Fun-filled Funereal Facts

Death Rattle

The death rattle is a very common occurrence among the dying. It is a noisy gurgling sound that can be heard with the pt's breathing. The cause is fairly simple... As the dying process progresses, we lose our ability to swallow and cough. Because of this, oral secretions accumulate far back in the throat. With every breath the dying patient takes, air passes through or around these secretions and creates the rattling sound.There is no evidence, at all, that the rattle interferes with the patient's comfort. However, that cannot be said of the caregivers hearing the death rattle for the first time.

I've received many phone calls from caregivers that are obviously unaware of this common sign of impending death. They almost always tell me that the patient is "choking" or "drowning". I advise the caller on the use of atropine drops, under the tongue, to help dry up secretions and will also recommend repositioning the patient on their side. This is always followed by a healthy dose of emotional support and a review of the dying process. Caregivers will often ask about suctioning the patient. Removal of these secretions would require very invasive, deep suctioning and is rarely accepted in the hospice field.

The importance of educating caregivers about the dying process cannot be stressed enough. The booklets and pamphlets that hospices give their clients are excellent resources, but I suspect that they are often put aside and forgotten. Nothing can replace the information and continuous reinforcement that can be given by the visiting hospice nurse. Of course, not every caregiver is receptive to this information at first, but the education process needs to begin as soon as possible. The more that caregivers know about the dying process, the fewer "shocks" and "frights" they will have as they take this journey with their loved one.

An Engineer's Guide to Cats

My son brought this video to my attention and I loved it. He's in college studying to be an engineer. This is a point of great pride for me and has also quashed any dreams I had for an early retirement. (sigh...)  Anyway, please enjoy...

Articles of Interest

Unbeknownst to me, there remains a degree of controversy regarding organ donation after cardiac death (DCD). Much of this controversy seems to hinge on the concept of "irreversible" cardiac death and even seems to bring into question how death is determined. Dr. Drew Rosielle, of Pallimed.org has an excellent post regarding this topic.

Staying on the same subject, please check out Dr. Maurice Bernstein's "Bioethics Discussion Blog". He discusses the "Dead Donor Rule" and accepted criteria for determining death. Don't skip the comments on his post... good stuff!

Hopefully, you've got a little extra time to devote to the New England Journal of Medicine's video roundtable discussion, "Organ Donation After Cardiac Death". The panel really gets to the crux of the matter in a straight forward and easily understandable way.

On a different note, Dr. Christian Sinclair of Pallimed.org has posted an article titled "Medications and Driving - Informed Consent?". It's a doozie... you've got to give this a look!

Last, but definitely not least, Hospice Guy at Hospice Blog has a great post that links to a blog where a hospice nurse writes stories about her adventures. Hey wait... that's ME!! THANKS, HOSPICE GUY!!!

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.

Ghost Tour

I decided to save this one for the beginning of the school year...

These images were captured on CCTV at a high school in Asheville, North Carolina on 8/01/08. 

The first video includes news coverage of the sighting. The second video isolates the images of interest and makes it easier to replay and study them. What do you think? A real ghostie or a bug on the lens?

Here's another reason to not go to school...

Don LaFontaine 8/26/40 - 9/1/08

A Little About The Job... ('Cause It's Labor Day!)

Please remember, as you read this, that I can only speak of my own job as assigned by my hospice. Hospices, throughout the country, handle their "after hours" emergency cases in many, different ways...

Many hospices rotate their day shift nurses to be "on call" at night.

Thankfully, my hospice has nurses that are dedicated only to the night shift. It's a staffing "plus" that allows the day shift nurses a full night's sleep thus allowing them to fully tend to their patients during the ususal 8A-5P hours. I truly believe that having dedicated night nurses contributes greatly to staff retention. A nurse that has devoted a full day to tending his/her patients and then has to be repeatedly "on call" during the night rapidly becomes an unhappy nurse. Unhappy nurses will soon look for work elsewhere.

I work alone, from home, and am responsible for approximately 180 patients scattered within an area of at least 1,500 square miles. At night, an on-call hospice physician and nursing supervisor are available if I should need them. They, of course, have also worked a long day and are surely hoping that I don't need to wake them up. I take great pride in that I rarely ever have to disturb anyone's sleep.

