• Home or building numbers are nonexistent, poorly maintained or unlit.
• Building numbers are placed so that they cannot be seen from the "road" or are obscured by the roofs of car ports.

I find myself hopping in and out of my car, like a nervous meerkat, trying desperately to find some kind of building number. Very nerve-wracking when one wants to get to an emergency situation as quickly as possible.


My Hospice's Pharmacy

• Will sometimes mail E-kits and pain medications to our new, suffering patients even though they have a courier to make home and facility deliveries.
• Believes that STAT equals four hours. (Yes, that's their policy)
• Will deliver meds to our inpatient unit 6 hours after the patient has arrived.

I have lost count of the times (and hours wasted) that I've driven to our pharmacy to pick up badly needed medications and delivered them to the patient myself. So should we fire this pharmacy? My hospice owns this flippin' pharmacy!


Whew... okay I'm done. All better now. Thank you for "listening".

Saved By Cesar

0720 hrs. -- I've been here before and I didn't like it. At least, now, the poor woman has died and is free from the filth and emotional wasteland that was her home. Such is often the case when your caregivers are addicts...

All the adult members of the family are out on the porch, drinking cheap vodka straight from the plastic, gallon bottle. Walking up the long, winding ramp to the trailer's front door, I'm met by the family dog. The anxious and aggressive pit bull is barking ferociously. Someone, out on the deck, yells at the animal from twenty feet away, but the dog pays no attention and stands its ground. Clearly, no one is going to get up to handle the dog for me.

Okay, deep breath. It's time to draw upon the power of The Dog Whisperer. I quickly remember his mantra... "exercise, discipline and affection". Shit! Wrong mantra. I don't think I have the time for exercise, discipline and affection. Okay, got it. It's "no touch, no talk, no eye contact".

Head up, shoulders back, I walk past the territorial pit bull and just hope that it doesn't bite me in the ass. I briefly greet the members of the "cocktail party" and enter the mobile home. Safe at last. All alone with poor, dead Sally in the midst of almost, unbelievable squalor.

Twenty minutes pass...

I'm done with my reports and computer work and am now just waiting for the funeral home to arrive. Outside, the pit bull is acting up again and the party goers, resenting the interruption to their witty repartee, open the door to the trailer and kick the dog inside. With me. Alone.

I recall the "mantra" that served me so well before and at a time like this, it can't hurt to pray either... "Hail Cesar, full of calm assertiveness. Blessed are you among frustrated humans with bad doggies..."

Enema Addict Meets Enema Enabler

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(Warning: Unless you are a hard-core, hands-on, health professional, you may not want to read this while eating your lunch.)

I was having one of those "theme nights". The patients were providing a veritable potpourri of gastro-intestinal delights. Nausea and vomiting, intractable diarrhea and constipation...

Now constipation is rarely considered an occasion for an emergency home visit, but in this case I was compelled to go. Willard was insisting on getting an enema now and his caregivers at the assisted living facility were not allowed to administer enemas (lucky shits...my apologies, I couldn't resist). It was either take care of the situation or Willard would be making a trip to the hospital. I had to set aside my suspicion that the patient was stereotypically "bowel obsessed" and accept that he was truly in distress.

After purchasing a couple Fleet, disposable enemas at a nearby Walgreen's I made my way on over to Willard's poorly lit, tiny apartment in the assisted living...

You can get a twin-pak of these for less than 3 bucks! Who knew?

Well, the results from the procedure were truly disappointing. My puppy has produced far more impressive turdage. However, Willard was happy and that's all I needed to know. I helped him with the post-enema clean-up and went into his bathroom to wash my hands and leave the spare Fleet enema there for future emergencies. That's when I first took a good look at my surroundings...

The bathroom shelves and cupboards were filled with disposable enemas! When I returned to the living area, I then noticed that every shelf and bookcase in the room was bursting with boxes of enemas. Oh my God! Willard is enema dependent and I'm an enema enabler! Fine, Willard... I'm taking my extra Fleet enema home with me. That'll show you!

Two days later, Willard called "911" for "intolerable constipation". Poor fellow...

