Sunday, March 20, 2011

The Hospice Front: House of Morphine

"When do we reach land?"  The elderly gentleman in the armchair asked me.  He was wearing plaid flannel pyjamas and blue house slippers.  His metal walker was situated next to him.  We were in the dining room downstairs at Coming Home Hospice, a little yellow house located across the street from Most Holy Redeemer Church in San Francisco's Castro district.  I had just introduced myself to the patient.  He was new here, apparently suffering from dementia, and with his question I realized that he believed we were all passengers on a boat.

So I replied, "Saturday."

"Aren't we supposed to be off the coast of Mexico?"

"Yes.  We're going to dock in Los Angeles in two days."

The conversation continued, and I found myself surfing upon the story lines of his reality.  We were cruising along the Pacific Coast with two other (invisible) couples, and he was supposed to pick up a friend's boat in San Diego.

By definition, a hospice patient has six months or less to live.  This end-of-life diagnosis from a physician is required for admission to such a facility, which delivers 24-hour medical supervision and personal care that loved ones are unable to provide.  Some patients outlive this diagnosis and may reside at hospice for a year or more, but nevertheless the average hospice stay in our fair city is a mere eleven days.  Therefore, whenever I meet someone at Coming Home, I expect that our acquaintance will be brief.

Such conversations like the one with the cruise-ship passenger in the dining room are common.  In my short time at the hospice so far, I've had lengthy conversations with patients who believed that they were living in a 100-unit apartment building with noisy neighbors (quaint Coming Home has a mere fifteen beds), or who were permanently suspended in the 1940s, or who communicate with invisible people and animals in the room.  Some of the patients are young, and many are alert and clear-headed for a while, but for most of them, the combination of dementia, the exhaustion from their illness (mostly cancer), and the effects of medications slips them into their own private dimensions where a visitor can only join for the ride.  

In speaking with the dying, I wish I were as graceful as the hospice nurses and other employees at Coming Home.  But after talking with a handful of patients, they have taught me one thing very quickly:  Accept their reality.

To put it briefly, the last weeks and days of life are not the time to argue with someone.  Thus, if a patient thinks that the room is crawling with black-and-white puppies, then let it be.  If she believes that there is a Mexican fiesta making its way down the corridor, then she's right.  By the same token, if the patient believes that his or her end-stage cancer will be cured against all odds, and is looking forward to "moving back home and going back to work", then I play along.  I never ask them about their illness.  If they want to tell me why they're dying, they will.  And some even insist that they are healthy.  But there is no point in correcting their reality to fit mine.

We also have to assume that someone has already attempted to steer the patients' reality back to the middle lane.  The most obvious response of family and friends to so-called jibberish is "Honey, what are you talking about?  You're going crazy."  And indeed, some patients at Coming Home apologize to me for speaking nonsense or being a little nutty, or perhaps even rave about the "grooviest trip" they've ever been on, and still others have no short-term memory left so they meet me for the first time every week.  In any case, they can't help it.  So the best one can do is explore their worlds with them.

Then comes the day when the fantastical adventures vanish and the talking, clear or hazy, ceases.  I arrive at the hospice and check in with the nurse in the staff room to ask if any particular patient needs attention.  And often the answer is something like, "The patient in 206 is actively dying."  Active dying is the body's natural process of shutting down its systems in predictable stages: refusing food, rapid weight loss, cooling of extremities, periodic agitation, shortening of breaths.  No more talking, nor more eye contact, and ever dwindling consciousness.  Only labored breathing and foggy gazing into the distance.  And no turning back towards life.  So my duty is to sit with that patient in silence because often times he or she has no one else.  We all envision ourselves dying in the company of loved ones, but a hospice is where patients come when if don't have anyone.  Thus, I may be their company on that day.  I go to their room, pull up a chair, place my hand on their hand or arm, and wait.

When the last hours arrive, the nurses coming into the room subtly shift gears, and the morphine flows freely.  Many of the residents are cancer patients whose tumors have grown invasively large, pressing excrutiatingly on organs and nerves.  Pain management is the goal now, and more than ever, this is no time to argue; a dying patient in pain cannot be wrong.  And for non-cancer patients, the discomfort of fluids accumulating in the throat and lungs as organs shut down is likewise relieved by the magic liquid morphine.  The patients are monitered closely for groans, grimaces, and writhing, all non-verbal signs that another oral milliliter is necessary, administered by the nurses who are intimately acquainted with the stages of dying.

When was the most recent whimper?  Is she gripping her fists?  How long are the pauses between breaths?  The hospice staff is watching as they deftly flutter from room to room on their rounds, and sometimes the nurse will sit with the patient for an hour or so.  It is an incredible thing to watch.  As the patient's body knows exactly how nature has programmed it to die, the hospice workers help to bring them in gently for their final adventure.