Depression is a common problem encountered among patients on the palliative care service. Also there is a lot of concern about dignity and preserving it. It has been suggested that when working with debilitated people and looking toward the end-of-life, that a screening question could be asked about what brings a person pleasure; a common part of dignity preserving therapy is life review. It is surprising how often fishing comes up when you talk to older men. I have taken to asking people how long it has been since they have been fishing.
Today was the day of the end of the world for one of my patient’s. Mr. N was old, sick for many years and his wife only recently deceased. After more than a month in hospitals and nursing homes we (the experts in medicine) decided that the Aortic Stenosis is too severe to repair, the coronary arteries are too badly narrowed and that there are no “targets”. Palliative Care is called to see him because he is short of breath and every time they have given him furosemide his renal function has worsened. Only we are brave enough to bring him to our unit and give him furosemide even if his creatinine goes up; he is much less short of breath.
There are so many things we do out of habit. Things that maybe we just don’t need to do anymore. Does anyone need a “landline” when they have a mobile phone? And don’t get me started on pennies! They are so pointless, and they cost more to produce than they are worth. While the number of landlines is falling, the Penny lobby remains strong and we will have them around for the foreseeable future.
The following message was written by Dr. Mark Earnest, MD, PhD, division head of the Division of General Internal Medicine, to the Internal Medicine faculty. It is a beautifully written message that resonates with all of us.
I had a prospective palliative NP shadowing our team to see what our workload looked like. While sitting in my office in the ICU, we heard a woman cry out and continue in distress. The Neuro-intensivist had just declared her 45-year-old husband with brain death. Like many times before the physician came to my office and asked for my assistance in helping this wife with her grief and knowing there were 2 children ages 11 and 14, he himself had tears in his eyes and looked overwhelmed which was unusual for this physician. I quickly listened to the details and said yes I would help. After he left, the NP looked at me and said “We are not grief counselors and that is an inappropriate consult.” While her response took me back, she went off with the palliative SW and I continued to move forward in assisting this family.
Aug 24, 2021
by Melissa C Palmer, LCSW, ACHP-SW, APHSW-C, JD
If you asked me who was the most influential people in my life, I would tell you about my grandmother. Rita was a force of nature when she worked as the head nurse in a nearby hospital and everywhere else in her world. Gram would always say, “I was a nurse when we touched people”. She bucked the system frequently in order to advocate for patients, and she rarely took no for an answer. Not surprisingly, many of our intelligent and strong healer/cunning women ancestors were tried and killed for witchcraft for speaking out and helping others. I am sure she burned a fair number of bridges along the way in the name of justice and equality.
A Latina mother sits holding her 6-month-old son in the pediatric intensive care unit (PICU), visibly upset, tears rolling down her face as she kisses his forehead and states in a strong firm voice “All I ask of you is to respect my decision. I will never decide to remove life for my son, I couldn’t live with myself! Please do NOT ask me again what I wish to choose.”
“John” was a 60-year-old man with cirrhosis who presented to the hospital with an incarcerated umbilical hernia, with an elevated lactate and an elevated white count. He was awake and alert, and he wanted his hernia repaired. It was an emergency, and he was very ill, so he was consented and taken to the operating room that night. Because of his cirrhosis and concern for sepsis, the decision was made before surgery that he would go to the SICU postoperatively.
On a recent camping trip to multiple southern Utah national parks, I awoke in the middle of the night to the most glorious, glimmering, star filled sky I have ever witnessed in my life. I had gone to bed with dark and cloud filled heavens hovering above, assuming I would not see anything overnight. As if by magic, at 1am, the clouds had moved out, and the stars were so innumerable it seemed like the stars had stars and the Milky Way twinkled as I had only seen in pictures. I quickly jumped into a startled frenzy grabbing my camera and waking my husband to attempt to take photographs of the majesty and reflect in awe.
Jul 20, 2021
by Tristen Dinkel, BSN, RN, CPN, CNRN
39 weeks of a pregnancy in which we were riding the rollercoaster of will she or won’t she... survive. Is she big enough? Did she grow enough lung tissue? Is there too much fluid? The rollercoaster ride took its final drop when I got the call just days before delivery that they have a genetic diagnosis, and we need to come in the office. My husband was at work. As we had been told of all the possibilities from the 20-week mark, I thought was strong enough to hear whatever they could tell me that day on my own. .So I picked up my rug and trekked into my doctor's office.
