Spirituality and Death

Recently, I cared for a 90 year old woman who was transferred to me from another facility because she had suffered a massive head bleed. For those of you who know a little about neuro, "massive head bleed" is not good, especially when you are 90. When the patient arrived she was unresponsive. Over the years I have learned to instantly recognize when a person is near death. It is a very distinct look and most nurses who work in the ICU are very familiar with it. Taking care of dying patients has become an increasingly large part of an ICU nurse's work and many of us spend 36 hours a week watching people and their families struggle with this inevitable event . This woman was obviously near the end of her life and it was imminent that I had a discussion with the patient's husband about end of life. We explained to him that nothing we do will change the outcome of his wife's prognosis; despite this conversation, her husband still wanted us to do everything. As I was talking with him a phrase he spoke of stuck in my mind and actually confused me just a little bit. He stated that "his wife's fate was in God's hands." We immediately had to put a breathing tube in this woman's lungs, 3 hours later her heart stopped and we ended up doing CPR on her two different times. For those of you who have not witnessed CPR it is very violent and we ended up breaking many of her ribs in the process. This woman eventually passed away.
I struggled more than usual with this particular case because in my eyes the decision to let this woman pass away peacefully and pain free seemed so obvious; I feel like a head bleed at the age of 90 and your heart stopping is a significant sign that death is your fate at this moment; why would her husband allow us to do these things to her? If he was truly a religious man then why would he not let her meet her full union with God? To me there is an obvious disconnect between the healthcare world and the spiritual world and I needed clarification.
Because I consider myself more of a spiritual person than a religious person, I enlisted the help of my friend and hospital chaplain Stephanie Wright. Stephanie's job is to help patient's and their families who are struggling with spiritual and end of life issues (she is also a pseudo-therapist for nurses too). After talking with Stephanie and doing a little research myself, I have determined that people and their religious communities have not caught up with constantly changing medical technologies. The general population does not understand what it means to be intubated (be on a breathing machine), what artificial nutrition entails, what happens when you have a stroke or heart attack. Most people don't even know what a heart attack or stroke is. How can we entrust them to make good educated decisions about themselves and the future of their family members if they don't fully understand what's going on? Many people turn to their faith to guide them when they don't know what to do but nowadays most religious communities don't even know what to do. It's like the blind leading the blind.
Not too long ago death was something that was experienced in the home. People would gather around the dying individual praying, singing, performing sacraments and rituals, welcoming death as this person's full union with God. Death was not foreign and was considered just a part of life. Nowadays, people spend their last days in the hospital laying in an insanely uncomfortable bed, being poked multiple times a day for lab draws and IV's, attached to monitors, eating really unhealthy hospital food, probably on some form of life support, and surrounded by doctors and nurses who I guarantee are not singing or praying. What I find more interesting is that studies show 7/10 Americans say they would prefer to die at home but only 25% of people actually do; 70% of people die in the hospital and the remaining 5% , I guess, die outside. Here is the website with the facts and figures http://www.pbs.org/wgbh/pages/frontline/facing-death/facts-and-figures/.
There is a huge disconnect between what patients say they want for themselves at the end of their life and what actually happens to them when they get there. I think there are various reasons for this mass confusion in the decision making process (later blog topics) but today I am only going to focus on spirituality. How do we help people and religious communities clarify and start addressing end of life decisions?

• If you are a religious individual I think it is especially important to understand how your particular denomination addresses end of life issues. Stephanie has informed me that in her practice as a chaplain she has noticed that many religious leaders and pastors are not comfortable talking about death and dying with their patrons. If this is the case in your spiritual community maybe it would be a good time to bring up the topic and start the conversation. Stephanie has begun end of life discussions in many of her local churches and finds that there is a great need for education.
• Educate yourself and ask questions. What does it mean to be on life support? What is artificial nutrition? Do I want CPR and a breathing tube if my heart stops? What are the risks of certain procedures and are the risks worth it? What are my options? Ask your religious leaders how they feel about life support and death and dying. If you are uncomfortable with their answer then seek out other spiritual practices that might have a more definitive answer that suits you. The link mentioned above is a great source of information in the area of end of life. 
• If you are in the hospital, ask the nurse to speak with the hospital chaplain. Hospital chaplains are trained specifically for patients struggling with spiritual and end of life concerns. They are excellent listeners and play a significant role in the holistic approach to patient care. 
• Nurses, fill in the religion box in the admission history and ask the patients if they want a hospital chaplain to visit them. Recognize when your patients or families are struggling with end of life issues. Are they worried about dying? Have they been diagnosed with a terminal illness? Are they not getting better? If you have a palliative care team in your facility utilize them. 
• The most important step of all is to determine what "quality of life" means to you. How do you want to spend your last days? This is especially important for people who don't follow some form of organized religion or spiritual practice. When you feel like you know what you want, write it down in the form of a living will.

