To ask is to believe that somewhere there is an answer. ~~ Jonathan H. Sacks, PhD
Fear of dying is an existential experience for everyone. It is a common denominator in the human condition. Continue reading
To ask is to believe that somewhere there is an answer. ~~ Jonathan H. Sacks, PhD
Fear of dying is an existential experience for everyone. It is a common denominator in the human condition. Continue reading
“Oh God!” she groaned, looking upward with tears flooding her cheeks, which were stretched into the shape of agony. Her chest heaved uncontrollably with grief.
“I am so very sorry,” I whispered again while leaning in and stroking her hand.
This is what death notification often looks like and feels like. We doctors should be masters of delivering some of the worst news that could ever be uttered, the worst news that could ever be heard. Continue reading
By now you’ve surely heard that Medicare is going to pay doctors and other qualified healthcare providers for advance care planning with patients in 2016.
Aren’t you excited?!?
Ok, so if you are not utterly thrilled or even if you are nonplussed about the whole issue, then let me give you a different perspective on why you should rush into your friendly local doctor’s office to make a living will and chat about your future.
Here are 8 unorthodox reasons to create your own advanced care plan in 2016:
1. You don’t want your Aunt Bertha changing your diapers.
Maybe your Aunt Bertha did change your diapers when you were 6 months old, but do you really want her cleaning your feeding tube and wiping up your poop stains when you are 60? I mean heaven forbid that you end up in a chronically dependent or even vegetative state at such a youthful age, but what if…??? Did you even want to be kept alive in such a state at all…??? Certainly something to think about. Maybe you should give Aunt Bertha a call?
2. The loudest person in your family may not have your best interest in mind.
Oftentimes the loudest relative “runs the show” in the hospital- by guilt, intimidation, and a host of other aggressive or passive-aggressive strategies. If you don’t want “you-know-who” making decisions for you or bullying around your other relatives, while you lie helplessly in the hospital bed, then for Pete’s sake, choose and document your own healthcare proxy today! Make sure they know EXACTLY what’s acceptable and not for you.
3. I’ll bet you know who you DON’T want making decisions for you.
Simply put, some people can handle this kind of pressure and some people can’t. The people who would wilt under life and death decisions on your behalf should NOT become decision makers for you, either by intention or default.
4. Hell hath no fury like your family fighting over your fate or your fortune!
I’ve seen feuds break out around a deathbed that would make the Hatfields and the McCoys cringe. I always want to scream, “What the hell are you people doing? Can’t you see that your loved one is dying here?” (Of course that kind of outburst is never good for the physician professionalism scorecard, so I usually manage to translate the sentiment into something a bit more PC.) So, please, please I beg you to have your fate and your fortunes pre-determined before that fateful and inevitable moment arrives!
5. Grudges can come back to bite you.
One time the closest available relative to my unresponsive patient on full life support was his estranged wife. She had carried a grudge for 20 years. When we finally tracked her down to make a decision for my patient, with glee she whispered evilly, “Pull the plug.” (YIKES!) I’m pretty sure that guy would have had someone else in mind to make this decision, but IT WAS TOO LATE! No advance care plan was in place with his doctor. (I sense that you are getting my drift…)
6. No one knows your secret priorities.
During one of my traveling lecture series last year I met a gerontologist who shared some of the idiosyncrasies of his advance care plan with me. He had in writing, that should he become demented and placed in a nursing home: 1) Under no circumstances should he ever be physically or chemically restrained, and 2) He should be allowed to have sex with anyone who is willing to engage him
7. No one knows you like you… and you deserve a fitting exit.
I would like to die on a blanket under the oak tree at bottom of my field. My dad would like to be buried in a bright red racecar motif casket. My husband wants a Viking funeral pyre. I’m sure you have some pretty unique idea about your final goodbye as well… do you have the plan in place?
8. Embracing death will allow you to embrace life.
Is this too much for you? Think it’s too morbid? Let me tell you the great secret… when you embrace death in its inevitability, then each moment of life itself becomes more precious. Now will never come again. Planning for the end-of-life awakens you to the gift of this very moment of life, this very second. What a gift.
