Something to Think About.
For the last 30 years all of my patients have died. I will be sharing observations and ideas that I have gathered from working with people in their final months of life.
You may not agree with what I am saying. I don’t pretend that what I have figured out about living and dying is true or is absolutely how everyone dies. This blog is just an expression of my experiences and ideas.
Dear Barbara, Will you talk about a chemical straight jacket at end of life? My mother is a dementia patient in a memory unit. Hospice now. They are giving increased Ativan & morphine to "keep her comfortable". We are in very last
days now. I don't want her to suffer, but somehow this seems wrong.
I have not heard the words “chemical straight jacket” before but I see the implication---controlling patient movements with drugs rather than physical restraints. Nursing facility regulations are very strict now about physically restraining agitated patients. Medication regulations aren't as strict if you can justify the reason.
I do not think there is a need for narcotics just because death is approaching. Dying is not painful. Disease causes pain. Dementia does not cause pain unless the person is actively hurting themselves or there is another physical condition that causes pain.
Part of the natural dying process is restlessness. There is a picking of the clothes and bed linen. There is an agitation of just not being settled, tossing, and turning. If that restlessness is not causing harm or putting the patient at physical risk then I do not feel medications are necessary. If the restlessness puts the patient in harms way (falling out of bed, injuring themselves) then Ativan or some relaxant seems appropriate.
Increased use of narcotics and relaxants as end of life approaches has become quite common in the end of life area---much to my concern. Why is this happening? One: end of life has become more medicalized, more intertwined with the medical system. We seem to have forgotten that dying is not a medical event. It is a social, communal event. (Another whole blog article) Two: I think there is a lack of understanding of the dying process. What is natural versus what is pathological (even among medical professionals). With this lack of understanding is the deep desire to keep a person comfortable. To help them approach death in as comfortable a way as possible. Not ending life but providing comfort until death comes. I think this is admirable but based in lack of knowledge. Our end of life professionals need to know this.
When working with end of life what we need to remember is to treat pain when present with as much medication as necessary to keep a person comfortable. And we continue giving that medication until the person’s last breath.
When a person is in the labor of dying and pain is not a part of the disease process, we do not need to begin a pain management protocol just because the person is dying.
I have a new resource that would be perfect for this situation. It's called HOW DO I KNOW YOU? Dementia at the End of Life. It is specifically written to help families understand their loved one's process in the final months before death. NEW RULES for End of Life Care is my DVD kit that has a whole section on narcotics at end of life. So helpful for families during the final challenging weeks.
Dear Barbara, I would like to know why the breathing pattern is different at
end of life. My Mother had fast and labored respirations. She did have
COPD, but my Dad had the same breathing pattern and he did not die from
COPD. This was very disturbing to me. Are they suffering when breathing
The irregular, difficult breathing that occurs at end of life frightens most
people. As we watch we feel something bad is happening. Our loved one is
hurting, struggling, suffering, and of course this is disturbing to us.
In the hours to minutes, sometimes even days, before death, a person’s
breathing changes. First it becomes fast, often with congestion, and then
gradually the breaths becomes slower and slower. As breathing slows (ten
times, or even six times, a minute) the person actually breaths like a fish,
with their mouth opening and closing. This can be frightening if you don’t
know that it’s normal.
The congestion that occurs before death will depend upon how hydrated or
dehydrated a person is. The more fluids in their body, the more congestion.
Sometimes changing their position (laying them on their side) will help to
redistribute the fluid, and the breathing will sound quieter. Suctioning the
fluid generally does not eliminate it. The bottom line is that congestion and
difficult breathing are a part of the normal dying process.
Is the person suffering? I think not, although it appears that they are. By the
time they are hours from death their awareness of what is going on around
them and of their body has diminished. What I envision is the little chick
working hard to get out of its shell. In the hours before death from disease
our body is shutting down. It is laboring to release itself from this planet. It
is a struggle, just as the chick is struggling, but I don’t think either the
person or the chick are suffering.
Something more about Laboring to Leave:
Difficult breathing during the natural dying process is only one of the many changes that we will witness when a person is dying. It's comforting to know what to expect during that process. Gone From My Sight (The Little Blue Book) is a "road map" of what will occur during the dying process. The Eleventh Hour is the companion book and is more specific about the changes in the last days, hours, minutes, seconds and just after death. These two books, along with your nursing staff, will provide knowledge so that you can better support the one who is laboring to leave.
Dear Barbara, There seem to be family caregivers who feel that everything falls on them when they have other family members, siblings, etc that could help. Burnout of the main caregiver happens and then everyone is frustrated that the caregiver isn't continuing to do more. Sometimes the caregiver gets short and verbally abusive after being the main caregiver and other family members are mad about it...