Hospice Hitwoman and the C.Y.A.: Part 2

(This is the second part of a two-part Adventure. To access the first part of the story, please click here.)

This has gone beyond the pale. I take a look at Mrs. C. and Marcy. They look almost frozen in time; mouths slightly open, eyes unblinking. I can't tell if they're in shock over Bob's outburst or anxiously awaiting my answer:

"Bob, I'm not killing anyone for you. I'm not a murderer."

I can't help it. I'm taking this personally and it's pissing me off. What in the name of God makes him think that I'm capable of murder?

Is it because I look like this?

Bob's demeanor changes instantly... His anger and desperation have crumbled into nervous back-peddling. He's said far too much and he knows it:

"Oh God, no really. I didn't mean that... it's just that we're... we can't..."

Oh God, I think I really want to leave this house right now..."Okay, let's just put an end to this subject", I say. "You know that Raymond's time is coming very soon and that I've told you that he appears to be comfortable. Please just try to stay as calm as possible for Ray and just give me a call if he passes on."

Returning to the quiet of my car, I decide to call my supervisor and "cover my ass". I tell Kathy as much as I can remember about this disturbing visit and then head for home. I don't get very far at all. Less than twenty minutes has passed before the answering service tells me that Mr. C. has died. I turn the car around and head back. Crap...

It's like a different house. The place is buzzing with friends and neighbors and the grieving family is happily soaking up all the attention. This is good. I'm able to keep the family informed and then fade into the background. After the funeral home leaves, I say goodbye to Mrs. C., update my supervisor and continue with the rest of my shift.

The next day...

I get report before the start of shift from my supervisor. Just before I hang up the phone, Kathy says, "Oh, by the way, there was a complaint from Mr. C's family today."

"Really? What was wrong?"

"They said that a hospice nurse never showed up at the house when they called last night", answers Kathy with a little chuckle.

Wow, wow, wow... See? It does pay to CYA.

Chattering Irma and the Ghost of Mr. H.

0610 hrs -- Irma forgot to call the hospice when her husband died, but she did think to call just about everyone else in town that drives around with flashing lights and sirens. That's okay, it happens. It always gets itself sorted out when I get to the home.

After all the emergency personnel had left the house, one visitor remained... a volunteer, that had been called in by the paramedics to help with the distraught widow. Susan, the young, sweet-faced, nursing student was one of our city's volunteers that sit with victims and families after a traumatic event. It's a wonderful program with nothing less than saints who sign up to take the training and then go forth into horrible, gut-wrenching situations.

Although Mrs. H. was no longer overtly distraught, Susan decided to stay for the duration. Something for which I was exceedingly grateful, because it didn't take but a moment for me to realize that something was a bit "off" about Mrs. H. The poor woman wouldn't, or more likely couldn't, stop talking.The chattering was ceaseless and exhausting. Thankfully, Susan's presence added an extra pair of sympathetic eyes and ears to keep focused on the grieving widow.

Irma's conversation was largely centered on friends, neighbors and her husband. Her rambling was often hard to follow and frankly, tested one's patience. However, when she began to describe events leading up to finding her dead husband, my ears pricked up considerably:

"I was sleeping in the other bedroom and I swear, I heard Gordon say 'Goodbye!', real loud. I mean, it actually woke me up! I ran into his room and found him dead."

Well, that got my attention... Mr. H. had been deeply comatose for several days!

Irma then quickly switched her subject to the various character flaws and idiosyncrasies of her husband. As the three of us sat at the kitchen table, Mrs. H. went through the lengthy list of Gordon's faults, including anecdotal evidence to back up her conclusions. Suddenly, the patio blinds to my right, gave a "snap", swung wildly and then settled.

Susan and I looked at each other in amazement and immediately returned our attention to the closed, patio door and blinds. The blinds took one more big swing and then became quiet. Irma, with her back to the door, just kept on chattering... until she noticed that neither Susan nor I were paying attention to her:

"Well, what on earth would make that happen?", she asked.

"I don't think Gordon likes you talking about him, Irma", I answer. Susan nodded her head in agreement. Without so much as a tiny acknowledgment of the freakiness of what just happened, Mrs. H. began talking about the family friend with the low IQ.

