Food For Thought - On Dying

Can you honestly say that you have seized a moment in your life, when nothing else but whatever you were doing mattered?  Can you say that you truly were present when talking to someone or being with someone?  When was it?  How did it happen? It happened to me to and it was very powerful.  Here is how it changed me. 

Majority of the patients I work with are terminally ill, with the underlying disease of cancer masked by pressure ulcers, congestive heart failure, pathological fractures, pneumonias, seizure disorders, pleural effusions, falls, critical diabetes, strokes, renal failures, sepses, etc.  It is true that cancer, at its early stages, can be fought aggressively with radiation, chemotherapy and strong will.  And there are those who win, they go home and treat cancer as just another hurdle of life, they get over it, start fresh, and live on. But some cancer, whether of the brain, tongue, throat, bone, lungs, liver, bladder, leukemia, lymphoma, myeloma - you name it - has the power to weaken the immune system so much, that at times it causes it to give in and stop fighting, surrendering to other diseases and letting them take over.  And so there are those, at later stages of cancer or post unsuccessful chemo (sometimes after fifth or tenth try), that even though willfully fighting they can't win and the battle causes irreversible damage that often leads to death.  And because of this sad truth, I have taken the time to sit back and not only think about all the patients that I lost, so many of them, but the entire process of death and my role in it, as a healthcare provider. 

There are two persons whose deaths really touched me, and really changed the view life.  Mrs. B, a 46 year old woman, with a loving husband, an 18 year old daughter, a 24 year old son, and a 2006 diagnosis of tongue cancer.  Mrs. B was a fighter, she underwent extensive chemotherapy and radiation treatments, but time after time they failed success.  The incidence of tongue cancer is increasing, and survival has not improved since the majority of patients present at an advanced stage, just as Mrs. B did.    In June, 2007, she learned about metastases to her throat, esophagus and lungs.  Upon learning this devastating news, Paul (her son) proposed to his girlfriend and planned a wedding for May, 2008, in hopes that his mom can be there.    Unfortunately, in December, 2007, things have gotten worse, cancerous cells were found in Mrs. B's liver and everything seemed to fall apart.  Mrs. B could not eat, so every hour she was fed 60cc of carefully designed formula through a jejuna-gastric tube.  She could not speak, only mumble softly, but her eyes did all the talking - her gaze and her expression were so powerful.  I worked two 12 hours shifts the week Mrs. B passed away.  The first shift I was just getting to know her, she was transferred from ICU, her vitals unstable, her glucose levels climbing, her liver function deteriorating.  I spend most of the day in Mrs. B's room, even though her vitals were q2h, I felt as if I should check them continuously, she was in visible distress - her heart beating very fast (130-140 bpm), her breaths were labored with a rate of 35-45 per minute, her skin clammy, her temperature high, her urine output low, her lungs crackly with decreased entry (which I learned later were full of fluid).  I wished I could just take it all away and make her well, I couldn't, all I could do is ensure that she is comfortable and that her family was with her as she wished.  Deep inside I knew unless things took a quick turn for the better, she would not make it.  Deep inside I felt she was dying.  She fought so hard, when asked if she was in pain she put on a soft smile and shook her head no, she asked to go to the washroom but she had no strength to get up so I begged her to go in the diaper, after a few hours she went and she cried the entire time I changed her, apologizing.  Few minutes toward the end of my shift I was approached by the head nurse, Mrs. B was septic, and yes even though the condition was life-threatening at least there was a plan to do something as opposed to just watch.  In some odd way, it was comforting to know that septic patients often will have fever, chills and severe shaking; the heart may be beating very fast and they may be breathing rapidly; these patients may be confused, disoriented and agitated, and they may have decreased urination.  I felt as if at least I knew why things are happening.  I stayed longer that night and worked with my preceptor as we carefully gave IV antibiotics and fluids trying to knock out the infection.  Mrs. B's blood pressure was stabilizing and her fever was going down.  Leaving home that night I was very hopeful.  At about 2100, I walked in to Mrs. B's room to say goodnight, she grabbed my hand with both of hers and held it, unable to speak she just looked deep into my eyes.   It was a pleasant gaze, warm and comforting.  I went home.  The following morning I came anxious to find out how Mrs. B was doing, unfortunately she coded 3 times during the night and passed away at 0435.  I was, and still am, devastated when I think of her and her family.  I truly feel so sad that she lost the battle with cancer, I will remember her forever.  I will remember as she thought me the true meaning of a fight, she thought me the true meaning of perserverance, and grace, and kindness.  She thought me how have dignity and respect until the last breath.

And then there was Mr. H, a 79 year old male, diagnosed with bone cancer in 2001, with metastases to the lungs.  He was cheerful, polite, strong-willed.  He had a great sense of humor - he made me laugh so often and so much.  He came in to our floor beginning of January with a pathological hip fracture, and even though there were great risks associated with surgery to repair it, he and his family opted to go for it.  He was in visible excruciating pain.  Mr. H refused to live with this pain, when talking about the surgery with my preceptor and I, he said to us, "I'd rather die on the operating table than live with the pain I am feeling."  He clearly understood the risks, but he was hoping for the best.  He was fighting the battle full force.  The surgery was rescheduled three times, three times Mr. H was taken to the OR and came back within and hour or so to our floor - either the equipment was broken or there was an emergency surgery that was prioritized.  I was amazed to see how well he took all of that.  He remained in excellent spirits - laughing, cracking jokes, etc.  Finally, mid afternoon, Mr. H went down the final time.  At last he was getting his surgery.  About two weeks passed since I saw Mr. H, I thought of him a few times but I was sort of afraid to check how he was doing, I guess I did not want to take the chance on the possibility of bad news.  And then towards the end of my shift I was notified of a partial admission, someone was being transferred from another floor.  It was Mr. H, I was ecstatic to learn he made.  I took the report and learned how poorly he was doing - his blood pressure was very low; he was disoriented and confused; his lungs were full of fluid; he was in renal failure; and so on.   Still optimistic I waited for his arrival to our unit.  To my surprise he was still Mr. H I knew - joking, complaining of the small elevator, etc.  I, again, was hopeful.  For the next few days, even though rough Mr. H was hanging on, and then Sunday morning my preceptor pulled me aside and suggested that we phone the family, she said that the night nurse did not think he will make it another day.  We called the family, they arrived within minutes.  We sat together in the room, Mr. H deteriorating.  He was gasping for air, yet he managed to tell me that he slept well.  He kept looking up, so holding his hand I asked, "Mr. H what do you see there?  You keep looking up?"  He said, "I see a light, and a woman."  Tears trickled down my cheek, I tried to fight them but I just couldn't.  He was dying.  I was searching within myself to find something more to offer him, I was lost.  I sat with the family, taking his vitals, increasing his oxygen, making him comfortable, making them comfortable.  Some of the nurses came to say goodbye, they held his hand and whispered things to him.  I saw him take his last breath, and then he was gone.  He passed on. He thought me how to be with someone in the moments.

Both of these patients made me realize how important it is to be with people and to try to understand people no matter what.  Our role, as healthcare providers is to act as a bridge between health and illness, between sadness and happiness, between surrender and victory.  Being with our patients allows us to reach out our hand and let our patient know that there is hope, hope in recovery, hope in happiness, hope in humankind.  Are there people in your life that influenced who you are today?  Think about it!  And don't forget to thak them.