Warm Hands

Colleen MacDonald

I wanted to share with you one of the most special moments I have experienced in caring for dying patients. It is not dramatic, or spectacular, but for me a palliative care nurse working in a small town Ontario Hospital, it has had a special place in my heart.

Sara, a seventy-something married woman with two successful grown daughters first came to our unit in the summer, for symptom management related to chemotherapy for breast cancer. She had been battling cancer for six months and her last dose of chemo really took a lot out of her.

Sara was a charismatic woman, active in the community and had many friends. She was kind and quick-witted, always ready to share a laugh. At the time of admission, Sara was nauseated and weak, but uplifted at the fact that the chemotherapy had been quite effective in shrinking the now open tumor consuming her right breast. Unfortunately, she was too ill to undergo any more chemo, so she was referred to a larger center to consult a radiation oncologist. She underwent five doses of radiation as an inpatient at the larger hospital and was then transferred back to the unit where I work.

With every dressing change, we watched in amazement as the tumor continued to shrink. Sara, her family, and the entire palliative team were uplifted by the positive effects the radiation had had. Sara began eating more, building strength and overcoming symptoms. Her pain decreased and her attitude soared. She was beating her cancer! She returned home for, and had another, consultation with her oncologist, who decided to resume chemotherapy as an outpatient. Sara would visit our unit when in the hospital for her chemo. She was always very appreciative of our care and her enthusiasm and joy brought hope and strength for many of our staff. Although I love my job within palliative care, and I find it extremely rewarding to be successful in guiding patients toward a comfortable and peaceful death or controlling patients' symptoms effectively, I found it refreshing to have a patient who's health improved so dramatically.

Sara finished another round of chemo and was able to stay home for another ten months or so, before she returned to our unit. She was very ill, confused and dehydrated. It was next to impossible to get an IV started or blood drawn. She was having more pain and the tumor had begun to grow again since her therapy had stopped.

As you can well imagine, many of the team members were quite upset by this, as it was obvious to us that she was dying. Her family continued to be very attentive and were open to discussions about the fact that Sara life was coming to an end. I am not sure exactly what it was about the situation that pulled at my heartstrings so much. Whether it was the fact that I had a close relationship with this patient and her family, built over time, or that I liked an respected her so much, or that to me she represented hope and strength in the face of uncertainty.

As a palliative care nurse, I have become fairly skilled at assessing patients as they near death and communicating with families so that they can be present with their loved ones if they wish to do so. However, on the evening before Sara died, I would not have guessed that she would only have a few hours to live. Her daughter had spent the night, but was sleeping in the family room at the end of the hall. For whatever reason around three o'clock she woke up and went into the room. After a few minutes I followed her in and we sat at the bottom of the bed and she told me of all the wonderful memories she had of her mother.

Sara's respirations were easy and she was comfortable. We had a quite CD playing in the background with water and birds singing along with classical music. As her daughter shared her precious memories and we giggled together over funny stories, Sara's eyes opened wide and she looked down towards us. We both moved up the bed flanking Sara on each side, each holding her cool hands. She continued to look ahead but was very peaceful and serene, her breathing easy. Her daughter began to pray out loud, and as she did Sara's hands became very warm and I could feel a heat all around her. She took only a few more breaths and very beautifully closed her eyes and died. Her daughter and I spent some time sitting quietly, shared some tears and even some laughter. The heat that I felt when Sara was dying stayed with me throughout the shift and I felt very honored to have shared in such a beautiful and intimate moment in such an extraordinary moment in Sara's life.

© MacDonald, Colleen. (September 2006). "Warm Hands" in Selected Journals of Successful Hospice Palliative Care from the 16th International Congress on Care of the Terminally Ill, September 26-29, 2006 in Montreal, Canada. Toronto: Legacies Inc.

Colleen MacDonald RN BScN
Palliative Care Unit, Northumberland Hills Hospital
1000 DePalma Drive, Cobourg Ontario K9A 5W6 CANADA
905.372.6811 x 3219,

Guardian Angel

Marie Macková

I am a hospice social worker in the Czech republic. I have worked in palliative care for 10 years. I have had many clients during for this time and I have many stories. One is particularly special for me. It is from when I first started in this field.

One month before Christmas I met a woman in the hospice who had breast cancer. She looked very poor and everybody thought that she would die soon. She was 49. I spent a lot of time with her because she did not have any family; only her old parents.

She was an English teacher. Time continued on and she was still alive. She taught hospice staff English. We read books about ethics, philosophy etc. together. Every Friday we had a discussion club in her room.

I built a friendship with her and we became like sisters. More and more we discussed faith and life after death.

One day she asked me, if I would be able to stay with her in her moment of death. I said, "Yes." She asked me, too, if I was afraid of ghosts. I said "No, I am afraid only of being a bad person."

