1. Schwarz, Thom RN, CHPN


Presence, improvisation, dark humor-crucial skills of a hospice nurse.


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Late evening, early spring, the peepers not yet trilling. I am in my car, rain streaking the windshield, reading a New Yorker essay about war writing, an ironic distraction from my visiting hospice nursing work. My patients' families say later, "She fought so hard." I nod, as if in agreement. I have never been a warrior; I was a conscientious objector during the Vietnam War. I don't know war nor have I fought a fatal disease. I suspect I wouldn't battle cancer-not after what I have witnessed in my hospice patients' homes. All wars are futile.

Figure. Illustration... - Click to enlarge in new windowFigure. Illustration by Pat Kinsella

Earlier tonight, I was called to evaluate Molly's change in condition. Her mother and sister, both RNs, have been providing her home care, and they've noticed that something in this 30-year-old woman has shifted. They want my dispassionate clinical eyes. Molly has spent the last two years fighting a cancer that has left her a skeletal ghost. For the past few days, she's been sitting long hours at her bedside, her skeletal self supported by a small army of friends and family. Her eyes stay shut most of the time. I've seen this state before, an internal escape to a place apart from the patient's agonizing passage. Molly's pain and anxiety are, for the most part, held at bay by large, frequent doses of intravenous drugs. It is nausea and vomiting that are her enemy and mine. No medication has been left untried in my effort to provide a peaceful and comfortable death. Our fight has been futile.


While I am driving to her home, something unexpected but not unfamiliar happens to her. When I arrive, she is returning from her first grand mal seizure. She is, as ever, sitting on the edge of her bed, being held upright by her mother. She is trembling, her breath shallow and rapid.


"I feel sick, I feel sick," she repeats fearfully.


One of her sisters asks, "Do you feel like you're going to throw up, Molly?" "Yes," she whispers.


"Give her a basin!" someone says frantically.


"No, wait." I kneel in front of her, my hands on her knees. I lean in, my face close enough to smell her cracked lips.


"You aren't going to be sick. You wouldn't throw up on me, would you?" I ask gently. She lifts her chin from her chest and tries to focus on me, leaving her interior escape place. I have her attention.


"Molly, breathe with me." Her efforts are exhausting. She leans forward, lays her cold hands on my forearms, and droops her head onto my shoulder. After a few minutes of conjoined breathing, she pushes herself away, reaches out for my identification badge.


"Schwarz," she reads in a shallow whisper.


"It's German for 'black,'" I explain.


"Shorts," she says. Is she actually teasing, twisting my name? Her family chuckles. Anything except "I feel sick" is funny.


"Hold me, Schwarz," she asks again. I hold her emaciated forearms. She leans against my chest, her bones against my bones. Her cool cheek touches my bearded cheek, then slides down against my neck. Does she want my warmth? I want to tell her to escape back to that inner place, that the seizure and nausea have ended. Instead I stay silent, hoping she can join my easeful breathing. Her IV pumps of narcotics and anxiolytics whirr dutifully. This is as close to dying as I want to get for many years.


I breathe with her, for her, hoping her heart will continue beating with mine but unsure if it will. She tries to lift her head, again and again, but she is almost out of life.


"Lay down now, Molly. I promise you will have a wonderful night's sleep."


"Tommy," she says, remembering my ID badge. I laugh aloud. Her family chuckles, but don't know why I'm laughing. It feels OK to laugh, a relief. There have been only three people who've ever called me Tommy. Now her.


Two nights later I return to her. She is almost gone, crossing the river-supine now, her family on and around the bed, barely enough room for me to kneel at her bedside. I slide my finger into her palm.


"When you get there, three people will meet you-my parents, and an old friend named Lindy. They all call me Tommy, too. You are number four. I'll see you later, Molly."


Her fingers twitch. Surrender.