Hospice Nurse Considers Hiring with LinkedIn

The other night I was making myself a cup of ginger tea in a vain attempt to ensure myself happy dreams. The teabag had one of those little tags attached to its string with a comforting saying. I look forward to reading comforting teabag sayings sort of like I read my horoscope occasionally, hoping it will tell me that everything is going to be okay and I am about to come into a surprisingly vast sum of money.

My teabag saying was this: When fear is forcing you to give up, call upon your heart’s courage to continue. I stirred the teabag disappointedly about in the hot water. I had been kind of hoping my teabag would tell me someone else’s heart courage could be called upon for me to continue. To be thrown back on my own resources by my teabag was deflating. Plus that night I had my usual crappy dreams. That’s the last time I’m relying on ginger tea.

I have been thinking lately though about the resources I draw on for strength to continue. It’s not that I have such a terrible life. In the grand scheme of terrible lives, I have it really good. Also, it’s not a competition. So some mornings as I drive around between my nineteen dying patients, I feel quite sorry for myself and my stress load seems temporarily unbearable and I cast about to see what sources I can draw on to make myself feel better.

In the absence of teabag comfort, there’s always Deepak Chopra’s Infinite Potential podcast, which I have been tuning into lately. Deepak describes this as a metahuman miniseries about what makes us conscious beings and why it matters that we are. The main thing I love about this podcast is his introductory ad honoring his sponsor, LinkedIn. It affords me endless joy to listen to him extol in his impeccable Indian accent the virtues of mindful hiring. It is little wonder, he intones earnestly, that someone is hired every eight seconds using LinkedIn. Even though I don’t actually run a business, it just makes me want to rush out and hire someone.

After he has glorified mindful hiring for a bit, he goes on to interview some of the great minds of our time: Dr. Oz, Don Hoffman and, well, those are the only two great minds I have heard him interview so far. But just listening to him riffing with Mehmet Oz about the heart as I drove to work the other day set me completely on fire. Oz told a story about a mentor of his who pioneered a method of open heart surgery on kids in the 1950s whereby he hooked the mother up to the kid so when the surgery was underway, the mother’s blood was coursing through her child’s veins while their heart was temporarily stopped for the procedure, and her lungs were oxygenating her child’s blood.

This idea just made me start leaking tears on my drive up the 9G towards the Kingston Rhinecliff Bridge. Then Oz talked about how he lamented to this mentor that his open heart surgeries had a 25% fail rate. So one in four times, he would lose a child and have to go out and break the news to the waiting parents. His mentor said well my fail rate could potentially be two hundred percent, because I could lose both child and mother. 

Now I was crying in such a way that I could barely see the road. Nothing appeals to the hospice nurse sensibilities like a potential two hundred percent surgery fail rate.

But the two of them also talked about how the heartbeat continues from the moment in utero when fetal heartbeat is first detectable (and here they played a recording of that rapid fetal heartbeat I recalled so vividly from my first pregnancy ultrasound) to the moment it flatlines at death (cue recording of an ICU monitor going from intermittent to continuous beep). 

The essence of hospice care is that death occurs outside of the ICU, ideally in the home environment. There’s no hookup to machines, no flashing lights, no beeps. Often the moment of death goes unrecorded. Family members find the person dead in their bed, or the death occurs at some difficult to determine moment while loved ones are in and out of the room. Sometimes the dying wait to be alone. Sometimes they wait for a specific person to be present. At least, that’s what we like to think. In reality, there’s no saying exactly why a person dies the moment they die except that their heart just stops beating.

And yet, that moment is a profound one. I have laid my stethoscope against the chest of a recently deceased patient many times, and each time I feel again the weight of what has occurred. I am struck by the absence of sound. Where moments ago there was the familiar lub-dup of a heartbeat, no matter how faint or irregular, now there is silence. If it’s a patient I am familiar with, I will have listened to their heartbeat many times and be familiar with its peculiarities. And now I’m putting my steth against their left chest wall, and there’s nothing.

When a patient dies on hospice, a nurse usually makes a visit we call a pronouncement. It sounds like we declaim something from the rooftops, but in reality it is usually an extremely quiet moment. Families can decline this visit, but mostly they want a nurse to come and support them at the time of death. Some families actually rely on the nurse to convince them that the death has actually occurred. I have been called to homes where a patient was so clearly dead there was no way anyone could dispute it. And yet the family need me to tell them, sometimes they need me to go through the motions of listening for a heartbeat with my stethoscope. I have to do this, and then turn to them and say something like your mom is gone, or he has left us for them to begin their process of grieving. It can be a curiously formal and final moment.

For me, it is sometimes a heavy responsibility, and sometimes a moment of black comedy. I have pronounced patients who were so clearly dead it felt sort of ludicrous to apply my stethoscope to their cold chests. And yet, that can sometimes be what the family needs, and that is what you do. 

Aside from my life of pronouncing people dead, I do like to listen to instructive podcasts, enlivening music, and to read the odd horoscope. Just now for example, a random online search of my daily horoscope told me that responsibilities at home and upsets in my circles of friends could distract and stress me. Make an effort to balance it all, instructed my online psychic confidently and yet completely unhelpfully, and you’ll make it through the day. It’s 9:26pm. Maybe I’ll just go on LinkedIn and see if its mindful hiring practices will get me through the last two and a half hours.

