1. Clark, Akisha BS, RN

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As a little girl I was always enchanted by the night. My father worked endlessly and if I wanted to spend time with him it would often be during the night. He would come in from a long shift, tired and underpaid. I would pretend to be sleeping on the couch, his favorite spot to relax and watch the late news. I would lay very still hoping to fool him and be a spy to his nightly ritual. After what seemed like eternity to me, I would slowly open my eyes, watching him through slits. While I thought he had no idea of my tactic, he would prove he was aware all along. In an instant, with his face inches from my nose, he would shout, "Boo!"

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Nighttime has always been magical for me. So it will be no surprise when I say I work night shift as an on-call home hospice nurse. Although I may be a little bit biased, nighttime is when things truly go bump. It's 5 p.m. in a suburb of Detroit and I am starting my shift that will not end until 8:30 a.m. I noticed a feeling of butterflies in my stomach and my heart feels like it's following a tune to the Morris code. I wonder why I still experience this sensation at the beginning of my shift; I've been a hospice nurse long enough to handle most situations with finesse. But it's not my patients that worry me. It's the encounters that lie ahead. In what ways will they shape my life? Will it be for the better or will I throw my hands up, move to a tiny island, and sell seashells to tourist? You never know.


At 5:00, I take a deep breath and open my laptop and start syncing it with the main systems. It's very important in home care because, if I don't do this, I won't have the latest up-to-date information on my patients, which could spell disaster. While my laptop is loading, I head to my car to check supplies. My car is a one-stop shop for all things medical. I have Foley catheters, gloves, IV start kits, specimen cups, even kitty litter for proper medication disposal. If I notice I'm running low, I could make a trip to my home office to restock, but today I have everything I need, including my medication tackle box. My medication tackle box contains a variety of medications most likely needed as we progress through the stages of death. I have Haldol for psychosis or vomiting, Thorazine for extreme agitation, Tylenol suppositories for fever, Ativan for anxiety, and a host of other medications.


By now my computer is ready. It's now time to listen to report. Being on-call means I have no idea what patients I will need to see. I'm at the call of the patient and family. A family member, caregiver, or patient places a call to the triage team for assistance. Reasons for calls vary from medication refills to active death, to death completed. The triage nurse decides whether or not it is possible to handle the problem over the phone or if a nurse needs to be dispatched. Deaths require a nurse visit to pronounce the deceased. The triage nurse leaves report on our general line. Report includes details regarding any necessary visits, and any other significant information. Once I'm finished with report, I wait for a call from triage with location and request for care. After about an hour I receive a call for my first patient. Kathy is a 45-year-old female, diagnosed with breast cancer. Her aggressive form of cancer has migrated to her lungs, her lymph nodes, her spine, her ovaries, and has recently begun to cause openings in the skin on her back, abdomen, and under her arm-cancerous tumor pushing through. Once vibrant, she is now exhausted and in pain. Kathy's husband reports that even though he gave his wife the ordered pain medication around the clock, she is still moaning as if she is in pain and has not communicated with him in a few days. I throw on a set of scrubs and head to the residence. Once I arrive I grab my computer bag, supply bag, and my medication tackle box. I normally do not bring my tackle box, because all medication needed for the patient should already delivered to the home, but with the situation at hand I have a feeling more will be required. Kathy's husband Tim is anxiously waiting at the door. I introduce myself as I entered their cute bungalow. Kathy, sitting in a recliner, appears to be sleeping. I am comforted thankful she is able to get a little rest no matter how short. Tim explains the medication he has given in the last 24 hours, with intense accuracy. He looks worn down and tired. I thank him for his report, and I assess Kathy. Heart rate elevated, blood pressure low, respirations 43/minute, legs are cool to the touch, 100 cc of dark tea colored urine in catheter bag, facial grimacing, and slight moaning every 1 to 3 minutes.


My assessment suggests Kathy is in a pain crisis and is in the active stage of death. I make a phone call to the on-call physician and obtain additional orders for pain medication. I administer pain medication immediately and waited to see if medication change will be effective. As I turn around to give report to Tim, he is sitting at the kitchen table head in hands, crying quietly. As an on-call nurse you don't always have an opportunity to get to know the family of the hospice patient. You're often only there for the moment. So I don't know if Tim has dealt with his stages of grief, if he understands what is happening, if he likes to be touched. So the only thing I have to go on is intuition. I walk to the table, place my hand on his shoulder, and as he looks up, I reach down to hug him. Tim returns the hug, hugging so tight I almost need my own nurse. We let go and I assess Kathy who is sleeping quietly, peacefully. I explain the new regime to Tim and prepare to leave. No other words are spoken. Tim takes the orders like a private in the military. As I exit the house, Tim calls my name, looks into my eyes, and simply says, "Thank you, I needed that." I smile and turn to leave.


As I drove to my next call I looked at the moon and the stars in the sky. I reflect on my mission and why I'm here in this moment. I became intoxicated with the cleanliness of the air and the peace of the night. I think of the many nurses I know and why we do what we do. There's this sense of yearning in me to help, to provide. I couldn't see myself doing anything else other than what I do. It's not the pay, it's the people.