The following is my hospice nurse job interview. It is also a fly on the wall look into hospice. It goes beyond a definition of hospice. It defines hospice by looking at what hospice is and does. If your considering a hospice RN job, then you need to read Dying to Be There, What Hospice Is, Does and Why in the Health You Need to Know.
Note: This is the version of the book for marketing hospice. There is also a public version with a slight variation in the story line.
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It happened one sunny mid-summer day. I awoke from the slumber called life. Unlike normal sleep when you are aroused by someone calling your name, perhaps by a light touch, or even by a gentle shaking, my wake-up call came in the form of a single, direct question, that yanked me awake, ―"How do you want to die?"
That question, 'How do you want to die?' brought home to me the fact that life has an end and someday each of us will die. We will have to face the question of ‘how’ either for ourselves or for a loved one. Fortunately, I was helped to find the answer sooner than most.
What circumstances would lead someone to ask such a question? Death isn't a typical subject we discus, let alone even want to think about. Please listen to my story of how this came about.
After over a decade as a registered nurse, I began to feel the need to take my career in a new direction. So I set out for a job interview, having no idea that my entire viewpoint on life was about to change.
As you read my personal account, I believe you, too, will be touched by what I found to be a taste of the extraordinary. It is called Hospice, and it is an invaluable tool for individuals who are faced with the necessity of coping with end-of-life issues. Hospice will not be the answer for everyone. Some of us will deny that our life is ending. Others will feel they are quitting or giving up hope, so they will not choose hospice Care.
The fact is that over 75 percent of patients who qualify for hospice are not getting it. Of those who do take advantage of hospice, they have gained knowledge of something from which we all can benefit. They know why hospice is the best answer for them and their loved ones when facing the end of life. They have overcome misconceptions and misunderstandings because of their love for family and their belief in social responsibility.
What are some of these misconceptions? Of the many, one is that hospice facilitates the dying process, even speeding it up. There is also the view that when people stop eating they will suffer. The best way to change these and other misconceptions is to look at the research and hard science, the truth.
As my hospice job interview proceeded, it was easy for me to appreciate the truth or falsehood of these beliefs. Please come with me as I take you through each step of my job interview and open up to you the wonderful world of hospice.
Before we proceed, we need to discuss the confidentiality aspect of reading this book. While the stories are real, the names have been changed and the peoples identities have been protected. Every effort was taken to maintain peoples privacy.
Confidentiality is an essential aspect of all health care and especially hospice. So as you read on, I need to ask a favor about the information you will be reading here.
Before sharing my journey, your sharing this information needs to be addressed. It is essential for others to learn about and understand what hospice is and what it does. It is imperative that others know the good that this can do for so many, if only it was available.
As you read on, it is our hope that you will not keep this confidential. It is hoped you will share this with others that they may benefit.
People like to be in the know. People like to be informed.
Please share this information. Start a conversation. Too many people simply do not know….
What hospice is
What hospice does
The Myths about hospice and what the truth is
While sitting in the waiting room, a kind man named Tom welcomed me and invited me into his office. He explained that he was a registered nurse and the Patient Care Coordinator. His first questions to me were, "So, why do you want to work in Hospice?" and "What especially drew you to our office?"
I really did not know how to answer, so I explained, "I want to learn what hospice is, and whether I have something to contribute to what you do."
He asked me, "When you hear the word hospice, what comes to your mind?"
The two words that immediately came to me were cancer and death, but my reply was, "The usual things you hear in the nursing field."
What I did not say was what one of my nursing instructors had taught us 15 years earlier. Although I deep down I did not believe them, the words were echoing in my head and causing my heart to beat faster at that moment in time.
Tom continued by helping me examine some of those things that we all hear about hospice. One such conception discussed amongst professionals is that hospice presents nurses with an ethical dilemma.
Apparently some professionals have the view that administering morphine to manage pain results in lowering the respiration's to a rate that will not sustain life and results in the death of the patient. Thus, there is a perception that the death of patient is hastened, by the management of their pain. In ethical terms, this could be read, 'Kill a patient to manage or even eliminate his pain.' According to numerous scientific research papers, nothing could be further from the truth.
