Tag: End-of-life care

Hospice Care – Quality Care at the End of Life

Published on by Marilyn6 Comments

In an appropriate follow-up to yesterday’s post, Jan Klingberg takes us into the realities of hospice care. Hospice care is often misunderstood and I’m grateful to Jan for giving us first hand information about this important service. 

Kristine’s husband, Gerry, returned home from the hospital with end-stage cancer after his doctor bluntly told him to get his affairs in order. The family panicked. How would they manage? Especially with twin preschoolers at home.

During many years as a communications and fundraising professional for a hospice program in Illinois, I have seen firsthand the challenges of life-threatening illness—for the patient and family alike. When treatment becomes futile at best, hope for a cure disappears and hopelessness can set in.

But what if instead of being hooked up to machines in the hospital or going it alone at home, your loved one could be cared for in a program that would reawaken hope—a hope for comfort, peace and dignity …

  • Encircle you and your loved one with care and support tailored to your needs,
  • Arrange for the delivery of a hospital bed, supplies and medication,
  • Visit your loved one regularly to provide medical care and other treatment to ease pain and discomfort,
  • Be at the other end of the phone 24 hours a day, and
  • Support you when your loved one is dying and for months afterward.

Our hospice program became Kristine and Gerry’s lifeline that made their last weeks together bearable. A team of professionals and volunteers surrounded the family with a multitude of services and strong support. Medical care addressed Gerry’s pain; counselors helped Kristine journey through her despair over losing her husband; social workers helped the extended family work through some tough issues; volunteers ran errands and shared babysitting shifts; experts in children’s grief worked with the twins and coached Kristine. And even when Gerry’s pain soared out of control at home, he was able to spend a few nights at our specialized hospice inpatient unit where 24-hour nursing care helped stabilize him.

Were the family’s last weeks together easy? Of course not. But they were transformed into a manageable journey that allowed Gerry to die comfortably at home, his wife and kids at his side. He was reassured to know that after his death, Kristine and the twins would be carried through their grief rather than being left alone with their terrible loss.

In the years prior to my retirement last fall, I became aware of many stories similar to Kristine and Gerry’s. The overwhelming emotion of family members after the death of their loved one was gratitude—for providing support and restoring hope. And I don’t believe I ever heard anyone say, “We called hospice too soon.” If anything, many were disappointed that they had waited too long before engaging a care system that could surround them and their loved one with what they needed to live life to the fullest in the time that remained.

Hospice has been a lifeline to thousands of people around the world for decades. The modern hospice concept actually got its start in the late 1960s in England where specialized care for the dying showed dramatic improvement in symptom control. This new unique blend of medical, emotional, spiritual and psychosocial care—palliative care—comprehensively treats the person rather than solely the medical condition.

Then amid the phenomenal medical advances of the 1970s, dedicated healthcare professionals and community volunteers in the U.S. saw the need stateside for an interdisciplinary and compassionate approach to end-of-life care. From the first U.S. hospice program in 1974 to the current 5,000+ programs nationwide, hospice professionals have relieved pain and suffering day after day, year after year. My own family—mom, dad, aunt—were cared for by hospice programs in other states. Though they operate slightly differently from the one I worked for, they have the same core belief that drives the care they provide—everyone has the right to live with dignity until the last moment.

A long-time friend—a control freak who lived alone and had every loose end tied up—said when she became one of our patients and entrusted her care to my colleagues, “It is such a relief knowing that I don’t have to manage alone anymore. These people know what they are doing … they’re the pros.”

When a loved one has a life-threatening illness and the prognosis becomes months and not years … when the goal for care becomes comfort and symptom management … why not choose the hospice experts who promote quality of life until the very end of life?

