Midwifing, in death as in life

Circle of life, indeed. As I slowly moved the wand of the handheld doppler over the gentle swell of an abdomen, searching for the tell tale heartbeat of life growing inside, I was instantly transported to my days as a young nurse in the ICU. I was assigned a young woman who had experienced a large bleed into her brain, caused by a silent tangle of arteries and veins that usually go unnoticed. While she was non responsive, her assessments every 4 hours included that same kind of doppler wand, picking up the heart rate of her unborn baby. They had both survived, and our job was to make sure life continued for both. Over the many weeks of those continual checks of baby's heartbeat, the sad reality was caring for a mom who had woken, but was not aware of anything around her. We were making sure her baby made it to the point a c-section could safely be performed, all the while giving her weary, yet hopeful, husband and family all of the emotional support we could muster. As is life in the ICU, we don't always hear the longer term outcomes, but as we packed the doppler away to go back to the OB floor, word of a healthy baby boy taking his first breaths downstairs in OR gave us all reason to smile. 

Dealing with end of life matters occurs in all areas of health care, but for me, the transition from ICU to hospice was like taking a deep breath and recognizing "I'm home." That was 27 years ago, and while I miss the constant presence of attending those who are dying while I was an inpatient hospice nurse, it has been refreshing to return to visiting those we care for in their homes. As a home hospice nurse, we visit wherever "home" is for that person, be it a private home, a variety of care facilities, a homeless shelter, a trailer, or even a car. We are guests, there to guide and support during a time of high emotion, stress, and fear. Even after all of these years, the common response from others upon learning of my profession is "Isn't that so depressing?" For me, the answer has been and remains "Not at all!"

This has been a week of attending to two of my patients who are actively dying, a term we use in hospice when people reach the stage when death is hours or days away. As I gently cleaned thin and fragile skin, I was reminded of a multitude of shifts when we sat present for those close to death. Many of us in hospice nursing often equate our work to midwifing the other end of the life cycle. When death doesn't arrive swiftly and suddenly, there is a common pattern in how our bodies ease into the transition of leaving this world. It's not unlike a baby's arrival during childbirth. For some, it is quick and almost effortless. More commonly though, it takes time and work, is often messy, requires medications and a lot of coaching, education, and support. Being present at either birth or death elicits a wide range of normal emotions. As a hospice nurse, one of our most important jobs is to help prepare families and loved ones for all aspects of end of life, especially when the end draws near. I spent the morning explaining what was coming next and working out a medication schedule.

In my past life as a home hospice nurse, I hadn't fully appreciated the intimacy of being present with a person dying in their home. While all inpatient hospice facilities are mandated to appear homelike, we were able to provide care with the precision, albeit incredibly compassionate, of other hospital units. As a member of a home hospice team, I usually am by myself as I assess and provide hands on care. As I finished cleaning my patient, knowing I may not see her again, I gave a silent thanks to the opportunities I have been given to care for people in this way. I whispered into her ear to find the best cloud she could to float away on.  

As I left, I looked forward to the other aspect of midwifery I would soon be involved with. Indeed, birth is very much like death. On occasion, we get to welcome litters of puppies, just as we did JJ and her litter mates ten years ago. In Taoism, Yin/Yang is a fundamental teaching of life, demonstrating the dance of two becoming one. As a seasoned hospice nurse, witnessing new life coming into the world is a perfect complement to being present for those leaving. To know the puppies pictured below were cared for by the most amazing hospice therapy dog ever before her death, while remembering her own birth and life well lived is a comfort. Many times we have helped to bring new life into the world over the years and this legacy continues. In the next few days, the puppy in pink will be welcoming her own puppies into the world. A very special time to be a midwife indeed.


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