My brush with death

Nathan Zwintscher ‘03
Nathan Adelson Hospice

Death. The word alone has become taboo in today’s American society. It is often thought to be inappropriate to ever talk about death. No one ever dies. The word is always euphemized such that a person only passes away, passes on, expires, departs, or leaves us. Perhaps that is part of the reason why death is so difficult to deal with. We are unable to talk with one another about it.

Death and the issues surrounding end-stage healthcare became a big part of my life over the summer. This is because Nathan Adelson cares for the terminally ill and their families. In order to be placed on the hospice program the patient must be given a terminal diagnosis with a prognosis of less than six months to live. Hospice medicine is entirely palliative, not curative. That is to say that everything in modern medicine is done to make the patient comfortable. No efforts are made to hasten death, and conversely no efforts are made to prolong life. Now on a cursory glance it might appear that my summer must have been extremely depressing. I must have been surrounded by an aura of death…nothing could be further from the truth. The mission of the hospice is to provide compassionate care and comfort and this is exactly what they do. The compassion expressed by the nursing staff is quite remarkable and it is clear that nearly everyone that comes through the hospice is extremely grateful to the staff for their kind demeanor and excellent care. The patients, however, are not the only ones treated at the hospice. A large part of hospice work is dealing with the families. Often times treatments, therapies, and even extra attention is given to the patient for the benefit of the family. The care of the family continues after their loved one has died. Services and support groups and counselors are offered for a full year after the death. This year is ended with a memorial service, given each month for all those who had family members die that month, one-year prior.

The care at Nathan Adelson is really quite remarkable. Most people find it absolutely amazing that someone is able to do this type of work. I most definitely enjoyed my work and have an understanding of hospice medicine, yet I even find it amazing that the staff is able to work full time at such a place. It can be quite taxing on the emotions, especially if any connections are made with the patients. Yet it was still an honor to be able to work at a place that has the motto: “we can’t add days to your life, but we can add life to you days.”

So, first I’ll talk about my first week, the first week on the floor, then a typical day, and finally I’ll move on to some more specific experiences.

I walked through the front doors of Nathan Adelson Hospice not knowing quite what to expect, what my experience might be like, or even what the building and environment surrounding by dying people might look like. The hospice is really quite a great place. It does not have the feel of a hospital at all, but more that of a home. Five patient quads surrounded an inner courtyard. The courtyard itself was a place of serenity and peace. It was a place families could get away for a little while without actually getting away. Each quad has a distinctive, yet homey feel. Couches, TVs, sinks, ovens, refrigerators, and dishwashers are in every quad. A little reminder of home, and indeed that is what the hospice was meant to be. The staff knew this place as the Inpatient Unit or IPU. The IPU, where I spent 95% of my time, was meant to deal with immediate crises that patients were dealing with. Common reasons for a patient to be moved to IPU were pain management, nausea/vomiting, respiratory distress, or family/caregiver breakdown. Once the crisis had been taken care of and all the presenting symptoms were under control, patients were allowed to return home. During my time at the hospice one woman was in IPU three different times for three different reasons. Anyway, back to my first day…I was unsure as to the amount of supervision I might be receiving, but to my surprise I was handed a schedule for the entire week on that first day. Somehow there had been some misunderstanding between the person reading my résumé and the person typing the schedule, because I was handed a schedule for a one-week internship for a one Dr. Switchner (or something like that). So, I first had to clear up what had been clearly stated in my cover letter that I would be staying for ten weeks and that I was not yet a doctor, albeit an aspiring one. Following this minor problem the first week was spent in orientation to hospice and palliative care. I listened to speakers, saw movies, and shadowed physicians and nurses on their house calls and nursing home visits. It was both enlightening and made way for an easier transition to working on the floor of the IPU. The first week on the floor was an interesting one. I worked with one of the Certified Nursing Assistants (CNAs). So I guess my title was something like a nursing assistant assistant. I helped bathing patients, ordering food, feeding patients, repositioning patients, answering call lights, notifying nurses when patients were in pain, helping patients get up to the bathroom, listening to patients tell stories, sitting with patients who were alone, talking to families, assisting nurses in procedures such as dressing changes, and anything else a patient or family member might want. In several instances I worked in a one-on-one capacity to watch patients with fall precautions or those who were at risk for pulling apart diapers or colostomies. I even helped clean and prepare a few bodies before the mortuaries picked them up. I suppose my job description might have been: do whatever is in your power to make both the patient and family members comfortable and feel somewhat at home…and ultimately doing whatever is possible to aid in the grieving process that is sure to follow. And as I stated previously, nearly every single person that must come into contact with hospice is extremely grateful of the excellent care their loved one received and the outstanding staff that provided the care. In the end, however, no amount of palliative care can extend a person’s life indefinitely. Death is indeed inevitable and while I was working the floor that first week six people died…during my eight-hour shifts. Three died on Thursday and another three passed on Friday. Quite a welcoming to the world of hospice I thought.

