Hello, Folks! Summer is my favorite season and I’m going to take a little blog break and enjoy the rest of it. I’ll be back the week of September 10th (unless I can’t contain myself).
“How in the world am I going to chart this?” I wondered as I sat across from Nell, who filled her large wheelchair to overflowing. This was our second attempt at psychotherapy, which I’d discontinued a few months ago because I felt all my efforts had gone nowhere. Nell sat in her room all day, doing nothing and talking to no one, yet she was clear in her thinking and clearly depressed. She resisted all of my suggestions, recommendations, cajoling, begging, humor, and coordination with the team to adjust her medications. Efforts to connect her with her estranged family had produced a tepid response. “She’s been this way all her life,” her son told me when I’d finally called to tell him I’d stopped seeing his mom. “I’ve given up,” he added.
Now here I was, three sessions after the team had referred her for psychological services again, trying to determine a treatment strategy in the face of her extreme hopelessness.
“There’s nothing I can do,” she said, “because I can’t see.”
Her talking clock, talking watch, talking books, radio, and TV sat unused after her initial training in how to operate them.
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I consulted with colleagues the next week and they encouraged me to keep going. “You’re the only person she talks to,” they said. “That has value.”
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A couple of weeks later I ran into Nell’s aide in the elevator after I’d finished a staff training.
“You know she asks for you all the time, don’t you?” she said.
“She does?” I was shocked.
“You’re Eleanor, right?”
“Yes.”
“She calls ‘Eleanor, Eleanor, Eleanor’ all day long. And when she doesn’t want to take a shower, we tell her ‘Eleanor wants you to do it’ and then she goes along with it.”
“I had no idea! Thank you for telling me that.” I was flabbergasted — and relieved that my documentation could reflect some actual purpose and progress.
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The next week I sat across from Nell with a lighter spirit.
“There’s nothing I can do,” she said, “now that I’ve lost my eyesight.”
“I had a couple of relapses this week,” Betty told me, looking ashamed.
We’d been working in psychotherapy on her efforts not to snap at the aides and nurses who came to care for her.
“I try not use to my call bell,” she went on. “Sometimes I sit here for two hours thinking about it before I press it.”
“Maybe that’s part of the problem,” I suggested. “If you’re waiting for two hours before you let them know you need help and then it takes them a little while to get here, by the time they arrive you’re ready to explode.”
She nodded. “That’s true.”
Betty was more psychologically-minded than many residents, so I took things a step further. “It’s also not taking very good care of yourself to wait two hours to ask for help. If you had a child who needed help, would you make them wait two hours?”
“No!” Betty’s bulletin board was filled with the Mother’s Day, birthday, and Christmas cards her only child sent instead of visiting.
“Now you have a chance to give yourself the care you didn’t get as a child.”
“What do you mean?” she asked sharply, “My parents took care of me!”
“From the things you told me about what went on in that house, you children were not getting enough supervision.”
Betty, an incest survivor, stared at me. “I never thought of it that way.”
“This may sound corny, but now Grown-up Betty has the chance to take care of Little Betty, and ask for what she needs when she needs it.'”
Betty burst into tears. “Wow…wow…I never thought of it like that.” She pulled a tissue out from the box on her tray table and blew her nose. “I could do that. I could take care of myself.” She gave me a piercing look. “Wow…thank you!”
Ms. Williams was humming a tune as I rolled her wheelchair toward her room for our session. “What’s that you’re singing?” I asked her.
“I’m not singing, I’m humming. It’s a song I heard as a child. I can’t remember the words.” 84-year old Ms. Williams had been worryingly depressed for several weeks, and our sessions tended to be a litany of complaints that were somehow never resolved despite the best efforts of the staff.
“Do you remember any of the words?” I asked.
“Something, something, they tell me of a home far away…” She hummed a little. “That’s all I remember.”
I pulled out my iPhone and entered “a home far away” in the YouTube search box. Moments later I had the lyrics and music to her song. I turned up the volume and held the small screen in front of her. She hummed along, and smiled. “Yes, that’s the one! My father used to sing that to me.” She began singing, and seemed content for the first time in months. The song ended, and she beamed at me. “I haven’t heard that in a long, long time. Thank you!”