“The doctor will see you now…”
Change is part of the texture of life itself,
But it is often hard to bear
— Rabbi Lord Jonathan Sacks
Over the past century our society has become distant from both death and the tending to our dead. According to Gary Laderman’s book Rest in Peace: a Cultural History of Death and the Funeral Industry in Twentieth-Century America, “The divide was produced by three social factors: changes in demographic patterns, the rise of hospitals as places of dying, and the growth of modern funeral homes” (p 1). Our mental, emotional, spiritual, financial and societal health has been negatively affected directly and indirectly by this disconnect. Because our relationship to death is at the core of what it is to be human, this detachment affects both individual and societal health. Continue reading
“The most significant variable of a relatively uncomplicated bereavement period or a prolonged and
tragic mourning depends to a great deal on the relationship the child and the parent had, on the old unresolved conflicts they carried within, and on the level of communication they had. Last but not least is the mourner’s early experiences with death and loss.”
~Elizabeth Kubler-Ross, MD
She cried as she held the baby bird. I cried as I held her (my daughter), after all she was my baby
My daughter’s attempt at rescuing and feeding the baby bird who had fallen out of it’s nest had failed. The bird had become weak and then collapsed this morning during feeding. Now it was dying. Continue reading
“The Bereavement,” marble, 2010
Grief is a synonym for intense psychic pain. It is seldom invited and never welcomed. Death is not a gentle teacher. Everyone loses someone they love, and everyone dies someday. Everyone is afraid of it and everyone is angry at it. Some people say no no, I’m not mad and scared. Unfortunately, the truth doesn’t change because it is denied. Usually, everyone dies only once, and almost no one comes back to report the journey or the destination. For some, maybe that is one of the scarier aspects of death – the unknown. At least, it is intriguing. It is surely the essence of awe. We are left alive to wonder and imagine. We have lively imaginations. Continue reading
Advance planning is ultimately a spiritual practice. It requires that we face ourselves. It requires that we “number” our days. Continue reading
A “Sign” is defined as an object, quality or event whose presence indicates the probable presence of something else.
One day after having read, “Attending the Dying” by my friend Megory Anderson, I found myself at work in the ER. There was a half-naked psychotic lady screaming in the hall, the sound of a beeping ventilator alarm escaped from the curtained room of a man in respiratory failure, and a large crowd was gathering outside of Bed 2 because a matriarch was dying. Although I am accustomed to such visual and auditory chaos, it struck me that my dying patient and her family were not. Further, as I stood in this hall with the family whom I was attempting to shepherd along in creating a good death for their well-loved matriarch, I became acutely aware that I was not following the wise counsel set out by my friend, Megory.
In her brief and powerful tome, “Attending the Dying- A Handbook of Practical Guidelines”- Megory sagely advises those of us who accompany others on their journey towards last breaths. Standing in the bustle and roar of the ER, I could clearly recall her words regarding creating a sacred space for the dying and their loved ones:
“You have the calling and ability to set the stage for a good and holy death.”
“Creating sacred space is one of the first steps in setting the environment apart from day-to-day issues, which in turn helps everyone present remember the sacredness of the event unfolding.”
“Contain or mark the space.”
“Try to make this an intimate experience for the family, within the boundaries of the medical unit.”
“A sign on the door is always appropriate.”
Hmm…I thought, “What I really need is a sign. But what would it say?”
I mused that my favorite sign would go something like this:
“Shut up! Can’t you see that someone is dying in here?”
Being known for my public decorum, however, I decided against this one. But, what?
I could not imagine the family wanting a sign on the door that overtly stated that someone was dying. This would rob them of some of the privacy that I was hoping to create.
I could not come up with anything decent and reasonable on my own so I turned to the experts. In my ER, we have these fabulous humans called “Patient/Family Representatives” whose job is to socially, emotionally and spiritually help support and gain resources for people who are critically ill or dying. If ever there was a font of wisdom, these people are it! So, I presented the idea to them and of course they had the solution and here it is:
Ah, now there we go.