Sounds to me like you need a break. Within the family structure we have worker bees, players, watchers, talkers, all kinds of roles that get developed somewhere along the family path. We then perform the roles that are expected of us.
That is the dynamic that I think is happening here. As a worker bee myself I know it is very hard to ask for help. “I‘ll do it” is me. I may be tired, even irritable, but will keep going. I keep doing a task I have taken on (and I tend to take on lots of tasks) because that is who I am, or that is who I think I am, the role I play in the family.
Sometimes when we think that others think we are not doing enough, it may actually be us thinking that the others are not doing enough. When the worker bee caregiver is not getting enough help from other family members, often it is because others have not been asked to help. It can be hard for us to ask for help. We may want help but just don’t know how to ask for it---so we don’t ask and then feel put upon and over whelmed. It becomes a difficult situation of our own making. We don’t seem to know how to set limits for ourselves. The thing is if we don’t start asking for what we want and need, if we don’t stop doing more than we comfortably can, we will reach a point where we CAN’T continue.
Irritability can easily come with feeling overwhelmed, over worked and unappreciated. What can we do about all this? Ask for what we need. Show our vulnerability, practice saying no and setting limits for ourselves with others and with tasks. Have a family meeting and ask for the help needed. Try not to to point fingers but just honestly and directly tell those who can help that you are feeling alone in this heavy responsibly of caregiving, that you need their support and assistance. As a family, make schedules of who can do what during this meeting.
All of the above sounds so organized and reasonable BUT we are dealing with personalities, families and all of our dysfunction (We are all dysfunctional, it is the name of this life game we play). Asking for what you want may not bring you anything. What then? You can aways just walk away, leaving a mess, but it will force others to do something. (Really hard for us worker bees to do).
Something more about Which Knd of Caregiver You Are...
I suggest that nurses, caregivers and family members read A Final Act of Living, and particularly focus on the self care portion.
I am printing this letter and my reply at this holiday season because I believe this man is not alone in his feelings of hate, anger, and regret. Maybe by hearing his story others will find understanding. I don’t talk about my personal experiences, not the place of a professional caregiver. However, sometimes sharing your story helps create a bond of understanding and possible healing.
This email may get a little long, please forgive me. Through the years I have never found anyone I could talk to, one that could truly understand but you!
I have written to you before, the latest being when I told you what it was like to watch my wife being forced to carry to term our anencephalic daughter.
This article "Stuck in Grief" also hits home because it was 38 years ago on December 22, 1978, that she was born & died.
On that day, as I sat outside the delivery room, I cried, I prayed to both God & Satan they could have me, my soul, my being, any and everything of me either wanted if my daughter could just be normal healthy & whole. Obviously bargaining didn't work. So where was God & where was Satan. As you cannot have one without the other. How could a just loving God allow this to happen to a child. So much for there being a just loving God.
At that moment I started hating God, Satan, preachers, religious leaders, politicians, everyone & Christmas. And 38 years later I still hate the holidays, I hate Christmas most of all! I find absolutely no joy at all in any of the things to do with the holidays. As people bounce around with all their joyous b.s, they have no idea of the hurt & anger & heartbreak that is within me. And when you try to share they either don't want to hear or don't care because it doesn't affect them.
I asked my wife's doctor to allow me to view my daughter, which he did, but I could only stand & stare. He offered her hand to me but I couldn't take it (a decision which has haunted me ever since). I held my most prized bird dog as he was being euthanatized so he would know he was loved & not alone for his final breath & yet I could not even hold my dead daughter's hand.
It was certainly not a very bright or fun Christmas time. And my own birthday was coming up just 7 days after my daughter died.
Every year I always say nothing good ever happens at Christmas & nothing ever does.
I don't remember ever sitting down with my wife, holding each other & actually crying. We allowed the hospital to use whatever was viable for donation or research after they performed an autopsy (at my request) so there was no funeral, that decision still haunts me too! I know I made the best decision I could at a really bad time but it doesn't make it any easier. So I guess the crying and venting you see at funerals as a way of relief I deprived myself of.
My wife did say that our daughter did come to her in a dream & tell her "she was fine & happy &...." How do you question someone's dream, it's her story who am I to call her a liar. But nothing like that has ever happened to me. So needless to say people who claim to have had things like that or that God performs miracles just make me want to scream at them that they're full of b.s.
People have said things happen for a reason, 38 years later I still have never seen or been given any enlightenment as to why things happened. And to be honest it really ticks me off when people say it too.
