When we hear that we have a terrible illness that will shorten our life, it’s personal. When we learn about the benefits and trade-offs of the tests and procedures that will decide what treatments and medicines may help us, it’s personal. As we make our way through side effects, complications, insurance plans, phone calls, waiting rooms, pharmacies, labs, radiology departments, billing departments, emergency rooms, intensive care units, medical jargon, bad news, good news, family conflict, family meetings, caregivers, nursing homes, physical therapy, occupational therapy, speech therapy, psychotherapy, medication lists, medication interactions, medication errors, advance directives, wills, and the many losses, it’s personal. Continue reading
~Orchid in renewed growth – grace, strength, health, durability
Closure. What an enticing fantasy. It would be so comforting to think that all the grief will stop some day soon. Then life will proceed as before. The pain will come to an end. The hurt will be terminated, especially by the passing of time. Continue reading
“To every thing there is a season…”
I am highly tied to the earth. Living purposefully on a lonesome mountain (more like a hill), I almost feel like a participant in the season’s changes.
Within the cycles of nature I also witness the cycles of humanity, even the cycles of our personal lives. Trees change their shrouds just as time traces itself upon our faces and the hairs of our heads. Imagining winter, just like imagining my own demise, gives me a breathless appreciation for the present- for the deepening red of the leaf and for the smell of my child’s curly hair. Viewing the natural world and viewing our own lives with the end in mind awakens a deep reverence for the very act of living itself, and the opportunity to do so.
I have found that when we are not observant of the cycles of nature and the natural cycles of the human life, we become unseated at some deep level. Something feels awry.
Once I saw an old man, in the deep winter of his life. Despite his physical appearance- that of old, dead wood- he was receiving aggressive chemotherapy in desperate attempts to recover just a little bit of spring, a touch of summer, or at least a smidge of late fall. I grieved for him. Something was awry.
We cannot supplant the seasons and love them at the same time. We must learn to love and respect the seasons of our lives and to be one with them- only then can we know of their gifts.
Monica Williams-Murphy, MD
“If you don’t want to deal with death and dying, then you need to quit medicine now and become an accountant…because this is what we have signed up for and we’ve got to do a better job at it.” Continue reading
“No man is an island”, John Donne, meditation XVII, English clergyman and poet (1572-1631)
Ultimately, the story of your life is not your own but affects all whom you have ever known. The story of your life carries great power. That’s why we are so moved by the stories of individuals who have overcome unusual odds. Continue reading
I love hospitalists, they are some of my favorite people. Like me, they come into the hospital and work their butts off for 10-12 hours with very little food or water. We are essentially kinfolk, and we take care of the same patients.
Because we are comrades, I make sure to meet and greet with hospitalists each time I see them. (Some of us even hug!)
One of my favorite hospitalist was in the ER today when I arrived, and somehow (of course) we got on the subject of advanced directives. He told me that his own living will says that when he cannot wipe his own ass, then doesn’t want to be kept alive by any medical interventions. (Excuse his “French”)
We both laughed knowingly.
He said that when he shared his living will with his wife, she freaked out. In her distress, she asked, “Don’t you love me? Don’t you love the children?”
He said, “Of course I do, however my definition of life meaning means being able to actually live.”
Pensively, I remarked, “We’ve seen too much haven’t we?”
We both nodded in agreement. Then, we both smiled and he admitted my next patient-an hundred-year-old man who could no longer wipe his own ass.
Recent articles suggest that doctors typically do not want aggressive measures for themselves at the end of their own lives.
And why is that? It’s because we’ve seen too much haven’t we?
(photo credit: www.mdsalaries.com)
Most of the time I feel as though I am “running in quicksand” attempting to bring patients to a place of grace and dignity in dying. On occasion, there is someone who jerks me out of my quicksand and plants me squarely on stable shore and then proceeds to show me what grace and dignity in the face of death really look and feel like.
