Baby Boomers may find this beautiful. Nurses, doctors, ministers, social workers and therapists too. Kids of parents with Alzheimer s may find comfort. Anyone who reflects on life, it’s beauty and apparent sadness in it’s ending will find this beautiful. Hope you enjoy and share — and that it gives you more of your living today. Read More
Drawing On Awareness
December 13, 2012 By Leave a Comment
Seeing With Inner Silence
August 25, 2012 By 1 Comment
I have no thoughts, so I will see.
In order to hear the messages of those dying, we must carry no thoughts to their side.
Keep the bowl empty, so to speak.
Instead of thinking, clear your mind, ask, be still, and know.
Find out how:
“Browse through these posts to find a practice suited to your needs.”
Dr. Virginia L. Seno
Founder, Esse Institute LLC
Training for Ease and Competence in End-of-Life Communication
Access FREE Tips from the Mini-Course Mastering The Listening Self: Personal Growth Through End-of-Life Encounters
It All Counts
August 23, 2012 By Leave a Comment
Since we’re going to be here for only a short while — too short for witnessing all the marvels of it; wouldn’t it create joy for us if we knew how to make every action count?
For thousands of years, all the greatest people, sages and saints ever lived have been telling us that we need to realize it — that life is short and we need to pay attention!
If it’s true that we’re only here for a short while, shouldn’t we take responsibility for truthfully assessing what lies ahead of us? In this way, we can choose our actions with awareness.
What would you choose today if you peered into your awareness that life is too short for witnessing all the marvels of it?
As clinicians, shouldn’t we also take responsibility for learning how to help patients and families in critical care situations, to truthfully assess what lies ahead of them? In this way, we facilitate their choices with awareness of what matters most to them.
Similarly, as teachers or counselors, shouldn’t we also take responsibility for helping learner’s to truthfully assess what lies ahead of them? Wouldn’t this facilitate their choosing with awareness?
What contribution to choosing with awareness will you be today ?
Free Tips from the MINI COURSE: Mastering The Listening Self: Personal Growth Through End-of-Life Encounters, will help you learn to make every action count and to get over your natural anxiety in talking about death and dying, so that you can help yourself and others to make every action count.
If’ you’re ready, access your copy today! It’s in the sidebar.
“Browse through these posts to find a practice suited to your needs.”
Dr. Virginia L. Seno
Founder, Esse Institute LLC
Training for Comfort and Competence in End-of-Life Communication
Access FREE Tips from the Mini-Course Mastering The Listening Self: Personal Growth Through End-of-Life Encounters
Stand Aside for a Beautiful Death
April 22, 2012 By 3 Comments
The sage doctor who stood at the bedside as I held my dying grandmother said, “We seem to die one organ at a time.” I, however, have come to believe that we are too focused on the failing of the organs to rightly perceive the dying of the person.
Death comes in many different ways, in many different packages. Sometimes it arrives wrapped thoughtlessly in advanced dementia, other times the package is stained red with the blood of exsanguination. Usually, these packages are wrapped in a fashion that, for the careful observer, indicates the content. On occasion, the package arrives and is not recognized even by the most astute among us.
How can we learn to recognize death in the face of the myriad of medical disorders that may deliver it? How can we see the forest despite the distraction of the trees?
Let me tell you the story of Bonnie Mitchum, a patient of mine whose death arrived packaged only in a few broken bones.
“Dr. Murphy… Mrs. Mitchum, the 88 year-old mother of the trauma patient in bed 46 is being transferred in from Carltonville Hospital. She has 3 broken ribs, a fractured hand, and a broken foot. She will be here in 5 minutes, and I’m going to put her in bed 45 to be beside her daughter and so that the family can all be close together.”
“Good idea”, I responded to Kylie, the ER nurse supervisor for the evening.
“She doesn’t sound too bad off,” I thought silently. I was already mentally comparing Mrs. Mitchum to her daughter who was in bed 46– who did seem ‘bad off.’
They were both victims of a motor vehicle crash. The daughter had two open fractures in her right leg and had arrived with jagged bones sticking out of her thigh and calf; with a cold blue pulseless foot. She was about to go up the operating room for emergency surgery when her mother arrived.
I had wanted to give the daughter an update on her mother before she went up to the OR, so I went immediately in to see Mrs. Mitchum as soon as she was placed in her room.