I'd never before experienced "the unexplained" while attending the death of a patient. I must say... it was very cool.

Euthanasia: The Puggie Epiphany

(I have never had to euthanize a pet... ever.)

Two days ago, I scooped up my beloved, old friend, wrapped her in a blanket and took her to the vet. I really needed to talk...and I wanted to make sure that the doc could see who I was talking about.

Opal is 10 years old, nearly blind, nearly deaf and a bit senile. Over the past year and a half her back legs have gradually become useless. She drags herself about far more than she walks and if she walks, she falls. Opal has also become incontinent of bowel and bladder.

So why haven't I done something about this a long time ago? Well, she's not in pain and she enjoys her food and a good gnaw on squeaky toy. Opal is also alert and still gets great joy from scolding anyone, real or imaginary (usually imaginary), that should pass by her windows. And most of all, I love her dearly. So up until now, the positives in Opal's life seemed to outweigh the negatives. Though as I reread these last two paragraphs, I think that I can see a woman in denial.

All right, back to the vet's office... Dr. B. has examined Opal and listened intently to my tearful tale of woe and ambivalence. I know that she cannot tell me what to do about Opal, but in the midst of all of this she says:

"Euthanasia is absolutely the worst part of my job. But I have come to really believe that, if it's possible, it's far better to end a pet's life before they are completely debilitated, miserable and in pain. I think it's better for them to still be able to have the ability to enjoy their owner's love... and a lot of spoiling before they go."

Dr B.'s words are no less than a kind of enlightenment for me. I can actually feel them physically impact me. It's a quick jab to my solar plexus. Before I can even respond, the doctor adds:

"Oh, the vet tech mentioned that you asked if someone would be able to euthanize in your home. If you choose to do this, I'd absolutely come to your home. It's what I'd want for my dogs."

And that's when I wept.

(Next Friday, Opal will be surrounded by all those who love her and we will all wish her well as she goes onto her next adventure.)

Hospice Hitwoman and the C.Y.A.: Part 1

1820 hrs. -- This visit is going poorly. Raymond C. is very close to death and his wife, daughter and son-in-law are completely freaking out. The tension and edginess in this house are palpable and I just can't seem to give this family whatever it is they need.

"You know he's sufffering and he doesn't deserve this! No one should have to die this way!", blurts Bob, the son-in-law. Bob's wife, Marcy, is up and pacing, wringing her hands and making little whimpery noises. Mrs. C. is sitting at the dining room table and giving me the cold stare of doom.

Too Noisy

"Please, Bob", I say, "I've sat with Ray twice now and I truly feel that he's not suffering." It's true... Mr. C. is quite peaceful. Semi-comatose, no restlessness, no grimacing, not even a "rattle". Only a rare, unintelligible, soft vocalization. Maybe that's what's got them in a tizzy. Maybe they're interpreting any noise he makes as an expression of agony. One thing I feel sure of... Raymond isn't suffering. It's his family that's in torment.

Too Messy

Calmly, gently I explain my position on Mr. C's comfort in detail and attempt to assure the family that they are providing excellent care for Ray. I end by saying:

"Please, everyone...I truly feel that your suffering far exceeds anything that Ray may be going through. What can I do to help you through this difficult time?"

Hissing, nearly spitting the words through his clenched teeth, Bob responds immediately:

"I want this over with now! You, you stop it! He doesn't deserve this!"

Just Right?

Jesus, Buddha, saints and angels... I've run into this sort of "request" before, but have never heard it expressed so blatantly. How dare you think of me in this way? What were once sincere offerings of compassion are quickly turning into feelings of contempt.

To be continued...

A Talk With a Doc II

1945 hrs -- Hospice consult in hospital emergency room (New Year's Eve)

Telephone Conversation

"I see from your orders that you want Mrs S. to be admitted into an inpatient hospice unit. She just doesn't qualify for that right now..."

"WHY NOT, WHY NOT, WHY NOT!?!!"

My God, he's screaming... I hold the phone out at arm's length. He's caught me completely by surprise. It's been a very long time since I've been on the receiving end of an MD's temper tantrum.