At the time of the interview, I did not know if the many things said about hospice were true, but curiosity opened my mind so that it was now the time to learn more. Despite the many negative things previously heard and even taught in nursing school about hospice, here I was applying for a job. There was an irresistible force drawing me here, as though my ship had come in and it was time to get on board.
As Tom opened my mind and the door to hospice, a larger picture came into my view. The height, depth and breadth of this picture was as big as life its self. This picture included an understanding about life and the most important things in it. A feeling of being gently awakened embraced me in the process of this picture being unrolled. The many misconceptions about hospice slowly disappeared as the human as well as the scientific lights were shined on those untruths.
Of the many questions Tom asked me that day, another was, "If given the choice and you were facing the end of your life, where would you want to be?" and, "How would you like to feel when dealing with your end?"
"How would you manage the stress, pain, anxiety, and the concerns facing you?"
At that time, no answers came to me. Take a moment to imagine how you would feel in that position. These were not your typical employment interview questions. But then, this is not a typical job.
Up till then, only a few of my hospital patients had died on my shift while working as a floor nurse. Of them, none were on hospice and five of the deaths were expected. Even though I had seen others die, I never though about my own death. Why should I? Why would I? Being young, strong and healthy, and basically planning on living forever, these were not questions to be entertained. Besides, as far as my life was concerned, so far so good.
But then came the very poignant question from Tom, the one that started this narrative...
'How do you want to die?'
Please allow me to explain why this question had such a profound effect on me, outside the obvious.
Up until that moment, like most people, I was going through life without considering management of my end or even that it would end. Actually, I was more inclined to live in the past by thinking of the things I used to do and only rarely of the time and power I had lost along the way.
Perhaps you too, have found yourself saying, '―remember when...'
It seems we are prone, throughout our lives, to revisit past experiences. We savor the good ones and perhaps re-live sadness for but a moment in the bad memories. So thinking about how we want to die tends to make us uncomfortable. Some may feel that asking someone else about death would be inappropriate and strange. We want to live, so why even think of how we want to die?
For some, death comes unexpectedly by means of accidents, a natural disasters, or even a terrorist attack. They are robbed of their life through a little known tenet called the 911 principle. This principal seems to govern our lives, and is found in the Bible at Ecclesiastes 9:11. Whether you are a Bible reader or even believe in it or not, the fact that this was written thousands of years ago begs us to consider the words.
According to a modern English translation, (New World Translation of the Holy Scriptures) it reads: "I returned to see under the sun that the swift do not always have the race, nor the mighty ones the battle, nor do the wise also have the food, nor do the understanding ones also have the riches, nor do those having knowledge have the favor because time and unforeseen occurrence befalls them all." Sometimes bad things just happen unexpectedly.
Then there are times when people know death is near. It may be a loved one, or perhaps we may be aware of our own approaching death. When that happens, people have differing wishes. Some want to be at home. Others want to see or do some particular thing before they die. They have a bucket list as it were.
Of course, on our journey through life, human nature is to avoid pain and maintain dignity.
There is another reason why the question, 'How do you want to die?' affected me so deeply. You see, I have had several near death experiences. Please bear with me and my explanation.
One day in the past, when tearing down a country road on my motorcycle, there was a car passing and approaching me head on in my lane. The only option available was to veer to the right and take the shoulder of the road. In a split second, memories of watching Steve McQueen in the Great Escape motorcycle scene flashed through my mind. Rather than jumping a fence, there was only a ditch that needed to be jumped.
The only problem was that the shoulder of the road could not accommodate my speed. My front tire caught in the pea gravel of the shoulder, which instantly slowed my bike but not my body. Flipping over the bike like a wet rag, I landed on my back in the hallow of a gulch. The result, every last bit of breath was knocked out of me.
The bike, now without me on it, also took to flight. Lying on the ground in the ditch, helpless and breathless, gasping to suck air into my lungs and powerless while looking at the blue sky a new horror was unveiling. The bike was filling my visual field. As if in slow motion, it was right above me and appeared to be aiming for me.