I understand what it's like to be stuck & not able to get past something & have no idea of how to do it. Those who say just lay it down have never been through it. If they had maybe they could have a glimpse of that person's feelings.
People have told me "hating " is a waste of time & only destroys you. The people you hate don't know it, & they could care less if you do hate them, because it doesn't affect their lives.
I know all this to be true, but I just cannot stop those feelings of hate.
As I finish this long email I look at the clock & I know in a few hours it will be the 38th anniversary of my daughter birth & death. The hate, anger, and sorrow is still there and it's there every year & won't go away.
I'll end this now with an apology & a thank you. Apologies because it is so long & thank you because you took the time to read it & most of all because you understand.
I am glad you feel comfortable enough to reach out to me during this life challenge that becomes more intense at holiday time. Here is my two cents worth:
I don't know that there was a reason your daughter died at birth and I don’t believe that everything happens for a specific reason. I do believe there was a life lesson in everything that happens to us. For you, your wife, and your other daughter there was a lesson. The lesson was how to go on living when a dream is shattered, when life did not go the way you planned or wanted. That is the lesson. In looking back on your life it looks like you handled your lesson with hate (your words), guilt, and regrets.
It is not too late to examine the lesson, to rethink your reaction to it and to put all those tormented thoughts and feelings to rest. I am not expecting you to change but am saying you have the opportunity, if you want to take it, to reevaluate the lesson life gave you.
You may be thinking how can Barbara say these things to me, she hasn't experienced the loss that I have. She doesn't know what it feels like. BUT I do. I too had a baby girl, actually twin girls, die. They died in my belly a month before I gave birth to them. I knew for a month they were dead in my body. I did not see or hold them when they were delivered, no funeral. I delivered them, spent the night in the hospital and went home empty. I was just given a card with "Baby girl A and Baby girl B" written on it. I know your pain of anger, feeling cheated, wanting to blame someone other than myself.
What I have written to you is what I came to believe in order to move on with a healthy life.
In the Blog article "Stuck in Grief" I suggest writing a letter to the person that died and saying from your heart what you need to say that you didn't say before. I recommend that you write your baby girl a letter. Pour your heart out to her and offer to her your wanting to let go of all the negative feelings you have been carrying all these years. Tell her, from the bottom of your heart, how you want to be free of this heavy weight you have carried all these years.
You might also start a yearly ritual of blessing your daughter. On the day of her birth and death light a special candle and let it burn through out the day. Talk to her, tell her you miss the opportunity her life would have given you both. Then at the end of the day blow out the candle, put her to rest, until next year. Give it a try. I think you have carried this long enough.
Something more about When a Dream is Shattered...
We often feel quite alone with our "dark" feelings. We need community. Others who can listen, offer ideas and support. That is why I have a FaceBook Group, End of Life Care and Bereavement ~ a place where we share. I hope you will join us.
Barbara, My mother is in final stages (or is she?). Has not had food or drop of water in 16 days. She is in a coma state and receives morphine several times a day. Her only illness is dementia. I guess my question is how much longer can she survive?
Friend, I don't have an email address to write you back, so I am putting my response on the Blog in hopes that you will read it. Your question is so time sensitive this is the only way I could think to respond quickly.
Many factors will affect the time in which your mother dies. Her body size is the key factor, the heavier she is the longer it will take. Also I am wondering if the morphine is being given with IV fluids. If so then she is being hydrated and that can extend her life as well as contribute to increased congestion. If she has no other disease process I wonder why she is receiving any morphine at all. Dying is not painful, disease causes pain and dementia is generally not physically painful.
If she has had no water of any kind for 16 days I would expect her to die at anytime--maybe before I write this.
I do not have enough information to be specific as to the unfolding of your mother’s dying process. I do know that dementia is not a disease in itself. It is a symptom of many different diseases. If there is no disease process other than dementia then her body is shutting down because of the lack of food and water. I know that sounds harsh but if she is in a coma (I am wondering what caused the coma?) then by not intervening with artificial feeding and hydrating you are allowing death to arrive in its natural, normal way.
Remember there is a huge difference between just breathing and actually living. I alway ask “Would you like to be attached to machines and just breathing with no other cognitive functioning?” Most of us would not. It is not wrong or a “sin” to refuse medical intervention when quality of living will not be an expected outcome.
In these last days with your mother talk to her as though she can hear and understand you. Tell her what she has meant to you. Tell her of your love. Use this special time to say goodbye.
Something more about "16 Days Without Food or Water"...
The use of narcotics with end-of-life pacients is confusing. I clear up much of that confusion on my DVD, NEW RULES for End of Life Care.
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