Some hospices assign a "back-up" to the night nurse. This nurse, from the day shift, is to assist in the event that multiple emergencies happen simultaneously. I don't have a "back-up". When all hell breaks loose, I take a deep breath, mentally triage the events and just "do it". I also very carefully explain the situation to the caregivers and assure them that they will be seen as quickly as possible. Caregivers are almost always very understanding in these situations. They also understand that the needs of the living patient will always override the needs of the dead.

Emergencies are as varied as the patients. Intractable pain, terminal restlessness,respiratory distress, malfunctioning equipment, occluded Foley caths, family "freak outs" ... the list is endless. Unfortunately, some caregivers are disappointed in my reluctance to respond. Linen changes, dirty diapers and constipation will almost never warrant a visit from an emergency night nurse.

It's a lonely and sometimes, dangerous job; but the rewards are beyond compare. The caregivers are very appreciative and relieved when I walk into their home and I'm happy to be there... because I know that I can help. I am one of the lucky few that can say, "I love my job."

Yay!!! Labor Day!... it's a holiday!

Articles of Interest

A couple of recent articles, in the hospice and palliative care arena, have piqued my interest this week...

Dr. Christian Sinclair of pallimed.org posted an article on 8/23/08 titled, "Hospice in Prison vs. Hospice for Released Prisoners". This piece raises some important questions regarding the care of terminally ill and/or aging prisoners that have been released into the community before their sentences have been served.
Pallimed: A Hospice & Palliative Medicine Blog: Hospice in Prison vs. Hospice for Released Prisoners

Hospice Guy of hospiceblog.org, posted an article on 8/27/08 titled, "The Tale of the Vanishing Hospice Chaplain". Hospice Guy reflects on recent changes in the Medicare hospice benefit and its potential effect on the services that hospices provide.
Hospice Blog: The Tale of the Vanishing Hospice Chaplain

There are very few blogs on the subject of hospice and palliative medicine that keep me coming back, but these two are exceptions. Pallimed is a veritable buffet of topics on all things relating to palliative medicine and hospice. Their approach is often academic, mixed with a healthy dose of humor. Hospice Blog, written from the perspective of an insider, is straight-forward, well written and very informative. The blog's series called "How to Choose a Hospice" is a must read.

My Apologies... but it's Lolcats Time!

It's been at least a couple of years since I last checked out Lolcats and Loldogs. Once again, I got completely lost in the site's wholesome, fuzzy goodness and spent a crazy amount of time there.

Here's a few pictures from the site along with links to both Lolcats and Loldogs. Click on the links below so that you, too, may sit transfixed and lose more time than an alien abductee.









Lolcats
Loldogs

How Will YOU Be Remembered?

We don't give much thought to what our obituary will say about us. Habitual obit readers, such as myself, see a lot of the usual "she lit up the room when she walked in.." or "he'd give the shirt off his back...". Then, of course, the obligatory Old Testament-like listing of all family members.

Well, here's something a little different. You have a couple choices if you don't want an obituary like this written about you. Either change your evil ways... FAST! Or write your own obit and entrust your lawyer to have it published before the kids get any ideas.

I discovered this link while "lurking" in the Boomers Forum on craigslist (thanks, Helen_Back!). Click on the link below for a very unusual memorial written by one of the daughters of the deceased. Snopes.com has confirmed that this obituary is real.

snopes.com obit

Drunken Fists of Fury -- Part 2

[This is part 2 of a two-part story. To pull up Part 1, just click on the label "Drunken Fists of Fury"]

I have a sudden and ominous thought: What if Junior attacks the body removal team? In Junior's drunken logic, that would be a fortuitous "two-fer". He could make sure that all the attention remains on him AND prove how much he loved his mother. The funeral home is due to arrive at any minute. I quickly turn to Diane:

"Look, I'm really sorry, but if no one here can get your brother under control, we need to call the police. If you're not willing to do it... I will."

"It's a done deal", says Diane and she reaches for the phone.

Almost immediately, the police officer arrives and we are all witness to Junior's magical transformation. Drunkenly swaying from foot to foot, he smiles broadly as he chats up the cop and promises to be a good boy. While I am well aware that the mere presence of a cop can deescalate dangerous situations, this was almost too easy. As I see this miracle unfold before me, I'm pretty sure that the MPD is now issuing magic pixie dust to their officers.

Officer Johnson enters the double-wide and scans the living room. He spots me and asks, "You alright, Ma'am?".