"Well, Mrs. S. just doesn't fit any of the criteria for admission. There are no symptoms to manage. She... "

"THAT'S NOT AN ANSWER! Give me an ANSWER! Why? WHY?!"

"Look", I continue, "Mrs. S. is stable. Her vital signs are good. No more respiratory distress, her O2 sats and vital signs are fine, she's coherent and in no pain whatsoever. There's no reason for her to be admitted into the unit." (What's wrong with me? Why am I allowing his abusive behavior to continue?) I forge on ahead... "With her history of COPD, I'm sure she's appropriate to receive our services in her home. Just discharge her home and we can sign her up tomorrow."

"What does her family have to say?"

"There's no family with her right now", I reply.

"Well, of COURSE NOT! They're gone because they think she's going into a hospice bed. They can't take care of her anymore. Isn't THAT a reason for hospice admission?"

A not so pretty picture is coming together in my head... The family is out partying like rock stars right now on New Year's Eve because Dr. E. told them that she's going to live in a hospice until she dies. Great.

"Actually, Dr. E., my supervisors have told me that that hasn't been an acceptable reason for admission for over a year now. Listen, she's a Medicare patient, if you're so determined to have her go inpatient, you can try calling any other hospice in the city and have them come give her a look!"

"She's NOT Medicare, she's got "Senior Perks" coverage and only YOUR hospice can TAKE her!!"

Okay... I've had enough. Reaching deep within, I manage to find the tiny, "Testicle of Intestinal Fortitude". Clutching the little guy within my sweaty palm I say:

"Dr. E., it's common knowledge that anyone that has Senior Perks insurance also has Medicare coverage. But I imagine that it's so much easier to be abusive than informed, isn't it? This conversation is over and I'm giving the phone back to the Charge Nurse."

I hand the phone over to the RN. As I write a progress note detailing why the patient is not suitable for inpatient admission, I notice that the Charge Nurse is writing an order for another hospice to come in and evaluate the patient. Ah... the next hapless victim. I hope that they're able to find their "Testicle of Intestinal Fortitude" a lot faster than I did.


Click here to get the Joint Commission's take on bullying in the workplace.

Superstition

I was on duty last night. Not only did I not have to leave my house, but I didn't even get so much as a single hospice-related phone call! I even called my company-issue "Zoolander phone" to make sure that the tiny, little piece of plastic was still functioning. It was.

Zoolander phone... for people that can't talk good.

Yeesh... the karmic bottleneck must be of apocalyptic proportion! I am so not looking forward to the rest of my work "week".

Oh, and please don't wish me a "quiet night". Use of the "Q word" is guaranteed to send me into spasms of superstitiousness.

The Photo Op

Image via Wikipedia
2315 hrs.

"How's this one?" I ask, cocking an eyebrow in her direction.

"Yeah, well no... you've got to get in a lot closer," advises Mrs. J., "Let's try again."

I figured she'd say that. It's not quite what I wanted to hear, but this camera phone is awful. I've already taken three pictures and so far, none were to her liking. Mrs. J. lies down again by her husband, positions his face cheek-to-cheek with hers and she smiles. I bring the cell phone in much closer and get another shot.

"Okay, better?"

"Oh, tons", she replies. "Can we do one or two more like that?"

"Sure."

The patient's wife resumes her position and as I lean forward to take the picture, a stream of green-black secretions oozes from the dead man's mouth; just missing his wife's hand. Mrs. J. simultaneously drops her husband's head and bolts from the bed.

"What the f*@k was THAT!?!"

"I think we'll call that a wrap, Mrs. J."


For information on post-mortem photography click here and here.

A Talk With a Doc

1900 hrs. -- I'm at the hospital on a consult for a prospective hospice patient. At the nurse's station, I sit near Mrs. L's primary physician as I study her chart.

"So, what do you do over at hospice?" asks Dr. S.

"Well, my primary duty is to take care of after hours emergencies", I reply."

"HAH!", laughs the doc. "What emergencies could hospice patients possibly have?"

I keep silent. A little anger is rising up within me. There is no way to respond to his thoughtless remark without betraying my feelings. I get up and go into Mrs L.'s room.