Pope Paul VI said "science without conscience can only lead to man's ruin. Our era needs such wisdom more than bygone ages if the discoveries made by man are to be further humanized. For the future of the world stands in peril unless wiser people are forthcoming." It is time for us to be the wiser people and educate ourselves and our communities in the area of medical technology and end of life. We must use our hearts, minds and moral principles when making such decisions in order to prevent technology and not spirituality from determining our fate. 

The Potential Threat of Diabetes

You know what scares me more than a crazy North Korean man with nuclear weapons?...  Diabetes. Yeah that's right, the extreme poor health of our citizens scares me more than having missiles fired at my house. This may sound absurd to some, but for those of us who work in the trenches of healthcare this my friends is a reality. As a nurse you start to worry about things that most other people wouldn't pay attention to; like washing your hands before and after you go to the bathroom, just to be safe. I was at the beach the other day just relaxing when I noticed a group of school children getting off a bus. For a moment I had trouble determining who were the children and who were the teachers because virtually every one of them was obese. I eventually discovered that the children were all wearing the same color shirt... Smart on the teachers part (I'm sure I am not the only one who has noticed this phenomenon). I was extremely bothered by this but didn't quite realize why.  I didn't think too much more about it until I went to work the next day and met one of the nicest young ladies I have ever met. This young lady came in to the ER complaining of shortness of breath, fatigue and that she was peeing a lot (which are all hallmark signs of diabetes). Now, because she is only 21, no one, including her doctors even considered diabetes as a potential diagnosis. Not only was she diabetic, but she was also suffering from DKA (diabetic ketoacidosis) which is a potentially life threatening complication of diabetes. DKA occurs when there is not enough insulin to transport sugar into the cells; if the sugar doesn't make it into the cells than the body assumes that there is no sugar present and begins to breakdown fat as an alternative fuel. This may sound awesome for those trying to lose weight but I promise you this is not the way to go. The breakdown of fat causes a build up of acids in the body, causing a whirlwind of life threatening problems. DKA usually occurs in patients who have type 1 diabetes but it can also occur in type 2 diabetics in some instances. This patient was officially diagnosed with type 2 diabetes and a urinary tract infection, which is what most likely caused her to be in DKA.
This patient was very aware of what diabetes was because her father had it but was unaware of how serious the disease really is. I truly believe that most people do not understand the seriousness of diabetes and all the potential health complications associated with it; such as losing their eyesight and limbs, increased risk for infection and slower healing, increased risk for heart attack and stroke, chronic pain from nerve damage, vascular disease, kidney disease leading to dialysis and even death. A survey completed in 2006 indicated that a substantial number of people with prediabetes were unaware that they even had it. Prediabetes means that you are already starting to have higher than normal blood sugars but aren't officially diabtetic. How are we suppose to prevent people from going into full blown type 2 diabetes if they don't even know that they are going down that road? How do we recognize the risk factors for diabetes and prediabetes before it's too late?

Risk Factors We Can Control

• Obesity - BMI and Waist circumference are commonly used screening tools to identify weight problems and associated health risks. BMI calculators and charts are available online. A "normal" BMI is considered 18.5 and 24.9. Waist circumference can be done at home. Place a tape measure around the bare abdomen just above the hip bone. Excess waist circumference is considered 40 inches for men and 35 inches for nonpregnant women. If you have a BMI greater than 24.9 and you have excess waist circumference you are very likely to develop diabetes and cardiac disease. If you are concerned that your child is overweight please seek the help of someone who can help you improve your nutritional habits. Fast, processed and sugary foods are the main reason for childhood obesity.
• Sedentary Lifestyle - I think most people know in the back of their minds whether or not they are exercising enough. There are different types of exercise and finding the one that fits your lifestyle is going to be the most beneficial. A lot of people go "all or nothing" and become easily discouraged when starting. Instead, try easing into an activity such as walking. 
• Low HDL cholesterol and high tryglyceride levels - To improve your HDL score you have to exercise. Some studies show eating Omega 3 fatty acids also helps. To decrease your trigylceride levels avoid sugary foods such as soda and pastries as well as trans fats, which are identified as hydrogenated oils on a food label and are also found in fried foods. 
• Polycystic Ovarian syndrome - Many physicians believe that this cannot be prevented but I have heard of and know a few woman who have reversed this disease with proper nutrition so I am going to count this one as one we can control.