“My pleasure.”
“That’s a shame about Whitney Houston,” she remarked. “Such talent, wasted.” Then she told me for the first time about the alcoholism in her family, and the effect it had on her life.
I hadn’t been on the North wing of the nursing home in a while, and when I saw Juanita Johnson sleeping in a geri-recliner, I turned to the nurse, aghast. “I barely recognized her! She’s lost so much weight!”
“I know. It’s terrible,” the nurse replied. “We’re having her evaluated by hospice today.”
Ms. Johnson was accepted into the hospice program, and died two days later.
I’ve seen many late referrals to hospice in my years as a nursing home psychologist. It’s the rare older resident who wants every treatment possible late in life. Most of the time, the resident is going along with the program, waiting for the doctor to say that it’s time to rethink how we’re handling things. The resident is waiting for “the conversation,” but all too often the conversation doesn’t happen until it’s too late. The resident’s last days and months are ones of unpleasant medical interventions rather than a time of comfort and emotional support. This affects their family as well, with the emotional ripples of a “bad” death living on for years.
It’s not so easy to determine when someone is dying, but this week’s article by Paula Span in the New York Times, Interactive Tools to Assess the Likelihood of Death, discusses the use of interactive tools and how they can help us make better end-of-life medical decisions. The tools are posted at ePrognosis.org.
Coping with Grief, for Staff Members: Conversation with grief expert Courtney Armstrong, LPC
Beloved residents decline and then die, their families stop visiting the nursing home — coming to terms with these losses is an unacknowledged challenge of our work. Especially helpful for training directors, new employees, or those struggling with a current loss either on or off the job, this 20-minute audio will help staff members:
Understand their feelings
Recognize symptoms of grief
Identify coping skills
Assist each other in creating a supportive community
Includes FREE:
Signs of Grief checklist
LovingKindness Meditation Sign suitable for posting at the nursing station
She sat quietly in her wing chair, lost in thought . Hearing my knock and spying me standing in the doorframe, she sighed. “You might as well come in, but I have nothing to say.”
“That’s what you tell me every week, and then you talk my ear off!” I teased her.
She smiled. “That’s true.”
“You seem like you’ve got a lot on your mind,” I said, settling down on the chair across from her. Her face looked tired and was devoid of color.
She nodded. “It’s that Arthur. He’s come visiting again.” She rubbed her swollen knuckles, and elaborated on her pains. “I wish that Mr. Itis would leave me alone, but I guess I’ve got to live with him.” She sighed, and then looked at me brightly. “My niece took me out to the movies this weekend!”
“Really! What did you see?”
“Well, she said it was My Day, so we went to see that vampire movie, even though she’d seen it twice already.”
“Twilight?” I was surprised.
“Yes, that’s the one!” Her voice sounded chipper. “Oh, honey, there was a scene where a couple spent the night together and afterward, that room was just torn up! What did he do to her, I wondered, but she said she had the night of her life.”
“Really?”
“Oh, yes.” She paused for emphasis. “Honey, that’s My Man!”
“Hi, Mabel! Do you have some time to talk to me?” Mabel, I knew, had all the time in the world, since she refused to go to activities. She sat across from the nursing station, her hefty frame filling her extra-large wheelchair, watching the nursing staff, the other residents, and the passersby.
“If you want to,” she replied without enthusiasm. “What are we going to talk about?” Her greeting hadn’t warmed during the six weeks I’d been seeing her.
“Well, let’s get started and see where we go,” I said, slowly wheeling her into her room. “Your social worker says you’ve got a photo of yourself when you were young. I’d love to see it.”
She started rummaging through the frayed and bulging pocketbook on her lap, pulling out paper after paper.
“What are those?”
“Menus. They’re mementos.”
“Mementos?”
“I get three each day, and there are seven days a week, so that’s 24 a week. I’m saving them to make a scrapbook.”
“I see.” Her poor math skills took a back seat to the revelation that she was collecting the daily meal stubs distributed with each resident’s food tray. “Is that a hobby of yours, collecting menus from when you traveled?”