Earlier in the day, Dr. S. had ordered a Dilaudid drip for the patient. Running at a rate of 1 mg. per hour, it clearly is inadequate for Mrs L's pain. She's in agony. Her poor husband, sitting by her side, is suffering nearly as much as she. I immediately return to the nurse's station.

"Dr. S., could you please write titration orders on the IV Dilaudid so we can get her comfortable? The hospice won't be able to get her into an inpatient unit until tomorrow and her pain isn't under control yet."

The doc's eyes widen considerably. I instinctively know that he's hesitant -- no, he's afraid to increase the rate of the drip. "Noooo... I can't do that", he finally answers and gets up from the desk and walks briskly away.

Watching him leave, I raise my voice, "Why did you order Dilaudid if you weren't going to use it for her pain?"

He disappears into the elevator. Shit.

Joie de Vivre et Madame M.

1940 hrs. -- It was an ordinary house in an ordinary neighborhood until I walked inside. The home is filled with lush, expensive furnishings. My eyes are dazzled by the glittering, crystal chandeliers, rich rugs and fabrics. Nearly every square inch of available wall space is taken up by gilt-framed oils and drawings. Books, trinkets, memorabilia and personal photos inhabit nearly every flat surface in the home. Mrs. M. once had a lot of dusting to do!

I follow the deceased's daughter, Iris, to the hospital bed in the dining room. Mrs. M's body is lying in dignified repose. A turban hides her thinning hair and her face is in full makeup.

"Oh my, she looks beautiful!", I exclaim.

"Well, I know Mom would never want to leave the house unless she was completely made up", says the daughter.

Although tearful, Iris is eager to tell me a bit about her mother's story. A singer, dancer and artist, Mrs. M. was well loved by all who knew her. Many of the treasures in her home had been collected from her frequent ventures abroad. In a photo, from her "prime", Iris' mother bears an uncanny resemblance to Brigitte Bardot and likewise, the '60's was certainly her decade.

Looking at the daughter, I can clearly tell that she loved and admired her mother. Nevertheless, a parent like this would be an almost impossible act to follow. I make a point of not inquiring about Iris' own work, interests or accomplishments.

The doorbell rings... Not wanting to see her mother's body taken away, Iris retreats to her own home, just next door. I greet the funeral home's removal team at the door. From the foyer, one of the men is able to see straight into the dining room where Mrs. M. lies.

Leaning close to me he whispers, "Is she a gypsy?"

It's true, even from nearly thirty feet away, the rouged cheeks, painted lips, false eyelashes and turban are striking.

"No", I reply. "What you see is je ne sais quoi."

Fin.

1,000 Cranes

0535 hrs. -- As I approach the door to the home of Mr. and Mrs. O., I see that the sun will be rising soon and it's going to be a beauty. It seems that now, I rarely get to see the sunrise... which I think is far superior to a sunset. Lately, only the death of one of my patients gives me this opportunity.

A little over twelve hours ago, Mrs. O. had just returned home from an overnight stay at a psych hospital. Her suffering, from her terminal illness, had compelled her to make a sincere, but clumsy, suicide attempt. Newly "signed" onto hospice care, we were all hopeful that some relief could be found for her...but now she is dead.

After making my pronouncement, I perform a brief examination of the body. No new marks, no remnants of pills in her mouth or in the bed. No orange-colored, oral secretions from liquid morphine. She is, in fact, for lack of a better word, "pristine" and her facial expression is well... beautiful and serene.

Mr. O. prepares a simple breakfast for himself while we wait for the funeral home to arrive. Sitting at the table I notice, hanging from the ceiling, an amazing origami display. Seemingly countless, shimmering, paper cranes, suspended from colorful strings, that reach from ceiling to floor.

"What is this?", I ask. "It's absolutely stunning!"

"Oh, that's one thousand cranes," says Mr. O., looking up from his bowl of cereal. "Well, actually, it's two thousand cranes," he adds. " I made them."

Mr. O. quietly explains the two occasions that inspired him to make the origami cranes and then falls silent. For several minutes we share a comfortable silence. He with his breakfast and me with my tea.

"You know, she went so peacefully," says Mr. O., and I look into his kind eyes and nod my head.

