1. Ufema, Joy RN, MS

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Striking the right note

My husband was treated briefly by one of the cardiologists at the hospital where I work. After his death from heart failure, I received a hand-written sympathy note from this physician. I was extremely touched because my husband had been his patient for only 3 months. I'd like to let this kind man know what his thoughtfulness meant. Do you have any ideas?-J.F., QUEBEC

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This is, indeed, a fine physician. I once counseled a widow who was upset when she received no acknowledgment of her husband's death from his physician-and her husband had been his patient for over 30 years!!


I suggest making a phone call or short visit to personally thank this physician. Tell him how much his kindness meant and how fortunate you and your husband were to find him at such a difficult time. Give him a small flowering plant, green and healthy, that he can keep as a reminder that life goes on in spite of death-and that the art of medicine was well served by his thoughtful gesture.



Healing takes many forms

My patient has been hospitalized frequently this month and now seems terminally ill. Her family members are openly religious and say they're praying for her to be "healed." When they gather around her bed, holding hands and praying, I feel uncomfortable being part of their false expectations. What can I say that's kind and respectful, yet realistic?-A.P., ORE.


You consider the possibility that healing comes in various forms. Some religions teach that even death is healing because the spirit becomes whole again. Or you could gently suggest that healing means finding peace and forgiveness at the end of life.


I recall a 48-year-old woman dying from rapidly advancing malignant melanoma. I was convinced that her grief over the loss of her murdered son had made her vulnerable to disease. She talked about feeling enraged for many years. Eventually, she began writing letters to the man convicted of her son's murder, pouring out all those angry feelings. Over time, she decided to speak with him in prison and hear his explanation for killing her child. Slowly, she began to forgive. And then she allowed peace to enter her heart.


As she lay dying, she took my hand and instructed me, "Go be with some other patient who needs you. I'm fine. In fact, I'm the healthiest I've ever been in my life."


So perhaps you can help this family recognize the miracle that's already present[horizontal ellipsis].their love and dignity in abundance around your patient's bed.



Dying as she lived

My mother, a retired nurse, is seriously ill with metastatic bone disease. The oncologist warned her about potential pathologic fractures, yet I find her climbing ladders in the barn and dragging bags of feed to the cows. I'm worried sick that I'll come home and find she's fractured an arm or leg, but she refuses to consider my feelings. Is it unreasonable to expect her to take care of herself so she'll live longer?-C.L., WASH.


This is about taking ownership of the process of finishing a life. As a nurse, your mother probably saw many people die in the hospital. She doesn't want to do it that way. Your mom's saying, "I'm not dead yet, and until I am, I'm going to do this my way!!"


Even though you love her and want her to live long, it's her life and she needs to finish it her way. It may be hard to hear, but this isn't about you. She's doing the dying, and that means squeezing in all the living she can until she can do it no more.


She's her own person and this is her choice. Of course, other people make very different choices. I remember a former patient of mine who regally took to her bed to be bathed and massaged by strangers, fed by family and friends, and ministered to by white-collared ministers in black cars. She invited in anyone who'd come and received them like a queen. That was how she took ownership of her dying process.


We all must die. When your turn comes, will you want someone telling you how to finish your life? I hope you'll be comforted by the memory of how you helped your dear mom die her death as she lived her life.



How near is death?

As a case manager for a busy medical unit, I typically initiate discharge planning soon after admission. Recently I was pressured to get a terminally ill patient out of the hospital and back to the nursing home. When I visited him he was comatose. I couldn't predict how long he'd live, so I arranged for the ambulance to arrive early in the evening. He died about 5 hours after transfer. I feel awful. How can I prevent something like this from happening again?-R.S., TENN.


No one can guarantee that a terminally ill person won't die during transport anywhere, anytime. But you have resources to help you make a judgment about whether death is imminent.


First, you have a reliable resource in the patient's attending physician, who's no doubt equally aware of the pressure to discharge. An assessment of level of consciousness, vital signs, and other clinical indicators would provide fairly clear indications of expected survival time.


You can also rely on the assessment skills of the patient's nurse. She's at the bedside for hours and may be assigned the same patient for several days. You can trust her experience and intuition about the patient's condition.


As I witnessed hundreds and hundreds of deaths over many years, I too developed those observational skills. They proved invaluable at advising exhausted families whether they could safely go home for a shower or should instead urgently call the grandchildren.


But I also listened to them. For example, a wife of 50 years knows the patient far more intimately than clinicians and clergy. She recognizes a diminished life force, like a clock in their home, simply winding down.


Listen to the spouse who never sat in an anatomy and physiology class yet intuitively knows. Listen and cancel the ambulance when she says "I don't think he's got long."