PALL CARE

hospice nurse secured her bag over her shoulder and inched along the ramp that sloped down to the tiny weathered houseboat. A stoopshouldered man with red eyes and a red nose greeted her and pulled her into a smoky bedroom. He was Earl, the patient’s husband. His wife was a new referral to hospice for an expanding brain tumor. His words tumbled out of his mouth, “Yesterday she was fine. Today she’s choking on water. She won’t talk to me. She can’t stand up. What can I do? What does it mean? It’s a nightmare.” The nurse investigated further to learn that Marge had eaten Swiss steak and peas the evening beforehand and was able to walk to the kitchen table. She had been able to speak in brief sentences and could follow instructions. The nurse examined her headto-toe to identify a flat expression, moon face, no ability to follow instructions, evidence of urinary incontinence, cyanosis, mottling in her lower legs, BP 76/30, and periods of 30 second apnea. Nursing interventions included calling the physician to report her terminal status and ask him to consider prescribing an increased dose of dexamethasone that might reduce the swelling around the tumor. He had a long-standing collaborative relationship with the nurse, and agreed to increase the dose in hopes of achieving temporary improvement. The nurse sat down at the kitchen table with Marge’s sister, her son, and Earl to discuss the disease course, possible reasons for Marge’s deterioration, and what to expect. They concocted a thick frozen yogurt shake that she was able to swallow. This meant that the dexamethasone, analgesics, anti-convulsants, and laxatives could be administered by this route until she stopped swallowing. The family returned to the bedroom to learn how to care for an incontinent bedridden patient. The nurse ordered a hospital bed and diapers from a medical supply house. The signs of imminent death were reviewed with Earl, and the nurse gave him the hospice on-call nurse number. Before she could leave, the nurse facilitated an emotional 20-minute family discussion of whether or not they would call 911 if she stopped breathing. They all agreed that they would call the hospice instead of the paramedics. They agreed to a visit from the hospice chaplain and considered beginning 24-hour continuous care because death was imminent.