Suddenly, sunlight spills through the window and sets the origami cranes ablaze in flashes of light and color. I can't take my eyes away from it. It's indescribably beautiful. For now, I will only look at this. Maybe later, I will think.

Bad Kitty and the Hospice Nurse

2250 hrs. -- After being, seemingly, on his death bed for several days, Stanley L. has "rallied". Not only is he now up and about, but he's also being abusive, paranoid and is refusing to take his meds.

I sit at the cluttered, kitchen table with the patient and his wife. Marie looks disheveled and exhausted. Stanley is painfully gaunt, grizzled and exuding obstinance. Frankly, I'm a bit surprised that this frail, dying man has made the trip from his bedroom to the kitchen. Note to self: never underestimate the power of the near-death "rally".

"Please, take your pills, Stan", I beg. "I know that you'd feel so much better."

"Forget it. I just want you to call the police and get that crazy woman out of my house! She has no business bein' here!"

All of my pleas and logic are for naught. Our conversation is going in circles. Stan vehemently refuses to take his medications and then returns to his delusional train of thought. I look at Marie... she rolls her eyes and gives a little shake of her head.

Suddenly, a cat jumps onto the table and positions itself directly in front of me. Its face is within inches of mine.

"Don't touch him!", shouts Stanley. "He's mean!"

I can take a hint. The cat is matted and filthy. Its left, front leg is missing, his left ear is nearly bitten off and the left eye is also gone. Good grief... no wonder the cat is so ill-tempered, it's missing at least one of everything.

"Hello, Tripod," I say.

"How the hell did ya know that's his name?", laughs Stanley. I feign surprise about my "lucky" guess and manage to get him to chat a bit about his beloved cat. Maybe now, I can take advantage of Mr. L's improved mood...

Taking the small cluster of pills in my hand, I explain the purpose of each one to Mr. L., hoping that he'll realize that no harm is intended.

"Okay, I'll take them.", he says, reaching for the pills. I hand them over and Mr. L. promptly flings them to the floor. Tripod immediately makes a three-legged leap from the table and heads for the medications.

"Gahhh!", I screech as both Marie and I dive to the floor to retrieve the pills. I mutter and curse myself for my stupidity as I crawl on all fours under the kitchen table.

Once again I am face to face with Tripod as I fumble amid the piles of fur and petrified cat turds. The cat has found one of the small tablets and is batting it around. With some hesitation, I reach for the pill and Tripod smacks me across the face with his paw. I jerk back and hit my head sharply on the underside of the table.

"Oww! Crap! Ohhh... that hurts." I'm seeing stars and need a few seconds to clear my head. The fog lifts and I see that both Tripod and the pill are gone. Still on the floor, I peer over the edge of the table and look at Mr L.:

"Mr. L., I'm pretty sure Tripod took off with your Ativan. It'd be awful if something bad happens to him!"

"Yeah, I'd feel real bad. I'm really sorry about all this."

Marie and I do a pill count. We're missing just the one Ativan and the cat is nowhere in sight. For now, all we can do is hope that Tripod has no interest in eating it.

Done in by all the excitement, Stan is happy to let us tuck him back into bed. Marie, satisfied with this turn of events, bids me "goodnight". So I head for home... covered in fur, smelling a bit "cat pissy" and sporting a new bump on my head.

Two days later, Mr. L. passed on and Tripod is still among the living. I'd like to say that, thanks to Ativan, he's now sweet, cuddly and anxiety-free...but I'd be lying.

The Mean Kitty Song

The "Inhalinguisher"

1800 hrs -- Telephone conversation:

"Hello... is this the hospice nurse?"

"Yes it is. How can I help you?"

"Well, we keep a little fire extinguisher by Marvin's chair because we're afraid that he'll forget to take off his oxygen when he smokes. He's so confused nowadays."

"Okay..."

"Well, he just took a big puff off the extinguisher because he thought it was his inhaler."

"Oh, my God! How's he doing?"

"Well, he's rolling around on the floor right now."

"Ma'am, please call 911 right now! There's nothing that I can do for him. He needs to go to the hospital!"

"Well, he says he doesn't want to go to the hospital."

"Does he have his oxygen on?"

"Well, no."

