Textbook death 13.1.2013


I am cautiously optimistic that we have managed to stop the bleeding ulcer and that the new medicine regime has the vomiting under control.  Vic is still running a fever, her BP is dropping and her heart rate has stabilized in the 110’s.  She appears to be more stable than she has been in a couple of weeks.IMG_8501

This morning, after I washed her and changed her pyjamas she said “Mommy, I would like to go to the supermarket today…”

“Cool, what do you want to buy?”  I asked

“Tippex (correction liquid) for the boys and Stilpain and Syndol (Tablets)” she said.

“Okay….” I said

“But I think you will have to drive Mommy… I don’t think I should be driving!” Vic said

This incredible young woman just does not know how to die!  Vic had a good breakfast this morning.  Vic has not eaten since Christmas!

The boys are fleeing home.  Jon-Daniel has spent the past day and a half at Esther and Leon’s.  Jared went to his Dad’s.  I wish I too could flee.  For the first time in my life I have come to understand why families place their dying loved ones in hospital of in a Hospice In-Patient unit.  The waiting is gruelling and heart wrenching.  The rollercoaster of dying is horrific!

I previously researched the “length of dying”.

The Journey Begins: One to Three Months Prior to Death

As one begins to accept their mortality and realizes that death is approaching, they may begin to withdraw from their surroundings. They are beginning the process of separating from the world and those in it. They may decline visits from friends, neighbors, and even family members. When they do accept visitors, they may be difficult to interact with and care for. They are beginning to contemplate their life and revisit old memories. They may be evaluating how they lived their life and sorting through any regrets. They may also undertake the five tasks of dying.

#1: Ask For Forgiveness

           #2: Offer ForgivenessTask

           #3: Offer Heartfelt ThanksTask

           #4: Offer Sentiments of Love

           #5: Say Goodbye

The dying person may experience reduced appetite and weight loss as the body begins to slow down. The body doesn’t need the energy from food that it once did. The dying person may be sleeping more now and not engaging in activities they once enjoyed. They no longer need the nourishment from food they once did. The body does a wonderful thing during this time as altered body chemistry produces a mild sense of euphoria. They are neither hungry nor thirsty and are not suffering in any way by not eating. It is an expected part of the journey they have begun.

One to Two Weeks Prior to Death

Mental Changes

This is the time during the journey that one begins to sleep most of the time. Disorientation is common and altered senses of perception can be expected. One may experience delusions, such as fearing hidden enemies or feeling invincible.

The dying person may also experience hallucinations, sometimes seeing or speaking to people that aren’t there. Often times these are people that have already died. Some may see this as the veil being lifted between this life and the next. The person may pick at their sheets and clothing in a state of agitation. Movements and actions may seem aimless and make no sense to others. They are moving further away from life on this earth.

Physical Changes

The body is having a more difficult time maintaining itself. There are signs that the body may show during this time:

  • The body temperature lowers by a degree or more.
  • The blood pressure lowers.
  • The pulse becomes irregular and may slow down or speed up.
  • There is increased perspiration.
  • Skin color changes as circulation becomes diminished. This is often more noticeable in the lips and nail beds as they become pale and bluish.
  • Breathing changes occur, often becoming more rapid and labored. Congestion may also occur causing a rattling sound and cough.
  • Speaking decreases and eventually stops altogether.

Journey’s End: A Couple of Days to Hours Prior to Death

The person is moving closer towards death. There may be a surge of energy as they get nearer. They may want to get out of bed and talk to loved ones, or ask for food after days of no appetite. This surge of energy may be quite a bit less noticeable but is usually used as a dying person’s final physical expression before moving on.

The surge of energy is usually short, and the previous signs become more pronounced as death approaches. Breathing becomes more irregular and often slower. “Cheyne-Stokes”breathing, rapid breathes followed by periods of no breathing at all, may occur. Congestion in the airway can increase causing loud, rattled breathing.

Hands and feet may become blotchy and purplish (mottled). This mottling may slowly work its way up the arms and legs. Lips and nail beds are bluish or purple. The person usually becomes unresponsive and may have their eyes open or semi-open but not seeing their surroundings. It is widely believed that hearing is the last sense to go so it is recommended that loved ones sit with and talk to the dying during this time.

Eventually, breathing will cease altogether and the heart stops. Death has occurred. http://dying.about.com/od/thedyingprocess/a/process.htm

Vic has experienced severe delirium or rather terminal restlessness, which is apparently a fairly common symptom in many dying patients.