She said, "O.K., when I die I will come back to tell you if there is life after death.

Time continued on and she was still alive. One day I had to tell her that I was going for three months to Britain. She said, "Never mind, I will be waiting for you."

And she did wait. I called her every day and when I came back I called her to say that I was back. That same day, I got a call from the hospice. She was dying. I went over immediately. I was sitting with her and was holding her hand. She died early morning with a smile on her face. She had died 15 months after coming to the hospice.

I went home after her death and my mum told me, "She died and she died at 3.42 a.m." I was surprised because it was exactly the time of her death. My mum sat down and just said, "I was in my bed and I felt somebody sit down beside me. I opened my eyes and I saw a little women. She said, "Thank you" and put her palm on my face. I am sure it was her. I believed it too and I believe she is in heaven. But I feel at the same time, that she is with me if I need help and she is my guardian angel.

© Macková, Marie. (September 2006). "Guardian Angel" in Selected Journals of Successful Hospice Palliative Care from the 16th International Congress on Care of the Terminally Ill, September 26-29, 2006 in Montreal, Canada. Toronto: Legacies Inc.

Marie Macková PhD., RSW
Hrabenov 115
789 63 Ruda nad Moravou, Czech Republic
Mobile phone: +420 775 224 962,

Ten Commandments of Healing

Balfour Mount

How important to attend to the insights of our teachers, that is to say, the men, women and children who have been our patients and their families. We are indebted to them for the legacy they leave us. Paradoxically, their end-of-life lessons have not been about dying, but about living. What is the core lesson they have taught us? It is that healing is the central goal of life. I am not speaking of physical healing, a person can die healed: what I mean by 'healing' is a shift in our quality of life away from anguish and suffering, toward an experience of integrity, wholeness and inner peace. Jon Kabat-Zinn defines healing as a process of adaptation, a "coming to terms with things as they are."

The psyche, it would seem, has an intrinsic tendency toward healing, a will-to-wholeness, as it were. How can we experience that? How can you and I find inner peace in the turmoil of each day? Let me summarize our patients' message to us as "The 10 Commandments of Healing." They are:

1. Be Truly Present to this Moment

Healing, like love, celebration, awe, wonder and ecstasy, happens in the now, in the present moment, free from ruminations of the past and fears about the future. As Oliver Wendell Holmes stated it, "What lies behind us and what lies before us are tiny matters compared to what lies within us."

And yet I find that I spend most of my time preoccupied with the past or the future. I must come into the present; be aware of the persons and things that are around me right now

2. Trust

Healing involves letting go, a leap of faith, 'dving not drowning' as Carl Jung expressed it. Lou Gherig's disease patient Phil Simmons called it 'learning to fall.' We fall from head, to heart; from egoism and our carefully constructed defense mechanisms, we fall into forgiveness of ourselves and others, the realization of the staggering potential of our essential selves, and an awareness of healing connections.

We may experience these connections at four levels: a sense of connection to self (Carl Jung's individuation); connection to others (Martin Buber's 'I-thou' relating); connection to the world perceived through our senses (as with music, or the grandeur of nature); and connection to ultimate meaning, however perceived by that person: God, the Other, the Cosmos, the More, the unity of all things.

3. Attend to Your Whole Person Needs

According to the time-honored metaphoric classification, we are 'body, mind, and spirit', or, 'body, spirit and soul', depending on you preference. We must care for our needs in each of these domains every day.

4. Open to Deeper Relating

Recall that our inner life is relational in its expression. It is reflected in how we relate at the four levels noted above.

Within your religious or wisdom tradition seek out teachers who speak from personal experience, not dogma. Go to depth. As C.S. Lewis observed, "The process of living seems to consist in coming to realize truths so ancient and simple that, if stated, they sound like barren platitudes." Lewis continues, "They cannot sound otherwise to those who have not had the relevant experience: that is why there is no real teaching of such truths possible and every generation starts from scratch."

5. Listen to Your Intuition

As Joseph Campbell put it, "Follow your bliss."

6. Create

Identify things you like to do. Make time for your creative side each day.

7. Develop Self-Reflective Skills

Monitor self, noting your thoughts and feelings. They are not reality. They are your response to reality. Let go of them and come back to your centre of calm. Work on becoming self-aware with questioning that asks, "What is my personality type and how does that influence how I feel about myself, how I relate to others and to the situations I find myself in? What are my defenses - the walls I build to protect myself, but that also imprison me?"

8. Be Gentle with Yourself

Progression toward healing is slow. Indeed, the goal is never reached. The journey is everything. You are a unique experiment in creation, with a particular potential to contribute to this world. What is it that you alone can do, must do, if you are to fully express your potential?