I know for certain that some people find hospice care depressing. I suppose for some it is indeed quite difficult to care for people you know are ultimately going to die…but aren’t we all going to die at some point, it’s just some of us sooner than others. Personally, I find that nursing homes are depressing. The care in some nursing homes is not fit for an animal. All people are deserving of dignified health care, including the terminally ill. It is in attempting to offer the best care that I met some interesting patients and made some friends with the staff.

One of the first patients that I had the pleasure of taking care of was 74-year-old Mrs. B. She was both pleasant and sometimes amusing despite suffering from squamous cell cancer of the mandible. Most of the time she was quite confused. She would often say loudly, “Oh dear Lord, oh dear Lord.” She had funny hand gestures that went along with it as well. What I will remember the most about Mrs. B is how grateful she was. Often she would say, “You people are so wonderful.” Once when she was particularly confused I sat with her in order to help her calm down. She grabbed my hand and said, “thank you…we made it.” What we made it through is not exactly clear…perhaps it was just a rough hour or so for her, or perhaps she felt as though death was near, but regardless we had a connection, and it is a moment that I will never forget.

Another patient that I became close to was with us in the IPU for at least a month, which is considerably longer than most people. His name was Mr. R. He was in IPU for a number of reasons, one being breakdown of care. Anyhow, he had a cancer growing on the side of his face, and it continued to spread while he was with us. Unfortunately, had he been willing to have it treated when it first started, it could have been surgically removed with a few small cuts. It supposedly began about the size of a pea. Mr. R refused treatment and thus ended up on hospice. The first day I met him I sat in his room and just listened to him tell stories of his life for a total of at least two hours. He was a very intelligent man and quite well spoken. He told fascinating tales of inventions he had created, creations that had patents pending, and even how at one point he was day-trading on Wall Street with sums totaling more than one-million dollars. All his stories could have very well been true, could have been lies, or could have been events he thought were true. It does not really matter. The fact is that he chose to talk to me and I was honored. I believe that I may have helped him a great deal over the course of his stay simply by listening, paying attention, and being interested in what he had to say. It is indeed a part of the end-stage process to review one’s life. I’m glad he chose me to share moments of his life. Besides telling fanciful tales he was one to have rather eccentric requests. He once asked me to photocopy a form that was in triplicate. I was specifically asked to make copies of each page; I was not allowed to make three copies of the first page even though the second and third pages were exact copies of the first. He had numbered the pages just to make sure I did the job correctly. There was a period when he wanted to have oatmeal for every single meal. Dinner might consist of oatmeal and peas. I would not consider this to be the most appetizing, but as I said before, it was my job to whatever possible to make the patients comfortable.

The next experience that I am about to describe does not really have anything to do with what any single patient did for me during her stay. Indeed it was post-mortem. A relative of Mrs. D found me a week or so after Mrs. D’s death. She sought me out just to thank me for the care that I had given to Mrs. D. She then showed me a picture of Mrs. D prior to her being placed on hospice. Indeed, she was a beautiful woman once…she only vaguely resembled the woman I had been caring for. She then gave me a two-pound box of chocolate to share with the other nurses. I was greatly touched by the gift and it only makes me want to continue in my work to become a physician.

There were even more experiences that touched my life. A few occurrences were actually quite amusing, hilarious even. Mr. S was hallucinating and told me of vivid visions that included an Indian flirting with Captain Kidd and Peter Pan and then kissing them both. Green creatures were hanging from an awning outside his window. And there was a group of people on the other side of a fence talking. Not a one of these visions existed, nor were there any real objects that could be misconstrued into these visions. One cannot, however, tell him they these visions did not exist. They did indeed exist in his mind. One can only try to talk about the visions or change the subject altogether. Mr. S also decided that I, a volunteer, should be in charge of everything. He later told me that he regretted putting me in charge of everything because I was taking charge of everything.

