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Inevitably, healthcare workers will be faced with the imminent death of a patient. Author and palliative nurse Sallie Tisdale* helps carers navigate this emotional journey.

One of the roles a good nurse fills is that of witness. When we care for people who are dying, part of our nursing will be to look. We look, and we explain: 鈥淵es, this is normal. This is what happens. This is how we die. This is what it looks like.鈥� But we can do this only if we allow ourselves to see.

It鈥檚 not that easy to see death clearly. We are filled with contradictions 鈥� never entirely believing in our own deaths, struggling to accept the deaths of others. We push and pull patients in various ways.

Most people know when they are dying. They don鈥檛 need to be protected from the knowledge. But people who are dying will try out ways to respond to what is happening to听them.

Denial

A person may say things that sound ridiculously optimistic. 鈥淚鈥檒l be playing tennis by Christmas.鈥� She may just want to feel better for a time. Families can cultivate denial, and to do so is common in many cultures. We shouldn鈥檛 insist on taking it away. Part of good nursing care is allowing people to find their way in their own time. This includes coming to terms with the truth of their own death.

Everyone involved may join in the denial. As the writer Cory Taylor said in her memoir of dying from melanoma, 鈥淚n hospitals we don鈥檛 talk about death; we talk about treatment.鈥� Research shows that doctors generally overestimated survival of cancer patients, and that health professionals are overly optimistic about medical treatment in general. We鈥檙e all afraid to die, and it shows in our care sometimes.

Doctors and nurses have all kinds of human reasons to avoid the truth. It鈥檚 hard to lose a patient you鈥檝e come to like; it鈥檚 hard to fail at a cure.

I work in a palliative care program. Most of our clients die after a slow decline, telegraphed for weeks or months. In the last few weeks of life, the nurse often visits every day; she or he teaches the caregivers and the family what to expect, what symptoms mean, how to use medications, how to do everything possible to keep a person comfortable and how to know when death is imminent. And yet that same nurse may be unable to chart that a patient has died. He has passed away, or expired. Sometimes the nurse cannot bring herself to write the bare, undeniable word.

Selfishness

The hardest part of a death is the simple loss of a person. But a close second is the need to shove your own fears and desires to the side. Sherwin Nuland noted that at such time 鈥渆verybody becomes enormously selfish鈥�, and he emphatically includes doctors and nurses along with family.

We may not even recognise that selfishness is driving our choices. We work within an inevitable conflict of interests 鈥� you are dying and I want you to live. Doctors may not know they are doing this; when they offer yet another experimental drug, they may genuinely believe they know what鈥檚 best for the patient. But best: best is subjective. Best is your point of view. Best is what you want, and it may not be best for the dying person.

The nurse is acting on behalf of the person in the bed. What that person wants is what counts. It may be quite different from what you would choose for yourself in the same position. You want the person to live. You want the person to die your version of a good death, or to live another week or try another course of treatment. But it鈥檚 not about what you want.

Above all, if you are talking with a person who is dying, be aware of what you want and what you think the dying person should do and should feel, and keep it to yourself.

Instead, explain how you will give support, no matter what happens. Explain that, whatever the shape of her last moments, the dying person will be allowed to make what choices are possible. (These choices may be few, and they may be based on plans made months or years before.) The person is always spoken to at the bedside, not about. Symptoms are treated, but only in the way the dying person wants. The person in bed leads the way. No-one 鈥� family, nurse or doctor 鈥� imposes their beliefs.

Despair

A person may say something that sounds completely hopeless: 鈥淭here鈥檚 no point. It鈥檚 no good. This won鈥檛 work.鈥� He may be trying out this possibility, seeing how it feels. It鈥檚 not very helpful to say, 鈥淵ou鈥檙e going to be fine!鈥� when you know better.

Towards the end of life, many aspects of medical and nursing care become futile. Other treatments may simply be unnecessary or intrusive 鈥� drawing blood for lab work, certain medications (are you really worried about the cholesterol level at this point?), even checking blood pressure, can be stopped. But sometimes we describe this as 鈥渨ithdrawing鈥� treatment, or 鈥渄oing nothing more鈥�.

One of the worst sentences a patient can hear is 鈥淭here鈥檚 nothing more to be done.鈥� Not only does this undermine a person鈥檚 fragile composure, it鈥檚 not true. There is so much to be done. At the end of life, we will be busy offering emotional and physical support, managing symptoms, protecting privacy and providing the many small actions for family and patients that allow for a comfortable death.

Acceptance

Experience helps; there鈥檚 no way around it. If you want to be more comfortable with death itself, with your death and the death of others, spend time near it. Sit with the dying, and pay attention.

Acceptance is found only by wholly inhabiting our own denial of death. Contemplating death is really contemplating resistance, for a long time. How do we get ready to die? We start with not being ready. We start with the fact that we are afraid. A long, lonesome examination of our fear. We start by admitting that we are all future corpses pretending we don鈥檛 know.

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*Sallie Tisdale is an听experienced palliative care nurse and the author of nine books, most recently 鈥�.

Top image credit: 漏stock.adobe.com/au/Photographee.eu. | Author and book images:听漏Allen & Unwin