I pulled back the trauma room curtain and stepped inside, pausing at the entryway. I was immediately puzzled, a look quickly picked up on by the nurse.
“What did the doctor at Carltonville give her for pain?” I asked, because Mrs. Mitchum was sitting up in bed, looking very peaceful with a faint drowsy smile on her countenance. She appeared to be completely comfortable, in stark contrast to every other trauma patient who I had ever cared for in ER with broken bones or other injuries who was actually conscious on arrival.
“Nothing.” He responded with eyebrows raised high, likewise in surprise.
“Nothing?” I asked to be sure, while rifling through her transfer paper for proof this was the case.
“Nothing.” He responded again.
He was right. According to the hospital who saw her first, the doctor wrote that the patient states she had very little pain and “didn’t want any medication.”
Still puzzled as to how she could be so comfortable despite her injuries, I put down the papers and moved toward her bedside for an official evaluation.
As I walked toward her bed, her facial features came into sharper focus. Immediately, I noticed two things which I found to be slightly disturbing:
1- Her eyes were gazing upward in what I sometimes call “the heavenly stare” (I consider it a near death sign when people appear to be looking beyond the room and not focusing on objects or people in the natural environment.)
2- Her lips were “poofing”—a very non-medical term for a gentle billowing of the lips when exhaling. This usually indicates to me: very relaxed facial muscles, usually seen in sleep states or impending respiratory failure. Given her rib fractures, respiratory failure was my first thought. I also knew that rib fractures in the very old could be the ‘kiss of death’.
Suddenly, I knew instinctively that Mrs. Mitchum was dying. In her face, I could see both the forest and the trees, the package and the message it contained. Mrs. Mitchum had, by most medical understanding, just a few moderate injuries, a few broken bones, but somehow I knew this would prove to be ‘too much’ for her.
I felt almost guilty having come to this conclusion without actually talking with her or closely examining her, so I proceeded with my usual.
“Mrs. Mitchum?” I used my most gentle voice.
To my surprise, she turned her gaze to my face and focused on my eyes. She was very lucid.
“Mrs. Mitchum, are you in any pain?”
“No, not really,” She replied very clearly.
I furrowed my brow, “These broken bones aren’t hurting you?” I touched her wrapped and broken left hand. “Do you want something for pain?”
“No, not right now,” she responded.
How could this be so? I again questioned whether she was really clear minded. “Mrs Mitchum, I’m going to ask you some dumb questions now, just bear with me and tell me the answers, okay?”
“Can you tell me your full name?” I asked.
“Bonnie Lee Mitchum,” she responded correctly.
“Do you know what year it is?”
“2010,” she answered correctly.
“Do you know where you are?”
She named our hospital correctly.
“Hmm,” I wondered aloud and turned to look at Adam, her nurse. Simultaneously, we walked toward each other for an informal conference just out of ear-shot of our patient.
“Adam, I think this little lady is going to die.”
“I’m glad you said that, Doc. I was getting the same impression,” Adam responded, appearing relieved that I was picking up on the same vibe that he was.
“Seems like she is thinking clearly. She’s got decision-making capacity, so we’d better ask her about ‘code status’ while we still can. I don’t want to end up doing chest compressions on her. Three broken ribs are enough for an 88 year old lady.”
Adam was nodding in agreement.
“Come on, you can be the witness,” I motioned to Adam and we both moved back to Mrs. Mitchum’s bedside.
I picked up Mrs. Mitchum’s hand and leaned over the rail of her bed close in to her face. “Mrs. Mitchum, I have some very important questions to ask you, OKAY?”
She opened her eyes and gave me her full attention.
“Rib fractures can sometimes make it hard to breathe. Some people who get broken ribs may have to be put on a breathing machine, if they couldn’t breathe well or if they stop breathing. We will keep your pain controlled no matter what, but if you couldn’t breathe well on your own or if you stopped breathing, would you want us to put a breathing tube in your throat and put you on a breathing machine to support your lungs?”
“No,” she shook her head.
“I understand your wishes, Mrs Mitchum. And I have two more questions like this.”
“If your heart stops beating, do you want us to do chest compressions on you? To do CPR?”
Very peacefully she responded again, “No.” There was no hint of shock or even concern that I was asking her questions of such gravity. She continued to have the same tranquil expression on her face that she had at her arrival.
The final question: “Mrs. Mitchum, if your heart stops or is beating in a way that would cause you to die, would you want us to give you electrical shocks to try to fix your heartbeat or to bring you back to life?”