Some characteristics of delirium include:

  • Impaired level of consciousness with a reduced awareness of the surrounding environment
  • Impaired short-term memory and attention span
  • Disorientation to time and place
  • Delusions and/or hallucinations (believing and/or seeing things that are not real)
  • Uncharacteristic speech – may be really loud or soft, very rapid or slow
  • Fluctuating mood swings
  • Sleep disturbances – insomnia or reversed sleep cycle
  • Abnormal activity – body movements may be increase or decreased, very fast or slow

 

Terminal Restlessness

Terminal restlessness is a particularly distressing form of delirium that may occur in dying patients. It is characterized by anguish (spiritual, emotional, or physical),

restlessness, anxiety, agitation, and cognitive failure.

Terminal restlessness is so distressing because it has a direct negative impact on the dying process. We all want death to be a comfortable and peaceful experience, but if a patient is dying with terminal restlessness, her death can be anything but comfortable and peaceful. http://dying.about.com/od/symptommanagement/a/delirium.htm

Vic is on massive dosages of medication.  She is peaceful now.

On Monday, the 14th, Jon-Daniel will receive his school colours for academic achievements.  Vicky is determined to attend the ceremony.  We will find a way of getting her to the school to witness this achievement.  I believe it is the last goal she has.

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Vic and her pride and joy, Jon-Daniel 4.1.2013

So despite me saying that Vic does not know how to die she is actually having a textbook death…

“Promise me Mommy…..” 13.1.2013


ImageIt has been a long day.  Vic is in a drug induced sleep.  She looks so peaceful.  Vic is not anesthetized – she wakes when she is thirsty or in pain.  She has only urinated once in 24 hours.  Her end is near.

Vic is looking angelically beautiful.  Her skin is blemish free and almost transparent.  Her hair seems to have taken on a life of its own.  Her little hands look skeleton like.  Her body is wasting away and yet she remains as beautiful as ever!

I will not sleep tonight.  Many years ago I promised Vic that she would not die alone or in a hospital.  The time is near and I must honour this promise.

Earlier tonight she woke up and I wasn’t in her room.  She had a panic attack… Danie found her trying to walk down the passage.  She was holding onto the wall and tears were running down her cheeks.  “Mommy, I am scared…”

Something has started bleeding again.  Vic vomited and there are signs of old and new blood again.  “Look Mommy, my mouth is bleeding…” she said.

Vic is deadly pale and her body has involuntary “jerking” movements.   She is decidedly unstable.

“Mommy, you have to get me to the awards evening.  I don’t care how.  Promise me Mommy!!!”  She sobbed tonight.  Tomorrow I will speak to the school and make the arrangements.  It is not a wheelchair friendly school and Vic could never sit through a two-hour ceremony.  We will find a way.

We had a strangely “normal” day today.  Jared brought his gaming computer down from the study into my TV lounge.  It is something I don’t encourage because there are wires and cords all over and I HATE the untidiness of it.  Today I welcomed it.  We needed to be close to one another.  I swam twice and we ate spaghetti bolognaise.

The boys have fear in their eyes.  I have fear in my heart.

“Being prepared to die is one of the greatest secrets of living.” George Lincoln Rockwell


It is strange the number of Stepping Stone Hospice referrals we have received over the past two weeks.  The patients have controlled pain and symptoms.  Many caregivers are also looking for a dumping ground.

Pain at the end of life is inescapably interwoven with, and often amplified by, multiple levels of emotional and spiritual angst as the inevitability of death looms. Fear, a potent pain magnifier, is the dominant emotion – fear of pain, fear of death, fear of the unknown…..

It is a fact that people at the end of life fear pain even more than they fear death. Sadly, for many dying patients, pain seems like the ultimate torment, and death is its cure. It does not have to be this way, and if you or a loved one is facing death, you have every right to ask that your final days not be consumed by pain.

It is estimated that a maximum of 5% of people who die from terminal illnesses in South Africa have access to adequate palliative care. Even in hospitals, treatment is far from ideal, because doctors and nurses have seldom had training in palliative care and have little idea of what to do with the patients.

Dying patients are often prey to a host of anxieties about the state of their affairs, about the fate of those who will grieve their loss, and about how their behaviour will be seen, and possibly judged, during their final hours. And of course, there are often deep spiritual and religious questions to address. Did my life have meaning? Will my soul survive my body? Am I at peace with myself, my family, and my friends?

Not least of all these concerns, people at the end of life worry about how their pain will be managed. Will they be under medicated and have to ask, or even beg for relief? Will they be over-medicated and lose consciousness during their precious waning days and hours?

They may even be afraid to complain. If they do, will they be seen as whiners or quitters? If they ask for narcotics, will they be judged by their doctors as drug seeking, drug addicts or even cowardly? Or will their medical care be relegated to comfort measures only, while all efforts to cure their illness are suspended?