9. Think Small

Give up illusions of control. Recognize that we are all in the same boat, exactly the same boat. The ego-driven values of Western culture ('I am number one'; the need for wealth, power and control; the distrust of all but the physical; the need to be the best in the world in what you do) stand in the way of healing.

Avoid power; neutralize the fantasies it creates in situations where it is bestowed on you. Humility and openness are essential antecedents to healing; joy, peace and a sense of connectedness its products.

10. Celebrate

In the direst of circumstances, boundless peace is to be found within. Recall Viktor Frankl's hard-won observation, "Everything can be taken from a man but one thing: the last of human freedoms ­ to choose one's attitude in any given set of circumstances, to choose one's own way." If Frankl can find life worth celebrating in Auschwitz, chances are I can find my cup half full, perhaps full to overflowing, here and now.

These are the 10 commandments of healing that our teachers have given us.

* * *

Healing involves a process of opening, slowing, centering, trusting, hoping and accepting. It involves recognizing the potential that still remains, in spite of all that has been lost.

For each of us the path toward healing will be different. The most certain path I have found is meditation. I do not imply that it is the only path. It is just the only path I know. The purpose of meditation, in its many forms, is to create alert awareness with a still mind and presence to the moment.

There is no shortcut to healing. Carl Jung put it this way, "The attainment of wholeness requires one to stake one's whole being. Nothing less will do; there can be no easier conditions, no substitutes, no compromises."

How do we find healing? We must take up the journey anew each day. What better day to recommit than today? No one else can do it for me. No one else can do it for you. Hillel expressed it succinctly, "If I don't do it, who will do it? If I don't do it right now, when will I do it?"

I wish each of you well on your journey.

© 2006 Balfour Mount used with permission from Lawrence Erlbaum Associates. "10 Commandments of Healing," in Journal of Cancer Education 2006, vol.21 #1, pp. 50-51.

Mount, Balfour. (September 2006). "Ten Commandments of Healing" in Selected Journals of Successful Hospice Palliative Care from the 16th International Congress on Care of the Terminally Ill, September 26-29, 2006 in Montreal, Canada. Toronto: Legacies Inc. with permission from Lawrence Erlbaum Associates. "10 Commandments of Healing," in Journal of Cancer Education 2006, vol.21 #1, pp. 50-51.

Balfour M. Mount
Emeritus Professor of Palliative Medicine
McGill University,Programs in Whole Person Care
546 Pine Avenue West, Montreal, Quebec H2W 1S6 CANADA

A Job Where Everybody Dies

Mary Murray

I am a hospice home-care nurse in northern New Jersey, about 15 miles west of New York City. Our area isa cultural melting pot. My work has brought me into the homes of immigrants from all over the world.

As part of my caseload, I was the primary nurse for hospice patients in a sprawling complex of brick apartment towers housing mostly elderly Russians who emigrated to the U.S. in the early '90s. Most of these people were older when they arrived in the States, and because the buildings were a nearly self-contained community, they spoke little English. They also held fast to Russian culture, and to beliefs about health, wellness and trust (or lack of) in the American medical system.

One fall day, we admitted to our hospice program a 96-year-old man from the Ukraine. Mr S. was oxygen-dependent and in the last stages of emphysema, but he expressed a fierce desire to maintain his independence as long as he was able. He walked around his apartment with mile-long oxygen tubing and accepted only a few hours a day of help from a health aide.

In Kiev, he had run a factory. Now years later, in Newark, NJ, it was clear he was a man still used to being in charge.

Through his interpreter, a younger man from Azerbaijan working as an aide, Mr. S. told the hospice team how he survived the brutal Battle of Stalingrad, and showed off his World War II medals. He told us about the day he met Khrushchev, and illustrated this story by pretending to bang his shoe on the table as the Russian leader once did at the United Nations.

When a new medication was needed, Mr. S. would patiently listen as the aide translated my instructions. He looked up every new med in his Russian-language drug book. When I would return, a shrug, another polite smile, and most often, no med in sight ... "I no need."

But Mr. S. welcomed visits from the hospice team, and was especially gracious to his nurse. When I would try out a few phrases in my fractured Russian, he would beam and gently correct me ... then encourage me to try again.

The hospice team looked forward to our visits with Mr. S, who inspired us with his stories and dignity. When his 97th birthday drew near, we wanted to celebrate. After we spoke to his aide who got the go-ahead from Mr. S, we decided on a cake and a time for the hospice team to bring him a party. His two nurses and the social worker would attend.

His birthday, Saint Patrick's Day, was cold and rainy. The rain turned the snow on the ground to a dirty deep slush. I wanted to stay in bed. But instead, I slogged out to work, my first stop to buy the cake for our party later.

At my first scheduled visit that morning,I arrived to find the patient near death. I had just a few minutes to spend with the family, gathered around the bed, before the patient took a last, quiet breath. It was obvious the family didn't realize their husband and father had just died. It fell to me to tell them.