This was one of those slow motion moments where each fraction of a second appeared as though it were as sharp and clear as a high definition blue ray video.
Fortunately, the bike flew past me, allowing me to live and even escape injury to all but my ego.
This was not my only escape from death. In my life, there have been several others. If like a cat, we sometimes get additional chances, then several of my nine lives have been used up.
Another occasion happened on climbing to the top of a scaffold, almost 50 feet above the ground. Adding my 6'1 stature to the height and while standing erect on planks on the top rung of the scaffold, an eerie feeling of something being wrong over took me. Something really wrong.
I looked down and, to my horror, as I stood up, the plank under my feet was no longer there. All I could see was the ground…and it was getting closer and closer!
Again, as with the previous experience, as this experience unfolded, each second was split into a thousand parts. Every sight and every movement was perceived in slow motion. Each moment in time I was in possession of crystal clarity in thought and action.
I fell over 40 feet right through the middle of the scaffolding and somehow was able to catch myself on one of the cross bars on the way down, preventing serious injury. Of course, the thought that I could have died was reflected on.
A more recent brush with death came more slowly. Because of being intolerant to certain chemicals in the food I was eating, my body became toxic, or more appropriately, was poisoned.
As a nurse it was not a surprise when the doctor informed me that that I was in septic shock. It was likewise not a revelation when he also told me that it was starting to affect my liver. For the first time in my life there was the fear that comes with the anticipation of death. The death rate for septic shock is around 50 percent. This means 50% of the people who go into septic shock die and 50% live. As a scientist, my statistical chances of living or dying were just a number. There was a 50-50 chance of dying in the next several days.
With these events and others, my own mortality had been clearly brought home to me. When thinking back, perhaps these contributed to my interest in applying for a position with hospice in the first place.
Experience, the great teacher, also taught me an important life lesson. Making light of such situations, my comment would be, "My life flashed before my eyes. Robert Redford (Bradley Cooper if you are a Millennial ) played the part of me and a Mercedes 450 SL (or a Ferrari Spider if you are a Millennial) played the part of my car." Little did I realize, or for that matter, probably few even know the truth of what happens when we face our own end.
When near death, your life does not flash before you. Something happens that seems more nefarious to who we really are. Rather than your life, your regrets flash before you. All the worthless, unfortunate and undesirable things you have done in your life are relived right before your eyes.
If only there was time to apologize, Only if there was a way to make things right. Yet some things we have done in life, especially the bad, cannot be undone. These are the thoughts that those having to face death have to deal with.
Little could Tom have known the flood of thoughts and memories his questions brought back to my mind. At this point he had my rapt attention as he began to explain the hospice philosophy.
He illustrated hospice with a diamond. Perhaps you bought your wife a diamond. Have you ever looked closely at it? Do you know what makes the colors and beauty of that clear stone so brilliant?
The beauty is from the facets of a diamond. Hospice is one of the most beautiful jewels of health care. However, it's beauty is because of the facets. The brilliance comes from each of the various facets or disciplines reflecting their virtues and values off one another.
If you truly want to know and understand hospice, you need to examine the various facets. Only by learning about the individual facets will you begin to appreciate the true beauty of the jewel that is hospice.
Before we look at the facets, though, you also need to appreciate the value of the setting that holds the jewel in place. There is a parallel between the setting for the jewel and the setting known as modern medicine. Modern medicine follows the philosophy of... first, 'Do no harm.' The medical mindset is that of saving lives, preserving health, and enhancing the quality of the patient’s life.
With this philosophy there is a point at which there comes a challenge. What kind of life can someone have without quality of life? What if there is no cure for what we have? What if the only expectation is death, or even worse, a painful death?
The medical-ethical dilemma that eventually has to be faced is, "Are we preserving life or prolonging death?" If we‘re prolonging death, at what cost is it to the patient? The patient could be your parent, another relative, a dear friend, or even you or me.
When Tom was asking, 'How would you like to die?' it was based on the assumption that I, or you the reader for that matter, are facing the end of our life, and that we would want to maintain dignity and avoid suffering. What if the possibility existed to allow death without pain, not using heroics to prolong life, an action which could result in more suffering? What if there was a way to die as comfortably as possible and maintain dignity up to death?