This sign promotes respect and privacy without announcing the condition of the patient.
So, I shared this on twitter and got this interesting response.
— The Quiet Man (@rctwilkinson) May 17, 2015
Love it! But this has to be “branded” or a commonly understood symbol for uninformed people to understand the message, or this funny response might be the product:
— The Quiet Man (@rctwilkinson) May 17, 2015
So the point is that indeed a sign is often a necessary, simple and powerful tool in defining a sacred space for the dying, particularly in a medical facility. But remember, when creating YOUR OWN signs for this purpose: A “Sign” is defined as an object, quality or event whose presence indicates the probable presence of something else. You have to understand the sign to obey it!
Make sure your sign is recognizable, respectful, and gets the job done.
Thank you, Megory, for teaching us how to better attend the dying and to groom the environment practically and with dignity, even within the chaos of the ER.
To learn more about Megory Anderson’s work visit the Sacred Dying Facebook page
Dr. Megory Anderson was called to a vigil at the bedside of a friend who was dying one night. That experience was so powerful that she began working with others who needed help attending to those who were dying. Today, Anderson is the executive director of the Sacred Dying Foundation in San Francisco, and trains others in the art of “vigiling,” a way of attending to the needs of the dying. She may be reached at: Megory@sacreddying.org
I was at the end of a long shift. I had already seen too many patients to have any common sense left and it felt as though there were no remaining neurons firing in any agreeable pattern in my brain. And here came my last patient. I peeked into her room before I showed my own face. She was 78 years old with long gray curls piled way atop her head. Her chest seemingly rose and fell too rapidly for comfort. The sounds of bubbles in her airway were audible even outside of the room.
“Uh oh,” I thought…fate has saved the toughest patient for last. Tough because at first glance I could already tell that I would need to have an end-of-life planning conversation with this little lady. She was already triggering my mental screening tool: Would I be surprised if this patient died within the next year?
The answer was a resounding “no.”
I pulled back the curtain.
“Hi Toots!” She called out to greet me as I made my way into her room. (This was a first…and I liked it!)
This spunky little lady was in the ER for shortness of breath. Again.
As we talked it became clear that she had entered her end-of-life pathway. The last six months she had multiple hospitalizations for pneumonia. She now only routinely walked to the restroom or to the dinner table. She was beginning sleep a lot and there was about 20 lbs. weight-loss.
Despite my fatigue it was my duty to have “the conversation” with this patient and her husband, regardless of the physical and mental energy costs to myself.
So I took a deep, tired, ragged breath and started my usual condensed ED-goals of care conversation:
“Do you have a living will?”
Her husband quickly responded, “What’s a living will?”
Secretly, in the recesses of my imagination, I slapped my forehead, yelled out “Oh brother!” and rolled my eyes. As I sat motionless, fake-smiling at the gentleman, I hoped that none of my true sentiments had shone through in my facial expressions or demeanor.
Before I could continue my spiel with this fake-smiling expression plastered on my face the husband asked, “Does that mean that we ask about her wishes?”
Suddenly I felt as refreshed as after a good nights sleep! “Why yes!” I gushed to
him, my fake-smile now genuine and deep.
“Well, let’s just ask her then,” he said turning to her as my smile turned to an expression of near-astonishment. This had never happened before.
“Honey,” he leaned over her bed rail, “This nice doctor wants to know your wishes like whether or not you want life support and things like that.” He looked toward me as he spoke to her searching my face for confirmation.
Boy, did he get it! I was shaking my head vigorously, “YES!”
“Well, I don’t want all of that. You see, I only want to die once.” She said impishly.
We all burst into laughter.
She apparently took this as her cue. So, she continued, “I mean who in their right mind would want to die twice? Right?”
(She began to remind me of Joan Rivers on stage.)
She kept going…”Why break my ribs just so I can come back to do it all over again? And who came up with that plan anyway, doctor ?!?”
#LOL #ROFL were understatements!
Observing my uncontrolled laughter she said, “At least you’ve got a sense of humor kid. But let’s get on with this admission, I’m hungry….”
So, we did.
