Author Archives: Dr. Monica Williams-Murphy

About Dr. Monica Williams-Murphy

Dr. Monica Williams-Murphy is a Board Certified Emergency Medicine Physician, who practices in one of the largest emergency departments in the United States at Huntsville Hospital. Through her writing and speaking, she is devoted to transforming the end of life into a time of peace, closure and healing. Media Page

 

Becoming what might have been

bewlidered

Bewildered

 

Solitude is fine but you need someone to tell that solitude is fine.

~~ Jean-Louis Guez de Balzac, Dissertations (1665)

An ancestral insight: We Need Others

Childhood bereavement changes the course of the future. All bereavement transforms the survivor’s future. Parent-loss in childhood is especially powerful because of the child’s immature, undeveloped psychological defenses and his status of enormous dependence.1 Continue reading

deathnotification

“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

Happy-Man-Jumping

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…”

One Washcloth: a Tool for Change

Wednesday, 16 Sep 2015 14:22

unnamedonewashclot

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
too.

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

updatedredcat

“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

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:

quiet please

Ah, now there we go.

This sign promotes respect and privacy without announcing the condition of the patient.

Brilliant!

So, I shared this on twitter and got this interesting response.

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:

Ha!

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?”

Oh wow!

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!”

Her response?

“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 :) )

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