"Get his oxygen back on and turn it up to six liters. I'm going to hang up now. Keep your phone line free because I'm going to call you back in less than ten minutes."

"Well, alright."

Lucky me... I just happen to have the phone number for our community's Poison Center on speed dial. The news isn't good. The knowledgeable woman on the other end of the line tells me that the effects of inhaling the contents of a fire extinguisher can be devastating even to much younger, healthier lungs. That's all I need to know. I immediately call Marvin's wife:

"I've just talked to the Poison Center. You've got to call 911 and get Marvin to the hospital now!"

"Well, okay."

The next day I call my supervisor to get report before the start of my shift. Marvin, I am told, is doing great. In fact, he hasn't felt this good in a very long time. My supervisor laughs and tells me that the hospice is considering issuing little fire extinguishers to all patients with respiratory problems. Well, well...

Articles of Interest: The Sandwich Generation

The "Sandwich Generation"

Those of us that are caring for elderly, ill or dying parents and also have children to tend to in the home are often labeled as members of the "Sandwich Generation". It's certainly not a new concept... humans have likely been "sandwiched" between caring for their children and ailing parents for countless generations. However, nowadays, many members of a single family may be scattered throughout the world... making information gathering, decision-making and "hands on" care more complicated than ever.

Over eight years ago, I became a member of the Sandwich Generation. My parents moved into my home to live with me and my twelve year old son. My father's dementia was severe and my mother could barely walk. After six months, the stresses of care giving, full time work, "making ends meet" and seeing that my son received the attention that he deserved took its toll. It truly was one of the most stressful, anxiety-filled and guilt-ridden times in my life.

It took a long time and a lot of hard work, but I finally found solutions in the form of a high, quality group home and later, an excellent long-term care facility. My parents have since passed on, but I have no doubt that they received excellent care in safe and attentive settings. It was not the ideal solution. I truly wished that they could have stayed with me until the end, but it was, indeed, the wise thing to do.

Internet access to resources, information and discussion forums was mighty thin when my parents were living with me. Google was less than two years old at the time. Fortunately, there is now a lot of information on the internet for those who are "sandwiched" and those who wonder if that time is looming on the horizon.

Finding local, community services
Department of Health and Human Resources -- "Eldercare Locator"

Solid, practical advice from CNN Money.com
"Sandwich Generation: Survive the Mid-Life Tug of War"

From HubPages.com
"The 10 Signs Your Elderly Parent Needs Help"

A more humorous slant from AGIS
"Top Ten Signs You Are a Sandwich Caregiver"

Shock and Shame

1300 hrs -- I've stopped by one of our inpatient units to see how our patients are doing. The charge nurse, Charlotte, stops me before I begin to make rounds:

"The family in 413 has gone nuts," she says. "We've all tried to calm them down, but nothing's workin'. At least now they're stayin' in the room instead of shriekin' up 'n down the halls and makin' all the other families upset."

"Great," I mutter. "When did Mrs. P. die?"

"Oh, she's not dead, yet... awful close, though," Charlotte replies.The charge nurse then informs me that the "noisy crew" consists of two, middle-aged daughters, one teen-aged girl and an infant.

It's become clear that Charlotte and her staff have "given up" on this group. The usual form of emotional support offered by hospice staff is lost on this family. As long as the family remains exiled in room 413, the nurses, patients and families can get through their day in peace.

I take a deep breath... it's time to introduce myself to Mrs P's family. I quietly open the door, enter the small vestibule and peer around the corner to get a view of the room and its inhabitants.

"Look at the baby, look at the baby, look at the baby..." , the women chant excitedly.

One of the daughters is in bed with the patient. She has straddled Mrs. P. between her legs and propped her up into a sitting position. She is also forcing the nearly dead woman's eyes open with her fingers. Daughter "number two" is dangling the infant directly in front of the unresponsive patient.

"Look at the baby, look at the baby, look at the baby...", the chant is rapid-fire and unending. A short gasp escapes from me and I immediately bolt from the room.

I have counseled many families on the importance of maintaining a calm energy around their dying loved ones. Scream and howl all you want out in the backyard... just don't bring it to the bedside. A "peaceful" death... right? Isn't that what we're shooting for?