Lesson 1- Things are not always as they first appear. Sometimes we are pleasantly surprised.
Lesson 2- Fatigue is no excuse for skipping what could be the most important healthcare planning conversation in a patient’s whole life.
Lesson 3- Always find a reason to smile or laugh with your patients (even if it’s a choice )
I grew up in just-post-segregation Alabama. In 1976, I was a kindergartener and my best friend was a little black boy named Kendall. We had a lot in common. I would chase him around on the playground and he would eat my crayons. Life was grand or so I thought, until my parents came and had a conference with my kindergarten teacher. The next day we were separated from each other in class. I remember crying to mom in protest saying, “But aren’t we ALL God’s children?”
I still feel the same way today. So, I’m extremely disheartened by the recent increase in racial tensions. But I have something very important to share with you…
Hospice care is the antidote.
(This photo is of one of my local hospice nurses comforting her patient.)
Hospice is the one social institution in 2015 which contains the seeds of healing for race relations. You may have never had a black, white, yellow or red-skinned person in your home in your entire life. But, if you are a hospice patient, some human with a different skin tone may very well come into your home to love, serve and care for you in ways you didn’t know were possible.
Also, as we travel the end-of-life pathway, we have opportunities to allow old prejudices to fall away in insignificance. Relationship healing and deepening can occur at accelerated rates. Love and even friendship may blossom more easily.
The giving and receiving of hospice care may be one of the most powerful current reminders that “we are ALL God’s children.”
Please share this message.
#healing #racerelations with #hospice
PS. My parents have long since grown out of their prejudices. No one needs to remain trapped by socio-cultural biases. We can choose a better way.
Antique Oriental rug
Study the past if you would define the future. (Confucius)
This could not have been a better time to demonstrate the significance of the past and its presence in our lives. Passover! Easter! The stories must be remembered and told, regardless of the pain. They matter. They make a difference in the way we live. They have the power to deeply influence our future. They belong to our very survival. They have changed the course of mankind and the quiet/silence of the individual soul. They teach us that no one is condemned to be a failure, and human dignity resides in each of us. They show us hope in the midst of despair and the importance of never giving up. They tell us that we can refuse to be defeated. They point the way to compassion and a shared moral life. That is what the past can do for the now and future Self. The past is transformative. It just takes an act of courage to face the fear of memory.
From the “dead” past comes new life — which means that the past never died at all.
Spring renewal and freedom heal. Looking back is easier then.*
* An earlier version of this “short take” was posted as a Comment on the blog of Monica Williams-Murphy, MD, here: http://www.oktodie.com/blog/forget-the-past-by-rea-l-ginsberg-lcsw-c-acsw-bcd .
Much gratitude to Rabbi Lord Jonathan H. Sacks, PhD, for the persistent eloquence and hopefulness of his writings. I have dipped into that rich pool often and joyfully, even here. His wisdom informs us all.
Tags: #grief #eol #memory #stories #healing #hope #compassion #transformation
Rea Ginsberg is a retired director of social work services, hospice coordinator, and adjunct professor of clinical social work. She can be reached on LinkedIn and on Twitter @rginsberg2.
Covered ginger jar, China, c. 1895
Life can only be understood backwards; but it must be lived forwards. — Soren Kierkegaard, 1843
Do thoughts of the past make you unhappy? Are you grieving? “Forget the past. You live now and into the future.” This is still the common-sense, persistent advice from the American public, the voice of the people. Many say the remedy for such unhappiness is simply to forget about it, live for today and – maybe – tomorrow. This remains conventional wisdom, the consensus opinion, the general agreement for an acceptable resolution. The people shall judge. Are the people of The Public right? Does “forget about it” solve the problems of past unhappiness and grief?
Forget the past. Such a curiously vehement, urgent order. Imagine living only in the present and into the future. Gone is childhood. Gone are youthful love and hate, joy and sorrow, laughter and tears. Gone is the spice that makes life rich, exciting, and meaningful. The sage voices of yesterday are silenced, suppressed. The advice to forget is intended as a loving kindness to us when we grieve. Forget about grief and the past. Move on, get over it. The past is past, dead and gone. Forget it.