AUTHOR’S NOTES:

  • The National Hospice and Palliative Care Organization (NHPCO) has a wealth of information about hospice care and can help you find a program near you.
  • The NHPCO service, Caring Connections, offers resources for advance care planning, caregiving and living with a serious illness.
  • A high percentage of hospice programs are certified by Medicare. This means that they have core services provided by a hospice team (physicians, nurses, nurse’s aides, social workers, grief counselors, chaplains and volunteers) and can receive reimbursement for the care of a patient who has Medicare Part A. Many private insurance companies and state Medicaid programs have modeled their payment systems after the Medicare Hospice Benefit, so the costs of care are covered for most patients who are eligible for hospice.
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End of Life Care and Cultural Competency

Published on by Marilyn3 Comments

I just finished speaking to a group of medical and nursing students on end of life care and cultural competency.

It’s a big topic.

In health care the two areas where cultural beliefs are profoundly obvious are during birth and during death. In other areas the belief systems are more subtle, the differences not always obvious.

But birth and death? These moments of coming into and going out of the world are rich with tradition, ritual, meaning, and emotion.

The first thing I ask people to do is to think back to their first memory of death in their family or community. Who was it? What were the circumstances of the death? What is their most vivid memory? What rituals and behaviors were observed by the family and/or community?

The answers are fascinating, particularly if it’s a diverse group. There are people who remember all the church bells in the town ringing — they knew someone had died because the bells were ringing at a time when they were usually silent. Others remember wailing waking them during the night. Still others will talk about death being a celebration, a party of sorts.

The important piece is that they talk. Most have never thought about this, let alone processed it in a group. And talking about their experience puts us in the best possible place to continue the discussion.

Because telling their stories helps them realize how significant those moments are, and how critical it is for them to hear the stories of their patients, to be fully present with their patients during the end of their lives.

We move forward into the discussion on the western view of the body as a machine, on how culture affects views of illness, expectations of care, and views of the process of death. We look at possible points of cultural collision – patient autonomy, organ donation, body preparation, the differences in both meaning and expression of pain and so much more.

I usually end the time with a short video telling the true story of a gentleman from Afghanistan named Mohammad Kochi. Mr. Kochi immigrated to the United States with his family and settled in California. At the time of the film he was diagnosed with stomach cancer. The film details some of his care and the disconnect and misunderstandings that occurred, resulting in his refusal of chemotherapy through a pump into his body — ultimately his death because of lack of treatment.

It is sobering and hard to watch. We sit somewhat stunned at the end and there is no gap in conversation.

How could this happen?

So preventable!

Such a misunderstanding!

But these types of cultural misunderstandings occur far too often despite the best of intentions.

There are so many things that come up in conversation, and so much to learn from each other. But we end talking about three areas where we can develop skills.

The first is in self-reflection – How do I react to cultural differences? How do I manage my own reactions? How do I negotiate with patients and families in the face of cultural differences?

The second is active listening – Listening to and with the body, listening in with self reflection, listening out by learning from others; listening with the mind by hearing facts and stories; listening with the heart by being willing to hear emotions and feelings.

The third is bearing witness – being fully present with the person, letting them know they’re not alone, listening to their stories and their symptoms. 

As is usually the case, I leave contemplative, thinking about life in its entirety, life from birth to death. And I also leave with a renewed resolve to continue developing skills in the areas of self-reflection, active listening, and bearing witness.

Skills not only important in end of life but through all of life. 

The Myth of ‘Death with Dignity’ – A No on Question 2

Published on by Marilyn16 Comments

As a nurse I’ve cared for hundreds of people who are going into surgery, women who are in labor, people who have cancer, people who are dying. It has been both a privilege and a burden. It brings me face to face with my mortality, my frailty, and my need to figure out what this thing called ‘Life’ is all about.

I have sat with people waiting for their last breath, only to realize there would be none. I have been beside women as they gave birth to still-born babies, weeping with them as tears streamed down their cheeks. Tears that fell on the heads of babies who did not feel them or know the pain of their mamas.

I have cleaned up vomit, suctioned mucus, emptied bedpans,

So there is one thing I can tell you with certainty: There is no dignity in being sick. There is no dignity in bed pans. There is no dignity in throwing up. There is no dignity in fainting or seizures; in high fevers or runny noses, in chemotherapy or intravenous antibiotics. There is no dignity in getting the dreaded diagnosis “You have cancer…”. None. There is absolutely no dignity in labor as you’re hanging out all over the place just waiting for that little muffin’s head to crown.