I read the post of an amazing woman who is suffering from congenital heart failure.  She is in so much pain.  I cried when I read her post.  http://thedrsays.org/2012/11/08/  She replied to a question whether better pain control was possible…..  “there is nothing that will let me participate in life and have relief. so at this point i am going for being lucid over some so-so pain relief. who knows how long before i cave. when the time comes i plan to take advantage of whatever is available to me. just my personal choice right now.”

I thank God that we are able to make a difference!

“Being prepared to die is one of the greatest secrets of living.” George Lincoln Rockwell

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Stepping Stone Hospice


This week I truly realised that the Stepping Stone Hospice patients are “our” people. Our friends. They are not strangers. They are people we know from church, they are our neighbours, our friends; friends of friends… Our Hospice cares for our own. We are not “removed” from the community.

We however continually grieve.

Stepping Stone Hospice is just so different. We are not a group of detached, paid staff doing a job. This is a Hospice driven by the tears of its members. It understands the fear in the hearts of its dying and its survivors. We see our loved ones

We have lost our fear of death. We have not become immune to the tears of our community and friends. We truly live and experience “Ubuntu” every day.

A little old lady has shuffled into our offices with R150.00 ($15.00). She told us that when the interest rate went up she would be in a position to increase her monthly contribution to our “worthy cause”. How amazing would it be if everyone in our community contributed $15.00 a month?

I love spending time in our building. I feel close to Vic.

Our Hospice journey is a healing journey. We have been helped over the stepping stones…now it is our turn to take the hand of another and help them over the stepping stones. What an amazing privilege. All built upon our own tears and the deaths of our loved ones.

Together We Walk the Stepping Stones
by Barb Williams

Come, take my hand, the road is long.
We must travel by stepping stones.
No, you’re not alone. I’ve been there.
Don’t fear the darkness. I’ll be with you.

We must take one step at a time.
But remember, we may have to stop awhile.
It’s a long way to the other side
And there are many obstacles.

We have many stones to cross.
Some are bigger than others.
Shock, denial, and anger to start.
Then comes guilt, despair, and loneliness.

It’s a hard road to travel, but it must be done.
It’s the only way to reach the other side.

Come, slip your hand in mind.
What? Oh, yes, it’s strong.
I’ve held so many hands like yours.
Yes, mine was once small and weak like yours.

Once, you see, I had to take someone’s hand
In order to take the first step.
Oops! You’ve stumbled. Go ahead and cry.
Don’t be ashamed. I understand.

Let’s wait here awhile so that you can get your breath.
When you’re stronger, we’ll go on, one step at a time.
There’s no need to hurry.

Say, it’s nice to hear you laugh.
Yes, I agree, the memories you shared are good.
Look, we’re halfway there now.

I can see the other side.
It looks so warm and sunny.
On, have you noticed? We’re nearing the last stone
And you’re standing alone.
And look, your hand, you’ve let go of mine.
We’ve reached the other side.

But wait, look back, someone is standing there.
They are alone and want to cross the stepping stones.
I’d better go. They need my help.
What? Are you sure?
Why, yes, go ahead. I’ll wait.

You know the way.
You’ve been there.
Yes, I agree. It’s your turn, my friend . . .
To help someone else cross the stepping stones.

 

The shadow of grief


Grief becomes a shadow. It finds you and follows you. At times the shadow is small and then at times it is big.

Your shadow is a constant companion. It keeps up with your pace… It will run with you but it will also crawl with you. When you stop it will stop.

It follows you into the valleys of despair and will climb mountains of triumph with you. Grief is a constant companion.

When you are in the deepest valley your shadow is there. When at the heights of the highest mountain it is still there.

A shadow is a dangerous thing. If offers a wonderful hiding place. A place to lose one self. At times the shadow invites me in and I get lost in my shadow of grief. In the shadow I am invisible and no one can see my pain, my sense of loss, my loneliness. My shadow is a safe haven where I get to become one with my grief.

The boys are a light that draws me out from my shadow. Hospice and my faith is a light that draws me out from my shadow.

The grief of losing a child is not only on high days and holidays. Grief follows you on bad days, good days, every day… It gets into bed with you and awakens with you.

It even permeates your dreams.

Today it is 8 months since Vic died. Not a single day has passed that I have not been acutely aware of the shadow of grief that accompanies me on my journey. Has it become a journey of recovery? No, I doubt it. I think it is too soon. I do have better days…Then I have days where I walk into a supermarket and see Vic’s brand of deodorant or shampoo. I will put out my hand to touch a @$*# tin of deodorant and tears will well up in my eyes.

For heaven’s sake! A stupid tin of deodorant now has the ability to reduce me to tears!