Risk Factors Out of our Control

• Age older than 45 years
• Family History of diabetes (parent, brother or sister)
• Belonging to certain racial and ethnic groups, including African Americans, Hispanic/Latino, Asian Americans, Pacific Islanders, American Indians, Alaska Natives
• History of gestational diabetes
• Women who have delivered a baby weighing 9 pounds or more
• History of cardiovascular disease
• Receiving antipsychotic therapy for schizophrenia or bipolar disorder

It wasn't until after I left work that day that I realized the significance of those school children at the beach and my patient. Seeing those kids was like seeing the life of the healthcare system flashing before my very eyes. Not only is there a large amount of baby boomers getting older but now there is even larger amount of young people getting sicker. Most of those obese schoolchildren are or will suffer from diabetes at some time in their life. The annual economic burden of diabetes in the U.S. exceeds $200 billion and spending is expected to triple in the next 25 years. If we don't do something about this sometime soon this country will not only be broke, we will also be unproductive, unemployed, not motivated, and unhappy; in other words North Korea has nothing on diabetes. 

The first step to prevention is recognizing what puts us at risk and becoming mindful of our bodies and our lifestyle. We often know in the back of our minds and our bodies will often tell us exactly what we need to be doing to stay healthy. You cannot wait for government to provide you with healthcare to make yourself healthier. Many of these changes only require education and motivation. There are many healthcare professionals and health coaches, including myself, out there for those of you who need guidance in the areas of nutrition and lifestyle changes. Find someone to inspire and support you in this process. Now is the time to improve your health. 

I will be hosting monthly online webcasts starting next month on how to improve your health. I'm looking for suggestions on topics for my webcasts. Feel free to comment on this blog with any suggestions.

Savor the Flavor: Why you should Enjoy your Meal Now

Have you ever thought to yourself "what would I do if I could never eat again"? If you are like the majority of people in the United States, this unfortunate situation has probably never crossed your mind; So lets take the time to think about it now. How would you feel if someone told you that you could never enjoy the refreshing taste of a cold glass of water or the sweetness of fresh strawberries (if you don't like healthy foods then you can imagine cold beer or ice cream). This unfortunate situation happens to many patients in the hospital on a daily basis. I recently took care of a gentleman who was unable to swallow after we removed the breathing tube from his lungs. Now this is not an uncommon occurrence in the world of ICU. If you are on a breathing machine this means you are not eating or swallowing. If you do not use your swallowing muscles they tend to get weak just like any other muscle and when you swallow food, liquid or even saliva it tends to go into the lungs instead of the stomach; we call this aspiration. It causes a nasty pneumonia and is often the cause of death for many elderly people. When this gentleman found out he did not pass his swallowing test he was devastated. I think many people associate their last meal with death row or Jesus, not the hospital. Many of his physicians found it odd that he was so devastated by the thought of never eating or drinking again. This made me realize how out of touch we are with the importance of eating. I will not get into  the details of nutrition on this blog, but I do want to discuss the importance of how we eat.
 People eat in a variety of ways: standing up, driving a car, watching television, reading a book, eating at the nurses station (yes JAHCO we eat at the nurses station). What we don't realize is that we absorb not only vitamins and nutrients in our food but also the energy that is happening in the environment around us. If we eat quickly or in an ugly, noisy environment that energy is going to penetrate us. This negative energy can present itself as acid reflux, irritable bowel syndrome, diarrhea, constipation and more. It is the nature of our bodies to "rest and digest." Our body likes to be relaxed, inactive and in an peaceful environment when eating. It does not want to be in "fight or flight" mode ( I feel like nurses and patients are in this mode in the hospital). So how can we learn to really experience and enjoy our food on a daily basis?

1.  If you are at work, try to find a quiet place to eat your meal. I prefer to sit outside and play some music on my phone. I find that sitting in the break room at work is the worst place to break. If you are home, turn off the television or computer and really pay attention to how you eat. You will find that you will feel more satisfied with your meal. 
2. Apply a simple ritual to your mealtime like lighting a candle or saying a blessing before eating. 
3. Eat meals with your family. There is a reason for the saying "families that eat together stay together." If everyone is eating different foods at different times, there will most likely be different levels of energy and moods. Experiment with eating a home cooked meal once a week and see what difference it makes. 
4. Focus on Chewing. Chewing prepares your entire gastrointestinal system for the digestive process. It enables you to breakdown your food better and also allows you to taste more of it. Try chewing your food 20 times before swallowing or setting your utensils down before taking the next bite. 
5. Try not to get intubated or have a stroke. I know this sounds far fetched but in some circumstances you do have a choice in the matter. I will get into the details of life support in a later blog but what I can say is that if you are elderly, like over the age of 70, or have some chronic disease like COPD or emphysema from smoking cigarettes please consider all of the risks for having a breathing tube put into your lungs. The likely hood that you will recover 100% is small and often you will be left with a feeding tube of some sort. As far as stroke goes eat healthy, exercise, don't smoke and recognize the symptoms of a stroke and if you have an irregular heart rate, take your blood thinners as ordered. 