And Psalm 23 is not kidding about the “Valley of the shadow of death” for there is little dignity in dying.

And yet the Massachusetts ballot is presenting me with a question come November 6 – a question where I have the choice to vote ‘yes’ or ‘no’. It is called the Massachusetts Death With Dignity Act, but it is really a vote up or down for Physician Assisted Suicide.

I get it. We hate pain – for ourselves and for others. “Needless pain!” we cry out! Why should we have to suffer? Why should those we love have to suffer? We’re going to die anyway! Why not be able to control the process?

So why do I, who ooze compassion when I see a hurt bird, let alone human, plan to vote no on this bill that would supposedly “alleviate” suffering?

There are several reasons.

1. While diagnosis is a fact, prognosis is an opinion. Most of us know people who have lived far longer than the prescribed prognosis given for a particular disease state. This is because many things go into living. It’s not about a doctor’s evidence, what has happened before, or what typically happens – it’s about the individual, it’s about will, it’s about faith, it’s about God.

2. Amazing strides have been made in pain relief and end of life care. No longer does end of life care need to be a time of intense suffering. Current research and practice gives great hope to patients and families who are dealing with end of life issues. Palliative care focuses on relief of pain, easing of symptoms, and improving quality of life. This area needs to be strengthened, not weakened by diminishing its importance through allowing patients to request medication that will end their lives.

3. There is no requirement in the language of the law that any family members be notified. This is unconscionable to me! That a patient can take the medication alone, with no one else present, and no record of having taken it is unbelievably bad practice. The potential scenarios this presents have law suits written all over them.

4. Death is not, and never will be, dignified. To paint the issue with language like this is disingenuous at best. Just because you are the one who holds the medicine that can end it all doesn’t mean it will be dignified. The very nature of death is that of losing control, taking a last breath, mouth gaping open, losing control of bodily functions, fighting to live only to die. I am all for easing some of the pain and discomfort of death but let me repeat: It is not, and will never, be dignified. It’s death.

The only dignity given in death is given by others to the one dying, it cannot be given to oneself.

5. Organizations that I respect are against it. The Mass Medical Society, Massachusetts Hospice and Palliative Care Federation, the American Medical Directors Association, and the Massachusetts Academy of Family Physicians are all against it. Why? Because it’s poorly written, because there is already a strong end of life care program in the state that aims to alleviate suffering, because patients are not required to see a psychiatrist or psychologist to check mental health status before being prescribed a lethal dose of medication to end their lives, and because they recognize that physicians should be in the business of providing “compassionate, high-quality care during every stage of life.”

6. I believe the act diminishes and violates the Hippocratic Oath at the deepest level. In the classical version of the oath the statement “I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect.” are words sworn by most physicians on graduating from medical school. The entire oath speaks to the need to practice medicine ethically and compassionately.

Lastly, it is because I operate from a God-centered worldview. I see all of life through this lens. And so I believe that all of Life is sacred – whether it be in the abortion clinic, the battlefield, the workplace, the slum, the homeless shelter, the hospital room, or the hospice. Life, all of it, is sacred. And in believing that Life is sacred, I believe that only One can give or take life. Only One has and knows the big picture.

Only One can offer death with dignity and so, clear-eyed and clear-headed, I’ll vote No. 

 “Take away my capacity for pain and you rob me of the possibilty for joy.” Ross W. Marrs

“The role of family physicians is to provide compassionate, high quality health care to all patients, in each stage of life. End-of-life care is no different. Given the tremendous strides made in palliative care delivery services, patients with terminal illnesses often live active and fruitful lives for months, if not years….“Given the seriousness posed by the ballot question, and especially given our daily experience as family physicians caring for patients, we urge Massachusetts residents to vote NO to Question 2 on November 6.” Massachusetts Academy of Family Physicians

“We’ll continue to educate voters that Question 2 is poorly written, confusing, and flawed. This is why concerned doctors, nurses, hospice workers, religious leaders and citizens have banned together to defeat Question 2. Visit our website to see the full list of organizations opposed to physician assisted suicide”. Coalition against Physician Assisted Suicide

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