“No. I’m 88,” she said, “I won’t need all of that.”
Adam started on the Do Not Resuscitate/Allow Natural Death paperwork that I would sign and I left the room to go find her family and to give her daughter in room 45 an update on her mother.
The entire family gathered round as I explained all of Mrs. Mitchum’s injuries and that, though minor for a younger person, these same injuries could prove to be too much for an elderly woman. I then explained the ‘questions’ that I had asked and the answers she had given. Hesitantly, I asked the family if they would be willing to support her in her decisions.
To my great surprise, they explained that Mrs. Mitchum was a strong woman with strong opinions, a family leader, having lived independently up until now. They agreed to support her and to honor her wishes. That “they’ did not include the 30 year old angry grandson who came bursting through the doors of the ER at just that moment…
“Where is my grandmother?!?!” I heard him yelling coming down the hall. “I’m going to kill the man who did this to her!!! That drunk driver is going to pay!!”
Family stopped him outside of her room, trying to calm him. I saw one of the family members motion for me to come over. “Please talk to him and tell him what is going on and what we have decided.”
I tried. I explained her injuries and my concerns. Then I explained her wishes to not receive any forms of artificial life support. This led to his emotional explosion.
“No, Doctor, you put her on life support if she needs it, you hear? That is my granny in there and I am not going to let her die!” he roared, his whole large frame visibly shaking as he stood before me, just inches from my face.
I gulped and tried to calm him, “This is her decision, not yours or mine, to make, Sir.”
He pushed past us and into the room. I followed on his heels.
“Granny”, he burst into tears, “I love you so much. I’m so sorry this happened to you, but you had better not let go, you hear? You are strong, you need to fight this! We take care of each other don’t we? Please don’t give up on me!” He was sobbing loudly and she sat herself up in the bed to comfort him. She sat up very straight and held herself as tall as she could, her stature containing remnants of the woman who had held this sobbing giant as a baby and who had led him by the hand as a child and chided him as a wayward boy. Now, she held him as a grown man, as best she could with her frail and now partially broken frame.
“Granny, you let them put you on a ventilator if they need to! If you die, I promise you I will kill that drunk driver myself. No one is going to hurt my granny and get away with it!” he called out from a place of pain and helplessness.
“It’s okay, Son. Your Granny will be okay,” She said with perfect peace as he shed the tears that only a grandson can.
Later, she refused to be placed on the ventilator even for the broken hand and foot to be fixed surgically. She, more than any of us, could see the forest and was not worried about the trees. She was delivering us the message, while we doctors could not get over the package.
On the second day of her hospital stay, she entered an “unresponsive state”. Any good doctor feels that it is his or her duty to ‘identify the problem’, to figure out the organ dysfunction, to analyze the wrapping of “the package” under a microscope or with a special procedure or test. So, a neurologist was called in to identify the reason for the ‘unresponsive state’. An EEG was done to analyze her brain activity. Mrs. Mitchum had entered a seizure state that kept her unconscious. Feeling compelled to “do something”, the doctor ordered an anti-seizure medication to treat the ‘brain dysfunction”—like almost all doctors would- yet focusing on the trees and not the forest, on the organ and not the person, on the package and not the message found within. This was the last cure-focused treatment she received. Her family honored all of her other wishes.
Four days later, Bonnie Mitchum passed away, peacefully, much on her own terms. No ventilators, no surgery, only after she was unconscious was she given a medication treatment in attempt to ‘fix’ her. Otherwise she was kept comfortable by a loving team of trauma doctors and nurses who were all willing to step outside of their usual roles (fix the organ, fix the problem) and allowed death to arrive, naturally, as desired by Mrs. Mitchum and most of her family—in a package of just a few broken bones.
Reproduced with permission from Monica Williams-Murphy, MD, Her Website is It’s Okay To Die.
(As always, elements of patient stories and names are altered to protect patient and family privacy. Date of blog publication has no relevance to date of patient encounter.)
“Browse through these posts to find a practice suited to your needs.”
Dr. Virginia L. Seno
Founder, Esse Institute LLC
Training for Comfort and Competence in End-of-Life Communication
Access FREE Tips from the Mini-Course Mastering The Listening Self: Personal Growth Through End-of-Life Encounters
On Knowing in Our Hearts
April 7, 2012 By 1 Comment
Everyone suffers when communication fails at the end of life. Though we may “know in our hearts” what to do in difficult situations; anxiety and bias close us down. We lose our ability to say and act on what we know is best.