Is the family dysfunctional? Are there cultural differences at play that I haven't been made aware of? I don't know, but the scene in room 413 has shocked me and I feel ashamed. Shame on me for being both shocked and incapable of going back into the room.

Humbled, I walk back to the nurse's station and sit silently next to Charge Nurse Charlotte. I don't even get a chance to warm up the chair's seat cushion and...

"SHE'S DEAD! SHE'S DEAD!", screams the teenager as she runs through the hallway. "SHE'S DEAD... SHE'S DEAD!"

"Hoo boy", I say. "I guess that means --"

"Yup...", interrupts Charlotte. "She's dead".

Articles of Interest

In July, of this year, the Joint Commission issued a Sentinel Event Alert that addresses "intimidating and disruptive behaviors" in the health care workplace. Wow! This is a biggie... and I'm not being sarcastic.

Many clinical settings are rife with abuse, intimidation and bullying. Trust me on this one... I spent many years working in a large hospital. During that period, I witnessed a lot of this and spent my share of time on the receiving end of it. To make matters even worse, many workplaces do nothing to encourage the reporting of such behaviors. Don't get me wrong; you can report it. It's just that nothing will be done to correct the situation. It's all too often a "just shut up and take it" kind of attitude.

Medscape Nurses blog submitted a short post on the Sentinel Event Alert earlier this month. I really want you to take a look at the comments. This subject will, no doubt, inspire a lot of passion in the coming months or even years.
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This next article also comes from Medscape Nurses titled, "Who Tells a Patient's Family That Their Loved One is Dying?". While this used to be a bone of contention when I worked in the ICU, I had no idea that this issue would follow me into the area of hospice. Imagine going to the hospital, in order to do a hospice consult with a family, only to find out that no one has told them that their loved one is dying. Being chased out of the room by a mob with torches and pitchforks is just downright... awkward.

Stabbity-Stab The Hospice Nurse

0050 hrs.-- The home is a split-level. I haven't been in one of these in many years. I thought homes like this were so cool when I was a kid. Little kids seem to love steps and stairways. Now, as a middle-aged woman, I have an aversion to them. The idea of lugging the vacuum cleaner, baskets of laundry and grocercies up and down... it's tiresome to me and too filled with "broken hip potential". 

Taking several steps down, I find myself in a small family room with a kitchen off to the side. The body of the deceased, Mrs. L., is in a hospital bed in what used to be the dining area. The dinette set is probably gathering dust in the garage. Families don't just devote massive amounts of time and physical labor to the dying. They also sacrifice square footage.

I make an official pronouncement of death and sit beside Mrs. L's three adult daughters. The patient's son, John, remains standing in the unlit kitchen. The daughters and I engage in the usual small talk as we wait for the funeral home to arrive. 

"Do people sometimes take it out on you when someone dies?", asks John.

"Well, yes," I reply. "But it doesn't happen very much. Most families are very nice."

Zip... click! John has pulled out a switchblade. I see the glint of a four inch blade reflecting from within the shadows of the kitchen.

"Would anyone here like to take a few stabs at her?", asks John, looking at his sisters. 

I quickly glance at the sisters. They sit motionless; their faces without expression. I determine that they're not interested in taking John up on his offer to stab the hospice nurse. Somewhat assured, I turn sharply to my left and stare at John with the coldest, dead eyes that I can muster. It's time to size up the situation.

John is thin and no taller than I am. He's going to have to either make a heroic leap over his mother's death bed or an awkward run around it in order to get to me. I have no weapons, but I'm more than willing to sacrifice my company's, crappy laptop to use defensively or to bash his brains out. John isn't moving. He still stands, in the dark, holding the knife. He has an idiotic smirk on his face. I look back at his sisters:

"That's just his sense of humor", says one of them.

 "If John gets any funnier, I'm calling 911", I return, flatly and coldly.

The knife quickly returns to John's pocket and we all wait in silence for the funeral home. There's nothing left for me to say to this family. Right now, I'm fresh out of conversation... and compassion.  I'm also busy thinking about my life insurance and disability benefits. Because one of these nights, one of these "comedians" just might get me.