Only minutes passed before my pager went off, and I was sent to another home where another person had just died. I knew this family well; the patient was the second in this family I had cared for in the last year.

I had made many visits to this home, and had been helped by the nephew of my patient (himself battling cancer) who had insisted on helping me change a tire when I came out of their house a few weeks before to discover that I had a flat.

When I left their house after Auntie's death on this cold gray day, a party was the last place I wanted to be. But my colleagues were waiting for me in their cars outside of Mr. S's apartment house, and I was late.

We gathered up our cake, paper plates and lemonade and piled into the elevator. I grumbled about the weather. I wondered out loud, and not very nicely to my colleagues, why anybody would want to have such a sad job where all the patients die.

We got to Mr. S's door. I went into nurse mode and knocked.

The home health aide opened the door, smiling and waving us inside like a game-show host. At his usual spot at his little table was Mr. S, no bathrobe today, in a full blue suit and tie. The table was covered with lace. There were Russian pastries and an unopened bottle of wine. The china cups and glassware usually collecting dust on a shelf were washed and sparkling.

At the center of the table was a bouquet in a vase, coffee and three wrapped gifts.

"Come in, my friends," said Mr. S. It was evident he had practiced a speech. "Please, sit down. Happy Birthday to me."

To our social worker (a man), he presented a wrapped gift; a bottle. To my nurse colleague and me, boxes of Russian chocolate. And to me, the flowers from the table. None of us had the heart to tell him we weren't allowed to accept gifts. We thanked him.

"Thank you, my friends.You good for me," he said.

He extended his hand, and I when I offered him mine, he kissed it.

About three months later, on a summer Sunday, Mr. S. died suddenly and without pain, sitting at the same table spooning sugar into a cup of tea.

In that moment when we steppedinto Mr S's apartment for that very special party, and whenever since I think of him, I remember or perhaps that was the day I really learned) why it is that I keep coming to work to do a job where everybody dies.

© Murray, Mary. (September 2006). "A Job Where Everybody Dies" in Selected Journals of Successful Hospice Palliative Care from the 16th International Congress on Care of the Terminally Ill, September 26-29, 2006 in Montreal, Canada. Toronto: Legacies Inc.

Mary Murray RN, CHPN
Saint Barnabas Hospice and Palliative Care Center
95 Old Short Hills Road, West Orange, NJ 07052 USA

Leaving with a Grace

Elizabeth Paddon

My father left this world with a grace he rarely exhibited when living. Oh, I'm not talking about lying in the hospital for days on end with all manner of tubes sticking out of his body. That was not graceful. Nor am I talking about the awkward dance that we family members made around him as we clumsily tried to make peace with the fact that he was dying. Lots of love there ­ but no grace.

Grace did come, however, in the ebb and flow of his last breaths. After the doctor turned the ventilator off. After those that did not want to be present had left the room. And after a hushed recitation of the Lord's Prayer and a sweetly sung "Amazing Grace" 'cause he enjoyed that song and it didn't seem quite appropriate to sing his true favorite song "O, how they danced on the night they were wed".

Eternity touched each soul present and guided us to be still. My father's breath became like the waves of the ocean ­ sometimes calm, sometimes wild ­ never steady. A soft inhale followed by an exhale so quiet it seemed not really there. Eternity opens her arms. A deep inhale followed by a crashing wave. A long silence. A quick breath in followed by a violent exhale. Silence again. I begin to weep. A warmth in my heart reminds me that I am standing in the presence of Eternity now ­ another inhale ­ this one deep ­ deep ­ deep ­ Eternity yawns wide ­ the body that belongs to my father shudders ­ Go to the light, Dad, go to the light - we say as our hands grip more tightly ­ and then, a movement so beautiful that only nature could choreograph it. The hands that belong to my father, the hands of the workman, the poet, the angry man and the healer ­ his hands pull his arms up into a fetal position, and then with the last crashing wave of breath exhaling he pushes down, down, down ­ as if pushing himself out of his body ­ pushing, pushing, pushing ­ untilit's as if I see him soaring out of his body, shaking his head, opening his arms wide and sayingjeez, it's good to be out of there.

That was a hard one. That was a hard life. I know Dad. But just look at you now. I couldn't stop smiling.

© Paddon, Elizabeth. (September 2006). "Leaving with a Grace" in Selected Journals of Successful Hospice Palliative Care from the 16th International Congress on Care of the Terminally Ill, September 26-29, 2006 in Montreal, Canada. Toronto: Legacies Inc.

Elizabeth Paddon
Director - Creative Voiceworks
Toronto, ON CANADA
info@creativevoiceworks.ca, www.creativevoiceworks.ca

Selected Journals of Successful Hospice Care

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