Physicians and nurses suffer when they “know in their hearts” that they are doing harm performing CPR on people at a natural end of their lives on people whose bodies can do nothing more than suffer and wherein all medical moves lead to more suffering and the patient dies anyway.
Families hurt when asked to make decisions in an unfamiliar setting, when they are paralyzed with anticipatory grief, and left without a roadmap and information that could help them understand their range of choices.
Patients suffer immeasurably when their last days are filled with probes and prods, jabs and shatters beyond anything they ever would have wanted to survive.
Who would choose that? Nurses and doctors want to help, care and comfort. Families want health professionals to help them verbalize what they “know in their hearts” and help them make choices that they can be at peace with. Patients certainly want dignity, care and comfort for the end of their lives; even if they can’t say so or didn’t document it in an advance directive… they want dignity, care and comfort.
At the end of life, most of us want to spend time together with loved ones in our last days and weeks; not in a hospital room, filled with eight other people hanging bags of blood and monitoring machines. We simply want to say what needs saying and do what needs doing before we breathe our last.
But people don’t get what they want. Palliative care conferences and hospice referrals are made way late to provide the benefits that are possible and way fewer people than are eligible and who would benefit by those services get them.
What would it be like if doctors and nurses knew how to guide effective end-of-life conversations that help people get what they want and be at peace? What if these conversations didn’t have to be emotionally draining, inter-personally complex or time consuming? And what if this were possible by going with the awareness of what we “know in our hearts” to guide these conversations? Here’s a true story of a conversation like that:
When I was a hospice director, there was a new admission and other nurses were busy, so I visited the 80-year-old man and his dying wife. The referring hospital and physician called hospice but had not told the husband and wife what to expect. No words on the patient’s prognosis.
The husband met me at the door, wringing his hands and asking, “Is she going to be okay?”
“Well, let’s go see,” I said, still standing on the front porch. He led me to his wife’s bedside at the other end of the neat, warm and cozy living room. She was sleeping deeply and appeared comfortable in a hospital bed set up there earlier that day.
While observing the resting patient, my practiced senses told me that she would live at least another few days or maybe a week if the disease took its normal course. Experience also told me that the husband ‘knew’ that his wife was dying. But no one had helped him to access that knowing yet.
So, after a silent moment or two, I looked at him and said, “You have been married to your wife for a long time. You know her better than anyone. When you look at her now, how do you think she is?”
He immediately dropped his head and said, “It’s not very good.”
I returned, “That’s right.”
Now that he had stated what he knew, he could be at rest and receive information about what to expect and how to handle the upcoming days.
“She’s not going to live as long as we would like, but you have some time yet,” I reassured him.
There we had it. He now knew cognitively what he already knew in his heart. Now he could act on that awareness and take the time he had left to do things he wanted to do and say what he wanted to say before his wife died. Now he could attend to her with keen awareness that these were the last days of their lives together.
Without that, he would have missed opportunities to deal with reality while hoping for a miracle that was never going to appear.
That conversation didn’t take long, and it can happen in an Emergency Room as well as in a home. I knew the patient was dying. He knew his wife was dying. She knew she was dying (patients who are dying know that). Acknowledging that opened up all kinds of possibilities that this man, his wife and their friends and family could get and give what they wanted in those last days.
Here’s another true story. This time I’m not a hospice nurse but a wife, soon to be widowed:
Both Josh, 60 and I, 53 knew that he didn’t have “six months to live”, though that’s what the first doctor told us. And I knew he didn’t have “weeks to live”, though that is what another doctor said. Doctors kept telling us we had more time than we did. We had 17 days from diagnosis to death.
Thanks to my hospice experience and sheer will, I got what we needed to have a good death at home, spending time with our children, sleeping together, time gathering with family and friends.
But I didn’t get what we needed from the best docs in town. I got it myself by calling hospice while a physician who thought I was jumping the gun admonished me for it. Really? I wasn’t riding a white horse. I was just trying to get our needs for information and comfort met.
But when at 2:00 a.m., an ER nurse who happened to also be a former nursing student of mine, caught glimpse of us after we had waited four hours in ER for a room upstairs; she wheeled his bed upstairs while friends and I, carrying cake pans full of medication, followed.