Today I stood outside the Hospice building. It is nearing completion. I experienced a profound sense of achievement. Pride and satisfaction welled up in my heart but disappeared into that massive, gaping hole left by Vic’s death.

“This is because my child died” it rushed through my brain….

Of course someone would have started a Hospice. That I don’t doubt for one second. Maybe the rest of the team would have been involved. Maybe the financial backing would have been better – who knows? The fact remains that the reason I got involved is because my child died and I promised her that her death would not be futile.

Hospice – friend or foe?


Hospice – friend or foe?

A blogger friend, Terry, is preparing for her beloved brother Al, to move home from an Assisted Living Facility. Al suffers from Parkinson’s disease and his general health condition is extremely precarious. Terry blogged: “I finally heard nothing from the phone. I had done everything I could find to do trying not to have to make the dreaded call to Hospice. I decided not to use the Hospice here in our county. I was very disappointed in them with the lack of care they gave to my father.” http://terry1954.wordpress.com/2013/06/17/al-and-hospice-meet/

Vic wrote this on her Face Book page on the 15th of May 2011… “Today Hospice came to access my Grandfather… They dripped him & made him comfortable. He has lost his swallowing reflex, sleeps most of the day, is completely bedridden & can barely talk… The suddenness of his deterioration is very difficult to comprehend. Could you all say a big prayer for my Gramps and especially my Mom, who lost her best friend of 25 yrs., age 51 to a heart attack last Tuesday. My Mother is one of the strongest, bravest people I know… How do we say goodbye, how do I take my Boys to say their Goodbyes tomorrow, how do we accept that this incredible man has such little time left regardless of the fact that we all know that its best for him. How can I be strong for my babies when my heart breaks all over again, every day when I see him…? Especially my Eunice Friends will all remember how desperately my Gramps and Gran loved and spoilt me and how VERY MUCH they meant to me… I don’t want to live without him even though I realise that that is extremely selfish, but I love my Grandfather so desperately, it’s not fair… All I ask for is compassion… Compassion for Gramps and my Mother… Thank you to everyone for all your love & support through everything… Love Vic…”

I am a great believer in the services that Hospices offer – worldwide. Hospice cared for my Dad in the last week of his life and for Vic the last 5.5 months of her life. My experience was positive.

The hospice movement was started in the 1950’s in London by Dame Cicely Saunders, and the first hospice facility opened in London in 1967. Seven years later the United States opened their first hospice facility in 1974. In America the hospice movement has blossomed and hospice now serves 44.6% of patient deaths. Unfortunately, the median length of service for hospice patients is only 19.1 days, which means many patients did not receive the benefit of hospice care until the end of a difficult illness. In my country only 5% of the dying actually have access to Hospice services.

The original idea of hospice is that once curative treatments are no longer effective, a patient enrols in hospice to receive comfort care. In our culture of “fighting” death illness that should be addressed through ongoing decisions about the risk and benefit of interventions gets turned into a battle that should be won or lost. No one wants to be a loser, so the patient is reluctant to quit curative care until there is absolutely no hope. Many physicians are geared the same way, and their desire to give hope and “beat” disease results in a reluctance to call in hospice even when they know the situation is bleak.

Hospice care is for a terminally ill person who’s expected to have six months or less to live. This doesn’t mean that hospice care will be provided only for six months, however. Hospice care can be provided as long as the person’s doctor and hospice care team certify that the condition remains life-limiting.

The benefits of hospice and palliative care

Research published in the Journal of Pain and Symptom Management found that terminally-ill patients who received hospice care lived on average 29 days longer than those who did not opt for hospice near the end of life.

Source: National Hospice and Palliative Care Organization

Hospice care providers offer specialized knowledge and support at the end of life just as obstetricians and midwives lend support and expertise at the start of life. Hospice can reduce anxiety in both the terminally ill patient and his or her family by helping them make the most of the time remaining and achieve some level of acceptance.

When terminally ill patients, who are often already in a weakened physical and mental state, make the decision to receive hospice and palliative care instead of continued curative treatment, they avoid the dangers of over-treatment. In-home care from a hospice team often means the patient receives greater monitoring than he or she would in a hospital. In addition to focusing on the physical health and comfort of a patient, hospice care also focuses on the emotional needs and spiritual well-being of the terminally ill and their loved ones.

The above is all well documented facts. Yet, when a family is faced with that terrible decision to call in Hospice, it is a deeply emotional decision. The phone call is a terrifying telephone call. This is evident from Vic and Terry’s posts…..

It made me realise what a massive challenge lies ahead of us in Stepping Stone Hospice.  We need to educate the community.  We need to dispel the fear of and for Hospice.

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