Please meet Mr. Jefferson. Continue reading
I recently got back from an exciting vacation which included zip-lining and whitewater rafting. Repeatedly during this trip, my oldest daughter and I would encourage each other with the trendy term “#YOLO“-“you only live once,” before we did something that felt risky but adventurous. (No offense to my Hindu and Buddhist friends who might prefer another acronym such as “you only live as many times as you need to get it right”! #yolamtayntgir (Sorry…not terribly catchy guys!) Continue reading
Should you shield the canyons from the windstorms,
You would never see the true beauty of their carvings.
-Elisabeth Kubler-Ross, MD
Fore words. To listen: concentrate and make an effort to hear someone. To heal: treat a scarring wound by assisting in its natural repair. To love: appreciate; care deeply; regard with affection and compassion; feel a warm personal attachment also to humanity.
The power of listening is immense and immeasurable. It changes lives. Continue reading
I live and work in the house medicine. You would think that those of us who have chosen this profession would actually know what dying looks like. Furthermore, one would hope that if the doctor could identify dying, he or she could share this with the patient and family (given that this is fairly significant medical information!). Continue reading
The moral life, the life that transforms lives, begins in the ear, in the act of listening.
— Rabbi Jonathan Sacks
Listening: we take it so much for granted that we have forgotten how to recognize and appreciate its uncommon worth. We worry about what to do and what to say but not how to hear. Listening is the first language skill to be acquired by the child. Listening is a form of art. It requires long training and a lot of humility.1 We must do it for those who grieve. Active, involved listening leads to better understanding of others. Those who grieve need that understanding. Listening is a rare gift to give. Sometimes the most healing thing we can do is to listen, just listen. Continue reading
Ok, well I am neither a good actor, nor producer but don’t let that stand in your way of receiving my message…Hospice care can be activated ANYWHERE within the healthcare system (and even outside of it) when the patient is ready!
The ER (besides the ICU and Surgery Suite) may be one of the most aggressive, intervention-focused areas in the house of medicine. So, if WE can do it, then ANYONE can do it (meaning, transition patients to hospice care when appropriate.)
Here are some tips from my Emergency Department:
ER docs like to look at algorithms. It’s the way we are trained, just open up any ACLS guideline and you will see what I mean. So, in our emergency department we have a sign at each doctor workstation which reads:
“Signs that a person may be ready for hospice care”
- Weight Loss
- Increased pain, nausea, fatigue or other symptoms
- Increased need for assistance
- Decreased alertness
- Increased hospitalizations
- Family exhausted from care-giving demands
(At the bottom of the sign are directions on how to make a referral).
2. Train your staff to screen for hospice readiness
My nurses ask all kinds of questions to patients during their initial screening:
“Do you have any religious, or cultural preferences that might affect your care today?
“Do you feel safe at home?”
“Would you accept blood products to save your life?”
So, you see, we are accustomed to asking deeply probing questions from the get-go, so why not also ask end-of-life screening questions:
“How many times have you been to the ER or hospitalized in the last 6 months?”
“Do you feel like your health is steadily failing with worsening symptoms?”
“Are you feeling tired from the amount of care-giving required for your loved one?”
Identifying the potential hospice-appropriate population goes along way toward getting them the care they need in a more timely manner.
3. Build relationships with local hospice providers
Our hospital has an affiliate relationship with a local not-for-profit hospice who serves as our preferred provider. RNs from this hospice have affiliate hospital privileges at our institution. So, if we call… they come. This takes a huge burden off of the ER staff in transitioning care– our role just becomes one of “screener”- we “screen” the patient and family for physical and emotional “hospice readiness” and then can simply call for a consultation.
OR, if we have a patient who desires another hospice who doesn’t have affiliate privileges, OR if we have a clear-cut, “I want to go home on hospice” patient, then we can simply call the hospice service of choice (make sure their numbers are readily available to the secretary) and have the hospice RN meet them at their home or home facility for intake.
So, the bottom line here is, if we can do it, anyone can do it.
How does your department or institution make hospice referrals easier? Please share!
A monster named is easier tamed. — Old Adage
Crude self-examination is always an aftermath of loss. In the beginning, it is usually involuntary. It is impulsive. It is primitive, unrefined. It is based on emotion, not characterized by careful thought. It is a clear and often painful part of the grief process. Continue reading
One of the most common questions I receive is: “What should be done when the patient and family are ready for hospice (even asking for hospice), but the physician will not make the referral?”