Then that sweet nurse disappeared. And the chaplain she had called for me appeared. He prayed beside me in the hallway while the hospital staff got Josh settled in his room. Then I began weeping from deep within. A grief I will never forget and never know exactly that way again. Writing the story today, five years later, the weeping returns.
The physicians knew he was dying. I saw a young hospitalist crying in the charting office outside Josh’s room just after she had visited him. She knew he was dying. Must have been heartbroken to see him and me, and to know that we had but a few days. But she never talked to us about it.
On what basis do we keep what we know from patients and families? On what basis do we deny families and their dying members the many things that they would do differently and better? On what basis do we sacrifice the living we could do today for the hope that tomorrow we won’t have to face death?
Many things families would do never get done at all because they just don’t understand the time constraints under which they are living – and no one helps them access their awareness of what they already know deep down.
Had we been in the hospice program earlier, had someone acknowledged what we already knew, or had someone asked and listened to us, we would have had more than seven of our last seventeen days at home with hospice.
We got to celebrate our tenth wedding anniversary at home though. Josh was comatose by then but the pastor who performed our ceremony a decade before came over to hear us renew our vows. Mary, our Matron of Honor, brought a rose, which I laid across Josh’s chest. A few friends also attended. I read aloud Josh’s vows to me and mine to him. He died two days later.
Because I’m an experienced hospice nurse, a researcher and a family member, I am profoundly aware that most people already know the truth of the matter when it comes to a natural end of life; and I know that it takes only a short conversation for clinicians and patients and families to get on the same page.
Research tells it to us too. But everybody knows it’s true, we don’t need science or stories to know what we know. We just know it. What we don’t know is how to go about talking about it.
So what does it take to have successful end of life conversations? Conversations guided by what everyone already knows in their hearts, conversations that get more of what everyone wants?
- Begin by reminding yourself that we all know what’s going on. If you think that your time and ideas are worth more than the patient’s, you’re not ready to talk about death and dying.
- Be sure that you have quieted your mind before you approach the people you are attending. Being-with patients and families in these conversations requires a spacious inner silence, which creates spaciousness for them. We breathe the atmosphere, so to speak.
- Know that your patient and family already have an awareness of what’s right for them, but they need your support and quiet presence to access it. Their awareness will arise as a ‘sense’ of knowing. That’s what you want to learn from them.
- Be mindful that what you are doing is asking questions that allow family and patient to access their awareness of what is true for them.
- Open-ended questions work. “What do you think is going on when you see your mom?” Or “What’s most important to you right now?” are good quesitons.
- Don’t worry about what question to ask. The right things to say will arise in your mind if your intention is to only understand what they know in their hearts.
- Once you’ve asked a question. Be quiet and ‘wait’ for their answer. If you have that inner silence already, this will be easy. It may be more than a few seconds for them to come up with the answer.
- They may have questions. Answer truthfully from what you know in your heart.
- When everyone is on the same page, you’ll know it and then action can be taken and people can be at peace.
- Practice all of this in non-threatening situations.
- Make rounds with a colleague who already knows how to do this well.
- Remember, this doesn’t take as long as we may imagine. Even in complicated situations with multiple family members, you can come to an understanding in less than a half an hour.
Sample illustrating a powerful, warp speed encounter:
Daughter to Hospice Nurse: I live in Milwaukee and I’ve been with Dad in New Glarus for a week now. Should I stay or go home?
Hospice Nurse: Well have you asked your Dad about what he thinks about that?
Daughter: No. How do I do that?
Hospice Nurse: When he wakes up from his nap, tell him that you’re thinking about going home and ask him what he thinks about that.
Daughter to Dad: Dad I’m thinking about going home. What do you think about that?
Dad to Daughter: You stay. I’m going…
Take Away Message:
Why would we sacrifice a day in someone’s end-of-life for a presumed better tomorrow? Let’s stop pretending we don’t know what to say and do in end-of-life situations. Let’s begin asking about, and telling what we “know in our hearts”. If we do, everyone will be happier and we probably won’t mind minimizing Medicare payments for unwanted treatments and private medical bills for someone else to pay either!
“Browse through these posts to find a practice suited to your needs.”
Dr. Virginia L. Seno
Founder, Esse Institute LLC
Training for Comfort and Competence in End-of-Life Communication
Access FREE Tips from the Mini-Course Mastering The Listening Self: Personal Growth Through End-of-Life Encounters
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