6.10.2009

That Magic Time of Night

I first noticed it while talking to one of my mentors, a retired psych nurse. When she was the most comfortable, I was not consciously aware of the fact that she's disabled.

I have the privilege of working the 3-11 shift, and I'm lucky enough to be present for their transition into sleep, a critical factor in maintaining health and speeding recovery.

When someone is really comfortable, the fact that the person has an illness or disability just melts away in my mind. When the lights are low, the features of the face soften and you see them the way they might remember themselves. The brave warrior and the epic princess are still the brave warrior and the epic princess... but how many people can see them?

What you do to the infant, you do to the old man. What you do to the old man, you do to the infant.

The life span isn't some sequence of events. It's a life. Sometimes this is hi lighted dramatically when persons with dementia begin to step backwards through all of the developmental stages, more or less in order. At a variable rate. Until they're infants again, back to basic trust vs. mistrust, requiring what we like to call "total care".

This particular disease process is illustrative in that some particularly tricky areas to enforce arise which I'll call "dignity".

Say someone has mentally regressed back to their toddler stage of development. They may still recall war stories and be able to tell jokes and stuff but if you start contradicting them and yelling at them, you can expect some people to act more childish. This is well understood in pediatric nursing, where they have to deal with kids dropping a developmental level or two because of the psychological adaptation to hospitalization.

There's a hard and fast rule in pediatric nursing that I picked up in school, one that I haven't always seen enforced. Basically, "don't do invasive procedures while the kid's in the bed, take them to the treatment room and do the procedure so it doesn't screw up their association with their bed and sleep/rest".

This seems obvious, but the connection between all of this I think is that this is an area of improvement for adults in skilled nursing facilities. If we should strive to preserve the sacred space of the bed for children in health care facilities, why not for adults? Especially adults with cognitive decline?

No matter what bed it is, there's a chance it's the last bed you'll ever lay in. This is more obvious at some times than others.

Customer Service is an inadequate term for what I'm describing, despite it's popularity in the corporate world.

The only thing required is to be here. Now. The 8-year old ballerina is still there, see? The daring captain of industry is still at sea, see?

When people's caregivers start TREATING them like children, however, you head down a slippery slope that tends to end in behavior tracking and routine antipsychotics. When you treat people kindly and be there for them and listen to them, they'll still have their good days and bad days, but they'll present less problems for you in the course of provisioning them with care. Always. When the work of their care increases, it doesn't even seem like work.

It's your dear friend. The princess. The emperor. The fool. The hanged man. Any other series of archetypes you want to throw at it. This is what all of those symbols were tasked with describing. Some people do this, some people do that. They all get taken care of, because they're all here to be taken care of.

Whatever difficulties or concerns or hallucinations that arise are perfectly acceptable and to be expected. If a caregiver reacts to one of these difficult times with hostility, a tragic and avoidable spiral of behaviors increase our workload by 10.

Care requires a negative amount of effort. It actually makes the work at hand easier, because you're actually interested in what's going on. I first applied this oft-written about trick while I was in nursing school, and really found my instructors fascinating and wise people for 20 or so hours a week, even if I didn't like them at first. I learned more from them when I really listened to them. No notetaking, just paying attention. I eventually became fond of all of them, of course.

It's impossible to learn something from someone without becoming fond of them, I've almost always said.

A sleep doctor once told me that the bed should only be used for sleep and sex to prevent associations that interfere with sleep.

Still, once in a while, it's nice to have a conversation while lying in bed.

6.06.2009

The Long Goodbye

A person I've become very close to is about to pass. I was surprised he didn't pass in front of me...I secretly wished he had passed on my time instead of with someone who didn't appreciate him the way I thought I did.

Everyone says their goodbyes in different ways. Sometimes they'll say their goodbyes before they go on vacation, or they'll say them with a song sung at their bedside. They might say goodbye literally, or they might not. They might say goodbye with a deep, passionate kiss of lips or morphine. Sometimes with a touch or swab-on-a-stick full of ginger ale.

I never feel obligated to perform a goodbye ritual. As I see my friend dying in front of me, the care I give is the care I gave him every day. No goodbye is necessary. Every act was the goodbye. Every encouraging word conceals a cognitive assessment. Every touch relays volumes of information about the body.

Touch is so important but so overlooked and suppressed in our culture (and, curiously, in middle-eastern cultures...both are comortable a foot-and-a-half away from eachother, while most of the earth's population is comfortable six inches away from the person they're talking to), so I take every opportunity to make those simple connections that the "professional" world overlooks..something a cherished colleague referred to as "comprehensive care", which I prefer to refer to as "holistic care"(.


I got the compliment regarding delivering comprehensive or holistic or whatever care because I dropped some music he liked in his room with one of my devices. While I was a nursing student I always imagined some nonprofit service that would provide any music electronically for free to the dying. Now I've done it.

A concept related to this in some arcane way in my mind is the concept I ran across in a journal article I read while working on a resolution for the NSNA (a beautiful and talented colleague of mine did the actual research). I don't remember the name of the article or where you can find it, but it was about a synergistic model of nursing education (maybe that was the title).

From this article I extracted an axiom of sorts. Don't treat anybody else around you worse than you'd treat a patient. Even more than that, use the same approach to teach a patient as you would to teach junior faculty. The nursing process is basically the scientific method personalized a bit, and you can apply it to anything, just as you can apply the scientific method to anything. "Assessment, Diagnosis, Planning, Implementation, Evaluation" might as well be "Characterize, Hypothesize, Deduce and Experiment". The major difference is that in the provision of routine care, you don't experiment. You implement the evidence-based practice that has been proven to optimize outcomes (if you have the resources). Nursing Research, of course, is a rich field of exciting developments in evidenced-based practice, but the in-the-trenches reality of the workplace often necessitates a certain amount of compromise.

Some measures are easy to implement, however, those "holistic" or "comprehensive" nursing measures. The most obvious way to enact these holistic or comprehensive provisions of care is to make the process pervasive in all interpersonal communication. Why would you treat a patient worse than a dear friend?

The largest obstacle or biggest challenge I see reflected in my compatriots is not being fully present. Everyone in every role requires us to be HERE AND NOW and not somewhere or sometime else. Routines make this difficult. A sense of reverence makes this easy.

At first it's difficult to meditate because it hurts. Later it's hard to meditate because you fall asleep. See?

I don't say goodbye because it's all a goodbye. To you, to them...is this me saying goodbye? I hope not. I'll always hold out hope for some amazing advancement in science that allows my consciousness to exist anywhere, indefinitely. Secretly I'm afraid it'll happen while I'm on my deathbed, and I'll be left behind, forgotten.

It's ok, you did it right. Don't worry. Here, have some of this. We'll miss you. Maybe we'll see you soon.