I have roots in the Deep South of our country. We are known for our cuisine, hospitality, poverty, racism, pride, arrogance, and ignorance, and… our accents. There is also a great and continuing fount of Southern Literature with many writers I could recommend to you, such as William Faulkner, Maya Angelou, Reynolds Price, and many more.
Jun 29, 2021
by Melissa C Palmer, LCSW, ACHP-SW, APHSW-C, JD
Let’s admit it. This past year has been a bear. Between the COVID pandemic, forest fires burning across the West, and political nonsense causing polarization, we are lucky if we have survived relatively unscathed. Healthcare workers are the wounded warriors who keep pushing through and persevering. During 2020, healthcare and other organizations have been battered by the frequent changes made to accommodate the safety and welfare of our patients while making difficult choices about financial resources that impact workers’ daily lives.
Whenever I hear the term “Time-Limited Trial”, I think for a moment about a Time Limited Offer and the pressure this term suggests making a purchase while supplies last. It always feels a little bit like a shady salesperson pitch.
Discussion about “aid in dying” (AID) has re-emerged recently with Diane Rehm’s book and documentary on PBS (“When my Time Comes”), and the Katie Engelhart book “Inevitable”. And, just in time, this week an acquaintance called me to ask about a friend who wants “Death with Dignity.” The phrase makes me wince (just as much as “physician assisted suicide”, I think). I liked the more profound discussion of the role of Aid in Dying by Dr. Lonny Shavelson in a recent “lunch conversation” as part of the Completed Life Initiative series. (https://vimeo.com/534607128) Shavelson is Chair of the Board of Directors of the American Clinicians Academy on Medical Aid in Dying. In his presentation, he challenges the false dichotomy between a miserable or a merciful death too often implied by proponents of AID, and their “usurping” of the term “dignity”. As he points out, “dignity” language linked to AID is deceptive and wrong, even if it may be useful to galvanize the public to adopt state laws that allow physicians to write prescriptions for terminally ill patients. There are many paths to dignity as we die, many ways to maintain self-respect, and to move into our death in ways which accept and gracefully face our ending. None are perfect and none is clearly “better.”
I have found the discussions within my community to elicit rich conversations about what matters to people as they approach the end of their lives. Likewise, the ethics consults I am part of are complex and thoughtful. Two contrasting dilemmas are seen pretty regularly. There is the distraught family in the waiting room with little insight into what mom, critical in the ICU, would want as she struggles on a ventilator, near the end of life. There is also the family who holds in their hands documents written 5 years before which say their father would want “everything” done to prolong his life. Sometimes it feels like “I don’t know” versus the “I know too much.”
I slowly sipped my coffee as I sat down at the desk and logged in to the computer. It was a Sunday morning and I was on my last day in a long stretch of shifts. It was the middle of winter and the census was heavy, full of patients with respiratory infections, congestive heart failure, the usual. I’ll admit I was planning to round quickly and get home. My family was arriving in town later that day and I still needed to clean the house and buy groceries. I opened the chart of a 33-year-old man admitted overnight and was immediately struck by his diagnosis: acute respiratory failure, history of metastatic lung cancer. And only 33 years old. As I read on, I learned that he was diagnosed 2 months ago when he had a cough that just wouldn’t resolve. At the time of his diagnosis, it had already spread to innumerable additional sites. His prognosis was extremely grim, but he was still doing everything he could to “fight” it – chemotherapy, radiation, a feeding tube.
May 25, 2021
by Melissa C Palmer, LCSW, ACHP-SW, APHSW-C, JD
I wanted to share a powerful commencement ceremony speech by my dear friend, Dimple Dhabalia. Dimple reminds me of how I want to strive to live my life every day. Although she is not working in healthcare, her message of choosing to “live above the line” inspires me to be a role model for acceptance and kindness in the world.
Recently I visited a patient who was recovering from major surgery. She was terrified. Apparently, all night she had thought someone was trying to kill her. She was concerned that the staff might poison her and was reluctant to take her medicine.