Mrs. P must have had some eye problems because at first she thought I was a girl. When the other CNA told her that I was a man, she said while in shock, “a man?” She then proceeded to say that all handsome young men look alike. I was quite flattered. Later she asked me if I had a banjo so that she could do a jig. I nearly cracked up laughing. Humor can be an important part of medicine. I do not think it was at all irreverent to be laughing in that particular situation, even considering that all our patients were near the ends of their lives. They were near the ends of their lives; they were not dead yet.

Another patient, Mrs. S, even saw fit to give me a present. Granted, it was only a bottle of Treasure Island conditioner, but it was all she had in her room. It was a generous offer. She was grateful of my work. I was happy to receive the gift and know that she felt she was being well cared for.

One final touching moment came after my internship was over. I received a certificate in the mail from the Las Vegas Chamber of Commerce. It was a Customer Service Excellence Award. The reason I received it was that a family member had submitted a form detailing one moment of “exceptional care.”

The exact quote is as follows:
Nathan (Medical Student)
“I caught you caring!” Kindness and caring of my Father, Mr. D. He and Dave took special care of my Dad the night before he died.

I do not remember doing anything that was particularly special in my mind; however, that is not the point. The family felt that I took special care. I would hope that special care was given to all my patients. I do not remember a special incident, but the family does; that is what is important, and that is what makes all the work worthwhile. Someone noticed my work and I was extremely moved and honored.

It was not all happy times at work though. After eight weeks of working at the hospice I had come to be close with several members of the staff. One woman, a CNA, came to be my buddy…I worked with her three days out of every week. I even went to her birthday party. I was the only male among a group of ten women, each one old enough to be my mother or grandmother. She became a good friend. Two weeks before I was about to leave she had a massive stroke and died while in the hospital. This was the most difficult death I had to deal with all summer. Here I would like to attach copy two things from her memorial service at work.

Psalm 23
The lord is my shepherd,
I shall lack nothing.
He makes me lie down in green pastures,
He leads me
Beside quiet waters,
He restores my soul.
He guides me in paths of righteousness
For his name’s sake.
Even though I walk
Through the valley
Of the shadow of death,
I will fear no evil,
For you are with me;
Your rod and your staff,
They comfort me.
Imagine by Michael Podesta
Imagine stepping onto a shore and finding it heaven
Imagine taking hold of a hand and finding it God’s hand
Imagine breathing new air and finding it celestial air
Imagine feeling invigorated and finding it immortality
Imagine passing from storm and tempest to an unknown calm
Imagine waking and finding it home

Each deals with death, yet each deals with it differently. I feel that both were helpful at the time. Sure they are just words, but words can do a lot of good. I’m going to miss her, but at least I was able to work with her for eight weeks. I’m better for having known her. She was a great friend.

I’ll say it again; nearly every person that came through the hospice was grateful of the care given. However, there was a rare exception or two. A typical exception would involve a family member feeling that their loved one was not receiving adequate attention because a symptom such as difficulty breathing would be noticed. This is not really something to become frantic over. But patients and families alike are under a great deal of stress. The fact remains that death is near. Furthermore, it can also be true that families attempt to find someone to blame for the situation to attempt to displace their own guilt for not properly caring for their mother or father. Now they will not have that chance. Moreover, the family may be having difficulty letting go, which is indeed the most difficult part of the entire grieving process. Once the family and patient are able to accept and come to terms with the terminal diagnosis it is less likely for any staff member to be forced to face any hostilities.

And now I’m back at Dartmouth College amongst youth, virility, athleticism, and people with dreams for the future. It is great to be back at school, but I feel that it was even better to be given a chance to care for those nearing the end of their lives. I believe it is a discipline of medicine so rarely experienced, especially by people of my age. Students at school like to tell others of their goals, dreams, and aspirations for the future. Patients at the hospice enjoyed telling what they had accomplished in life and in the past. After all, reviewing one’s life is part of the acceptance process. I feel quite fortunate that I was able to lend an ear to my patients and to aid in the end of life.

Prior to this internship, when asked what type of medicine I intended to pursue I would have said orthopedic surgery. However, after working so closely with my patients I feel that I may need more that just surgery. I need to be more of a primary care physician in which I will be able to have close, long-term relationships. This internship has only deepened my love for medicine and the art of caring for the sick. Medicine is my calling. I am extremely grateful for the opportunity I enjoyed to serve my community in hospice medicine, and I only hope another student will enjoy it in the future.