My advice is simple… Fire the doctor. Continue reading
My step-father likes to tease a lot. One of his favorite sayings is, “Even a blind bird sometimes gets a worm!” That’s what I feel like with this BIG tip that I am about to share with you…
You see, I serve on the Board of Directors for two non-for-profit hospices (Hospice Family Care and the Los Angeles Hospice at Anam Cara), so I know how hospices are always strenuously brainstorming on how to get more market-share and how to get more referrals. I have on occasion offered a few weak suggestions to which everyone responds in a polite but we’ve-already-tried-that-one kind of way. Let me assure you, this idea is different. This idea is one whose power I learned first-hand as a physician…
So, here it is…
Are you ready?
You’ll never believe you didn’t think of this yourself!
Just have the hospice patient and/or family write a personalized thank-you letter to the referring doctor!!!
Here is why this works. You see, as a doctor, and I know what it’s like to have drug reps and service marketers come up to me and try to get me to use the “best and newest” medication or the “best” service. Do you know what my brain does in response to these requests?
(Yawn…..) Then I think, “Hmm, did you bring donuts?”
OK. Now this is why my recommendation is so radically different…
You see, on the rare occasion that I get a “thank you letter” (and even more, rarely, a “thank you visit”) from a former patient or their families, something totally amazing happens to me.
I feel warmth in my heart. I smile. I forget that I am tired or hungry. For a moment, I think that I have the best job in the whole world… and most importantly, Whatever I did to make that patient or family “thank me”… whatever I did, well I want to do that OVER AND OVER AGAIN!! It’s like hitting the Jackpot in the physician’s heart! He or she will want to do “that” (ie. make that hospice referral) over and over again!
So, when the time is right, bring a pre-addressed stamped envelope bearing the referring physician’s name and office address to your hospice patients and their families. Say something along the lines of this: “If you are grateful for our services, please send your doctor a little thank you note so that he/she will know that he/she made a good decision by referring you to our care. We will even drop it in the mail for you.”
“Ah ha!” you are saying, “Why didn’t I think of that?”
–Again, doctors listen to two groups of people primarily, patients and other doctors. I am happy to be the “other doctor” who makes the argument for hospice as the way to best serve our patients at the end of life! I do this in the easy-to-read book, It’s OK to Die. Give it as a “thank-you” gift to your doctors! For bulk purchases of 10 books or more, the price drops to $8 per book with only $1 shipping per book (in the Continental US). Email me if you are interested in this discount: DrMurphy@oktodie.com
(Photo credit: businessnewsdaily.com)
To Tell the Truth -
The Healer’s Wound: Grief Postponed
Rea L. Ginsberg, LCSW-C, ACSW, BCD
There are truths we can only tell through story.
— Jonathan Sacks, The Great Partnership
Everyone has a story. It is important and precious and unique. For the teller, it is the most important story in all the world. It is the story of personal creation. It tells the world who he is and how he got to be that way. It is a self-descriptor with a back story. No other person owns that identical story. No other person has ever lived that story or will ever have it again. It makes the teller completely unique for all time. Continue reading
The name of my book is “Bitter and Sweet, A Family’s Journey with Cancer.” Here is a brief summary. In April of 2010, my husband Tim began to have some strange sensations in his side. On May 7, we found ourselves facing stage IV gallbladder cancer rather than a simple gallbladder removal as planned. Five months and one week later, my husband died. Those five months were the most difficult and horrifying time of our lives. It was also an extremely beautiful time for us. We found ourselves using the phrase “bitter and sweet” so often during those five months, that it was an obvious title choice. What follows is the short version of our story…
Our lives had been full of paradoxes. How do you fight for your life and yet accept mortality at the same time? How do you maintain optimism, which is necessary for health, and prepare for your death and get your affairs in order? How do you understand God’s love and compassion, and yet experience cancer and suffering? Continue reading
Ok, so the ER is not the place where you can usually find ER doctors jumping for joy, but certainly stranger things have happened there…so, why not? Continue reading