Now is the time to really start thinking about what kind of food you are putting into our bodies and how you are doing it. The food you eat is the single most important decision you make on a daily basis. It is more important than the clothes you wear, the car you drive or what the Kardashians are doing. Now is the time to appreciate the fact that you have a choice in the type of food you consume and when you consume it. Appreciate that you do not have a tube down your nose or in your stomach with Jevity tube feeding infusing; if you're lucky you will get a side of 2 scoops of protein powder twice a day. I can tell you it smells horrible and I'm sure it doesn't taste good. If this doesn't sound enjoyable to you, then write it down. Make a living will or five wishes that states that you do not want a feeding tube placed. More importantly, take the time today to make better food and lifestyle choices because you never know when these choices will be taken away.

P.S. I have a five wishes that states that I never want a feeding tube. If it so happens that no one is around and I get one I want you to know that I am really intolerant to soy and if you give me that crappy tube feeding I will probably blow up like a balloon and have really bad diarrhea. I have also stated that I do not want a rectal tube either. Instead I expect top of the line smoothies with veggie protein powder. I will have the recipe written out. Also, I am really bony so make sure you turn me every two hours.

Thanks

A Patient's Guide on Keeping your Voice

A few weeks ago I had the pleasure of taking care of a very spry 89 year old man who suffered from a stroke. For those of you who do not know what a stroke entails, let me explain. There are two different kinds of stroke; Ischemic and hemorrhagic. Ischemic is where you have a blockage in an artery preventing blood flow to parts of your brain and hemorrhagic is when one of those arteries breaks and bleeds into your brain. Both of these can be potentially life threatening. This young man suffered from an ischemic stroke and was fortunate enough that his wife recognized the symptoms and called 911 immediately. We were able to remove the blockage in his artery and he eventually gained full function again (this is not always the case, believe me). Prior to this man's recovery he suffered from what we call expressive aphasia; this means that he is able to understand what you are saying and also form his own thoughts, however when he tries to speak, the words come out garbled. This man has lost his voice, literally. He has just found himself in a very vulnerable situation and unable to communicate his wants or needs. Now there are multiple ways, especially in the ICU that you can lose your voice. You can be intubated on a ventilator (breathing machine), you can be sedated with drugs, if you are elderly sometimes your family members will automatically assume you cannot make your own decisions even if you are of sound and mind and speak for you, you can be an alcoholic or drug addict going through withdrawal and be totally out of your mind, or you can have a doctor or nurse who just doesn't listen to you. So what can you as a patient do to keep your voice while in the hospital?

1. Prepare a living will or five wishes form before you get to the hospital. If you do not want to be put on life support and have feeding tubes, and other tubes (we have a tube for everything nowadays) put into your body and be left in a vegetative or bed bound state for the rest of you days then please write this down. It is not fair to your loved ones to leave them with this decision. I know that some people will state that they do not want to live this way and they do have this discussion with their spouse but that is not good enough, it must be written down. Here is a link to download the five wishes form http://www.agingwithdignity.org. This is the easiest way to let your medical providers and family members know your wishes. You can also ask for a living will form from your local hospital or download it off the Internet as well. 
2. Designate someone to advocate for you if you are unable to speak for yourself. You can do this by obtaining a medical durable power of attorney. These forms are state specific and can be downloaded from the Internet. To make it legal just have it witnessed and notarized. Try to choose someone who is not intimidated by medical professionals, who can ask challenging questions and who can put aside their own feelings in order to ensure your wishes are carried out. 
3. If you find that your doctor or nurse is not listening to you, ask to speak to the charge nurse or patient advocate in the hospital. Tell them your concerns, calmly, and maybe they can help address them. If this doesn't work you can always resort to firing your nurse or doctor. You have what we call patient rights and that's one of them. 
4. For some reason when elderly patients come into the hospital, people, including family members, tend to treat them like children. Do not let this happen to you and try not to do this to your family member. If you or your loved one are capable of making decisions then it would be best if they were involved in the decision making process. I have seen many occasions when patient's family members push a medical intervention on them just to show that they are not "giving up." 