Maintain dignity up to death – those words resonate with most people.
My thoughts went back to a time, early in my nursing career, when I met a patient who will live in my mind for the rest of my life. Her name was Shelly, a small older woman imprisoned for over a decade. Oh, there were no bars or shackles, but she was imprisoned nonetheless.
You see, Shelly had no legs, her amputations, one starting from above the knee and one just below. Shelly also had no arms. They had been amputated, one just above the elbow and one just below. She was a victim of a disease that there was not then and now a cure nor any stopping the destruction it does in life.
She had a tube inserted into her stomach that was feeding her because she could no longer swallow. In fact, she was unable to talk or communicate except for the look in her eyes. In Shelly‘s eyes all you could see was mistrust, sadness, anger and even disgust. That dark stare will go with all who cared for her, probably, until our death.
Medicine had saved Shelly‘s life. This, of course, happened to Shelly in part because there was no hospice in place at that time. It didn't exist for in our area for almost another decade. Perhaps Shelly was another part of the reason for coming to this interview. For a brief moment it seemed as though she was under my care just yesterday.
Bringing me back to the present, Tom stated, "The prospect of providing care to meet the needs of people at the end of life can be found in the setting of Hospice."
Using the illustration of the diamond again, he continued, "This setting resembles the setting of a diamond in jewelry. Like the posts or pillars that hold a diamond, hospice has four pillars that support it as the jewel it is. It helps people in four basic ways. These are the pillars that support the hospice system. They are the framework."
Provide palliative end-of-life care – not curative care. We manage symptoms, reversing them when possible. Our focus, though, is not on curing the disease process.
Maintain dignity during the end of life. Everyone deserves dignity and respect. There is no place here for the thinking ‘respect has to be earned.’ This applies whether you are the patient or a member of the team. Respect is an ethic and responsibility that needs to be shown on every occasion to each and every person with whom we come in contact. Whether a person is from the lowest station in life or the most prestigious, all deserve the same respect.
Being there, through the end of life. None should have to face the singular, most catastrophic event they will ever experience, without having someone help them with their thoughts and emotions is they so choose. No one should die alone if they don't want to. Some may prefer to be alone. However most in my experience want loved ones around them.
Hospice means being there for the patient and the families, filling the various needs of all concerned. Sometimes when a patient has started the active dying process, we will have a registered nurse, a licensed practical nurse (LPN), or a certified nurse‘s aid sit with the patient around the clock to manage symptoms or for comfort as the need may be.
Tom then asked, "Did you notice a common thread in each and every one of these pillars?"
I replied, "Life seems to be an aspect in each of them."
"That‘s right." Tom said. "Hospice is about life. When thinking of Hospice, people have a lot of ideas. Many think of cancer and death. But the most important thing people need to know about Hospice is, it means helping people live. It is about life."
Again he repeated, the four pillars are:
This is the setting that holds the diamond that is hospice, but to understand it completely will require discovering all the facets of the jewel. My time with Tom was thorough and next on my tour was Donna.
Interestingly, Tom asked for his own curiosity, which of the four pillars would or even should be considered the most important?
He did not let me answer, rather he suggested discerning which is most important during the meeting with other staff. On understanding the whole, decide which is the most important aspect of hospice.
As if on cue, Donna showed up at Tom‘s door. She introduced herself and invited me to follow.
Turning around to say goodbye, Tom handed me a printed index card and told me that to determine if working for hospice would suit me, it would be necessary to have answers that can only come from deep inside the soul. He then reminded me as to why, since as a hospice nurse, the question on the card is one all hospice nurses have to ask of those for whom they serve and care.
In order to be comfortable asking this question of the patients, it is something every nurse will need to know how they would answer for themselves.
For you, answering this question will help you examine a more timely question, perhaps an even more important question – "How do you want to live?"
On walking out the door, he handed me the card.
As I left the office I turned it over and read...
Would you like updates on the production of the book?
Introduction How I Got to Dying to Be There
Chapter 2: Hospice Social Workers
New June 2018