Last week we introduced the idea of “fighting” or “embracing” death. We examined the definitions of death and dying, as well as the scientific, pharmaceutical, technological, TV-Hollywood, and musical contributions to our stereotypes. Now, let’s look at some of the remaining sources of death stereotypes, and read the author’s compelling personal story led to his present approach to life and death. Continue reading
If one were to plot a person’s life on a number line, then death would be nothing more than an infinitesimally thin point, nothing more than a nanosecond demarcation from one state of being to another state of being. So why is it that some of us fight death with our last full measure while others embrace it like a new born baby? Continue reading
“Only with death is the story of our lives complete”
~Monica Williams-Murphy, MD
A Eulogy, the recitation of ones life story, is a powerful tool for transformation and growth among survivors. Perhaps, the writer of the eulogy experiences the greatest growth from penning the words. Below is a freshly-written eulogy by one of our readers. Beautiful, simple, even poetic. Afterwards, a short praise of the eulogy and legacy is discussed. Continue reading
We live on a farm. My kids have seen chickens “born” and chickens die. Some of our chickens have died of old age, some of our chickens have been eaten by the dog, and some of our chickens have been eaten by us. My middle daughter casually calls this “the cycle of life.” Continue reading
Buddhist tradition says that when an enlightened one dies there’s an opportunity for enlightenment for all of those present. In my personal opinion, when anyone dies, there’s an opportunity for enlightenment for those remaining.
Death ends a life, not a relationship.
— Morrie Schwartz Continue reading
I turn 43 on New Year’s Eve, not that you really care, but it does convey a certain perspective to be ending your year in two different ways.
So, as a general rule there are two things for sure with me:
1st- I always work in the ER on my birthday (it’s far more interesting than any party I have ever attended and I get paid to show up!)
2nd- I never make New Years resolutions. Continue reading
Her skin was smooth and unblemished. She had the legs of a dancer and wore a pair of well used running shoes. Her hair was delicately curled, a pale blonde hue. Her firm mounding breasts, which were pointing toward the ceiling, undulated under the pulsations of the Lucas Chest compression device (see this sample video). Continue reading
Most people wish that they knew what to say and do, and how to be when approaching dying, death and grief. Continue reading
(If you are not religious or are atheist, please do not be dissuaded from reading this article by the title:)
We just had a member of our congregation die relatively unexpectedly. He was in his early 50s and a father of 6. (That’s a big equation.)
My religious job is to teach our youth (teenager) Sunday School class, when I am not working in the ER or traveling to lecture. So, in this regard, today was like most other Sundays- I had gotten up early to prepare my lesson for the day. The problem was, the lesson wasn’t relevant for the day…meaning the death of this man was on everyone’s mind, and two of his children were in my class. Continue reading
I sat in silence wrestling with myself, shifting in my seat, as my husband drove down the road. He pointed out some beautiful fall foliage. I looked at the trees but could not appreciate the scenery due to my turmoil. All I could think about was how uncomfortable I was with my father’s hospital discharge plan and how fractured end of life healthcare planning is in some states (specifically, states without a POLST form), states such as mine, Alabama. Since becoming active in advocating for better end of life healthcare planning, I have been a supporter of the POLST for lots of obvious reasons- but most basically, it ensures that the medical system obeys the wishes of the patient or the acting healthcare proxy. I have known abstractly how important such a document is for my patients. But now, a new personal knowledge is dawning for me—I now know firsthand how the LACK of a POLST or POLST-like document actually LIMITS healthcare options for those who are near the end of life! Continue reading
If you don’t like the way the world is, you change it.
You have the obligation to change it.
You just do it one step at a time.
— Marian Wright Edelman
He looked dead. The paramedics brought him down the hall toward one of my critical care beds, and for a moment I thought the patient was dead. He was nearly the same color as the pale sheet covering his thin frame. His cheeks were sunken in and his eyes were gazing upward, in what I sometimes call the “death stare.” Then, surprisingly, he moved his arm upward to push his oxygen mask off of his face, resting it atop his head like one would wear a pair of glasses not in use. Continue reading