It is always best to have these discussions before entering the hospital system. Being a patient can be one of the scariest and most challenging events in a person's life. Making decisions under this amount of stress can just make situations more difficult. I know thinking about and addressing end of life decisions may seem like a far fetched way to spend your free time but the truth of the matter, is that death is inevitable and cannot be predicted. People's poor dietary and lifestyle habits are causing them to be more sick and at higher risk for disease and death at a younger age. Take the time this week or month to talk with your loved ones about end of life decisions. While your at it, may talk to them about their current life decisions as well:)

Grassroots Prevention: How to stay out of the hospital and protect yourself when you get there: How to Find Your Voice and Influence Change I had ...

Grassroots Prevention: How to stay out of the hospital and protect yourself when you get there: How to Find Your Voice and Influence Change I had ...: How to Find Your Voice and Influence Change  I had a comment on my previous post about how difficult it is in the world of healthcare to...

How to Find Your Voice and Influence Change

 I had a comment on my previous post about how difficult it is in the world of healthcare to have your voice heard and I have to say that I do agree with this statement, for the most part. There have been numerous times in my career that I have questioned current practices, suggested new ways of going about things and have been ignored. These failed attempts to influence change on a larger level have left me feeling hopeless and resentful; which is perfect for a travel nurse! I no longer have to get involved with the BS hospital politics. If they want to waste taxpayer dollars on flushing NG tubes with sterile water and placing everyone and their mother on the sepsis protocol then so be it. I am here to take care of my patient and that's it! Through this separation between myself and administration I have learned that the best way to have your voice heard is to speak with people who actually want to listen to you. This means avoiding those people who attempt to assault you with holy water because it's your fault their son is an alcoholic; this person is not a good candidate for influencing change. There are many people in this world who care about themselves enough to open their ears and listen to what we have to say. You may not find these people at work. This person might be your spouse, your child, your neighbor, a friend, or even a complete stranger. I have learned through my studies in nutrition that the most powerful way to influence change starts with the individual. Healthcare professionals as well as other professionals have a wealth of knowledge that can benefit the population as a whole. We have the ability to teach people about their bodies, how to take better care of themselves, the warning signs of heart attack and stroke and even save their lives. This information should no be kept to ourselves. It is time to stop trying to change the system and instead change ourselves and our community.

Opportunities for Change

• Feed your children healthy food and show them how to play
• Teach your children about the dangers of smoking, drinking alcohol and drugs
• Take the time to educate your patients and their families
• Volunteer 
• Teach a class to your neighbors on the signs of stroke and heart attack
• Set up a health fair at your church
• Educate yourself on proper nutrition and exercise, then spread the word

Today is the first post of my official Blog. To let you know I actually had to Google what a blog was before I even started so that lets you know the extent of my knowledge. I had recently been following the Zen Habits blog (which I didn't even know was a blog) and took the author, Leo Babauta's advice on the benefits of writing daily. I had also recently listened to a webinar from the Institute of Integrative Nutrition, where I am currently becoming certified in holistic nutrition, on the practice of "morning pages." The practice of "morning pages" involves writing every day as soon as you wake up in the morning. This daily practice is suppose to unleash your inner creativity and also serve as an outlet for stress. I found this to be very beneficial, but as most of you who know me personally, I like to share my opinions with the world, even if the world isn't exactly ready to hear about them. So here I am. Now according to a few websites on blogging, apparently you are supposed to write about something you are passionate about and that might interest others. I know I am passionate about health and wellness but telling people what to eat every day gets a little boring. So I asked myself what do I constantly complain about and guess what came to mind? The healthcare system. Yes my friends, and most likely co-workers, we all do it. Rather than going into the med room to complain about our crazy patients, their families, administration, physicians, other nurses and if Phil is involved the government, I have decided to bring my issues to the table to hopefully effectively start conversations and slowly change the way we practice healthcare. This is why the title of my blog is "Grassroots Prevention." We cannot sit around and wait for the government to change the system. The new healthcare reform act just passed which actually has nothing to do about people's health, only their health insurance. The government has no flippin idea what goes down in the real world. The people in the trenches, because that is what it is beginning to feel like, have to start changing the system. We the people have to start taking responsibility for our own health by eating better, exercising, educating ourselves about our diagnoses and medications, taking control of our own health, and preparing for end of life issues. These are just a few ways to improve the state of our healthcare system and it starts with the individual. I hope to spark conversation across the board. This will hopefully be an open forum for healthcare providers and patients, so remember to make sure your comments actually have a purpose and are respectful. Wish me luck. This is about to get interesting!!!