Hospice Nurse Turns up the Loud

I was driving to my first patient the other day. It was a beautiful Fall morning in the Hudson Valley and I was heading south from Kingston in the golden early light. My patient had taken a turn for the worst in the previous few days and I wasn’t sure whether he was going to recover or continue his downward trend. I felt that this morning’s visit was going to be pivotal. A mile south of the 199, I got a call from the son. His voice was unusually tense. We aren’t doing too well here, he said. I noted the use of the plural. Dad is sort of gasping for breath and he isn’t responding.

I had been driving on autopilot, chilling to some mellow music to get me into the hospice nurse frame of mind for a Wednesday, but in that moment my whole being shifted into a high gear. Okay, I said in my calmest voice, it sounds like your dad is leaving us. Does he look comfortable? Is he struggling? Yes, the son said, and no. I’ll be there in six minutes, I said. 

I sped up. I switched the music to something loud and insistent. And I turned it up louder. For those six minutes, very loud music and some over-the-speed-limit driving helped me to prepare for what I could imagine was waiting. I had a short talk with my patient in my head. He was this straight-up, no-nonsense but very lovable guy. Tommy, I said to him (not his real name) if you are going, I’ll try my best to keep you comfortable. I promise I’ll make this the best that it can be. Then I said to him in my head: I’m really sorry, hang in there, I’m driving as fast as I can.

When I got to his apartment, his son and daughter in law were sitting with him and I could see at once that he was close to death. Unresponsive. Flaccid limbs. Breathing agonal - what I call fish-gasping, which means breath that is coming in short infrequent gasps from the abdomen, really just a convulsing of the lungs due to medulla oblongata brain activity. His oxygen saturation was in the 30s. There was little to no frontal cortex brain function.

I spent the next three hours in his room with various family members. My memories of those three hours are like a time-lapse video. People came and went. My patient sat in his chair with his brain and body shutting down. I checked his pulse periodically. I went into the kitchen. I went outside. I talked with various family members. I texted the hospice team to let them know the patient’s status. I asked my supervisors to cover my 11am visit. I want to see this through, I texted, but I knew that this could be wishful thinking on my part. 

After more than three hours, I had to leave because I knew he could take many more hours to die and I had other patients to see. It can be a tough judgement call, when to leave an actively dying patient to take care of your other folks. There’s only so much help available from a hospice team already stretched thin. 

I made sure the family had everything they needed and knew to call me as soon as he passed. Twenty minutes down the road, I got the call to say he had taken his last breath. I made a couple of calls to reschedule my immediate visits. I also texted a hospice text thread that reaches over 50 staff: Tommy just died, on my way to pronounce. This would prevent any other staff from calling or visiting. It also, in my mind, allowed staff who had taken care of Tommy to learn of his death, grieve him, and send their good thoughts to the family.

In the three hours I spent with him as he died, and during my visit after his death, some moments stand out in my mind. I remember lurking in his kitchen, trying to afford some privacy to one of his sons who had showed up to say goodbye. For various reasons, the most involved son had asked me to be present in the room when this son visited. While I felt that my presence was something of an intrusion, I also understood completely and honored the request. Families are complex beasts. From the kitchen, I could not help hearing some of the words this son was saying to his dying father. These are the moment that get seared into a hospice nurse’s memory, the ones we carry with us in some compartmentalized part of our brain. I will never forget what I heard.

Nor will I forget the moments early in my visit when the catastrophic change in my patient’s condition was still new and raw to his son and daughter in law, and also to me. The three of us were gathered around him and his son reminded his dad of a precious and moving promise they had made each other. Then he started singing to him. That undid me. Paper masks don’t stand up too well to tears. Between the three of us, we were using up all the tissues in the house. I fetched a toilet roll and we started using that.

Is it okay for the hospice nurse to cry along with family at a death? Absolutely. And are there times where we need to rein it in and allow the family space and freedom to grieve while a professional holds the space for them to do so? Also yes. I just knew intuitively that in this situation, they would all be fine with me grieving alongside them. So I gave myself permission to do so. Plus it would have been pretty hard, if not impossible, to rein in the tears on this scene.

When I finally left there after the death, when the family was gathered at the bedside and I had notified the mortuary of the timing for pickup, I drove south to the visits I had pushed out till later that afternoon. I had a half hour drive to gather myself, and a few minutes to spare along the way. I tried to think how I could spend the time to both nourish myself and to honor my patient.

I passed a wonderful farm stand I had recently discovered. They had Fall color pots of chrysanthemums on sale. I had bought a pot a couple of weeks before to honor another beloved patient after attending his death. It had been hard to choose from the beautiful colors, but I had restricted myself to a single pot, dark red. I pulled over. There were just a few pots left now and they looked a bit ratty. The owner gave me a deal on two plants the color of Tuscan sunshine, and explained to me carefully how to keep them alive over the Winter. I stashed them in the back seat of the car. 

As I drove to my next visit, I was thinking how intense my morning had been and yet how lucky I am to do this work that I love, to meet the people I meet and see the things that I see. In the back seat, the mums glowed a glorious deep yellow. I could hear Tommy telling me how beautiful they were. If I plant them in the earth, let them die off to sticks in the snow, then cut them down to six inches when it thaws, I just might see them come back from the dead next Spring.