“No.” She pulled out her wallet and removed a tiny snapshot, bent in one corner, showing a shy, smiling young woman in an elegant dress, one hand resting on her slim waist, a flowered hat upon her head.
“Wow! Look at you!” We spent the rest of our time together reminiscing about the old days, and I left her smiling, back in her position across from the nursing station.
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“Hi Mabel! Want to talk?” I asked her the following week, hoping we could build on last week’s good will.
“What are we going to talk about?” Her question held more suspicion than curiosity.
“Oh, I don’t know. We had a nice conversation the last time.” I took her lack of refusal for acquiescence, and we sat in her room discussing her interests when she was young and active, trying to create a bridge to pursuits in which she could partake now.
“I’ve done it all,” she remarked proudly. “There’s nothing left for me to do,” she added, explaining her current disinterest in social activities.
Stymied, I asked to see her photo again. “I’ve already picked out the picture I’m going to post in my room when I’m a resident,” I told her while she searched her overstuffed bag. “It’s me dressed as Wonder Woman for Halloween.”
Mabel looked at me and smiled, then continued hunting through her bag. “Here it is.” She handed me the tiny image.
“Maybe I can enlarge this and we could hang it on your bulletin board. Would that be okay?”
She looked around her barren room. “Okay.”
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Downstairs, I showed the enlarged photograph to Mabel’s social worker. “I have a frame!” she told me. “You could mat it.”
I returned to Mabel and showed her the large gold frame holding the image of her smiling, young self. She stared at it in amazement, and then grabbed me by the hand.
“It’s beautiful!” She gazed at the photo and then looked back at me. “Thank you so much!”
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I approached Mabel for our session the following week. “What do you want to talk about?” she asked me sullenly.
Nan was in the hallway, looking as thin and pale as I’d ever seen her.
“Are you okay? Do you feel well enough to meet today?” I’d heard in morning report that she’d been diagnosed with pneumonia.
“No,” she croaked, and then hesitated. “I mean, yes.” She looked at me intently. “It might be our last time.”
Alarmed, I wheeled her into her room, stopping along the way to pick up the newspaper, as she requested.
“You said ‘it might be our last time.’ Do you think you’re going to die before next week?”
“Yes.”
I could feel the tears coming. I’d known Nan for years and was very fond of her. “Is it okay if I cry for a moment?” I asked her, but even if it wasn’t, I couldn’t help myself, and it took a minute for me to get myself under control. Nan busied herself with her newspaper.
“Do you feel ready?” I asked her. We’d discussed her thoughts and expectations about dying in the past.
“Yes.”
“Is there anyone you want me to call?”
“No.”
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I came back later in the day to check on her and found her in bed. She asked me for water. “Would you like to go on hospice? They’d have someone here four hours a day to help you with stuff like this.”
She took a sip of the cup I held at her mouth, and shook her head no. I felt bad leaving her alone in her room.
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On the way to work the next morning, I debated about whether or not to bring Nan some flowers. Would it violate my personal rule not to do things for one resident I wouldn’t do for another? I went back and forth for a while, and then decided that I’d probably do this for a resident I’d been seeing for a while who was dying and had no visitors to help them through to the end. I bought a flowering plant in a pot, not wanting to get something that might die before she did.
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“I brought you some flowers, Nan,” I told her when I came into the room the next day. “I’m going to put them here on the windowsill, and they’ll be like me watching over you.”
Her voice was weak. “You’re too good to me.”
“You know I’m very fond of you.”
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I came back to water the flowers after the weekend. “Someone else has done it already, Nan.” I remarked. Nan looked at me and nodded.
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By Thursday, Nan had passed.
I put the flowers on the desk at the nursing station.
Ms. Williams was humming a tune as I rolled her wheelchair toward her room for our session. “What’s that you’re singing?” I asked her.
Beloved residents decline and then die, their families stop visiting the nursing home — coming to terms with these losses is an unacknowledged challenge of our work. Especially helpful for training directors, new employees, or those struggling with a current loss either on or off the job, this 20-minute audio will help staff members:
She sat quietly in her wing chair, lost in thought . Hearing my knock and spying me standing in the doorframe, she sighed. “You might as well come in, but I have nothing to say.”