 I silently nod "yes", but I know my eyes are screaming, "Get me the !@#%  outta here!". 

Ignoring my screaming eyes, Officer Johnson walks throughout the entire house making sure that everyone is okay. Satisfied, the policeman exits and drives away, leaving a deflated Junior in the front yard. Once again, a sense of relief fills the room and I pray that, this time, it will be lasting. Then, ever so softly, a woman's voice: 

"He really is a nice man."

Looking to my left, I see that the woman is speaking to me. I also suddenly realize that this is Junior's wife and hopefully, his designated driver. Unable to think of an appropriate response, I smile weakly and nod. I look away and wonder what life with a handful like Junior must be like. It can't be very good.

The remainder of my visit is blissfully uneventful. The funeral home has come and gone and so has Junior with his sainted wife. I say my goodbyes to the family and return to the quiet and safety of my car. My nerves want to calm themselves, but my mind wants to rehash the events that occurred during this visit. 

My mind is right. I must not forget what happened here. Was Junior really dangerous or just being dramatic? It doesn't matter. Every home visit I make is a walk into the unknown. Officer Johnson has all the trappings of authority and weapons to boot. I have none of this... and I sure don't have any pixie dust.

Ghost Tour

Yep... I admit it. I love the ghosties. I even own a few pieces of equipment commonly used by ghost hunters and have participated in ghost hunting expeditions. No holiday destination is complete without visiting the local "haunted" sites or at least a good, rollicking ghost tour.

Although I never discuss my interest in this subject with my coworkers, it's probably natural for people in my profession to have an interest in ghosts. I only know that death and what may lay beyond, is on my mind... a LOT. Surely others involved in hospice and other related fields would also share this interest in the paranormal. Then again, maybe I'm just a nut case.

Anyway, today I'm introducing a segment called "Ghost Tour". It'll be a recurring segment, largely depending on the quality of video that I find. So enjoy your first "Ghost Tour" with the following video...  Oh, I also  promise that nothing is going to "jump out at you" and freak you out. I'm not that kind of nut case.

You Just Can't Fake This!

Your Moment of Awwwww ...

Drunken Fists of Fury -- Part 1

1845 hrs-- I'm having a hard time, here. Can't seem to find the place. Apparently, no one in this trailer park believes in house numbers. I pick up my cell and call the daughter of the deceased:

"Diane? Yeah, I know I'm really close to you, but I can't figure out which house you're at."

"Oh, our place is the one with all the cars and stuff in the front", she says.

Diane needs to narrow that down a bit. Her description isn't helping me at all.

"Could you please just come out and wave at me?" I ask. "I'm in the dark blue car."

I see a woman pop out of her front door and she's waving. Problem solved.

There's a lot of people in the double-wide. Kids of all ages are skittering around the place. I chat, briefly, with the husband of the deceased and can tell that he's handling the situation well. Mr. B. returns to the bedroom where his wife lies... he needs to be near her right now. I sit next to Diane and busy myself with phone calls and paperwork.

Suddenly, the living room becomes still and silent. Instinctively, taking the cue to not move, I dart only my eyes up from my work and see the figure in the doorway. He's big, he's beefy and he's very, very inebriated.

"WHERE IS SHE?", he bellows. Before anyone dares to answer, he staggers down the narrow hallway that leads into the back bedroom.

Accusations and questions begin flying around the living room: 

"Who called Junior?", someone snaps. " I didn't think we were supposed to let him know right away!"

"I didn't do it!"

"Me neither!"

"Well, she IS his MOTHER!", says one brave soul. Oops... All eyes fix on the culprit and the subject is dropped.

Ba-BAM! Ba-BAM! My body jerks in reaction to the noise. My heart is absolutely pounding. Still sitting, I lean forward and peer down into the hallway. Junior has just attempted to punch a hole in the wall. I can't see any damage... the wall has triumphed. Head bent, shoulders drooping, Junior wobbles on over to his sister, Diane:

"Junior", says Diane firmly, "We ALL loved Mom!"

"But I loved her MORE!", wails Junior and he spreads his arms widely, showing her just how much.

Diane's drunken brother manages to fumble his way out of the front door. Those of us left behind, in the living room, emit a collective sigh. The sense of relief doesn't last long. I hear banging and crashing. Looking out the window, I see objects flying through the air. Junior has taken his tantrum outside where he has access to an enormous selection of kickable and throwable items.

To be continued ...