This is an open expression of the advisor’s worldview, driven by impatience and the ubiquitous fear of death and self-awareness. In this view, death terror must be hidden and insight has no positive value. In fact, insight is seen as harmful, something to avoid and deny. Forget about it! Pursue happiness instead! According to this advisor, happiness excludes insight, the power of grasping the true nature of life and Self. This attitude lacks mature sympathy.
Furthermore, “forget the past” is an impossible imperative, however kindly it is meant. We cannot live as though the past had not happened. Our grief is one full measure of love given and/or received. To forget is also to deny this love. Forgetting would then become offensive. Why would that be desirable? It wouldn’t. Those who grieve are momentarily hypersensitized by loss and usually understand this. With such understanding, the mourner recognizes a profound absence of empathy on the part of supposed supporters. He feels misunderstood, reduced to silence, and abandoned. The supporter is exposed as emotionally bankrupt and asks the same from the mourner.
“Forget the past” is an authoritative instruction filled with fear, falsehood, and deliberately missed opportunity. (In this context, the directive often means “shut up.”) Such artificially induced forgetting is not genuine forgetting at all – not an inability to recollect. It is more like a conscious, deliberate withholding caused by self-defense and by mistrust or surrender to the supporter. It is ephemeral and provides no healthy returns for the mourner.
Now we see the past from another side. Our unique individual identity as biopsychosocial beings is a product of our whole lives: past, present, and hopes and plans for the future. The past is an undeniable part of this equation. It cannot be denied in the aftermath of a loved one’s death and our overwhelming grief. Health professionals even consider loss of the past to be a sickness: amnesia – a pathology, a defect in memory, a physiological and/or mental disorder.
The past makes us who we become. Who we are now can be explained, at least in large part, by who we were then – by our past. It is our foundation, the basis on which our identity stands. It creates the framework for the present and the future. The history of our lives is precious. We build on it. We treasure it for who was there and what it teaches us, how it informed our growing up. It begins our singular, signature life story.
Remembering can change the way we see others and the world, change it for the better. Remembering changes our Selves. Grief changes us. Active grief also holds close the memory of the loved one lost. That is the nature – and often the beauty – of grief. The past is present in memory. Ultimately, remembering becomes positive energy in the present and for the future. That is strength and growth.
Forget about it? Get over it? Move on? Better counsel may take a different path. We are beings who experience; memories from our experiences of living are all we get to keep. The past is an elegant archive of the mind, a place of intimate historical interest because of its large and ever-expanding collection of stored memories. Hold tight the past, in grief as well, and taste the tears. There is no shame in our tears. How they can refresh, once they are shed! They are filled with the promise of becoming. They are a necessary growth factor, a naturally occurring character stimulant. Memories sometimes bring tears, and that is normal and healthy. Tears are not a defect or disorder. Their absence, not their presence, may be a disorder.
The past is an agent of hope. It is present but not always conscious in our decision-making. It is a force for transformation. Metamorphosis. It is preparation for the future. Life can only be understood backwards. And understanding gradually unfolds into healing. Life is lived forwards and, with healing, into a Self more forgiving, confident, compassionate, peaceful.
The past is never dead. It is not even past.
— William Faulkner, 1936
Honor and revere both the present and the past; it is not a matter of either/or.
Both require gentle tending, cultivation.
Rea Ginsberg is a retired director of social work services, hospice coordinator, and adjunct professor of clinical social work. She can be reached on LinkedIn and on Twitter @rginsberg2.
Tags: #past, #grief, #eol, #forgetting, #denial, #memory, #PositiveEnergy, #hope
QUESTION: How can a little, frail 82 year old lady with advanced dementia have this written in her chart:
I have a very wise nurse-friend, we call her “Coop.” I have always thought that she double-dipped from the fountain of compassion. This paper, which she wrote for a Nursing 403 class, proves my suspicions true and gives us all a clue on how to become more like her. This lesson is applicable to ALL of us who care for and serve others, not just those called to nursing: Continue reading
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”
(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
(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